This issue received media attention when Dr. Oz highlighted a study showing a significant increase in thyroid cancer in the U.S. since 1998, and he theorized that this is due to radiation exposure to the thyroid gland during annual mammography. It is highly unlikely that mammography can be blamed for this increased incidence, as it seen in both women AND men, and men do not receive screening mammograms. A recent paper estimated that the lifetime risk for thyroid cancer resulting from annual screening mammograms is 1 in 17.8 million.

At Montclair Breast Center, if a patient expresses concern about this issue, she is given the option of wearing a lead thyroid shield around her neck while her mammogram is performed. Rarely, this shield interferes with the mammogram picture, and the image has to be re-taken. But if the patient has peace of mind by protecting her thyroid, I believe that there is no legitimate reason that she shouldn’t be given the opportunity to do so.
This issue received media attention when Dr. Oz highlighted a study showing a significant increase in thyroid cancer in the U.S. since 1998, and he theorized that this is due to radiation exposure to the thyroid gland during annual mammography. It is highly unlikely that mammography can be blamed for this increased incidence, as it seen in both women AND men, and men do not receive screening mammograms. A recent paper estimated that the lifetime risk for thyroid cancer resulting from annual screening mammograms is 1 in 17.8 million.

At Montclair Breast Center, if a patient expresses concern about this issue, she is given the option of wearing a lead thyroid shield around her neck while her mammogram is performed. Rarely, this shield interferes with the mammogram picture, and the image has to be re-taken. But if the patient has peace of mind by protecting her thyroid, I believe that there is no legitimate reason that she shouldn’t be given the opportunity to do so.

For digital mammography, the average radiation dose from a standard 4-view mammogram of both breasts is 3.7mGy; for film-screen mammography (not digital), the average dose is 4.7mGy. Data suggests that if there is any risk for developing breast cancer because of screening mammography, it is extremely small. In the Swedish Two County Trial, over 100,000 women have had repeated mammograms since the 1970’s, and the screened group has no more cancers than the group who has not had mammograms. It has been estimated that the theoretical risk of mammography causing a breast cancer is one in one million. That being said, we are quite aware that younger breast tissue is much more sensitive to the effects of ionizing radiation, due to more active cell division. Therefore, we use mammography very carefully in women younger than 35 years old.

If a patient is pregnant or could possibly be pregnant when she presents for a routine screening mammogram, it is prudent to delay screening until after delivery to protect the fetus from unnecessary radiation exposure, or to wait until the patient gets her next period in order to be certain she isn’t pregnant. If the examination cannot be delayed because the patient has a worrisome symptom, the patient’s pelvis is shielded with a lead apron when the mammogram is performed.
For digital mammography, the average radiation dose from a standard 4-view mammogram of both breasts is 3.7mGy; for film-screen mammography (not digital), the average dose is 4.7mGy. Data suggests that if there is any risk for developing breast cancer because of screening mammography, it is extremely small. In the Swedish Two County Trial, over 100,000 women have had repeated mammograms since the 1970’s, and the screened group has no more cancers than the group who has not had mammograms. It has been estimated that the theoretical risk of mammography causing a breast cancer is one in one million. That being said, we are quite aware that younger breast tissue is much more sensitive to the effects of ionizing radiation, due to more active cell division. Therefore, we use mammography very carefully in women younger than 35 years old.

If a patient is pregnant or could possibly be pregnant when she presents for a routine screening mammogram, it is prudent to delay screening until after delivery to protect the fetus from unnecessary radiation exposure, or to wait until the patient gets her next period in order to be certain she isn’t pregnant. If the examination cannot be delayed because the patient has a worrisome symptom, the patient’s pelvis is shielded with a lead apron when the mammogram is performed.

