Breast Cancer Screening
in Nova Scotia
According to the Canadian Society of Breast Imaging, a woman’s risk for getting breast cancer should be assessed by age 25-30 to determine if early screening is appropriate. Have a conversation with your health care provider about your risk factors. About 4% of invasive breast cancers were diagnosed in women in Canada under age 40 in 2019.[1]
When can I begin mammograms?
At age 40, it’s recommended that you have a conversation with your health care provider about the benefits and limitations of starting mammography. However, if your mother, sister, father, or brother had breast cancer younger than age 50, talk to your doctor about starting mammograms 10 years younger than their age when they were diagnosed, but not younger than age 30. Your health care provider will refer you for a diagnostic mammogram.
Should I perform breast self-examination?
The term you’ll likely hear now is that women should be “breast aware.” That means pay attention to how your breasts look and feel. Know what your normal breast texture feels like so you can recognize if there’s been a change. Check out www.knowyourlemons.com for examples of breast cancer symptoms and clear instructions on how to perform a breast self-exam. See your health care provider about any unusual changes to your breasts.
About dense breasts
It’s important for all women to know if they have dense breasts. About 43% of women have dense breasts.[2] You can only find out if you have dense breasts when you have a mammogram. The radiologist looking at your X-ray will assess the amount of dense tissue. Dense breasts increase the risk of breast cancer and also increase the risk that cancer can be masked on a mammogram.[3] How? Both cancer and dense tissue appear white, so cancer may be hard to see. To learn more about dense breasts, visit www.densebreastscanada.ca
Making an informed decision
The information in the Discuss and Decide section can help you to prepare for your conversation with your health care provider and make informed decisions about your screening. It’s your health. Be breast informed.
[1]https://www.cancer.ca/en/cancer-information/cancer-type/breast/statistics/?region=on
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4200066/
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3326547/
When can you begin mammograms?
Women with no symptoms of breast cancer can begin mammograms in the Nova Scotia Breast Screening Program at age 40. It’s recommended that you have a conversation with your health care provider about your risk factors and the benefits and limitations of mammography, starting at 40. The decision whether or not to have a mammogram is yours, based on your values and preferences.
How often can you book a mammogram?
You can book a mammogram every year from ages 40-49. You will receive a letter from the screening program every year to remind you to book. You do not need a referral.
What do Canadian breast cancer experts advise?
Current evidence shows the benefits of screening mammograms are greater than the limitations.[1] The Nova Scotia screening program follows the recommendations from The Canadian Association of Radiologists and Canadian Society of Breast Imaging which recommend mammograms starting at age 40 for women with no symptoms of breast cancer. The most lives are saved by starting mammograms at age 40 and then going every year.[2] 17% of breast cancers occur in women in their 40s.[3] These cancers tend to be more aggressive. Women aged 40-49 who have mammograms are 44% less likely to die of breast cancer than women who do not have mammograms.[4] As well, when you find cancer early, you may reduce the need for chemotherapy and mastectomy. You also reduce the risk of lymphedema.
Black, Asian, and Hispanic women are at increased risk for breast cancer at a younger age than white women.[5]
About family history
If your mother, sister, daughter, father, brother, or son already have or develop breast cancer, screening every year is recommended for you. Women with a family history are almost two times more likely to develop breast cancer.
About dense breasts
Only the radiologist who views your mammogram can assess your breast density. Breasts that are dense have more glandular tissue than fat. Dense breasts are common and normal, but they pose risks women should be aware of. Dense breast tissue increases the risk of breast cancer and also increases the risk that cancer can be masked on a mammogram.[6] How? Both cancer and dense tissue appear white, so cancer may be hard to see. Ultrasound can find additional cancers hidden in dense breasts and can find them when they are small.[7]
It’s important to know and understand your breast density. In Nova Scotia, your breast density category is included in your screening mammogram results letter mailed to you. Dense breasts are indicated by category letters C or D.
What can women with dense breasts do?
Women with category D density can return annually for a mammogram. Experts recommend both mammogram and ultrasound for women with dense breasts, category C and D. You can ask your health care provider for a requisition for a screening ultrasound.
Breast self-exams are important for women with dense breasts since they have a greater risk of finding a cancerous lump in between their mammograms. You can also consider modifying your lifestyle risk factors to decrease your risk. To learn more about dense breasts, visit densebreastscanada.ca
Making an informed decision
The information in the Discuss and Decide sections can help you to prepare for your conversation with your health care provider and make informed decisions about your screening. It’s your health. Be breast informed.
