COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 1

Comparing the Results of Early vs. Late Mammograms

Melanie Bakes 

Gina DeChellis

Rachel Sherick

Ella Simcox

Youngstown State University

NURS 3947 Nursing Research

and Dr. Mary Shortreed

Summer 2019
COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 2

Abstract

The intention of this paper is to compare mammography screening between the ages of 40 to 44

and mammography screening beginning annually at the age of 45.  In this research, the sources

used were narrowed down and focused on the time frame for a mammogram and the results that

followed.  The research was successful in proving that early mammograms do help decrease the

mortality rate overall compared to prolonging screenings until later in life.  There were many

results that proved when breast cancer was detected early, there was a higher survival rate

because treatment methods were better able to eradicate the cancer contained within the breast

before it spread to other parts of the body.  There needs to be further education about this topic to

women everywhere to help the mortality rate decrease even further.  In conclusion, this research

demonstrates that receiving mammograms between the ages of 40 to 44 decreases the mortality

rate overall compared to screening mammograms beginning at the age of 45.  

COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 3

Comparison of the Results of Early vs. Late Mammograms

In the article by DeSantis, Ma, Sauer, Newman and Jemal (2017), American Cancer

Society stated, “Approximately 252,710 new cases of invasive breast cancer and 40,610 breast

cancer deaths are expected to occur among U.S. women in 2017” (p. 439).  Prevention and early

diagnosis are key factors in treating breast cancer and improving patient prognosis.  Each year

women find or are screened for lumps or abnormal cells in their breasts.  Some are diagnosed as

benign, however there are many lives that are turned upside down with the diagnosis of breast

cancer.  Mammography plays an important role in early diagnosis of breast cancer.  However, as

vital as it is to use up-to-date technology, it is even more important that women are proactive in

their health and have the recommended screening done.  As health care professionals, nurses

need to provide accurate information about the importance of early detection and encourage their

patients to play an active role in their breast health.  So, the question that needs to be asked is:

Do early mammograms, initiated between the ages of 40 to 44 decrease the mortality rate of

breast cancer compared to those women who begin their annual mammograms at the age of 45?

Literature Review

Introduction

         In order to compare early versus late mammograms, we had to search for information on

breast cancer and mammography screenings on the Maag library and Google scholar databases

which led us to the reliable journals that we needed.  In the end, we concluded with nine

trustworthy sources that our information was reliable.  In the pages to come and the information
COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 4

that we will present about breast cancer and mammography screenings, the aim is to determine

whether early mammograms decrease breast cancer mortality in comparison to those who begin

their annual mammograms later in life. 

Mammograms

A mammogram is radiology of the breast, which allows for the early detection of breast

cancer because it is capable of displaying lesions at their initial stages, having sizes in the range

of millimeters (Nazare-Silva, Filho, Correa-Silva, Paiva, and Gattass, 2014, para 2). 

Radiologists are doctors qualified to view mammogram results and diagnose diseases and

injuries using imaging tests such as x-rays.  According to the “American Cancer Society”,

findings on a mammogram could include white spots called calcifications, lumps or tumors

called masses, and other suspicious findings that could warrant additional testing.  If an

abnormality is detected on a screening mammogram, the physician may recommend a diagnostic

mammogram to further evaluate the abnormality.  Also, breast ultrasound uses sound waves to

produce images of structures deep within the body that can be used to determine whether a breast

lump is a solid mass or a fluid-filled cyst.  Lastly, breast magnetic resonance imaging (MRI) is a

machine that uses a magnet and radio waves to create pictures of the interior of your breast.

Before a breast MRI, the patient will receive an injection of dye.  No radiation is used during this

procedure. 

