“I don’t want a mammogram.”

By Lisa Mullen, MD, Johns Hopkins Medicine

When we remind a patient that it’s time for their annual mammogram, some will respond by saying “I don’t want to have a mammogram.” What can we do when this happens? What information can we offer to the patient that may change their mind?

First, we should respond with curiosity. Ask the patient why they’re not interested in having a mammogram and what their objections are. We can then tailor our response to their concern, answering with respect and thoughtfulness. Here are some possible patient concerns about mammography:

Patient: “Mammograms are painful.”

Try saying: “Compression of the breast is required to obtain good mammogram images. Most women experience no discomfort or only mild discomfort during a mammogram. The mammogram technologist can work with you to minimize discomfort.”

Patient: “Radiation from mammograms causes breast cancer.”

Try saying: “Radiation can cause cancer at high doses. But the radiation required to perform a mammogram is very low, about the same as eight weeks of natural background radiation. No cancers have been observed at this low dose.”

Patient: “I’m very modest, and I don’t want to be exposed.”

Try saying: “The mammography technologists are all female and specially trained in making patients feel comfortable. They’ll be very careful about protecting your modesty during the mammogram.”

Patient: “I don’t need a mammogram. I don’t feel a lump.”

Try saying: “The purpose of a screening mammogram is early detection of breast cancer. By the time a cancer can be felt as a lump, it’s often larger, more advanced, and harder to treat.”

Patient: “I don’t need a mammogram. No one in my family has breast cancer.”

Try saying: “75% of new breast cancers are diagnosed in women with no family history of breast cancer. That’s why it’s important for all women to have an annual mammogram beginning at age 40.”

Patient: “I’d like to have a thermogram instead.”

Try saying: “Mammography is the only breast cancer screening test that’s been studied extensively and has been proven to decrease the risk of dying from breast cancer. Mammograms have been studied in multiple randomized controlled trials over decades. No other breast cancer screening test, including thermography and ultrasound, has been subjected to such close scrutiny or regulation.”

Patient: “I’m too young to have a mammogram.”

Try saying: “The screening guidelines recommend beginning annual mammography at age 40. Beginning at this age results in the most lives saved and the largest decrease in mortality. Screening every year finds more cancers than screening less frequently. One in every six breast cancers are found in women aged 40 to 49.”

Patient: “I’m too old to have a mammogram.”

Try saying: “Screening mammography has been shown to work well in women over age 75, with a high cancer detection rate, higher sensitivity, higher specificity, and lower false positive rate compared to screening in younger age groups. The risk of developing breast cancer increases with age. There’s no recommended upper age limit for a screening mammogram, but important issues to consider are your overall health and life expectancy, and whether you would choose to take action (such as biopsy or surgery) if an abnormality were found.”

Patient: “The mammogram will be useless. I’ve been told I have dense breasts.”

Try saying: “Mammograms are still useful in people with dense breast tissue. They can show calcifications and tissue distortion that can be signs of breast cancer and may not be visible on other tests. If you have dense breast tissue, we can also request supplemental screening with ultrasound or MRI.”

Patient: “I’m afraid that the mammogram will find a cancer.”

Try saying: “Early detection is key to early diagnosis and treatment and that leads to the best chance of survival. Finding a cancer early is very important and that’s the reason for doing an annual screening mammogram. If the mammogram detects a cancer, we’ll refer you to excellent specialists to provide you with the best possible treatment, and we will be here to support you.”

As with all patient communication, it’s critical to listen to the patient and try to understand their concerns, rather than responding with a lecture. The conversation could unfold over a few visits, with gradual movement toward improved mutual understanding. Additional information, including talking points about screening mammography, is available on the Society of Breast Imaging website.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.