Breast cancer screenings are now considered routine for women over 40. The good news is that there are increasingly sophisticated technologies available to women and their doctors. The bad news is that the findings they reveal do not always provide a clear result. Additional studies and biopsy procedures are expensive, stressful and sometimes risky. There are even questions about how effective certain technologies are in screening the denser breast tissue of a younger woman.
With so much information available, it’s easy to feel overwhelmed. It’s important to realize from the beginning that most of the time, further studies will show that your breasts are actually healthy. But when your routine screening finds something that concerns your doctor, the experience can truly feel overwhelming emotionally. We asked a few specialists how patients can move through the rigors of screenings while being their own best advocates, taking the time they need to ask questions which allow them the dignity of being a full participant in the process.
In particular, we spoke with the clinicians a patient (because men sometimes need to see breast specialists too) would meet along the diagnostic path: radiologists who read mammograms, specialists who read thermal imaging studies and finally breast surgeons who review all imaging results, perform physical exams, assemble detailed personal and family health history and perform biopsy procedures when indicated.
Still considered the “gold standard” among many physicians when it comes to screening choices, the mammogram is likely to be your first screening encounter. Digital mammography was approved in 1999 and now gives our doctors very detailed studies which are even more sensitive than earlier mammography technology.
When asked what specifically the mammogram tells us, Dr. Sonja Cerra-Gilch explained, “a mammogram is a very good screening tool and its primary role is to find early breast cancers. It also allows us to determine breast tissue density.” Mammograms of denser breast tissue, which is common in younger women, can be difficult to interpret fully because it is simply harder for the low-dose x-ray to penetrate the breast tissue to reveal the finer details radiologists need to study. If you have dense breasts, it is very important to know this and to discuss with your imaging specialist or breast surgeon options best suited to assessing your breast health. Dr. Stacey Vitiello, a radiologist with a specialty in breast imaging, added that specialists who review mammograms are looking for specific details that could be related to cancer, including: masses, changes in breast structure (she called these “architectural distortions”), micro calcifications and enlarged lymph nodes. She mentioned that breast density ratings appear on mammogram reports in some states thanks to the activism of women who are working to create awareness of this screening limitation. Both of these specialists stressed that making comparisons with previous images is very important because changes in breast tissue can be significant. They also agreed that it really matters who reads your mammogram; you want that specialist to be appropriately credentialed and a person with a high level of experience working specifically with images of the breast.
Because mammography does involve some exposure to radiation, we asked about the risk vs. benefit of this procedure. “The risk of radiation to the breast is so minimal it’s almost not measurable. A screening mammography program is expected to reduce fatality rate by about 40%. Truly the benefits outweigh the risks,” Dr. Cerra-Gilch responded when we asked her this question. Dr. Vitiello agreed, explaining that the radiation exposure from one mammogram was equal to taking a plane flight.
If your mammogram results are positive for a suspicious finding, it’s hard not to be fearful but Dr. Vitiello reminded us that 80% of biopsies come back benign (non-cancerous). If you are called back for additional studies, you want to ask what specifically was abnormal, suggested Dr. Cerra-Gilch. For example, she explained, there could be a mass or calcifications which merit further study. When a specific area of the breast is compressed and additional images taken, the picture may look different and that can happen because “we are taking a 3 D structure and looking at it in 2 D” she added for clarification .
Additional diagnostic imaging used along with mammography commonly includes ultrasound and MRI. Dr. Cerra-Gilch said that ultrasound is often used to investigate suspected masses. She further noted that MRI comes into the picture when there are questionable or inconclusive mammography or ultrasound findings. As far as what questions to ask, she suggested: “What does it mean that I have indeterminate calcifications in my breast?” “Other than cancer, what can the finding represent?”
Finally, both our radiologists stressed that knowing your history can be extremely helpful when a specialist is trying to interpret your studies. This would include any biopsies, surgeries, implants, history of breast cancer in your family and even personal details such as age at first pregnancy. Remember too that comparing images is very helpful so each study you have also becomes part of your history. The more pieces of information you and your doctor can assemble, the more data you have when determining your options and making decisions.
Another way to produce images of the breast for study is by using thermography – a form of infrared imaging that produces a picture of the breast that maps temperature variations. On his website, Dr. Philip Getson describes this technology: “Medical thermography uses infrared technology to provide an image of the body’s physiological responses. By detecting thermal asymmetry or by noting alterations of the vascular patterns, the physician now has more information with which to make an assessment of breast, neurological and other conditions.” Certified Clinical Thermographer Catherine Johnson further explained that such imaging shows temperature differences that can correlate with various types of abnormalities, of which malignancy could be one.
Dr. Getson explained that while a mammogram study shows us how the breast looks, the thermogram creates a picture of the way it works. He describes thermography as a “breast health risk assessment tool.” Mammogram and ultrasound are used to supply additional information about the breast. When asked about the risks of the procedure, both specialists said there is no risk because thermography does not use radiation, is not invasive and does not involved bodily contact.