            Breast cancer has the highest incidence and a relatively higher morbidity and mortality

rate of all cancers among women in the United States (Rajan, Suryavanshi, Karanth, and Lairson,

2017, para 1).  Regular screening, early diagnosis, and timely treatment initiation can

considerably reduce the morbidity and mortality rates associated with the disease.  Cost should

not be a deterrent for a female patient to receive a mammogram.  For an uninsured patient, a
COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 5

normal cost for a mammogram ranges from $80-$120 or more, with an average cost of

approximately $102, according to Blue Cross Blue Shield of North Carolina.  Some providers

charge more, and some offer an uninsured discount.

Under the Affordable Care Act, breast cancer screening and counseling is free.  All

healthcare plans must cover these benefits at no cost to the patient.  Some mammography centers

may require a prescription from a primary care physician or obstetrician-gynecologist.  Certain

guidelines must be followed under the Affordable Care Act.  The patient has to be over the age

of 40 and is covered for one screening mammogram every 1-2 years, as outlined in the summary

of benefits.  These mammograms are only without cost to the patient for women without

symptoms.  If a patient presents to the doctor with a symptom, such as a lump, the mammogram

would be considered a diagnostic test.  In that case, the patient would need to pay any

deductibles and copay or coinsurance.  Breast cancer is the second leading cause of women’s

death from cancer.  However, if breast cancer is found at an early stage, there is a 98 percent

chance of surviving.  The purpose of mammograms is to help with this detection of breast cancer

in order to increase the chance of survival.         

Breast cancer screening guidelines have changed a lot over the past twenty years.  

According to the “American Cancer Society”, the current screening recommendations are that

women at average risk of breast cancer should begin having annual mammograms by the age of

45 and can switch to having mammograms every other year beginning at age 55.  The Center for

Disease Control currently recommends that women ages 40 to 44 should have the choice to start

annual breast cancer screening mammograms if they wish to do so.  The risks of screening as

well as the potential benefits should be considered by these patients.  It is obvious that women

may be confused on the current screening guidelines and changes that have been made to them
COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 6

over the years.  In a recent study of women age 18 or older, 95% of these women said that they

had paid some attention to the recent discussions on mammography screening.  Only 24% said

the discussion had improved their understanding of mammography, while 50% reported being

upset by the public disagreement among screening experts (Woloshin et al, 2000 para 5). 

Statistics     

In 2017, about 40,000 women died from breast cancer (DeSantis et al, 2017, p. 439). 

That shockingly high rate is something we as healthcare professionals are trying to decrease.

Early detection and annual mammogram screenings are ways to help decrease the mortality rate. 

There are many reasons why women may not have detected the cancer sooner, but there are

some factors that are not modifiable and can increase their risk.  Two of these factors are

genetics and ethnicity.  When comparing ethnic groups side-by-side, the risk of breast cancer can

be higher for some and lower for others.  For example, non-Hispanic black women have a higher

mortality rate than non-Hispanic white women (DeSantis et al, 2017, p. 439).  When compared

by state, breast cancer death rates in black women “ranged from 20% in Nevada to 66% in

Louisiana” (DeSantis et al, 2017, p. 439).  In the study conducted by DeSantis et al. (2017), the

end of their abstract states

“breast cancer death rates were not significantly different from NHB (non-Hispanic black

women) and NHW (non-Hispanic white women) in 7 states, perhaps reflecting an

elimination of disparities and/or lack of statistical power.  Improving access to care for all

populations could eliminate the racial disparity in breast cancer mortality and accelerate

the reduction in deaths from this malignancy nationwide” ( p. 439).

COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 7

This is a goal that all healthcare professionals strive for when caring for their female patients of

any race.  All women need to have the availability of proper screening and education to help

improve their breast health. 

