I recall being calm, alert, surprising even myself. I was ushered into an exam room outside Dr. Wende Young’s office and waited a short time. I made a phone call to my husband who was at his appointment to tell him of the doctor’s suspicions. When Dr. Young entered and told me there was a lump in my right breast that was not on my films last year and she suggested a fine needle aspiration, I agreed, and it was done. Then a brief discussion of a stereo-tactic needle biopsy. I said, "Can you do it right now?" Very soon, I was lying on my stomach on a leather table, crying as much for the knowledge that I now have breast cancer as for the actual pain of the biopsy, as a nurse held my hand and spoke words of encouragement, and Dr. Young performed her unenviable task.

I have breast cancer, a small tumor—slow growing—that will be removed by lumpectomy and then I can be treated with radiation. With these results confirmed on April 26, and eager to move the process along, I phoned friends who have been through this, asking their opinions for surgeons, cancer centers, what to expect and more. We chose the surgeon and the Pluta Cancer Ccenter in Rochester and, based on what we knew right then, determined that, if you have to have cancer, this really wasn’t so bad. My attitude, I decided, would continue to be upbeat and positive through all of whatever lay ahead. ‘It’s all good,’ I kept repeating to myself and others.

Surgery was scheduled for June 2, 2010. It was same-day, but, because we live three hours away, the surgeon preferred that we stay overnight. But where? We heard about the American Cancer Society Hope Lodge Hospitality House, a newly-renovated building on the Colgate Divinity College campus, right near Highland Hospital where I would have surgery. A few phone calls later, Neil Monteiro, operations manager, had scheduled us for two nights in one of the 30 private guest rooms. "It’s free to cancer patient", Neil said. We were astounded during our first visit there—beautiful surroundings outside, and inside, Hope Lodge provided a very comfortable room with a private bath, queen bed, closet, cable TV, wireless internet, phone, library, a room for socializing with family and guests, a community dining room, three full kitchen areas and the comfort of knowing we had a welcoming place to stay. We needed to provide only our meals. The staff and volunteers at Hope Lodge were most helpful, and we met and came to know many of the other guests there during our short stay. While we were so grateful for what was available to us and for our experience there, we were anxious to go home so I could heal and then have a five-day, twice-a-day treatment regimen of radiation at the Pluta Cancer Center.

And that might have been the end. But when we got the surgical pathology report, there was a non-invasive cancer as well as the tumor. Because it was located on the far edge of the surgical margin, it was recommended I have a second surgery to increase the chances of being "cancer-free." We scheduled the next surgery for July 14, 2010. So, back to Hope Lodge for two nights, then back home for recuperation before radiation.

Now that there was a second surgery, the opportunity for a five-day radiation treatment schedule would not be adequate. I would need 27-33 treatments. Once I was well enough to begin, I called Hope Lodge—again! Might I stay for the duration of my treatment? I was welcomed as a friend, by staff and guests alike. Hope Lodge would become my home-away-from-home for nearly five and a half weeks. I lived there, partook of meals prepared by kind and generous staff and their families, by other guests and by medical students from the University of Rochester, engaged in conversations with guests about their health challenges, spent quiet nights in the comfort of a movie or book in my room and long hours online with family and friends to keep them updated on my situation, reminding everyone, ‘It’s all good’ because it was.

The Pluta Cancer Center medical, nursing and physics staff met with me during several appointments, conducted treatment simulations, took X-rays, marked positions on my breast for the laser-aligned radiation and provided a treatment plan. I began the first treatment on Aug. 9, 2010, with a great deal of apprehension. My concerns were addressed daily by the oncologists, nursing staff and the radiation therapists who took outstanding care of me. After assessing my overall progress, my radiation oncologist agreed I could do two treatments each day, beginning in early September. I completed 27 treatments on Sept. 14, 2010. Once patients at the Pluta Cancer Center finish treatment, you can ring a large bell to signify your success. With great joy, I was supported by hugs and good wishes from my husband and all the staff who gather to participate in this event, and I rang the bell three times. I was done with cancer.

How could we be so fortunate? The best possible care by all of the Pluta Cancer Center staff AND the best possible accommodations for our stay at Hope Lodge! We said our thank yous and farewells and signed out of Hope Lodge for what we hope will be the final time, and we drove home.

What a journey! I’ve learned a few things about myself. I’ve looked for the ‘lessons’ I think exist in this ordeal. After all, cancer is surely a new experience in our lives. I’ve uncovered several: have an annual mammogram, be grateful that my cancer was found early when it was more easily treatable, enlist the help and support of family and friends and stay focused on the challenge at hand. Unburden yourself as much as possible and allow others to share the weight of what you carry.

