Breast Cancer and Early Detection Imaging Techniques
Published September 2009 / Reviewed September 2010
As a radiologist specializing in breast Imaging and breast cancer detection, I encounter questions from women every day about breast cancer prevention, early detection, upcoming technologies and risk factors. Every day women have questions based on new information in the media, individual health care concerns and socio-economic issues. New research is published weekly that informs, excites and confuses the public. Recommendations by many of the medical groups and local or national organizations have been widely different and frequently contradictory.
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 the 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 recommendations for yearly mammograms in young women in their forties. Last year the US Preventative Services Task Force publicized recommendations that didn’t include routine screening for women in their forties. The American Cancer Society and all the medical organizations governing Radiology immediately responded with statements of the importance of annual screening mammography for women over forty In the last 30 years screening for breast cancer has reduced mortality by 30 percent. Mammography is credited for this reduction in breast cancer deaths and improvement in women’s’ overall prognosis and long term survival.
This past year brought out in the media 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 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.
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 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
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 percent
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.
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 those 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 useful in 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.
The most important thing for women to know is that most lumps that we palpate on our breast exam and most abnormalities detected on mammography or other imaging modalities will be benign. However, there is a small number 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.
Stamatia Destounis, MD (Elizabeth Wende Breast Care, LLC)
Associate Professor University of Rochester School of Medicine & Dentistry, Attending Radiologist , Elizabeth Wende Breast Care, Dr. Stamatia Destounis has grown up in Rochester and after graduating from medical school at the State University of New York in Syracuse in 1988, returned to Rochester to complete her Radiology residency at the University of Rochester school of Medicine & Dentistry. Dr. Destounis joined Dr. Wende Logan-Young at the Elizabeth Wende Breast Clinic where she completed a Breast Imaging fellowship and then stayed on as an attending radiologist since 1994.
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