         An additional factor that most women can change, is actively going to their mammogram

appointments annually.  But how early should they go? A study was shown that almost a total of

33,000 screenings were performed, and nearly 810 biopsies were conducted between June 2014

to May 2016.  Throughout these screenings and biopsies, about 220 breast cancers were

detected.  The results showed that women ages 40-49 had almost 19% cancer detected.  Those

50-59 years old had approximately 22% and ages 60-69 had almost 33%.  And lastly, ages 60-69

were at about 21% (Pitman et al, 2017, para 3).  In conclusion to the study, the two age ranges of

40-44 and 45-49 had similar rates of detecting breast cancer.  These rates support the

recommendation that both age groups need to have mammography starting at age 40.  Of these

findings, women ages 40 to 44 had an 8.9% of screen detected cancer and women ages 45 to 49

had 9.8% of screen detected cancer. Of these detected, 60% of the cancers detected were

invasive. Waiting to have an initial mammogram until later in the 40’s or even 50 years old

decreases the chance of early detection, and puts nearly 20% of all women at risk (Pitman et al,

2017, para 4).  These statistics are alarming and show how vital it is for early detection.

       The study also evaluated those with common risk factors for breast cancer and found that

“only 15% of women ages 40-44 and 32% of women ages 45-49 had a known first-degree

relative with a history of breast cancer” (Pitman et al, 2017, para 25).  The study further included

women with a genetic mutation known as BRCA.  Only 5% of women in both age groups 40 to

44 and 45 to 49 were known to have the BRCA mutation. These percentages are small and if

women that had risk factors were the only ones screened, there would be a large percentage of
COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 8

breast cancers that might be overlooked.  These statistics, along with the recommendations of

American College of Radiology, clearly support the importance of mammograms screenings

beginning at age 40.  

Early vs. Late mammograms 

The decline in death rates from breast cancer from 1989 to 2007 is reported to be a result

of earlier breast cancer detection through screening, increased awareness, and improved

treatment options.  According to the “American Cancer Society Recommendations” (2017)

(ACS), breast cancer death rates have continued to decrease throughout the years in women over

the age of 50. The ACS has updated their previous recommendations on how soon to begin

mammography screening based on these statistics and recent studies regarding mammography

screening and breast cancer mortality rates.  Current guidelines from the ACS necessitate

mammographic screening to begin at age 45 with the option to begin screening at age 40

(Fancher, Scott, Allen, and Dale, 2017, p. 847).  However, there are still several different

recommended guidelines on when to begin screening mammography from many major

healthcare organizations. 

One study, dating from 2006 to 2015, was performed to evaluate the impact of the most

recent mammographic screening guidelines and to assess nodal status, survival from cancer at

five years, and disease-free survival from cancer at five years.  In this study, 144 women, ages 40

to 44 diagnosed with breast cancer over the ten year period were sorted into two separate groups

based upon how their cancer was detected: screening mammography detected cancer (SMDC)

and non-screening mammography detected cancer (NSMDC).  These women were then further

divided into groups without evidence of disease at five years, recurrence at five years, or

deceased from disease in five years (Fancher et al, 2017, p. 848).  Of the 144 women included in
COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 9

the study, approximately 44% were SMDC while 56% were NSMDC.  The study’s results

showed that approximately 31% of the women had a positive nodal status.  Five-year disease

survival was roughly 85% and five-year disease free survival was approximately 82% (Fancher

et al, 2017). The SMDC and NSMDC groups were also compared and evaluated for overall

outcomes.  Those results showed women with SMDC had a significantly lower incidence of

nodal positive cancer (p<0.001).  Also, there were 10 recurrences noted in the SMDC cohort,

which was less than the 16 recurrences noted in the NSMDC cohort.  Lastly, five year survival

was 94% in the SMDC (p<0.05)  (Fancher et al, 2017, p.848).  This study clearly reaffirms the

need for women to have annual mammography screenings to help prevent the metastasis of

cancer and decrease the mortality rates from disease. 

Another study was performed using the average values of six Cancer Intervention and

Surveillance Modeling Network (CISNET) models to compare three different recommended

guidelines on screening mammography.  The purpose of this study was to evaluate the three most

common recommended guidelines and how well they reduce mortality rates from breast cancer.