When asked how this technique helps to find cancer, Catherine Johnson explained that the images reveal temperature variations that give us important health information. “It looks for an organized vascular heat pattern that supports abnormal tissue development.” It’s important to understand that a thermogram cannot identify tumors. What it can show is what is happening in the breast – specifically, heat patterns associated with increased activity of blood vessels – and such activity can be related to the abnormalities of the breast. It’s thought that by picking up on that activity, abnormalities of breast physiology can be spotted at an earlier stage, even before we can see or feel a tumor.
If you have a thermography finding that causes concern, you will most likely be referred for ultrasound or mammogram or both, Catherine Johnson told us. As with mammograms, you want to ask questions about what the specialist is seeing on the study and why this is cause for concern. It may also be helpful to ask which additional studies he or she suggests and what information those studies will add to help you understand more about your breast health.
As with mammography, ask about the credentials of both who performs the test and who reads it. Dr. Getson emphasized that the test should be performed by a board certified or board eligible technician and it should be interpreted by a licensed health care provider. He specifically recommends: DO, MD, DC. Catherine Johnson suggested asking the following: “Is the reader a board certified clinical thermologist (BCCT?)” “It the room temperature controlled? (18 – 22 degrees C) or (68 – 72 degrees F?) “Is a stress challenge test always done?” “Is a written report generated using comparative temperatures?” Ms. Johnson emphasized that women should know they can refer themselves for this test, saying that since mammography remains the gold standard, some physicians may know less about thermography and be less comfortable making a referral. In the medical community there are differing opinions as to the role of thermography in providing information about breast health. Make sure you are clear on what information any recommended tests are expected to give your doctor and how that information relates to your particular situation. Ask questions so you understand your options and are comfortable with the benefits, risks and possible limitations of each.
Surgical consult and Biopsy
If your imaging studies reveal information that is interpreted to indicate a concern about the possible presence of cancer or changes related to it, your imaging specialist will suggest you consult with a surgeon. At this stage, all your imaging studies should be compiled and brought to the surgeon who will take a detailed personal health history and perform a physical exam. Surgeon Dr. Karen Barbosa emphasized that changes are critical to her evaluation of films, saying, “90% is how has it changed; the change is what we evaluate.” She also uses the physical exam as an opportunity to educate patients about their own bodies, showing them how to look for symmetry, how one lump is different from another and the difference between fat and breast tissue.
Like our mammogram specialists, Surgeon Dr. Deanna Attai cautioned that the dense breast tissue decreases the ability of the x-ray to give a clear picture of the tissue, making this a particular concern for younger women who tend to have denser breast tissue. “In a woman with dense breast tissue, mammography is usually supplemented by other imaging such as ultrasound or MRI. In a young woman, mammography may not be recommended at all,” she pointed out.
In addition to a mass that may arouse suspicion, micro calcifications can also be another reason a biopsy is suggested. Dr. Barbosa said that while calcium is a normal part of the breast, its appearance can signal changes in nearby tissue that are associated with cancer development. If micro calcifications appear on your films, you will want to ask your surgeon about what makes the micro calcifications in your studies suspicious.
If after studying all this data the surgeon still has concerns, he or she will recommend a biopsy. This is a minor procedure where breast tissue is sampled from a targeted area and studied by a pathologist looking for the presence of cancer cells. A needle biopsy or core biopsy, both less invasive procedures, may be among your options. Your surgeon may recommend an open surgical biopsy but Dr. Deanna Attai suggested asking if you are a candidate for the needle or core biopsy. In weighing your options, she also suggested that, “a woman ask why a biopsy is being recommended and what alternatives exist. Both core biopsies and surgical biopsies are generally considered to have low complication rate but no procedure is without risk; observation may also carry some risk.” You may wonder if it’s a good option to “watch and wait,” perhaps redoing a mammogram after a specified amount of time; this is an opportunity to ask your doctor about the pros and cons of this choice while considering carefully your personal factors.
After the procedure, your doctor will receive a pathology report that will likely answer the question, “is there cancer is my breast?” While all of us feel incredibly relieved when our results are negative, some of us also feel perplexed by having to endure such extensive medical evaluation. This is an opportune time to talk to your breast surgeon about your history, risk factors and healthy habits that will enhance your health in the future. Being educated and proactive in all those facets of your life will make you an effective advocate for yourself and a strong partner with specialists along the diagnostic path.
By: Ginger Murphy
With appreciation and special thanks to:
Sonja Cerra-Gilch, MD – Section Chief of Breast Imaging & Intervention DII-Vrad Alliance
Stacey Vitiello, MD, Breast Imaging Specialist, Montclair Breast Center, NJ
Philip Getson, D.O., Thermographic Diagnostic Imaging, NJ
Catherine Johnson, CCT, Silk Thermal Imaging, CA
Karen Barbosa, D.O., Breast Surgeon in private practice, NY
Deanna Attai, MD, Breast Surgeon, Center for Breast Care, Inc., CA