Which Breast Screening Is Right for Me? A Step-by-Step Guide

Every woman's breast cancer risk is different, and the best screening plan depends on your breast density, your family history, and your genes. This guide walks you through each of these, one step at a time.

Questions to bring to your appointment

• What is my breast density category?

• What is my lifetime risk, and which calculator was used?

• Do I qualify for MRI, and will my insurance cover it?

• If I can't have MRI, is contrast mammography or ultrasound an option?

• Should I meet with a genetic counselor?

Step 1: Start with your mammogram

A mammogram is the foundation of screening for nearly everyone. The U.S. Preventive Services Task Force recommends one every two years for women 40 to 74. The American College of Radiology recommends yearly mammograms starting at 40 for women at average risk. Your doctor can help you choose a schedule. Some women need more than a mammogram. The next steps help you figure out whether that's you.

Step 2: Find out your breast density

Your mammogram report should tell you your breast density. Breasts are grouped into four categories, A through D. "Dense" means category C (heterogeneously dense) or D (extremely dense). 

Dense breasts are common and perfectly normal. They can make cancers harder to see on a mammogram, and they slightly raise breast cancer risk. Knowing your category is the first clue about whether extra imaging may help.

Step 3: Look at your family history

Ask relatives about breast, ovarian, pancreatic, colon, prostate, and skin (melanoma) cancers. Note which side of the family each cancer was on and how old the person was at diagnosis. Cancers diagnosed young, or several cancers on one side of the family, are especially important to share with your doctor.

Step 4: Get your personal risk estimate

Your doctor can use a risk calculator to estimate your lifetime chance of breast cancer. Some calculators include both breast density and family history. The American College of Radiology recommends that every woman have a risk assessment by age 25. A lifetime risk of about 20% or higher is generally called "high risk." That's the level where guidelines recommend adding MRI to your yearly mammogram.

Step 5: Match your situation to an imaging plan

Path A: Dense breasts, no other risk factors

Experts disagree here, so this is a decision to make with your doctor.

• The US Preventative Service Task Force says there isn't enough evidence yet to say whether extra imaging helps. uspreventiveservicestaskforce

• The American College of Radiology says women with dense breasts who want extra screening should have a yearly MRI starting at 40, in addition to a yearly mammogram. RSNA

• If MRI isn't an option, contrast-enhanced mammography or ultrasound can be considered. PubMed

The case for extra imaging is strongest if your breasts are extremely dense (category D).

Path B: Strong family history (high risk)

• The American Cancer Society recommends a yearly MRI and a yearly mammogram, typically starting at 30, for women with about a 20% to 25% or greater lifetime risk. American Cancer Society

• The American College of Radiology suggests MRI can start as early as ages 25 to 30 for higher-risk women. Jacr

• Some programs time the start of screening to 10 years before the youngest relative's diagnosis, with a mammogram not before 30 and an MRI not before 25. MD Anderson Cancer Center

Path C: Dense breasts and family history

The two factors add together. Density counts toward your risk score, so it can push you into the high-risk group. Once you reach about 20%, MRI is strongly recommended no matter how dense your breasts are.

A few practical notes

• Insurance is more likely to cover MRI when a guideline says it is "recommended" than when it says "consider," so ask about coverage early. DenseBreast-info

• Screening MRI is generally not recommended after age 74. DenseBreast-info

Step 6: Consider genetic testing

Genetic testing may be worth discussing if your family has several cancers, such as pancreatic, colon, and melanoma. It can also make sense if a close relative had pancreatic cancer at any age (this is one of the standard reasons to offer testing). Testing looks for inherited changes, including in the BRCA genes, that raise cancer risk. nih

What to expect:

• A panel checks many genes at once. One option is Myriad's MyRisk test, which looks at 63 genes linked to 11 cancer types, including breast, colon, pancreatic, and skin cancers. Other labs offer similar panels. Myriad Genetics

• Your breast risk can be fine-tuned. Myriad's RiskScore combines your family and health history with a genetic risk score to estimate your breast cancer risk. That can help show whether you cross the 20% line for MRI. Amazon S3

• A genetic counselor can guide you. They explain what results mean before and after testing. Myriad has genetic counselors available. Myriad Genetics

• A negative result doesn't erase your family history. Your screening plan should still reflect it, especially if affected relatives were never tested. If a relative with cancer is alive and willing, testing them first is often most informative.

• A positive result can change your plan. It may mean earlier MRIs, and screening for other cancers too.