Women were grouped into one of three categories including: annual screening beginning at age

40, annual screening beginning at age 45, and biennial screening beginning at age 50. CISNET

determined average number of prevented deaths from breast cancer by mammography screening

per 1,000 women (Arieo, Hendrick, Helvie, and Sickles, 2017, p. 3674).  The results of this study

show that the average mortality reduction per 1,000 women was the greatest when annual

screening began at age 40 (39.6%), as compared to annual screening beginning at age 45 (30.8%)

or biennial at age 50 (23.2%) (Arieo, et al, 2017, p. 3676).  These results clearly show that the

mortality rate is reduced by approximately 10% when screening begins at age 40 instead of age
COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 10

45, proving that it is important for women to begin their mammography screening earlier rather

than later.   

Outcomes 

 Receiving an annual mammogram at age 40 can detect cancer early on, which could be

missed if the recommended age for mammograms were set at a higher age such as 45 or 50.  In

the mid-1980s, when mammography was not widely known, the invasive breast cancer death rate

was the same for 50 years.  From the year 1990 to 2014, there was a drastic reduction of 38% in

the mortality rate for breast cancer.  Regular screening saved lives by decreasing the breast

cancer mortality rate.  There were 11.9% of breast cancer deaths averted for every 1,000

women starting screening annually at age 40, compared to 9.25% of averted deaths of women

who started annual screening at age 45.  Women who started screening annually at age 40 had

189 life years gained per 1,000 women.  The women who waited until 45 years old to start

annually screening had 149 life years gained per 1,000 women that were screened. (Monticciolo,

et al, 2017, p. 1139).  Starting annual screening at age 40 has given more women additional years

of their lives and has helped to avoid many more deaths from the disease (Monticciolo, et al,

2017 p. 1139). 

 In another study, women in their 40s with breast cancer detected during screenings from

June 2014 through May 2016 were placed in a retrospective cohort study to determine the rate of

breast cancer detection in women 40 to 44 and 45 to 49 years old.  In the study, 32,762

mammographic screenings were carried out with 808 biopsies and 224 of those biopsies being

invasive breast carcinoma.  Women ages 40 to 44 counted for 5,481 examinations and 132

biopsies with 20 cases of invasive breast cancer, while women ages 45 to 49 made up of 5,319

examinations and 108 biopsies with 22 invasive breast cancer detections (Pitman, et al, 2017,
COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 11

para 12).  The women in both the age groups of 40 to 44 and 45 to 49 had similar cases of

invasive breast cancer.  If the women ages 40 to 44 would have waited to start annual screening

until 45, the number of invasive breast carcinoma cases would be almost doubled.  By starting

clinical breast examinations at age 40, more breast cancers were spotted and diagnosed, and

more women had additional years added to their life. 

With the current screening guidelines, women ages 40 to 44 have the option to start

screening annually, women 45 to 54 need to have a mammogram every year and women 55 and

above can have a mammogram every other year if they choose.  Women who start screening at

age 40 have a lower chance of breast cancer being undiagnosed, compared to if they decided to

wait until age 45 to start screening.  A disadvantage to screening early at age 40 is that false-

positive test results are more common in women in this age group.  Short term anxiety was

shown to be increased from false-positive tests, but no long term effects to the body.  Also,

women who had a false-positive scan were more likely to continue to undergo recommended

screening at age 40 (Pitman, et al, 2017, para 10).  Women ages 40 to 44 had approximately 9%

of screen-detected breast cancer in the study and women 45 to 49 had about 10% of the detected

cancer.  An advantage of screening at age 40 is that more cancer can be diagnosed at an early

stage which can possibly increase the chance of survival.  If the women in the age bracket of 40

to 44 would have waited until 45 to have a mammogram, then around 9% of screen-detected

breast cancers could have been missed from the years of not screening (Pitman, et al, 2017, para

13). 

