The Truth About Mammograms – What should you do?

In September 2011, I was interviewed for an article in the hospital magazine about mammograms, in preparation for Breast Cancer Awareness month in October.  The one question I was asked that stuck out in my mind was, “What is you want readers to know about mammograms?”  My immediate answer was, “They are not perfect.”  Somehow that was not really explored in more detail and the point never really made it into the article.  I guess it might have discouraged women from getting mammograms.

Do mammograms save every woman with breast cancer’s life?  Unfortunately not.  As Peggy Orenstein in her recent article suggests, many women are under the misconception that if you have mammograms every year, it will save your life.  It can, but it does not necessarily mean that it will.  But just because it is not a perfect test, does it mean that it should not be utilized at all?  The media isn’t questioning the value of pelvic exams, prostate exams and colonoscopies and they are not perfect.  Patients are subject to false positives, false negatives and risks of procedures that result from those tests.  And, people are still dying from ovarian, prostate and colon cancer.

Do I believe that mammograms save women’s lives?  Absolutely.  I can for sure say that there are young women’s lives who have been saved by mammography.  The problem is that people have been made so aware of how mammograms have helped save lives, that not much has been discussed about the limitations of mammogram until recently.  As a result, people have lost faith in mammography.  However, if you understand the limitations in addition to the benefits of mammography, you can then choose how to best utilize it in screening yourself for breast cancer.

So what should you know about mammography other than it can save your life?

1.  Mammography is limited in dense breasts.  This point has been brought up in the media for a while now.  To understand in simple terms how the density affects mammography interpretation, see my blog “Breast Density and What Does It Mean?”

2. Mammography is not always able to image the entire breast.  The vast majority of breast cancers occur in the upper outer portions of the breast and so the views taken favor imaging those portions of the breasts.  However, the lower inner portions of the breast tend to be more difficult to image and as a result, some cancers that develop in the very inner and lower portions of the breast may not show up on mammography.  In general, the parts of your breasts that are the closest to your chest and farthest from your nipple can be difficult to image as it is difficult to pull every inch of your breast tissue into the machine.

3. The radiation dose of mammography is fairly low.  The dose of one mammogram is equivalent to seven weeks of radiation you get from natural sources in the environment.  The dose of a CT of your chest is equivalent to 10-25 mammograms.  The lifetime attributable risk of fatal radiation-induced cancer from mammograms is 1.3 to 1.7 cases per 100,000 women.  You have a greater chance of dying from a car accident (1 in 84 as quoted by the NY Times) but most people don’t even think twice when getting into their cars.

4. Not every mammogram reading is equivalent.  The number of false positives and negatives can vary depending on who is reading your mammogram.  The readings can also vary depending on how many comparison mammograms the radiologist has.

5. Some breast cancers are just plain difficult to see on mammography, even on easy to read mammograms.  The growth pattern can make some cancers easy to see and others not.  If the cancer grows along the breast tissues, as true of lobular type breast cancers, it can blend in with the normal breast tissue and be difficult to detect on mammograms.  These types of cancers tend to be larger by the time they are detectable by mammography.  However, if the cancer starts to distort the tissues around it, those changes tend to be more easily seen on mammograms, even dense ones.

6. Some breast cancers grow too fast to be detected at a small or early stage.  I have seen a perfectly clear mammogram one year and the next showing a large cancer that has spread to other parts of the body.  I really hate those cases.  I always ask, “What could’ve been done differently?”  Unfortunately, we can’t assume that because your mammogram is good today, you will be fine until you get your next mammogram.  Cancer can happen anytime.

So, what does this mean for you?

1.  Decide first if you want to be screened for breast cancer and at what stage you want to find your breast cancer.  Often DCIS (see my blog about DCIS) and sometimes very small invasive cancers are only seen on mammography.  Ultrasound tends to find breast cancers after they have formed a mass (i.e, become invasive).  If you want a chance at finding your breast cancer early, then have a mammogram done.  Remember that the cancers in women who are not in menopause (50’s and younger) tend to grow faster and be more aggressive than the ones that show up in those who are in menopause.

2.  If you decide on having a mammogram done, find out if that is enough when it comes to imaging studies.  If you have dense breasts, an ultrasound may indicated as an additional means of screening.  If you have a high risk or strong family history, MRI may be indicated for screening.  Talk to a radiologist whenever you can to find out what imaging tests are best for you.

3. Always feel your breasts, particularly in the areas farthest from your nipple.  THIS IS VERY IMPORTANT, for several reasons.  First, feeling your breasts allows the areas that can be missed on mammography and even ultrasound to be checked.  Second, it allows your breasts to be checked between the yearly mammograms should something grow in that interval period.  Third, no one is going to know your body better than you.  You are going to be better at finding that breast cancer than your doctor if you regularly check your breasts.  (Blog to follow about self breast exams…)

4. To reduce the false positives and negatives, be consistent.  Screening works the best when you have a timeline.  Get a mammogram done every year to reduce the chances that something might get missed.  Always have your prior films for comparison as it reduces the likelihood that you will get called back for additional imaging and helps the radiologist appreciate any change that might be significant.

