Breast Cancer Screening

When the tissue sample is inspected grossly, the tumor is measured in three dimensions using a ruler and the distance to all the margins of excision are recorded. Other observation such as the presence of satellite nodules, tumor necrosis (death tissue), calcifications, relationship with the skin, nipple or deep fascia etc are recorded. The presence of other possible non-cancerous lesions are described. Ultimately, samples of the tumor, margins, other lesions etc. are taken and submitted for microscopic examination.

I would reinforce Dr. Moore's answer that not all breast findings need an MRI. There is no way that any of us can tell based on the information provided whether or not an MRI or other imaging will be helpful or necessary in this case - an understanding of the patient's clinical situation as well as review of the mammograms and any available pathology reports is necessary. In general, calcifications do not show up on MRI. There is no question that there are cancers that will show up on MRI that are missed by other imaging, but again each case needs to be properly evaluated before a blanket recommendation for MRI is made. There is no best imaging test for the breast, but that also does not mean that every test should be done in every person.

Yeah. I hate this question. And I get it whenever the patient's cancer was missed on mammo. I think that so much emphasis has been put on screening mammos yet it is often not well known that mammos miss up to 20% of breast cancers on screening studies. [Reference: www.cancer.gov/cancertopics/factsheet/detection/mammograms] Crummy, I know, but when you look at the stats, it's still the best we have right now for mass screening. And it is responsible for the decrease in mortality and increase in early stage diagnosis over the last decade or so. [Reference: Regular mammograms may decrease the risk for deadly breast cancer by 49%, a new case-control study suggests.

According to the Dutch investigators, the greatest reduction occurred in women aged 70 to 75 years and represented a drop of 84%.

"Our study adds further evidence that mammography screening unambiguously reduces breast cancer mortality," said senior researcher Suzie Otto, PhD, from the Department of Public Health at Rotterdam's Erasmus Medical Centre, the Netherlands, in a news release.

The study was published online December 6, 2011 in Cancer Epidemiology, Biomarkers, and Prevention]


So even though it did not pick up the first cancer, odds are that it will pick up the next one if it occurs. That's why we still order it in these cases. Ultrasound is too time consuming and misses the non invasive cancers. MRI is very expensive and not specific enough for mass screening although we do use it in high risk patients even though we don't have a whole lot of data. MRI also does not pick up DCIS well unless high grade. Some argue that a previous diagnosis of cancer automatically puts you into a high risk category and therefore you should have screening MRI annually, but that is not yet standard of care and therefore not always covered by insurance.

How should you prepare?
1>If possible, you should schedule your test for the week after your period, and not before or during period, since your breasts may be tender.

2>Do not wear talcum powder,lotion or deodorant under your arms or on your breast on the day of the exam. These can appear on the mammogram as calcium spots.

3>Describe any symptoms or problems related breast to the technologist performing the exam.

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.

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.

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.

Due to the high risk of breast and ovarian cancer, most will recommend mastectomies and then ovary and tube removal as soon as child bearing is completed. This is the greatest risk reduction but is still not 100%. There is no consensus on how to follow patients with mutations regardless of cancer diagnosis or not. The NCI is currently doing clinical trials for patients with known mutations to try and answer this question. Here's a link: http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA#a18

I first noticed the tuck after losing about 45-50 pounds through diet and exercise. It was maybe about 3/4" long and looked a bit like tiny elves had stitched a "seam" along the inside of my breast just under my left nipple. The tuck didn't hurt and didn't really bother me all that much until I noticed that whenever I raised my left arm, my breast would "crumple" in a bit. That seemed more disturbing to me.

Since I'm a journalist, I first decided to check around online to see if I could find anything that described what I was seeing. I went to a few sites like the American Cancer Society and WebMD and Komen to read about the warning signs of breast cancer and while most of them mentioned dimples, none of them mentioned tucks or dents or tethering, which is what seemed to be going on. All the sites did encourage women to go to their doctor if they noticed *any* change in their breast, however, so after about two weeks of mulling (and hiding my head in the sand), I decided I'd better get it checked out.

When my ob/gyn examined me, she said she could feel something in there but said it didn't feel cancerous. She thought it was most likely a cyst. Since I was due for my annual mammogram, though, she said she wanted me to get a diagnostic mamm and ultrasound. I have dense breast tissue so it was the ultrasound (not the mammogram) that found the three masses in my breasts, two on the left side (one corresponding to the tuck and one above the nipple) and another on my right breast. During my needle biopsy the following week, another mass was discovered within my right breast. I figured if nothing else, at least I was symmetrical.

