Let me introduce you to two women. Radhika and Sunita.

Not their real names. They represent the profiles of the women I often meet in my clinic.

Both are 44, live in the city, juggle work and family, and feel perfectly healthy.

Both walk into my consulting room for their annual mammogram on the same morning.

If you saw them in the waiting room, you couldn’t tell them apart. But when I sit them down and ask a few questions, two very different stories emerge.

Radhika’s mother was diagnosed with breast cancer at 48. Radhika’s periods began early, at 11. She had her first child at 36 and could breastfeed only for a few weeks. Her previous mammogram shows dense breast tissue.

Sunita has no family history of cancer. Her periods began at 14. She had her first child at 25 and breastfed both children for over a year. Her breast tissue is mostly fatty.

Same age. Same city. Similar lifestyles. Both healthy. But Radhika has more risk. Why?

Risk is personal

Sure, age is the biggest risk factor for breast cancer, and every woman over 40 shares it.

However, apart from age, risk is shaped by your family’s cancer history, your hormones, your breast tissue and your lifestyle.

This is why one size doesn’t fit all. Let’s see what changes your risk compared to others:

Family history and genes: Having a mother, sister or daughter with breast cancer roughly doubles your risk.^[1] Ovarian, prostate or pancreatic cancer in relatives, on either your mother’s or father’s side, matters. Changes in genes such as BRCA1 and BRCA2 can raise lifetime risk very substantially, to as high as about 70% by age 80.^[2]

Breast density: Dense tissue has more glandular and fibrous tissue and less fat. It makes small cancers harder to see on a mammogram, and it is also an independent risk factor.^[3] You can’t feel your density. Only a mammogram shows it.

Hormonal and reproductive history: Early first periods, late menopause, a first pregnancy after 30 or no pregnancy mean longer or stronger exposure to oestrogen, which modestly raises risk. Breastfeeding lowers it.^[4]

Your breast history: A previous biopsy showing atypical cells, or radiation to the chest at a young age, increases breast cancer risk.

Lifestyle: Excess body weight, regular alcohol/ tobacco and inactivity all add to risk.

Lower risk doesn’t mean zero risk

I want to be very clear about this. Sunita’s risk is lower than Radhika’s, but it is not zero.

Most women who develop breast cancer have no family history and no obvious risk factor. Simply being a woman and growing older is enough.

The symptoms often appear late, when the cancer is untreatable or expensive and stressful for everyone around you to treat.

That is why every woman above 40 should have an annual mammogram, whatever her risk profile. Risk assessment doesn’t decide whether you get screened. It helps decide how and when to start, sometimes when you are younger than 40.

What a personalised assessment can change

For Radhika’s risk profile, I would likely suggest:

Starting screening earlier if her risk is high enough, in some cases well before 40.

3D mammography, which can be especially helpful in dense breasts.

Additional imaging, such as an MRI, when her overall risk is very high, or her breasts are very dense.^[5]

Genetic counselling and testing if her family history warrants it.

A tailored plan on weight, alcohol, exercise and hormone therapy.

For Sunita’s profile, the plan is simpler: a yearly mammogram, preferably 3D, without fail, and a fresh look at her risk at each visit.

But don’t take this as medical advice meant for you. I am sharing it only to raise your awareness. Meet your doctor and discuss what’s best for you.

What is 3D mammography?

Radhika’s dense breast tissue brings me to a technology that I wish to discuss a little more with you: 3D mammography.

A conventional 2D mammogram gives a single flat picture of the breast. Overlapping tissue can hide a small abnormality. A 3D mammogram captures multiple detailed images from different angles, which lets radiologists examine the breast layer by layer. Tiny cancers that might blend into dense tissue become easier to see. Since dense breasts are common among Indian women, this matters.

Many centres now also use AI as a second reader alongside the radiologist. Large studies note that AI systems have helped reduce both missed cancers and false alarms.^[6]

But AI does not replace your doctor. It is an additional set of expert eyes that helps us screen more women, faster.

The most important step is getting screened every year. Where 3D mammography is available, you may choose it for the added advantage it brings.

It is not your fault

Many of these factors cannot be changed: when your periods began, who your relatives are, when you had children. Please don’t blame yourself if you had a late pregnancy or couldn’t breastfeed as long as you’d have liked. Risk is not a verdict.

What you can do is know your risk and act on it. Keep a healthy weight, stay active, limit alcohol, quit smoking, speak to your doctor, and begin regular mammography for routine screening if you qualify.

Five steps you can take now towards a safer future

1. Write down your family history from both parents’ sides.
2. Note your reproductive, hormonal and breast history.
3. Know the three easy steps to choose the right mammography centre. Then find a 3D mammography centre near you.
4. Ask your doctor for a personal risk assessment along with your past mammogram.
5. Follow your personalised screening plan every year, or as advised by your doctor.

Radhika and Sunita will both keep coming back for routine screening, with a tailored plan for each.

Your body has its own story, and your screening program should reflect it.

Ask for your personalised risk assessment at your next mammogram.

A simple step that can save your life!

1. Collaborative Group on Hormonal Factors in Breast Cancer. Familial breast cancer: collaborative reanalysis of individual data from 52 epidemiological studies including 58 209 women with breast cancer and 101 986 women without the disease. The Lancet2001;358(9291):1389-1399. doi:10.1016/s0140-6736(01)06524-2
2. Kuchenbaecker KB, Hopper JL, Barnes DR, et al. Risks of Breast, Ovarian, and Contralateral Breast Cancer for BRCA1 and BRCA2 Mutation Carriers. JAMA2017;317(23):2402. doi:10.1001/jama.2017.7112
3. Boyd NF, Guo H, Martin LJ, et al. Mammographic Density and the Risk and Detection of Breast Cancer. New England Journal of Medicine2007;356(3):227-236. doi:10.1056/nejmoa062790
4. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease. The Lancet2002;360(9328):187-195. doi:10.1016/s0140-6736(02)09454-0
5. Saslow D, Boetes C, Burke W, et al. American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography. CA: A Cancer Journal for Clinicians2007;57(2):75-89. doi:10.3322/canjclin.57.2.75
6. McKinney SM. International evaluation of an AI system for breast cancer screening. Nature2020;577(7788):89-94. doi:10.1038/s41586-019-1799-6