Category Archives: Diagnostic Imaging

The Angelina Effect – 5 Common BRCA Gene Questions



1)What’s the scoop on the BRCA genes?

BRCA1 and BRCA2 are genes that can have mutations which may lead to an increased risk of breast and ovarian cancer.

2)How do I know if I should get tested?

Guidelines currently recommend screening for the BRCA1 and BRCA2 gene mutations if you have a strong family history of breast or ovarian cancer.  They also recommend screening for women who show early signs of developing cancer.

3)What should I do if I test positive?

Most importantly, do not panic!  Testing positive for the BRCA gene mutation does not mean you will get cancer.  Likewise, testing negative does not rule out your chances of cancer.  If results come back positive for mutations, you have taken your first step into a new journey.  Influenced by Angelina Jolie’s comment, “Knowledge is power,” this is a great starting point to gather information.  Educating yourself by consulting with physicians and joining support groups is important to fully understanding ALL of your options.

4)Does insurance cover preventative surgery if I test positive BRCA gene mutation?

If you test positive for the mutations, most insurances will cover preventative surgery.  The preventative surgeries may include the removal of breast tissue, ovaries, fallopian tubes, and your uterus.

5)What are my reconstruction options if I choose preventative mastectomies?

Breast reconstruction options for women who choose preventative surgery, such as aprophylactic double mastectomy, are the same as for women who have cancer.  Reconstructive surgery would be performed immediately after  breast tissue removal, allowing for optimal aesthetic results.  Women also have the added benefit of waking up with breasts.    Breast restoring surgeries include DIEP flapTUG flapGAP flap, and One-Step Implants.

Do I Need a Mammogram?

Spoiler alert – this will hardly be the last word on the screening mammography debate…

Last week, the British Medical Journal published a Canadian Study which concluded that mammograms are not effective in reducing breast cancer deaths. The study involved 90,000 women. However, there are some major flaws in the study, and “rapid response” letters to the editor were published within hours of the study release. So while the headlines scream “mammograms are not helpful”, the study is of poor quality and it is not possible to truly draw this conclusion.

While previous randomized trials have shown a reduction in breast cancer mortality due to screening mammography, there is no doubt that mammography is far from perfect. We have to screen a large number of women to diagnose one with breast cancer. In doing so, a percentage of women will require additional imaging and/or will undergo a needle biopsy for a benign finding. Mammography is not as helpful in younger women and in those with dense breast tissue. In addition, as technology has improved to allow us to see through the breast with more detail, we are diagnosing cancer (and precancerous conditions) that may never become a threat to a woman’s life. We are trying to find the balance between early detection which often (but not always) leads to improved survival, versus over diagnosis and over treatment.

 

Part of the problem is our technology. The results of screening mammography are highly variable depending on the patient’s age, breast density, weight, use of hormone therapy, and other factors. We have a one-size-fits-all test, which as every one knows, is really one-size-fits-none. We are also limited in who we screen. Women younger than 40 without a family history of breast cancer have no routine screening options, and mammography is not very helpful in this age group. Many will use this as an argument for the use of ultrasound or MRI examinations. While these modalities may be extremely helpful in a given patient, they have not been proven to be effective in reducing mortality from breast cancer when applied to a general screening population.

It is important to realize that we have an imperfect technology, and our application of that technology to the individual is also imperfect. More research is needed to determine who is actually at risk, and who will truly benefit from screening. In addition, screening needs to be more individualized – a mammogram is not the right screening tool for all. Dr. Peter Beitsch, President of the American Society of Breast Surgeons, has said on many occasions that “female and 40 is no longer acceptable for screening mammography – we need to risk assess each woman individually and use appropriate breast imaging tailored to them..” This will be the subject of a symposium held at our annual meeting in May – “Breast Cancer Screening – Does One Size Really Fit All?”