[1]https://www.ajronline.org/doi/full/10.2214/AJR.17.18730?journalCode=ajr
[2]https://academic.oup.com/jnci/article/106/11/dju261/1496367
[3]https://seer.cancer.gov/statfacts/html/breast.html
[4]https://pubmed.ncbi.nlm.nih.gov/25274578/
[5] https://pubmed.ncbi.nlm.nih.gov/21076864/
[6]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3326547/
[7]https://pubmed.ncbi.nlm.nih.gov/29317037/
How often can I go for a mammogram?
Women with no family history of breast cancer will receive a letter from the Nova Scotia Breast Screening Program every 2 years to remind them to book a mammogram. You can call to book your own mammogram.
What do Canadian breast cancer experts advise?
Current evidence shows the benefits of screening mammograms are greater than the limitations.[1]The most lives are saved by having mammograms ever year.[2] Women aged 50-74 who have mammograms are 40% less likely to die of breast cancer than women who do not have mammograms.[3] When you find cancer early, you may reduce the need for chemotherapy and mastectomy. You also reduce the risk of lymphedema.
Black, Asian, and Hispanic women are at an increased risk for breast cancer at a younger age than white women.[4]
About family history
If your mother, sister, daughter, father, brother, or son already have or develop breast cancer, screening every year is highly recommended for you. Women with a family history are almost two times more likely to develop breast cancer.
About dense breasts
Only the radiologist who views your mammogram can assess your breast density. Breasts that are dense have more glandular tissue than fat. Dense breasts are common and normal, but they pose risks women should be aware of. Dense breast tissue increases the risk of breast cancer and also increases the risk that cancer can be masked on a mammogram.[5] How? Both cancer and dense tissue appear white, so cancer may be hard to see. Ultrasound can find additional cancers hidden in dense breasts and can find them when they are small.[6]
It’s important to know and understand your breast density. In Nova Scotia, your breast density category is included in your screening mammogram results letter mailed to you. Dense breasts are indicated by category letters C or D.
What can women with dense breasts do?
Women with category D density can return annually for a mammogram. Experts recommend both mammogram and ultrasound for women with dense breasts, category C and D. You can ask your health care provider for a requisition for a screening ultrasound.
Breast self-exams are important for women with dense breasts since they have a greater risk of finding a cancerous lump in between their mammograms. You can also consider modifying your lifestyle risk factors to decrease your risk. To learn more about dense breasts, visit densebreastscanada.ca
Making an informed decision
The information in the Discuss and Decide section can help you to prepare for your conversation with your health care provider and make informed decisions about your screening. It’s your health. Be breast informed.
[1] https://www.ajronline.org/doi/full/10.2214/AJR.17.18730?journalCode=ajr
[2] https://academic.oup.com/jnci/article/106/11/dju261/1496367
[3] https://pubmed.ncbi.nlm.nih.gov/25274578/
[4] https://pubmed.ncbi.nlm.nih.gov/21076864/
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3326547/
[6] https://pubmed.ncbi.nlm.nih.gov/29317037/
According to the Canadian Society of Breast Imaging, it’s important to keep having mammograms as long as you are in good health, with a life expectancy of at least 5-10 years. Figures from Statistics Canada indicate the average life expectancy for a 75-year-old woman is 13 years.[1] At age 80, it’s 10 years. Breast cancer incidence and death rates generally increase with age. Women 75 years and up receive the same benefits of early detection from screening as younger women: more lives saved through less invasive treatment.
Women over the age of 75+ can continue to have mammograms every 2 years and do not need a requisition. A reminder letter will no longer be sent. If you have a family history, you can book annually. It’s recommended that you have a conversation with your health care provider about the benefits and limitations of mammography to decide if continuing mammography is right for you. You can book your own mammogram.
About family history
If your mother, sister, daughter, father, brother, or son already have or develop breast cancer, screening every year is recommended. Women with a family history are almost two times more likely to develop breast cancer.
About dense breasts
It’s important to know and understand your breast density. In Nova Scotia, your breast density category is included in the report sent to your health care provider and you can ask. Breasts that are dense have more glandular tissue than fat and are indicated by category letters C or D.
Dense breast tissue increases the risk of breast cancer and also increases the risk that cancer can be masked on a mammogram.[2] How? Both cancer and dense tissue appear white, so cancer may be hard to see. Ultrasound can find additional cancers hidden in dense breasts and can find them when they are small.[3] Experts recommend both mammogram and ultrasound if you have dense breasts. To learn more about dense breasts, visit densebreastscanada.ca
Making an informed decision
The information in the Discuss and Decide sections can help you to prepare for a conversation with your health care provider and make informed decisions about your screening. It’s your health. Be breast informed.