I use the HALO test fairly often in my practice. It is true that approximately 50% of women will produce fluid. Those that do not produce fluid are considered to have had a normal test, and it is unlikely that they have any abnormality of their milk ducts. If fluid is produced, it is sent for cytology evaluation to see if there are abnormal cells present. Some studies have suggested that if a condition called atypia is present, it has the same significance of atypical ductal hyperplasia found on needle biopsy, which leads to an increased risk of breast cancer in the future.

As the women undergoing the HALO test are often younger than 40 and not undergoing routine mammogram screening, if a patient has atypia found on the HALO test, I would likely recommend that she begin screening, possibly with ultrasound and MRI in addition to mammogram, earlier than age 40. However as pointed out by Dr. Bone, this can open up a whole host of other issues, including radiation exposure and false positive test results.

It is important to remember that the HALO test is not meant to detect breast cancer or to be a screening test for breast cancer. It is a form of risk assessment, meant to help us sort out if a woman should undergo screening when she normally would not. I generally do not recommend that the HALO test be performed on women over age 45.

Usually after mastectomy and reconstruction, imaging such as mammogram is not performed as all or almost all of the breast tissue is removed. MRI is sometimes performed every few years, but primarily to assess the integrity of silicone implants, if they were used for the reconstruction.

There are no standard recommendations for imaging in a patient that has undergone mastectomy and implant reconstruction - usually careful physical exam every 6 months is recommended as a recurrence will most often present as a palpable lump (able to be felt). In cases where it is difficult to differentiate scar tissue from recurrence, biopsy is usually performed.

If reconstruction is performed using a muscle flap, MRI or ultrasound are probably the most helpful tests to rule out recurrence, but again there are no standard recommendations for post-mastectomy imaging.

These are the guidelines:
For the general population, no family history of breast cancer:
Baseline mammogram at age 35 or 37. Mammograms every 1-2 years from 40-50, annual mammography above age 50.

I am sure that you are aware that there is a great deal of controversy regarding annual mammograms in the 40's. I believe that they should definitely be done. It is true that cancer is less common in this age group compared with women above 50, but unfortunatley we do see many cases in young women. Statistically, some argue that the mammograms are not reducing mortality, or saving lives. Well, in my opinion this is not the only criteria to measure, for example if you found an early cancer in a 46 year old women which will only require lumpectomy, but not mastectomy, or chemotherapy, (which might be the case had this only be diagnosed 4 years later), then we have done a great service to this patient and her quality of life. It is true that some of the cases diagnosed in the young women are particularly aggressive, and that the early detection may not save her life, but I do not think this is a reason for not offering it. Furthermore, some of the studies discouraging mammography discuss the anxiety related to additional workups (magnification views and spot views) and unnecessary biopsies, all valid arguments. But the anxiety can be allayed with proper discussions and education, and we are working on not biopsying findings that are not worrisome. But it is true that most biopsies are negative, still... we are doing our best with the technology we have, this may change in the future. I do not know the number of cancers I have identified in women under 50, on screening, but it is great! It is true that I have also biopsied many many benign nodules and calcifications, this is the trade-off.

In women with dense breasts and/or a family history of breast cancer, screening sonography should also be performed annually. Sonography may increase detection by 30% or so.

In women with a strong family history, or personal history of breast cancer, screening MRI should be performed, as well.

If both you and your mother have had premenopausal breast cancer, then genetic testing should probably be performed.
Good luck to you and your mom.

Both conventional (analog) and digital mammograms are still in use, but in major cities most facilities that do a lot of mammograms (and state-of-the-art imaging) have switched to digital. Similar to you photos at home, there is a great deal of benefit to being able to post-process or adjust the images for better contrast, magnification, etc. Also viewing on a computer moniter is beneficial. That being said, a large scale study was performed by Dr. Etta Pisano when digital first came out. The study determined that digital mammograms will benefit women with dense breast tissue, and those who are under age 40. So, if you are not in these categories then it is OK to get an analog study.

My personal opinion, yes, digital mammograms are the norm for NYC, where I practice.

BI-RADS stands for Breast Imaging Reporting and Data System. The American College of Radiology, AMA, and other medical organizations have agreed upon a reporting system that standardizes how radiologists describe findings on a mammogram, and more importatly how they make their recommendations so that the recommendation is clear, for the referring physician.

BI-RADS-1: NEGATIVE
This means no findings, nothing on which to comment.

BIRADS-2: BENIGN FINDINGS
This means that there is a normal finding such as a cyst or coarse (benign) calcification. No further intervention is indicated.