Like many cancer patients, I want to believe that I am now cancer free. I’m really good with that thought! For today then, I remind myself that ‘It’s all good.’

Self Breast Exam and Mammography

What should a young woman do for breast health? We recommend a young woman gets familiar with her breasts by starting in her late teens or early twenties to perform a self breast exam, perhaps in the shower with soap on the hands which makes palpating (feeling) lumps or differences between the breasts easier to find. A clinical breast exam by her primary care physician or gynecologist should start in a woman’s twenties, once a year.

We recommend a baseline mammogram between age 35-40 and then a mammogram after 40 every year. There are some medical organizations that may disagree or not make any recommendations for yearly mammograms in young women in their forties.

The American Cancer Society and all the medical organizations governing Radiology can’t emphasize enough the importance of annual screening mammography for women over forty. In the last 30 years, screening for breast cancer has reduced mortality by 30%. Mammography is credited for this reduction in breast cancer deaths and improvement in women’s overall prognosis and long term survival.

I sometimes hear from women, concerns over the radiation risks of imaging tests specifically CT scans. The amount of radiation for mammography is very small and there are strict regulations and quality controls that a mammography facility has to fulfill to be able to perform a mammogram.

Women of any age will come into my office and ask about the way they perform their breast self exam. They aren’t certain they know what to look for, or if they are pressing too much or not enough during their self breast exam. I find myself explaining that repetition and consistency is the best method we have to find changes. Performing the breast exam after onset of menses or, if post-menopausal, the same time of the month, can be helpful to establish consistency. If a suspicious area is found, looking for symmetry by checking the same region in the other breast can be helpful. Many women may have one breast smaller than the other and that may lead to differences in the breast exam; for women with changes after surgery or weight fluctuation comfort with the breast self exam will happen with practice and persistence.

Digital Mammography

Mammography remains the gold standard for the detection of breast cancer. In the last few years, Digital Mammography has become established and popular. It utilizes a similar unit to x-ray mammography to obtain the images and the patient gets compressed the same way for the total of four images; two per breast. The importance of Digital is that the images can be manipulated after the mammogram is performed by the radiologist (medical doctor) sitting at a workstation. The radiologist can enlarge areas of interest in the breast tissue to visualize these areas better, without having to call the patient back for additional views. A large clinical imaging study called ACRIN (American College of Radiology Imaging Network) was performed a few years ago, involving multiple medical sites all over the world. Data was collected on patients that had a routine x-ray mammogram and also a digital mammogram. This study compared the two mammograms, and determined that the digital mammogram performed better, meaning detected more cancers in young, premenopausal, women with dense breasts. For the other types of breast tissue that are easier to interpret when reading the mammogram, the study found that digital and x-ray were relatively equal. There are four subtypes we think of, when it comes to talking about breast tissue density:

1. Fatty—easiest breast tissue to interpret,
2. Scattered—mixture of fatty and glandular elements-able to penetrate through the tissue well,
3. Heterogeneously dense—difficult to visualize individual abnormalities on the mammogram as this breast tissue is dense and hard to interpret and
4. Extremely dense— very difficult to see any abnormality, mammogram may be significantly limited. Some recent studies discuss that when interpreting dense and extremely dense breasts with mammography the ability to detect an abnormality may be reduced by 50%.

Dense breast tissue has been a diagnostic dilemma for radiologists that read mammograms since mammography was developed. Breast imagers have known that reading mammograms with dense breast tissue is limiting and that we may not be able to find all abnormalities that are small and hide in the denser difficult tissue. Over the last few years, clinical studies have been published that confirm having dense breasts may influence breast cancer risk. Higher breast density has been added to the list of risk factors for breast cancer.

3D Breast Tomosynthesis

EWBC is committed to the fight against breast cancer and is the first breast imaging facility in our region to provide 3D breast tomosynthesis, the latest technology in breast imaging. Breast Tomosynthesis was approved by the FDA in February 2011 and is now available to our patients. 3D breast tomosynthesis is used in conjunction with a screening mammogram and acts an additional screening tool for the radiologist while interpreting the mammogram.

Breast tomosynthesis acquires digital breast images and displays them in stacks of thin slices, creating a three dimensional mammogram. By Interpreting three dimensional images the radiologist can view the breast tissue millimeters at a time, making tissue more visible and possibly reducing the need for any additional mammogram views.

The tomosynthesis exam occurs as the digital mammogram is being performed. The technologist positions you and compresses your breasts in the same way she routinely would, but while acquiring the standard digital mammogram images, 3D tomosynthesis images are also being captured.

3D breast tomosynthesis may be beneficial to patients considered to be high risk for breast cancer and also those with dense breast tissue.