[1]https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310013401
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3326547/
[3]https://pubmed.ncbi.nlm.nih.gov/29317037/
Discuss
Your voice matters in your health care decisions. All women have a right to accurate and current information.
To have an informed discussion with your health care provider, it is important to distinguish the facts from misinformation about the benefits and limitations of mammograms. Here are the facts based on current evidence:
Benefits of Mammograms
Mammograms can find cancer early.
Mammograms can find cancerous tumours 2-3 years before they can be felt.[1] Finding breast cancer early can increase survival and also reduce the need for harsher treatments like chemotherapy and mastectomy.
A mammogram can save your life.
Multiple studies have found that routine screening from age 40-74 substantially reduces deaths from breast cancer. Current evidence shows women aged 40-49 who have mammograms are 44% less likely to die of breast cancer.[2] Women aged 50-74 are 40% less likely to die of breast cancer.[3]
Mammograms help you find out your breast density.
It’s important to know if you have dense breasts, which can increase your risk. Your breast density can only be assessed by the radiologist after a mammogram.
[1] http://www.bccancer.bc.ca/screening/breast/breast-health/facts-myths
[2] https://pubmed.ncbi.nlm.nih.gov/25274578/
[3] https://pubmed.ncbi.nlm.nih.gov/25274578/
Limitations of Mammograms
Current evidence shows that the benefits of mammograms outweigh the limitations for women aged 40-74.
Mammograms may lead to more tests which can create anxiety.
You may be told that mammograms can result in “false positives”, but this term is a misnomer. Rather, any additional tests are simply recalls for extra images to make sure that there is no cancer. About 10% of women are recalled and over 95% of these women do not have cancer.[1] Waiting for the extra tests and the results can be stressful. However, evidence shows that the anxiety is short lived and does not harm women psychologically in the long term.[2]
Over detection/ Over diagnosis
You may be told that there is a theoretical possibility that you could be diagnosed and treated for a cancer that would never threaten your life, even if it was not treated. Since it is impossible to tell the difference between harmless cancers and deadly ones, all cancers are treated.
You may be told that the estimated rate of over detection is 41 percent of breast cancers.[3] Current evidence estimates the rate is actually between 1-10%.[4]
Not all breast cancers will be detected by mammograms.
Cancer may not be visible on the mammogram or may develop between two mammograms. A woman’s age, the location of the cancer, and a woman’s breast density can make cancers more or less difficult to see.
Not all women whose cancers have been found by mammograms will survive.
Treatment does not always lead to survival, even when cancer is detected at an early stage.
Mammograms use low doses of radiation.
A mammogram is an X-ray and uses a low dose of radiation, slightly higher than a chest X-ray. The risk of breast cancer due to radiation emitted during a mammogram is very low.[5] The benefit of early diagnosis and treatment for breast cancer far outweighs the risk of the small amount of radiation received during a mammogram.
[1] http://www.bccancer.bc.ca/screening/breast/results
[2] https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1861037
[3] https://pubmed.ncbi.nlm.nih.gov/6802546/
[4] https://pubmed.ncbi.nlm.nih.gov/22972810/
[5] http://www.bccancer.bc.ca/screening/breast/breast-health/facts-myths
Decide
Making a choice about breast screening over the age of 40 is your decision.
When discussing your risk factors and the benefits and limitations of mammograms with your health care provider, it’s also important to consider your values and preferences.
The 5 statements below give you a chance to think about the importance of early detection for you.
Consider each value statement using the following options:
Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree
- It’s important to me to find cancer early in the hopes of treating it sooner rather than later.
- I’m not very worried about being asked to return for additional images or follow-up tests.
- Since it’s impossible to differentiate between cancers that are harmless or not, I’m willing to accept that I may be treated for a cancer that might never become a problem if left untreated.
- I'm willing to do anything to avoid harsh medical treatments that would reduce the quality of my life.
- I’m very worried about my chances of getting breast cancer.
Considering your answers
If you agree with most of the value statements, the benefits of mammograms outweigh the limitations for you. Take control of your health by knowing your options and making the decision that is right for you.
What you can say to your health care provider
You’re in your 40s and you’ve decided you’d like a mammogram. You can self-refer in your province, but your health care provider dismisses the importance of you having a mammogram.
We’ve designed a script to help you advocate for yourself and overcome any potential barriers while having a conversation with your health care provider.
If your health care provider says: The Canadian breast cancer screening guidelines do not recommend mammograms for women in their 40s.
