Cancer Screening

When a woman is diagnosed with cancer, she needs to consider her family’s history of cancer. Some cancers are inherited; however, most are spontaneous. If there is a concern with a family pattern of cancer, then a thorough family history should be taken. Sometimes this leads to formal genetic counseling with blood testing for specific gene mutations. If you have a specific gene mutation putting you at risk for breast or ovarian cancer, then surveillance testing or procedures are different from those with a spontaneous cancer. Therefore, start with telling your oncologist your family history.

When the survivor has a deleterious mutation of the BRCA 1 or 2 gene that carries an elevated risk, or if ovarian cancer runs in the family.

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.

In patients with the BRCA gene, ovarian cancer can occur in addition to breast cancer. The risk depends on which BRCA gene mutation they inherited, with BRCA 1 patients having a risk of ovarian cancer as high as 44% and BRCA 2 patients having a risk as high as 27%. For patients without the BRCA gene, the risk is much lower. Breast cancer can metastasize to the ovary, causing tumors called Krukenberg tumors. Years ago, before the advent of medications to suppress estrogen formation by the ovary, many oncologists requested that the ovaries be removed to reduce estrogen in premenopausal breast cancer patients. That is not really done anymore except in extenuating circumstances. At the moment, there is no specific protocol to monitor the ovaries of breast cancer survivors. Some gynecologists will not change their standard care and others will offer sonograms (ultrasounds) both to assess the uterine lining in patients taking Tamoxifen and to look at the ovaries. Sadly, as mentioned in other questions on this site, ovarian cancer can be sneaky and not show up on scans. My thought is to not worry too much unless you are BRCA positive. Please ask your doctor if you qualify for testing.

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.

The demographics of the people we see are women age 40 plus who are at average risk for breast cancer. We are also able to screen women younger than 40 who are at high risk for breast cancer. Our Cancer Screening Partnership provides free screening and diagnostic work-up for uninsured individuals. A special Medicaid program is available for eligible individuals diagnosed with breast cancer. Seventy percent of the women we serve are Hispanic. Staff are fluent in Spanish and are culturally diverse.