Breast MRI

Breast MRI is the technology that has been the biggest breakthrough in the last several years for earlier detection in the high risk population, and also for finding additional cancer in women just diagnosed with breast cancer. Breast MRI is a test that requires specialized equipment. The exam takes 30 minutes or more with the patient lying on their stomach in a donut type unit similar to a CT scan. This may be difficult for claustrophobic patients. The test requires an intravenous injection of contrast material that through the blood stream goes to abnormal areas in the breast tissue and makes these areas brighter on the MRI images than normal breast tissue. Women with metal from any prior surgery, or pacemaker insertion, or with poor kidney function may not be candidates for this exam. The patients have to be evaluated prior to the test carefully for prior history of any metal clips, or other contraindications.

For the patients that can have the exam, the test may be especially helpful in the patients that have:

1. Prior history of breast cancer in which the lumpectomy scars and frequently dense breast tissue may limit the sensitivity of standard screening tests such as mammography.
2. Prior breast surgery revealing pre-cancerous cells.
3. Prior radiation treatment to the chest at a young age (ages 10–30), such as for treatment of lymphoma.
4. Strong family history with first degree relatives diagnosed with breast cancer.

There are other criteria that constitute what is considered a patient at high risk, such as a genetic mutation called BRCA1 or BRCA2; these women may have several members of their family, with breast cancer at a young age or breast and ovarian cancer; they may have the genetic mutation themselves or have first degree relatives that were tested and have it. There are also some other genetic mutations that are quite rare and also are known to predispose women to a higher breast cancer risk.

I advise women that if they feel they have any of the above-mentioned risk factors to discuss this with their gynecologist or other primary care physician. Your doctors may have risk assessment tools available to assess your lifetime breast cancer risk, which if it is 20% or more will place you in the higher risk category that would benefit from additional testing such as an MRI.

Summary

The most important thing for women to know is that most lumps that we palpate on breast exam and most abnormalities detected on mammography or other imaging modalities will be benign. However, there are a small number of findings that will be suspicious or cancer, so for that reason we have to address all new findings and be certain they are non-worrisome. At this time we have many new and emerging technologies that will continue to enhance our ability for earlier detection making the prognosis for the patient the best and the surgical procedures and follow-up treatments the least aggressive.

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Dr. Destounis joined the EWBC in 1993 after completing her Diagnostic Radiology training at the University of Rochester School of Medicine and Dentistry. She completed a Breast Imaging Fellowship at EWBC with Dr. Wende Young, and stayed on as a member of the faculty. She is a member of the American Cancer Society Medical Advisory Team. She sits on medical advisory boards for several breast imaging technology companies. Within the local community, she sits on radiology committees for several health care provider companies and is also a volunteer for many community organizations and activities. Dr. Destounis frequently lectures to professional groups, both nationally and internationally, on a variety of radiological subjects related to mammography and has been teaching Resident Board Reviews since 1994. She was honored as a recipient of the 2009 Health Care Achievement Award by the Rochester Business Journal.

• American Breast Cancer Foundation
• American Cancer Society
• American Society of Plastic and Reconstructive Surgeons (Breast Reconstruction)
• Breast Cancer Support
• Breast Ultrasound Foundation
• breastcancer.org
• Encore Plus Program of the YWCA
• Food and Drug Administration (Breast Implants)
• Food and Drug Administration (Certified Mammography Facilities)
• FORCE: Facing Our Risk of Cancer Empowered
• Imaginis
• Living Beyond Breast Cancer
• National Breast and Cervical Cancer Early Detection Program
• National Breast Cancer Coalition
• National Lymphedema Network
• Sisters Network, Inc.
• Susan G. Komen Breast Cancer Foundation
• Women's Information Network Against Breast Cancer (WIN ABC)
• Foundation for Women's Cancer
• Y-ME National Breast Cancer Organization

• Rochester: Borg and Ide Imaging PC multiple locations
• Rochester: Rochester Radiology Associates multiple locations
• Rochester: Elizabeth Wende Breast Care, LLC 170 Sawgrass Dr. Rochester
• Rochester: Highland Breast Imaging Center 500 Red Creek Drive Rochester
• Rochester: Ridgewood Diagnostic Imaging LLC 120 Erie Canal Drive, Suite 160 Rochester
• Rochester: Westside Imaging Center 1160 Chili Avenue Suite 120 Rochester
• Canandaigua: FF Thompson Hospital Mammography Center
• Newark: Newark Wayne Community Hospital
• Batavia: Advanced Imaging Associates 35 Batavia City Centre Main Street Batavia
• Batavia: United Memorial Medical Center 16 Bank Street Batavia
• Geneseo: Livingston Health Care Services 585-243-9230 50 East South Street Geneseo