Most women hear two different answers about mammograms. Start at 40, or wait until 50. Go every year, or every other year. On the first Saturday of Breast Cancer Awareness Month, Dave brought in someone who has been reading those images for more than half a century to sort it out: radiologist Dr. Donald Goodwin, MD, of TGH Imaging, the practice many people around here still know as Palm Beach Radiology. His answer was clear, and so was his explanation of what a mammogram can and cannot see.
By The First Rehabilitation Team · Reviewed by Dr. Dave Kashuba, Ph.D.
Fifty years of reading images, and a building Dave and Don put up in 2007
Dave and Don go back a long way. Their businesses ran side by side for years, and in 2007 they officially built a building together and rented it out, with Don as one of the owners of Palm Beach Radiology. Dave did the arithmetic on air. Don has been a radiologist for over 50 years, Dave is coming up on 40 in his own field, and “Remember when we started, we were the young guys.”
Before handing over the microphone, Dave ran through the things that are in your own hands: keeping your weight down, exercising, and eating more fibrous vegetables like sweet potatoes, carrots, broccoli and leafy greens. Then he got to his real reason for the episode. “But big thing is screening,” he said, and he asked Don to walk listeners through when women should start, and how often.
If you only know Don’s name from a report in your patient portal, his Pain 2 Power guest page has the background: the practice joined Tampa General and became TGH Imaging at the same North Palm Beach location, and Don stayed on. As he put it near the end of the show, they provide professional services for Tampa General now.
Start at 40 or 50? Every year or every other year?
Don started by admitting the confusion is real. The recommendation that gets the most press, he said, comes from the US Preventive Services Task Force, and it has often been at odds with what the medical societies say. That mismatch, in his words, “always, uh, causes some consternation.”
What the task force changed last year
Until last year, Don explained, the task force recommended starting screening at age 50 and going every other year after that. Last year it moved the start date from 50 to 40. It kept the every other year interval.
The American College of Radiology, the American College of Surgeons and the American Cancer Society, he said, have recommended starting at 40 with a mammogram every year for years, and they still do. So the two camps now agree on the starting age. They still disagree on how often.
| Who | When to start | How often |
|---|---|---|
| US Preventive Services Task Force, until last year | Age 50 | Every other year |
| US Preventive Services Task Force, now | Age 40 | Every other year |
| American College of Radiology, American College of Surgeons, American Cancer Society | Age 40 | Every year |
| Dr. Goodwin’s own view | Age 40 | Every year |
Why Dr. Goodwin leans toward every year
Don gave two reasons. The first was a trend. Breast cancer incidence, he said, has been rising by close to 1% a year since records began, and in women under 50 it has been rising by about 1.5% a year over the last 10 years. Dave asked whether better testing explains that. “Who knows?” Don said. “You just don’t know.”
The second reason is the job itself. “Our job is to find it as small and early as possible, because the smaller the lesion, the earlier the stage, the better the prognosis,” he said. Then he made the case against waiting in one plain sentence: “if you wait two years and, and it’s been growing for two years, and you could have picked it up last year, well, maybe you missed an opportunity.”
Mike picked up on the numbers. One and a half percent sounds small, he said, until you remember it is an annual increase. It stacks.
How much radiation is in a 3D mammogram?
Dave raised the worry a lot of women carry into the appointment: all that radiation, year after year. Don answered with specifics.
Mammography, he said, is very heavily regulated. His center is inspected every year, and the equipment goes through quality testing on a regular schedule. The expected dose from a 3D mammogram is about 0.4 millisieverts, “which is about two months’ worth of walking around on Earth.” He also put it another way: about the same as one transcontinental flight from here to LA.
He did not pretend it was zero. You cannot avoid radiation entirely, he said. There is radon in basements if you live in the Northeast, and there is radiation from the air. His point was to skip the unnecessary stuff, and he named CAT scans as the bigger exposure, anywhere from 2 to 16 millisieverts. And when Dave asked about MRI, the answer was short. “MRs have zero radiation,” Don said. “It’s all magnetic.”