BIRADS-3: PROBABLY BENIGN FINDING, SHORT INTERVAL FOLLOW-UP IS SUGGESTED
This is used when there is finding that is most likely benign, but the radiologist cannot say so for certain. A radiologist will only use this category when they believe the finding has less than 2% risk of malignany. This may be used for example, for something such as a lymph node, which has a characteristic appearance and location, but is not definitvely fulfillling criteria of such. Or for calcifications that look very benign, but this is the first time they are appearing. The six month follow-up is to establish stability. The radiologist does not expect this finding to change during the follow-up interval.
Unfortunately, some gynecologists and patients have a hard time accepting this category. They think "what does the radiologist mean by "probably" it does not sound very scientific," but indeed it is the official term of the BIRADS lexicon. Some patients will push for a biopsy of a finding in this category, it is technically an option, but usually overkill. If radiologists recommended biopsy on all of these "probably benign" findings we would really be doing a disservice and an inordinant number of biopsies on benign entities.

BIRADS-4: SUSPICIOUS FINDING, BIOPSY SHOULD BE CONSIDERED
This is used for a finding that is not definitively benign and requires biopsy. This includes lesions that the radiologist believes are likely to be benign, such as fibroadenomas, as well as cancers. To differentiate, some people divide this category into 4A and 4B, low degree of suspicion and higher degree of suspicion. If your report has this category you can ask your doctor to elaborate if the findings has features highly suggestive of cancer, or not. The radiologist usually knows. Statistically, most nodules in this category turn out to be benign (fibroadenomas).

BIRADS-5: HIGHLY SUGGESTIVE OF MALIGNANCY-APPROPRIATE ACTION SHOULD BE TAKEN
These lesions have a high probablility (greater than 95%) of being cancer. Honestly, many radiologists do not use this category since BIRADS4 is already recommending biopsy. But it is true that often a finding is so characteristic that the radiologist knows it is cancer, but still nothing gets treated without a biopsy first.

BIRADS-6: KNOWN MALIGNANCY
This is used when the patient has a biopsy proven cancer, but additional imaging is still needed. A common scenario of this, is the MRI that is done when cancer has been diagnosed but we are looking if there are any additional sites of cancer (extent of disease work-up).

BIRADS-O: NEEDS ADDITIONAL IMAGING (OR OLD FILMS)
This is basicaly saying that the work-up is incomplete and a final interpretation cannot be given. This is used in a screening situation. In most facilities four images are taken by the technologist and the radiologist interprets the study at a later time. If there is a finding, the radiologist will often require additional views (compression spot views or magnification views) to clarify the finding. The patient will be notified that they need to return to the radiology office. Statistically, most of these call backs will be normal, the patient will not end up having any abnormality or require biopsy. In a small percentage, a biopsy might be ordered, but most of these will still turn out to be benign.

As I understand it, if margins are positive, and there are cancer cells remaining, many surgeons will return to surgery to remove any positive margins. If this is not your scenario, then there are a number of options for imaging a mastectomy site; sonography and/or MRI are the most common. If you have a reconstructed breast, with either an implant, or TRAM-flap, a mammogram can be performed but this is not done routinely. Also physical exam is excellent, especially if the breast has not been reconstructed.

Mammograms have a failure rate of 10%, for women with dense breast tissue it is over 40%. this is not really the best imaging tool. there are others with potential, but the Mammogram Machine makers are large contributors to facilities and Cancer Societies, therefore the lock step validations.
Two issues were against my making an informed decision, first I was not aware of dense breast tissue, was never told by any treating professional, and only two states have made it a law to advise women, Connecticut and Texas.
My own Governor Brown of California had the bill to do so on his desk and on the last day to sign it into law he refused saying incredibly, "he did not want to cause women to have anxiety, and also possibly saving your life is too expensive to suggest better screening. "Liberal" democrat Governor Brown, "Conservative" Republican governor Perry did care about women's lives. Shame on you Mr. Brown.
I agreed to a six months wait and watch delay. Never would have, had I understood dense breast and mammography failure. the ultrasound failed as well. When six months later I heard "biopsy," I went for a second opinion of my choice.
I drove 100+ miles to Venice Beach, Ca. to Dr. Kevin Kelly, 30+ year radiologist focusing on breasts. Dr. Kelly invented SonoCine, a different way of screening using an ultrasound. A full 11 days, two core biopsies and an MRI after, my "esteemed" Imaging unit gave me the exact diagnosis. Dr. Kelly told me that there was no cancer where they were looking, but beyond and deeper is where his SonoCine detected my cancer, pathology reports support this as well.

Don't tell me there are not any other screening methods, stop stonewalling them.

Teresa Masters

Calcifications in the breast occur commonly. The issue is whether there are suspicious calcifications in the opposite breast or not. Benign calcifications will tend to be scattered and rounded in appearance, whereas suspicious calcifications tend to be clustered, pleomorphic (different shapes), linear or branching (conforming to the inside of the duct).