A mammogram is an x-ray image of the breast. Usually two pictures of each breast are obtained for a complete mammogram of both breasts; one picture is taken from the side, and the other is taken from the top. The breast is compressed between two plates, and the patient holds her breath for a few seconds while a beam of low-dose radiation is sent through the tissue to create an image. Compression is necessary for a few reasons. First, overlapping structures in the breast need to be separated as much as possible. Second, the more compression, the less radiation dose is needed. Third, better compression results in a sharper picture, as the breast is held very still while the picture is taken. The exam usually takes no more than ten or fifteen minutes. A mammogram is an x-ray image of the breast. Usually two pictures of each breast are obtained for a complete mammogram of both breasts; one picture is taken from the side, and the other is taken from the top. The breast is compressed between two plates, and the patient holds her breath for a few seconds while a beam of low-dose radiation is sent through the tissue to create an image. Compression is necessary for a few reasons. First, overlapping structures in the breast need to be separated as much as possible. Second, the more compression, the less radiation dose is needed. Third, better compression results in a sharper picture, as the breast is held very still while the picture is taken. The exam usually takes no more than ten or fifteen minutes.

If the target for biopsy is microcalcifications, the adequacy of the specimen can be confirmed by doing a modified mammogram on the obtained specimens, to make sure that calcifications are within the tissue being sent to the pathologist. For masses and other types of biopsied lesions, it’s a bit trickier. For all biopsies, the amount of tissue collected can be visually assessed by the doctor performing the biopsy. For ultrasound-guided biopsies, the needle can be seen in real-time on the screen, and the doctor can see the biopsy needle going through the sampled lesion. For an MRI-guided biopsy, the MRI images taken with the biopsy needle in position are important for confirmation of appropriate tissue sampling. Knowing that there is always room for sampling error by the needle, most radiologists recommend six-month follow-up imaging of the biopsied breast, to confirm that the area biopsied has not changed in any significant way. In addition, when the radiologist receives the pathology report from the biopsy, he/she decides if this result from the pathologist is “concordant” with the imaging findings. If the pathology is not an acceptable answer for the radiologist’s findings (discordant), the radiologist will recommend that the lesion be taken out surgically to confirm benignity. If the target for biopsy is microcalcifications, the adequacy of the specimen can be confirmed by doing a modified mammogram on the obtained specimens, to make sure that calcifications are within the tissue being sent to the pathologist. For masses and other types of biopsied lesions, it’s a bit trickier. For all biopsies, the amount of tissue collected can be visually assessed by the doctor performing the biopsy. For ultrasound-guided biopsies, the needle can be seen in real-time on the screen, and the doctor can see the biopsy needle going through the sampled lesion. For an MRI-guided biopsy, the MRI images taken with the biopsy needle in position are important for confirmation of appropriate tissue sampling. Knowing that there is always room for sampling error by the needle, most radiologists recommend six-month follow-up imaging of the biopsied breast, to confirm that the area biopsied has not changed in any significant way. In addition, when the radiologist receives the pathology report from the biopsy, he/she decides if this result from the pathologist is “concordant” with the imaging findings. If the pathology is not an acceptable answer for the radiologist’s findings (discordant), the radiologist will recommend that the lesion be taken out surgically to confirm benignity.

Over the past 20 years, the standard of care for sampling suspicious lesions in the breast has evolved from open surgical biopsies to the modern standard of minimally-invasive needle biopsy. Over many years, studies have confirmed that needle biopsies are as accurate as surgical biopsies in diagnosing breast cancer, and the needle has advantages: no operating room visit, less invasive, minimal if any scarring, no stitches, fewer complications, less expensive, quicker to perform. In addition, if cancer is diagnosed with a needle biopsy, the patient will have a greater chance of having just one surgery. (If the cancer is diagnosed on a surgical biopsy, the patient usually has to return to the operating room a second time to get all of the cancer out, and to sample the lymph nodes under the arm.) Although most biopsies can be performed with a needle, approximately 10% of biopsies must be performed surgically. The reasons include: living in a region where there are no specialists trained to perform the needle biopsy; the location of the lesion might be in a part of the breast that the needle cannot safely reach; patient inability to cooperate with positioning for the needle biopsy; medical conditions that make direct control of bleeding in the operating room necessary; a breast that is too small or large to allow for the biopsy to be performed with a needle; the presence of an implant, which might not allow for a needle biopsy without a high risk of rupturing the implant. Over the past 20 years, the standard of care for sampling suspicious lesions in the breast has evolved from open surgical biopsies to the modern standard of minimally-invasive needle biopsy. Over many years, studies have confirmed that needle biopsies are as accurate as surgical biopsies in diagnosing breast cancer, and the needle has advantages: no operating room visit, less invasive, minimal if any scarring, no stitches, fewer complications, less expensive, quicker to perform. In addition, if cancer is diagnosed with a needle biopsy, the patient will have a greater chance of having just one surgery. (If the cancer is diagnosed on a surgical biopsy, the patient usually has to return to the operating room a second time to get all of the cancer out, and to sample the lymph nodes under the arm.) Although most biopsies can be performed with a needle, approximately 10% of biopsies must be performed surgically. The reasons include: living in a region where there are no specialists trained to perform the needle biopsy; the location of the lesion might be in a part of the breast that the needle cannot safely reach; patient inability to cooperate with positioning for the needle biopsy; medical conditions that make direct control of bleeding in the operating room necessary; a breast that is too small or large to allow for the biopsy to be performed with a needle; the presence of an implant, which might not allow for a needle biopsy without a high risk of rupturing the implant.