5.  Have a breast radiologist read your mammograms.  The more mammograms someone reads, the better they will be at knowing what is normal and what is abnormal.  Also, radiologists who perform biopsies get feedback after getting the results, thus learning what varying forms cancer can present as.

The problem with breast cancer screening is that everyone’s breasts look different and not every breast cancer acts or presents the same way.  It’s hard to have a “one size fits all” approach.  Mammography is not perfect but the things listed above can help overcome its shortcomings and improve detection of breast cancer at an early stage.   If you don’t do mammography, what are you left with?  You are left with waiting until you develop a mass, or invasive breast cancer.  The larger the cancer, the higher the risk of it spreading to other parts of your body.  That’s the risk of not doing mammography.

As you will find on my blog, my philosophy is that the patient always has a choice.  Just be properly informed of the risks and benefits of the choices you have.  Don’t be afraid to ask what your options are.   It is your body and ultimately you are the one who has to live with the decision you make, not anyone else.

Stay tuned for upcoming posts about self breast examination, breast MRI and ultrasound.

DCIS, To Treat or Not to Treat? – 2nd part of response to Peggy Orenstein

What is DCIS, or ductal carcinoma in situ?

DCIS means that there are cancer cells in your breast but they have not gone anywhere.  They have not invaded beyond the normal breast structures (ducts and lobules) into the surrounding tissues.  Once the cells break through ducts and lobules, it is called “invasive”.  Once it is invasive, it can spread to your lymph nodes and the rest of your body.

Peggy Orenstein is correct in that DCIS alone will not kill you.  Breast cancer solely in your breast will not kill you.  Even breast cancer in your bones will not kill you.  However, when the cancer cells take over vital organs, such as the liver, lungs, and brain, that is when people eventually die from cancer.

Although some DCIS will never become invasive cancer, DCIS has the potential to become invasive.  Although there are some cancers that may never spread to other parts of your body, all invasive cancers have to potential to go to other parts of your body.   The problem is it can be hard to predict what the cancer cells in your body are going to do.  The blanket statement that DCIS in a 40 year old “quite likely would never become life threatening” (I have seen cases that have proven otherwise) is just not true.  It is not that simple and not everyone can be fit into a one size fits all category.  So, what is the likelihood that DCIS will become invasive cancer?   There are a few things to consider:

1.  How aggressive is the DCIS?   DCIS is broken down into low, intermediate and high grades, which are determined by characteristics indicative of cell growth.  High grade or comedo type DCIS means that the cells are rapidly growing and it is very likely that if you leave it in the breast, you will at some point develop invasive cancer.

2.  How much of it is there?    If you have a large area of DCIS, there are more cancer cells there, and thus a greater chance for one of those cells to start invading.

3.  How much life to you expect to have left?    The more time you let DCIS stay in your breast, the higher the risk for developing invasive disease, as you are giving it time to grow.

4.  Is it hormone sensitive and are you premenopausal?  If it is sensitive to estrogen and progesterone and you are still having menstrual cycles, then you are stimulating the cancer cells to grow.

So, if you are 40 year old woman with high grade comedo type DCIS, regardless of the size, I would say that it is in your best interests to remove whatever DCIS is there, as there is high risk that you will develop invasive breast cancer, probably sooner than later.  If you are 70 year old woman a small area of calcifications that showed low grade DCIS and you have diabetes and heart disease, the DCIS is probably not going to do you in before your diabetes and heart disease will.

And if you are somewhere in between?  It may not be so clear cut.  You will have to ask your doctors what they think the likelihood that your DCIS will be come invasive is.  Then you will have to decide, “Do I want to wait to see if this will become invasive cancer, or, do I want to remove these cells now and not give them a chance to become invasive.”  Most people would probably opt for the latter.  Perhaps the point Peggy is making is that we should be giving people the option, which is not something I am against.  It is okay not to treat DCIS as long as you understand the risks.

However, treating DCIS is reducing your risk for developing invasive breast cancer in the future.  Should it be grouped together with invasive cancers in the statistics? Maybe not.  Should it even be considered a cancer?  Maybe not.  (It should be called pre-cancerous in the least.)  To say that we are “over treating” DCIS is a matter of opinion.  Perhaps it should be looked at as a preventative measure rather than treatment.  It may be one of the few things you can do to reduce your risk of dying from breast cancer.  If someone chooses to do that, I ask, “What is so wrong with that?”

Is Breast Cancer Awareness Overhyped? – First part of the response to Peggy Orenstein’s article

Probably.