Conclusion 

After exploring the research on breast cancer and the recommended mammography

screening guidelines, the results suggest that annual mammography screening is best when done
COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 12

as early as possible in women with average risk of breast cancer development.  The early

detection of breast cancer is essential for the prevention of potentially metastasizing throughout

the body and to allow methods of treatment to work better in eradication of this disease. 

Beginning annual screening at age 45 or older not only increases the chance of late cancer

detection, but it makes treatment methods less effective in curing the disease since the cancer has

most likely started to spread to other parts of the body.  In conclusion, nurses and other

healthcare professionals should encourage women to begin annual mammography screenings at

age 40 to help reduce mortality rates from breast cancer.  

 COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 13

References

(2017). American cancer society screening recommendations for women at average breast cancer

risk. American Cancer Society. Retrieved from https://www.cancer.org/cancer/breast-

cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-

early-detection-of-breast-cancer.html#written_by

Arieo, E. K., Hendrick, R. E., Helvie, M. A., Sickles, E. A. (2017). Comparison of recommendations

for screening mammography using CISNET models. Cancer, 123(19), 3673-3680.

doi:10.1002/cncr.30842

Desantis, C. E., Ma, J., Sauer, A. G., Newman, L. A., & Jemal, A. (2017). Breast cancer statistics,

2017, racial disparity in mortality by state. CA: A Cancer Journal for Clinicians, 67(6), 439-

448. doi:10.3322/caac.21412 

Fancher, C. E., Scott, A., Allen, A., Dale, P. (2017). Mammography screening at age 40 or 45? What

difference does it make? The potential impact of american cancer society mammography

screening guidelines. American Surgeon, 83(8), 847-849. Retrieved from

https://web.a.ebscohost.com/ehost/detail/detail?vid=3&sid=3f06fdc1-916b-46a9-aeb0-

2cd9763294c0%40sdc-v-

sessmgr01&bdata=JkF1dGhUeXBlPWlwLHVpZCZzaXRlPWVob3N0LWxpdmUmc2NvcGU9

c2l0ZQ%3d%3d#AN=124755515&db=rzh 

Monticciolo, D. L., Newell, M. S., Hendrick, R. E., Helvie, M. A., Moy, L., Monsees, B., Sickles, E.

A. (2017). Breast cancer screening for average -risk women: Recommendations from the ACR
 COMPARING THE RESULTS OF EARLY VS LATE MAMMOGRAMS 14

commission on breast imaging. Journal of the American College of Radiology, vol 14, iss. 9,

pp. 1137-1143. doi: 10.1016/J.JACR.2017 .06.001

Pitman, J. A., Mcginty, G. B., Soman, R. R., Drotman, M. B., Reichman, M. B., & Arleo, E. K.

(2017). Screening mammography for women in their 40s: The potential impact of the American

Cancer Society and U.S. Preventive Services Task Force Breast Cancer Screening

Recommendations. American Journal of Roentgenology, 209(3), 697-702.

doi:10.2214/ajr.16.17759

Rajan, S. S., Suryavanshi, M. S., Karanth, S., & Lairson, D. R. (2017, April). The immediate impact

of the 2009 USPSTF Screening Guideline Change 

          on Physician Recommendation of a Screening Mammogram: Findings from a National      

Ambulatory and Medical Care Survey-Based Study. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/27564582

Silva, J. D., Filho, A. O., Silva, A. C., Paiva, A. C., & Gattass, M. (2014). Automatic detection of

masses in mammograms using quality threshold clustering, correlogram function, and SVM.

Journal of Digital Imaging, 28(3), 323-337. doi:10.1007/s10278-014-9739-3

Woloshin, S., Schwartz L., Byram S., Sox H., Fischhoff B., Welch G. (2000, May 22). Women’s

understanding of the mammogram screening debate. Retrieved from

https://jamanetwork.com/journals.jamainternalmedicine/fullarticle/485334