Dense breasts, and what a mammogram can miss
This is the part of the hour the episode title comes from, and it is worth hearing if you have ever been told your breast tissue is dense.
In an average risk screening population, Don said, a radiologist expects to find four, five or six cancers per thousand women screened with an annual mammogram. In women with dense breasts the mammogram is less sensitive. “You can miss up to 60% of the cancers less than 10 millimeters in size,” he said. So radiologists add other tools, starting with ultrasound, which he said can increase the sensitivity of cancer detection by about 50%.
The BRCA study: 15, then 22, then 42 per thousand
Dave asked Don to explain BRCA for listeners. Everybody has the BRCA gene, Don said, but a mutation in it makes you more likely to develop a variety of cancers, breast cancer among them, with what he called basically a 50 to 70% lifetime risk. Then he described a study done years ago on a population of BRCA positive women, screened three ways in turn.
| Method | Cancers found per thousand |
|---|---|
| Average risk women, annual mammogram (for comparison) | 4 to 6 |
| BRCA positive women, mammogram | 15 |
| Adding ultrasound | Another 7, for 22 in total |
| Breast MRI on the same women | 42 |
That makes MRI, in Don’s words, “about twice as sensitive for cancer detection as mammogram plus ultrasound.”
So why doesn’t everyone get an MRI?
Because it is very expensive, it involves an IV injection, and you have to lie still for 20 or 40 minutes, depending on the protocol. Dave said that was something Mike could never do. Mike agreed.
Don said MRI is reserved for the high risk population, which is now defined as greater than 20% lifetime risk. That risk can come from family history, a prior biopsy that showed some atypia, or other genetic mutations besides BRCA. He also uses it as a problem solver. Sometimes a finding on the mammogram and the ultrasound still is not clear, and the next step is, as he put it, “let’s get an MR.”
After the mammogram: BI-RADS scores, callbacks and core needle biopsy
Mike mentioned someone he knows with dense breasts who got the same news almost every year: something questionable, more testing. Don said that is one of the real frustrations for women. You go in for a mammogram and, in his words, “Oh, geez, they called me back again.”
What a BI-RADS score is for
Dave brought up the BI-RADS score, which he described as running from zero to six. Don called it a classification of imaging findings that the government mandates, “as it should be, because it, it f- it forces the radiologist to make a decision.” The decision is whether a finding is benign or needs more evaluation, such as additional imaging or a biopsy. Dave’s point was the human one: with a score on the report, the doctor has to commit, and that is why he would rather have someone with Don’s 50 years making the call.
How 3D mammography cut the callbacks
Before the 3D mammogram, Don said, callback rates ran 10 to 12% of initial screenings. With 3D imaging, a lot of what used to trigger a callback can be resolved on the first set of images, and callback rates now run maybe 6 to 8%. That means fewer return visits, less radiation and, his phrase, “less aggravation.” Dave added less anxiety.
The money part is less tidy. Supplemental screening is sometimes not covered by insurance, Don said. The mammogram is covered, and then you get hit with additional tests, out of pocket payments and deductibles. He called it “a real bummer.” If dense tissue is part of your history, it is worth asking your insurer about supplemental imaging before the bill arrives rather than after.
Biopsy without the operating room, and what stage 1 means
Dave asked whether Don’s center does core needle biopsies. It does, and Don explained why that matters with a number from early in his career. In the 1980s and 1990s, he said, about 95% of breast surgeries across the country were for benign disease. You had a lump, it got cut out, and that meant an operating room, general anesthesia and a big bill, for something that turned out not to be cancer.
He counts the ability to make a benign diagnosis without surgery as one of the great contributions of breast imaging. And when a finding is malignant, the surgeon knows what he is dealing with before going in. Don said the need for re-operations is much less, a sentinel node can be taken at the same time, and the surgical treatment is completed in one go. “It’s just much more precise and much more efficient,” he said.