You can respond: I understand that is the recommendation but it also states, that the decision whether or not to have a mammogram is a woman’s and that depends on the values she places on any possible benefits and harms.[1] Therefore, based on my values, this is my decision and I’ve decided to get a mammogram.
If you need a further response: You can use this quote from Task Force vice-chair Dr. Ainsley Moore, “The new guidelines are intended for an empowered position, which puts the decision-making in the hands of the individual woman in terms of what she prioritizes.”[2] Based on a woman’s values and preferences, the decision to undergo screening is conditional on the relative value a woman places on possible benefits and harms from screening.
If your health care provider says: You don’t have a family history or other risk factors and so you don’t need to start screening in your 40s.
You can respond: I’m aware that the biggest risk factor for breast cancer is being a woman and that over 75% of women diagnosed with breast cancer have no risk factors.
**If it applies to you, you can remind your health care provider that Black, Asian and Hispanic women are at an increased risk for breast cancer at a younger age than white women.[3]
If your health care provider says: Having a mammogram can result in a “false positive”, meaning you may be recalled for more testing. These tests can create anxiety for you.
You can respond: I understand there’s a chance that more tests will be needed after my mammogram to make sure there is no cancer, but I’m not very worried about being recalled. I understand that less than 10% of women are recalled.[4] I’d rather be safe than sorry. I understand any anxiety I experience will be short-lived if I have a normal result. And if the result is not normal, I’d prefer to have cancer found at an early stage, rather than a later stage.
If your health care provider says: Having a mammogram can result in over-diagnosis. That means finding a cancer that if left untreated would never cause you any harm, but if detected requires treatment and surgery.
You can respond: I understand and I’m willing to accept that I may be treated for something that might never have become a problem if left untreated. Again, better safe than sorry.
If your health care provider says: This graphic shows that out of 1000 women who have a mammogram, only 1 life is saved.
Your response: I learned the Canadian Society of Breast Imaging states 2 lives are saved.[5] I also know that finding cancer early means I may avoid harsh medical treatments like chemotherapy and mastectomy that can reduce the quality of my life.
As stated in the Canadian guideline, the decision to have a mammogram is yours and therefore you have a right to have a mammogram in your 40s, no matter what province you live in.
[1] https://canadiantaskforce.ca/guidelines/published-guidelines/breast-cancer-update/
[2] https://www.ctvnews.ca/health/mammogram-guidelines-now-consider-women-s-personal-values-not-just-age-risk-1.4211240
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875337/?tool=pmcentrez&report=abstract
[4] http://www.bccancer.bc.ca/screening/breast/results
[5]https://csbi.ca/education/
So, you’ve had a mammogram and learned you have dense breasts. Since dense tissue can mask cancer on a mammogram, you would like additional screening. You need a requisition for a screening ultrasound.
We’ve designed conversation tips to help you advocate for yourself and overcome any potential barriers while having a discussion with your health care provider.
If your health care provider says: The Canadian breast cancer screening guidelines do not recommend screening ultrasounds for women with dense breasts.
You can respond: I understand that is the recommendation but since there is an increased cancer risk with dense breasts and since mammograms are not as effective because of the masking effect, I would like to schedule an ultrasound to be safe.
Additional information: Since 1995, ultrasound has been proven in multiple studies to detect additional cancerous tumours missed by mammogram.[1]
If your health care provider says: You don’t have a family history or any other risk factors and so you don’t need to worry about additional screening.
You can respond: Dense breasts are actually a more prevalent risk factor than family history.[2] Most women diagnosed with breast cancer have no risk factors they are aware of. I would like to go ahead and schedule an ultrasound.
**If it applies to you, you can remind your health care provider that Black, Asian and Hispanic women are at an increased risk for breast cancer at a younger age than white women.[3]
If your health care provider says: Having a screening ultrasound can result in a “false positive”, meaning you will be recalled for more testing. These tests can create anxiety for you.
You can respond: I understand that there’s a chance that more tests will be needed if something is picked up, but I’m not very worried about being recalled. I’d rather be safe than sorry. I understand any anxiety I experience will be short-lived if I have a normal result. And if the result is not normal, I’d prefer to have cancer found at an early stage, rather than a later stage. I would like to go ahead and schedule an ultrasound.
[1] https://acsjournals.onlinelibrary.wiley.com/doi/abs/10.1002/1097-0142(19950815)76:4%3C626::AID-CNCR2820760413%3E3.0.CO;2-Z
[2] https://jamanetwork.com/journals/jamaoncology/article-abstract/2599991
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875337/?tool=pmcentrez&report=abstract
Resources
To book a mammogram call 1-800-565-0548 or for more information, visit the Nova Scotia Breast Screening Program.