For stereotactic biopsies and MRI-guided biopsies, I use a vacuum-assisted device.

For ultrasound-guided biopsies, I have found both core needles and vacuum devices to be equally successful in my experience, although the scientific literature reports fewer false-negatives with the vacuum-assisted devices. I prefer to use the smaller, less expensive, less scary core needle when possible. If a lesion is very small or subtle on the sonogram, I tend to use the vacuum-assisted device to obtain larger specimens and ensure adequate sampling. For stereotactic biopsies and MRI-guided biopsies, I use a vacuum-assisted device.

For ultrasound-guided biopsies, I have found both core needles and vacuum devices to be equally successful in my experience, although the scientific literature reports fewer false-negatives with the vacuum-assisted devices. I prefer to use the smaller, less expensive, less scary core needle when possible. If a lesion is very small or subtle on the sonogram, I tend to use the vacuum-assisted device to obtain larger specimens and ensure adequate sampling.

When you schedule your mammogram, try to avoid any times in the month when you know your breasts are bound to be more tender. No need to suffer if you don’t have to. You might also consider taking a dose of Ibuprofen or Tylenol about an hour before your appointment time. On the morning of your mammogram, do not put on deodorant, creams or powder. These things can potentially cause artifacts on the films, and result in you being called back for more pictures. In terms of your outfit on the day of your mammogram, it’s better to choose two pieces (top with pants or a skirt) rather than a dress, since you’ll be asked to undress from the waist up. Finally, if you’ve had breast imaging studies in the past at a different facility, get copies of the films and reports to either bring with you on the day of your test, or have them sent in advance. Having prior films for comparison makes the reading more accurate, and you’ll be less likely to get called back for additional pictures. I tell patients to schedule the mammo just at the end of menses or shortly thereafter so it doesn't hurt so much. Try a morning appt and do not use deodorant, lotion, or powder as it sometimes can show up as calcifications [which are really on the skin but the radiologist can't tell]. This could result in a call back and unnecessarily upset you. Bring your deodorant with you and put it on after your mammo. And lastly don't assume that "no news is good news". If you haven't gotten a letter in a couple of weeks, call the doctor who ordered the mammo to get results. Human error happens.

If you follow the news reports about breast cancer risk, it seems that recommendations change practically every day. However, there are a few lifestyle factors that I advise my patients to consider, since I believe there is enough scientific evidence to support them.
1. Exercise (brisk walking) 30 minutes per day at least 5 days per week led to a 20% decreased risk of breast cancer in the longstanding Women’s Health Initiative study.
2. Keep Body Mass Index (BMI) under 25. Being overweight increases the risk of breast cancer after menopause by 25%. Limiting red meat also seems to be useful.
3. Quit smoking. Many years of smoking increases breast cancer risk up to 30%. Secondhand smoke also seems to be a risk factor for non-smokers to develop pre-menopausal breast cancer.
4. Limit alcohol. 2-5 drinks per day leads to a 1 ½ times risk of breast cancer compared to non-drinkers. A recent small study suggested that red wine might be an exception, but more data is needed on this to know for sure.
5. Avoid exogenous hormones if you can. At the current time, we don’t know if there is a “safe” level or type. Many of the suggestions for lowering risk for breast cancer are the same recommendations I would give to lower the risk for most chronic illness. I like to speak in terms of creating the optimal healing environment in the body.
- Engage daily in moderate physical activity
- Avoid alcohol, transfats and processed foods
- Use stress reductions techniques often
- Have a positive mental outlook
- Detoxify your living environment, use less synthetic chemicals in your day to day life. Use products that are healthier for your body and the environment.