When a biopsy does show cancer, the pathologist runs what Don called a breast profile: the estrogen receptor, the progesterone receptor, the HER2 receptor that Dave had asked about, and Ki67, which Don described as a kind of proliferative index. In the old days, he said, everybody got the same chemotherapy. Now the aim is to match treatment to the specific tumor, getting the most effect on the tumor and the least on the rest of the body. He was careful to add that treating breast cancer is “way out of my field,” but that it has vastly improved over the last 10 to 20 years.
His example: with a stage 1 lesion, the five year survival is about 98 to 99%. Stage 1, he explained, is based on small size, usually less than two centimeters, with no nodes and no extension outside the breast. Which loops right back to his opening point about finding it small and early.
Mike also asked about preventive double mastectomy. Don called prophylactic mastectomy a viable alternative for some women, usually in the high risk group: BRCA positive women, people with strong family histories, or women with a cancer on one side who choose to remove the other breast at the same time as reconstruction. He noted that, generally speaking, there is no survival benefit of a mastectomy over a lumpectomy for a malignancy, and that it is probably not recommended for fibrocystic changes. These are decisions for a woman and her own surgeon.
Men get breast cancer too
Mike wanted the guys listening to hear this part. Breast cancer conversations center on women, he said, but men get it, and he named a few who went public: Montel Williams, the actor Tyler Mane, and Peter Criss, the drummer from Kiss. “There’s a lot of stigma around that and people don’t talk about it,” he said.
Don put numbers on it. Maybe 12% of women will develop breast cancer, he said, and in men it is maybe one out of 1,000. Men have breast tissue, and testosterone makes it shrink, which is part of why it is so much rarer. But men develop lumps. Some come in with a lump in the armpit, which he said means it has spread.
The most common reason men see him, Don said, is gynecomastia, a growth of breast tissue behind the nipple that usually shows up as tenderness and sometimes as a lump. Imaging can usually sort that out. His advice for men was direct: “with those symptoms, you ought to get checked out because every once in a while there’s a cancer in there.”
Hormone therapy, a bad pun, and how to reach Dr. Goodwin
Dave turned to hormone replacement. Earlier guests on the show have talked about it, and Dave’s view is that women need to watch their bloodwork closely and see someone who really knows what they are doing. Don’s answer was measured. “There’s a lot of conflicting research about that,” he said. It used to be thought that hormone replacement raised breast cancer risk, then studies said no, then yes again, then that estrogen alone did not but estrogen plus progesterone did.
He added that much of that data is old, that today’s bioidentical hormones are used at lower doses, and that they have not been around long enough to know for sure. If you need hormone therapy to get along, he said, okay. His one condition: “keep up with your screening, that’s all.” Mike summed up the whole hour the same way, women first and guys with symptoms too. Get screened.
Then came the dad joke, which Dave warned Don about, since the two of them share many bad dad jokes. A grape sees a farmer coming with a press. What did the grape do? It whined. Mike said the right response was a groan.
To reach Don, the number he gave on air is 561-841-8588, at TGH Imaging. Dave thanked him for coming in that early instead of going fishing.
Where a therapy clinic fits after a breast cancer diagnosis
We do not read mammograms at First Rehabilitation, and nothing in this post replaces the conversation you should have with your own doctor about screening. Where we come in is later. Episode 17 opened a run of breast cancer episodes. The week after Don, Dave and Mike talked with dietitian Elyse Marrone and Danielle Armstrong of Pilates Life about food and movement before, during and after a diagnosis, and Dave’s advice there was supervised exercise over jumping straight into a hard class. We wrote about why supervision matters in our post on starting a gym program after physical therapy.
That supervised work happens in our on-site wellness gym, with a team that knows your history and what your body has been through. The wellness and gym FAQ covers the common questions, and anything about memberships or schedules is a front desk conversation.
You can hear Don’s whole conversation on the Pain 2 Power podcast page, watch it as “What Your Mammogram Can Miss” in our video library, and catch new episodes Saturdays at 8:30 AM on 100.3 Legends Radio. If you are rebuilding strength or range of motion after treatment or surgery and want a plan built around you, call us at 561-624-4263 or request an evaluation.
This article is general information, not medical advice. Every situation is different, so please consult a qualified professional about yours.