In the past month or two, I saw three young girls for a lump in their breast.  One was 19 years old, the others 15 and 12.   The mother of the first girl was recently diagnosed with breast cancer and was finishing up chemotherapy.  I put the ultrasound probe down and saw a benign appearing mass, most likely a fibroadenoma.  I told them that just that.  I looked into both their eyes and there was no sense of relief.

Ok, maybe they need more than that.

Not entirely sure what it is they needed to hear, I continued on:

“The options for management include watching it in 6 months or biopsy.  I am not sure if you would want to consider biopsy, given your own personal experiences and that way you will have a definitive answer.”  The mother breaks down crying.

Oh shoot.  I said the wrong thing.

I gave the mother a moment.  She apologized.  It was okay.  By now I have gotten used to cancer patients having moments where they just need to break down and cry.  Finally, when she was able to gather herself, I tried again:

“I am 99% sure that this is not cancer.  It would be incredibly unlikely in someone of this age to have a mass that looks like this end up being cancer.  If she were my daughter, I would opt for watching it, just to make sure it does not rapidly grow.”  Finally, I see some relief in my patient and her mother’s eyes.

I don’t know know why I even mentioned biopsy as an option.  I almost never suggest biopsy in someone of this age because it is so unlikely to be something abnormal.  If it were my own daughter, I wouldn’t have even worried for a second.   Now, in this situation, the patient’s mother had breast cancer, and that probably contributed largely to their fear, and probably to some degree mine.  But the mother of the second girl I saw did not have cancer.   The mother of the third, 12 year old girl, repeatedly asked me if the several benign cysts were normal.  I couldn’t help but to wonder if this is just a normal parental response, or is there so much hype around breast cancer that we are now making our teenage daughters check their breasts for lumps.

I see the look of fear almost every day in my patients’ eyes.  For many patients, if I offer six month follow up, I get this look of “are you sure?”  I have actually done biopsies when I didn’t think someone needed them because the patient wanted it.  Many women can’t stand the thought of waiting, as though there was a ticking time bomb in their breast.

Awareness is a good thing.  It helps people take initiatives to get preventative services that might actually save their life.  But all of this awareness has instilled a great deal of fear, in not just patients, but their doctors as well.  We have to live up to the notion that early detection will save our patient’s life.  Don’t miss that breast cancer when it’s early!  If you don’t biopsy and something turns out to be a cancer, be ready to explain that to your patient (and possibly their lawyer)…  And it’s not just radiologists who fear it too.  When my partner and I felt that we could safely follow certain things in a year, we received some nasty responses from referring physicians who basically told us that that was not the protocol and we were putting them at risk for lawsuit.  They would no longer send us patients unless we forced people to come in at 6 months for followup.

I agree with Peggy Orenstein about how the “awareness” aspect of breast cancer is borderlining on hysteria.  We, as a community, need to have a rational outlook on breast cancer so we can better focus our energies on prevention, detection and treatment, and make sure that what we are doing is really helping women.

Why I am here

This past weekend there was an article published in the New York Times Magazine by Peggy Orenstein titled “The Feel-Good War on Breast Cancer.”  I was warned by a colleague to be prepared to address the article with patients.  So, on Sunday night after my girls went to bed, I looked it up on the internet and read it.

I immediately had mixed feelings about it.  There are some things I agree with and some things I disagree with.  But my concern was mostly about how women might react to such a piece.  As with most articles I read on the internet, I continued on to the comments section.  As expected, many breast cancer patients described their experiences, some with good results, many with bad results.  There were also some people who described facing the possibility of having breast cancer, ultimately ending up with benign results, and how that experience negatively affected them.

Although I did see a rare post from a radiologist defending mammograms and the need for biopsies and surgery, there is very little out there about what it is really like to be in our shoes.  Every day, we sit here examining numerous mammograms, trying to determine whether or not we should call someone back for additional views.  Could that be a cancer?  Or when we see something we are not sure of, do we biopsy or watch it?  Our patients’ lives rest in our hands and our decision at this moment could mean the difference between someone having cancer and doing well versus someone having cancer and ultimately dying from it.

Part of my job includes performing biopsies and giving the results.  I have told many women that they have breast cancer.  Fortunately, I have been able to tell many women that there are reasons to stay positive.  But like the article describes, there are still many women I cannot tell that to, and some I know have not done well.  There are many times I have wanted to cry with the patients but because of professionalism, I hold back the tears.  But I am right there with them feeling the sadness, the disappointment that I couldn’t find this earlier, and the fear of what their future holds.

I have had so many experiences with patients that have changed my outlook on life in so many ways.  After reading several blogs of breast cancer patients, I thought to myself, “It might be nice to share some of my experiences with other people.”  Perhaps, it might be reassuring to some patients to know that we (as breast radiologists) are on their side.

That is why I am here.