The mammographic appearance is graded according to the BIRADS system, which goes from 0 to 6. BIRADS 1 and 2 and benign (no need to biopsy), BIRADS 3 probably benign (6 month follow-up or biopsy), BIRADS 4 and 5 suspicious (must biopsy), and BIRADS 6 (known cancer).

If there is a known cancer in one breast, any calcifications in the other breast will be regarded with heightened awareness, and may need additional workup. The incidence of synchronous bilateral breast cancer is in the range of 2-5%. Contralateral cancer may not appear in the same way as the cancer in the breast where the first cancer was found. It may be a mass on mammogram on the other side, or may only be detected on MRI, with no mammogram findings.

There is debate on whether MRI of the breasts should be done in cases of newly diagnosed breast cancer. In my own practice I usually order bilateral MRI to look for more than one cancer in the breast in which the first cancer was found, and to look for cancer in the other breast.

Molecular breast imaging is also known as breast specific gamma imaging or BSGI. Molecular breast imaging is promising as it can find cancers with a sensitivity of less than 3mm (this is better than MRI). The drawback is the high level of radiation currently associated with MBI. There are many centers working on the technology of MBI to get the radiation level of MBI to an acceptable dose. I look forward to this advancement as I feel it would be an excellent, more sensitive screening test once the radiation level is lowered. Here is my overview of BSGI.

BSGI stands for breast specific gamma imaging. BSGI is a fairly new technique that involves injecting a radioactive substance technetium (t-99) into a patient's veins and then scanning their breast with a gamma camera.
The gamma camera takes images of the breast and the areas where the radioactive substance has concentrated (this may indicate a breast cancer) will show up darker.
Pros of BSGI are increased sensitivity for detecting tumors at a smaller size than other available imaging techniques.
Cons of BSGI are the higher amount of radiation the person is exposed to during the test.
Some considerations: This test is reasonable for a person to have performed if they are first diagnosed with breast cancer to assess for occult cancers in either breast. Another scenario is a person who cannot have an MRI but requires a more sensitive test. Currently this is NOT a test for women to have yearly, too much radiation!

To read more in depth information on BSGI please visit http://www.mybreastcanceranswers.com/bsgi-breast-specific-gamma-imaging

Resources:

http://www.medscape.com/viewarticle/727881

http://www.gm-ideas.com/

www.dilon.com

1) 3D mammograms are also called tomosynthesis and they are superior to 2D (regular) mammograms. This type of imaging is a special kind of mammogram that produces a 3D image of the breast. The image is obtained by using several low dose x-rays taken at different angles. The breast is compressed similar to the way it is for a mammogram except the x-ray tube moves in a circular arc around the breast; the imaging is completed in less than 10 seconds.
The reasons tomosynthesis is superior to 2D mammograms are:
Less breast compression (less discomfort)
Shorter length of time for test to be completed (10 seconds vs. several minutes)
More pictures are obtained in multiple different angles of the breast (more accurate)
A 3D image makes it easier to find an abnormality than traditional mammogram.

2) There are some discrepancies in the difference in amount of radiation exposure between standard mammogram versus 3D mammogram.
According to the American College of Radiology there is about twice the amount of radiation in a 3D mammogram but “it improved the accuracy with which radiologists detected cancers, decreasing the number of women recalled for a diagnostic workup.”

A study published in Radiographics, peer-reviewed journal, lists the radiation dose of tomosynthesis at 145 mrad.

Just an fyi, the National Cancer Institute lists an average two-view mammogram as delivering 200-400mrad.

Everything I read and studied listed the doses for 3D mammogram as being under 300mrad (see resources below).

Thanks,
Heather

Resources:

http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/page6" target=_blank>http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/page6

http://www.acr.org/SecondaryMainMenuCategories/NewsPublications/FeaturedCategories/CurrentACRNews/FDA-approves-first-3-d-mammography-system.aspx" target=_blank>http://www.acr.org/SecondaryMainMenuCategories/NewsPublications/FeaturedCategories/CurrentACRNews/FDA-approves-first-3-d-mammography-system.aspx

http://radiographics.rsna.org/content/27/suppl_1/S231.full#sec-2" target=_blank>http://radiographics.rsna.org/content/27/suppl_1/S231.full#sec-2

http://www.acrin.org/PATIENTS/ABOUTIMAGINGEXAMSANDAGENTS/ABOUTMAMMOGRAPHYANDTOMOSYNTHESIS.aspx" target=_blank>http://www.acrin.org/PATIENTS/ABOUTIMAGINGEXAMSANDAGENTS/ABOUTMAMMOGRAPHYANDTOMOSYNTHESIS.aspx