In addition to more individualized screening, research is needed into which cancers even need to be treated. Many breast cancers found on mammography may never become a threat to a woman’s life. However, a hallmark of cancer is cell mutation – the slow-growing cancer today may not behave that way in the future, so at this point we err on the side of over treatment, as we cannot reliably predict future biologic behavior. Dr. Robert Miller, a medical oncologist at Johns Hopkins, stated that “we simply can’t tell if early breast cancer diagnosed by mammogram will be indolent or not. For the individual patient we can’t say it’s ‘over diagnosis’. ”

And that’s really the bottom line. For an individual patient, we do not always have the right answer – our science and technology are just not there yet. While this is frustrating for many patients as well as for physicians, it is exciting to be practicing in a time when we are making progress (albeit slow) towards more individualized screening and treatment recommendations.

American Society of Breast Surgeons Statement

By: Dr Deanna Attai

 

Dense Breast Tissue

There has been much in the news lately regarding dense breast tissue and the concerns regarding risk of breast cancer as well as the inability of routine mammography to detect breast cancers in women with dense breast tissue.

First of all, it is important to understand what is being discussed when you hear the term “dense breast tissue”. The breast is normally composed of fat and glandular tissue – the higher proportion of glandular tissue, the denser the breast. It is important to note that “lumpy” breast tissue is not the same as dense breast tissue – density is determined by the appearance on a mammogram, not by feel. The denser your breast tissue, the more “white” the breast will appear on a mammogram; women with primarily fatty breasts will have a mammogram that appears darker. Digital mammograms (compared to older film screen mammograms) have an easier time seeing through dense breast tissue, but all mammograms are limited in their ability to see through dense tissue and identify cancers, as cancers usually appear as dense white lumps on a mammogram. In general approximately 10-20% of breast cancers are missed by standard mammography – that percentage can approach 40-50%  in women with dense breast tissue.

 

Breast Density

It was previously thought that mammograms simply had a harder time detecting breast cancer in women with dense breast tissue. However, we now know that a woman with dense breast tissue does have an increased risk for developing breast cancer and this is the subject of intense research. There are many factors that influence breast density including age, hormone levels, genetics, age at first pregnancy and number of pregnancies, use of hormone replacement therapy, overall body weight – just to name a few. And as younger women naturally have denser breast tissue, that does not mean that women in their 20’s and 30’s have an increased risk of breast cancer – in fact the risk of breast cancer increases with increasing age; it is hard to sort out when the increased risk as it relates to breast density develops.

Unfortunately, it is sometimes difficult for a woman to know if she has dense breast tissue – remember it is not the same as “lumpy” breasts. When you undergo a mammogram, the radiologist is required to make a comment regarding breast density in his or her report. However, patients often do not receive the radiologist’s report. Mammography performance and reporting in this country is regulated by the FDA, through the Mammography Quality Standards Act, and currently it is required that patients receive a “lay letter” – a report written in layperson terms that gives a basic summary of the findings and recommendations. Your physician who ordered the mammogram will receive the official report with a notation of density.

Several states (including California) have now passed legislation requiring that patients be informed of their breast density. While I agree that patients certainly have a right to their full and un-edited test results, it is unfortunate that legislation was required to ensure that women receive their complete test results. Federal legislation is pending regarding this matter.

If you have dense breasts, what should you do?  We know that MRI, and certain forms of ultrasound, especially automated whole-breast ultrasound, can be very helpful in evaluating women with very dense breast tissue. While I do recommend these studies for some patients, realize that there are no formal guidelines by either the American College of Radiology or the American Cancer Society regarding breast imaging for women with dense breast tissue, unless the woman is also considered to be in a high-risk category (for example those with a strong family history of breast cancer). Some of these tests are not covered by insurance. Also realize that MRI and ultrasound also have some limitations when imaging dense breast tissue – there is no perfect method of evaluation.

Newer methods of mammography such as tomosynthesis and contrast-enhanced mammography are showing promise, but studies are still being performed; these exams may also expose a woman to higher doses of radiation and/or a contrast material injection.

My recommendation is that women speak to their doctors. Ask if your breast tissue is considered dense, and if so, would you benefit from additional testing. Stay tuned for more information as newer imaging techniques which improve the rate of cancer detection in women with dense breast tissue are being developed.

Dr. Attai was one of the physicians invited to testify before the California Legislature in support of SB 1538, which was eventually signed by Governor Brown, requiring that mammography facilities in California inform patients if they have dense breast tissue on mammogram.

By Deanna Attai