We use Breast Specific Gamma Imaging (BSGI), which is a molecular breast imaging test, at my practice in certain circumstances. This is a nuclear medicine study where a radioactive substance is injected into an IV catheter in the patient’s arm, and images of the breasts are obtained with the patient in a seated position. The test looks for spots in the breast that become “hot”, or that take up the radiotracer more avidly than the surrounding tissue. Although not all hot spots will be cancerous, they do need to be checked with further tests. If the BSGI is negative, there is a very high likelihood that no cancer is present in the breast.

At my practice, we use MRI (in addition to mammography) to screen patients at high risk for breast cancer, to further evaluate questionable mammographic, sonographic, or clinical findings, and to fully evaluate both breasts in patients newly diagnosed with breast cancer. Sometimes a patient cannot have an MRI, and in those circumstances we will usually recommend a BSGI test instead. Patients unable to have an MRI (with contrast) include: claustrophobic patients; those with pacemakers or other implanted devices that are not MRI-compatible; patients with metal aneurysm clips in their brain, or with metal fragments in their eyes; severe kidney disease; patients whose bodies are too large for the MRI unit; allergy to Gadolinium contrast dye. We use Breast Specific Gamma Imaging (BSGI), which is a molecular breast imaging test, at my practice in certain circumstances. This is a nuclear medicine study where a radioactive substance is injected into an IV catheter in the patient’s arm, and images of the breasts are obtained with the patient in a seated position. The test looks for spots in the breast that become “hot”, or that take up the radiotracer more avidly than the surrounding tissue. Although not all hot spots will be cancerous, they do need to be checked with further tests. If the BSGI is negative, there is a very high likelihood that no cancer is present in the breast.

At my practice, we use MRI (in addition to mammography) to screen patients at high risk for breast cancer, to further evaluate questionable mammographic, sonographic, or clinical findings, and to fully evaluate both breasts in patients newly diagnosed with breast cancer. Sometimes a patient cannot have an MRI, and in those circumstances we will usually recommend a BSGI test instead. Patients unable to have an MRI (with contrast) include: claustrophobic patients; those with pacemakers or other implanted devices that are not MRI-compatible; patients with metal aneurysm clips in their brain, or with metal fragments in their eyes; severe kidney disease; patients whose bodies are too large for the MRI unit; allergy to Gadolinium contrast dye.

We look for microcalcifications, masses, and architectural distortion on mammography; solid masses on ultrasound; and enhancing masses or lesions that “light up” with contrast on MRI. No imaging feature is 100% indicative of malignancy, and very often tissue sampling is needed to arrive at a diagnosis. We look for microcalcifications, masses, and architectural distortion on mammography; solid masses on ultrasound; and enhancing masses or lesions that “light up” with contrast on MRI. No imaging feature is 100% indicative of malignancy, and very often tissue sampling is needed to arrive at a diagnosis.

A short-term follow-up MRI is usually recommended if the radiologist saw something on the original MRI that he/she thought was most likely benign (not cancer), but wants to be more certain. If the finding doesn’t change over time, the radiologist can more confidently call it benign.

A “clogged milk duct” generally refers to a duct in the breast that looks dilated, and may have some debris within it. It is usually a benign finding, but if the radiologist is not sure why the duct is blocked, he/she may choose to either biopsy it or follow it depending on how it looks on the MRI. A short-term follow-up MRI is usually recommended if the radiologist saw something on the original MRI that he/she thought was most likely benign (not cancer), but wants to be more certain. If the finding doesn’t change over time, the radiologist can more confidently call it benign.

A “clogged milk duct” generally refers to a duct in the breast that looks dilated, and may have some debris within it. It is usually a benign finding, but if the radiologist is not sure why the duct is blocked, he/she may choose to either biopsy it or follow it depending on how it looks on the MRI.