A dear friend of mine sent me a panicked, cryptic email late on a Friday night: “call me immediately” (followed by her cell phone). As a doctor, I usually know that these kinds of requests are triggered my medical emergencies, so I anxiously picked up the phone and called my friend, hoping that I wasn’t going to hear some alarming story about a tragic accident.
And low and behold the story was this: “I got home from work late and picked up the mail. There was a letter in there from the radiologist’s office. It said that my mammogram was abnormal. Do you think I have breast cancer? Am I going to die?”
Remaining calm, I asked what sort of abnormality was described. She read the letter to me over the phone:
Your recent mammogram and/or breast ultrasound examination showed a finding that requires additional studies. This does not mean that you have cancer, but that an area needs further evaluation. Your doctor has received the report of your examination. Please call us at XXX to schedule the additional examinations.”
I knew immediately that this was a form letter (heck the letter didn’t even distinguish between whether or not my friend had had a mammogram or an ultrasound) and it made me angry that it had frightened her unnecessarily. I knew that as many as 40% of women who have mammograms have some sort of “finding” that requires further testing. Usually it’s because the films are too dark or too light, the breasts are particularly large or dense, or there is some cyst, calcification, lymph node, or shadow that the radiologist picks up. And in a litigious society, a hint of anything out of the ordinary must be reported as an abnormal “finding” until proven otherwise.
I did my very best to reassure my friend – to tell her that if the radiologist were truly concerned about what he or she saw on the mammogram s/he would have called the physician who ordered the test right away. Receiving a vague letter like this is reassuring, because it’s an indication of a low index of suspicion for a malignancy. I also told my friend that if a true mass were found on the mammogram, that a biopsy of that mass still has an 80% chance of being normal tissue.
But even though I did my very best to reassure her, my poor friend didn’t sleep well that night, and worried all weekend until she could speak to her physician on Monday. As I thought about her experience, and the unnecessary fright that she was given… I began to wonder about how common this experience must be. How many other women out there have lived through such anxiety?
Personally, I think that women who get mammograms should be warned up front that there is a high chance that the radiologist will find something “abnormal” on the test, and that these abnormalities usually turn out to be any number of typical breast characteristics. They should be told not to worry when they receive a letter about the abnormality, but come back for further testing in the rare event that the finding is concerning.
I decided to do a little research about this phenomenon (women receiving scary letters out of the blue about their mammogram results) and interviewed Dr. Iffath Hoskins (Senior Vice President, Chairman and Residency Director in the Department of Obstetrics and Gynecology at Lutheran Medical Center in Brooklyn, N.Y.) about her experiences.
Please listen to the audio file for the full conversation. I will summarize her opinions here:
Q: How common are abnormal mammograms?
Mammograms are considered “abnormal” in some way in up to 40% of cases.
Q: What sorts of things are picked up as abnormal without being true pathology?
Overlapping tissues in women with larger or heavier breasts, fibrocystic breast tissue, calcium deposits or the radiologist doesn’t have the last mammogram to compare the new one to and sees some potential densities.
Q: What happens next when a woman has an abnormal mammogram?
It may take a week or two for the patient to get scheduled for follow up tests. Usually the physician will choose to either repeat the mammogram with targeted views of the area in question, request a breast ultrasound, biopsy the mass, or remove the concerning portion of the breast tissue surgically.
Q: When would a physician choose a biopsy?
A biopsy is indicated if the mammogram and follow up tests all are consistent with the appearance of a concerning lesion. Sometimes the physician will do a biopsy on a lump if a woman says that it’s unusual, new, or tender and the mammogram result is equivocal.
Q: What percent of biopsies confirm a malignancy?
It varies from physician to physician because some have a lower threshold for performing biopsies (so therefore the percent of biopsies that are malignant is lower). But on average only 10% of biopsies pick up an actual cancer.
Q: What does a radiologist do when he or she finds an abnormality on a mammogram?
First of all, the patient must be notified of the abnormality. Secondly, the radiologist reports the abnormality to the referring physician, usually by fax. They do it either in batches, or one at a time. If the person reading the film has a serious concern about the breast tissue – or if it appears to have the characteristics of a malignancy, the radiologist will personally call the referring physician right away.
Q: What advice would you give to a woman who receives a letter in the mail indicating that she’s had an abnormal finding on her mammogram?
Please try not to be concerned yet. Wait for the doctor to fully evaluate the mammogram and do further testing before you make any assumptions about the diagnosis. Although it’s almost impossible not to feel anxious, you must understand that the vast majority of “abnormal findings” on a mammogram are NOT cancer.