IMAGING FOR BREAST CANCER
When should I start – and stop – getting mammograms?
Women’s Diagnostic Imaging agrees with The American College of Radiology (ACR) recommendation of a baseline mammography at age 40. If you have a family history of breast cancer, you may need to start earlier. For example, if your mother had breast cancer age 40 you should get your first mammogram at age 30.
Dr. Weinstock recommends stopping mammography when you no longer get your hair done – in other words, as long as you are able. Surgery for breast cancer, even at age 80, can give you more years to watch your grandchildren grow up and be with your loved ones.
How often should I get a mammogram?
We recommend annual mammography. Cancer that develops between mammograms, called interval cancers, can be more aggressive and difficult to treat. Additionally, if you have dense breasts and other risk factors, we may recommend alternating mammography with ultrasound every six months for optimal monitoring.
What is the difference between mammography and tomosynthesis?
Tomosynthesis is also called 3D mammography as it takes images of the breast in slices and looks similar to a 3D movie on the screen. Tomosynthesis is really enhanced mammography; similar to the way iphone adds new upgrades. A standard 2D mammogram is still needed to give a composite picture of the breasts.
We are now imaging all our mammography patients with Hologic Low Dose Breast Tomosynthesis with C-View Imaging software. The C-View Imaging software takes the 3D images and combines them into composite 2D images. With this technology you only need one exam which means less radiation and less time in compression. We are the only health care facility in Bergen County, New Jersey using C-View imaging software.
Is Tomosynthesis enough to image dense breasts?
Tomosynthesis added to standard mammography has been shown to find more cancers in dense breasts. But supplemental imaging may still be necessary. Like standard mammography, tissue and tumors appear white on Tomosynthesis. Tumors can still be obscured.
Why is ultrasound recommended for dense breast tissue?
Breast tissue is sonographically white on ultrasound but tumors are gray so they can be seen more easily in dense, white tissue. Breast ultrasound performed in conjunction with mammography in women with dense breast tissue significantly raises the sensitivity of detecting early breast cancer.
Why don’t I skip mammography altogether and go straight to the ultrasound?
Ultrasound does not replace the mammogram. Mammography is still the “gold standard”. Mammography detects calcifications which are rarely identified on Ultrasound as well as subtle density changes and changes in breast tissue “architecture.”
I’ve been told that too many biopsies are recommended due to “screening ultrasound.” Why should I have it done?
In inexperienced hands normal tissue and benign lesions can be misinterpreted as suspicious masses. When breast ultrasound is performed by an experienced breast imager these “benign findings” are either followed with short term follow-up ultrasound or dismissed entirely. Of course, as with mammography there will be benign lesions which may have to be biopsied. There must be a certain number of “benign biopsies” in order to detect tiny malignancies (which is what we want to detect early!).
Should I have my screening ultrasound at the time of my mammogram?
There are two ways to have the screening ultrasound done. One is at the time of the mammogram. A second option, if the current mammogram is stable, is to return in 6 months for what we call an “interval screening ultrasound”. This option gives you the opportunity to be imaged twice a year so that small interval cancers can be found. If you have a strong family history of breast cancer it may be prudent to have the ultrasound at the time of the mammogram and at the 6 month interval.
What is a diagnostic ultrasound and when is it recommended.
If you have a “palpable” finding such as a lump or thickening (meaning you or your doctor feels a lump), a directed or targeted ultrasound of this area may be indicated. In addition, if there is a focal finding on the mammogram, a directed ultrasound of that region may be warranted. Ultrasound is excellent at distinguishing fluid collections (known as cysts) and solid masses which could be either benign or malignant.
Besides ultrasound, are there other imaging modalities you recommend for dense breasts?
Molecular imaging, Breast Specific Gamma Imaging (BSGI), is an excellent modality to screen for breast cancer in dense tissue, as it images the way cells behave, not the way they look (anatomic structure). BSGI patients are injected with a tracer that “lights up” in abnormal tissue, producing a black spot on the images. An early concern about molecular imaging was the additional radiation used in the exam. Not only has the level come down, it is comparable to the amount used in a cardiac stressed test and is not considered significant.
Magnetic Resource Imaging (MRI) uses a computer, magnetic field and radio waves instead of x-rays to produce images of the soft tissues of the body. When used with mammography, MRI can provide valuable information for the detection and characterization of breast disease. Women’s Diagnostic Imaging does not use MRI but we refer patients to facilities where we have confidence in the radiologists who are reading and interpreting the images.
Does it make a difference who reads my images?
Yes. The experience, training and skill of the physician interpreting physician is as important, if not more important than the technology used. Many missed cancers on mammography are the result of a failure on the part of the radiologist to either identify or correctly interpret the cancerous abnormality. Studies have own that an experienced breast imager will detect more cancers than general radiologists.
What are calcifications?
Calcifications are calcium deposits found within the breast tissue. These deposits can be identified by mammography. They are extremely common and are frequently due to non-cancerous causes. Calcifications are not related to or caused by dietary intake of calcium. They can, however, be an early sign of breast cancer and should be analyzed carefully by your radiologist. There are two main types of calcifications:
• Macrocalcifications. These calcifications are usually large and round.
They are ordinarily recognized as benign (non-cancerous) and need no additional testing.
• Microcalcifications. These calcifications are smaller and may be numerous.
They can be random or clustered and may vary in size and shape. The radiologist may request additional
mammography views for further evaluation. For example, magnification views (enlargements) may provide more
detailed information. There are several kinds of microcalcifications. Three frequently noted types are as follows:
• Benign. These microcalcifications can be identified clearly as benign (non-cancerous)
by an experienced radiologist and need no further work-up.
• Indeterminate. Such calcifications are not clearly benign or malignant and need additional work-up.
• Malignant. These microcalcifications are almost always related to malignancy and a biopsy should be performed.
My breasts are extremely tender especially around the time of my period. Can I have a mammogram or ultrasound at this time?
For your comfort, it is best to have these studies performed when your breasts are not tender (especially the mammogram which compresses your breast). If you think you can tolerate the compression, then you can have your exam performed as it will not interfere or affect your study.
IMAGING FOR AREAS OTHER THAN BREAST CANCER
Why would I need a pelvic ultrasound?
There are many indications for pelvic ultrasound: pelvic pain, irregular bleeding, and postmenopausal bleeding. Ultrasound can evaluate benign masses of the uterus (fibroids) and ovarian masses. In addition ultrasound is useful in early pregnancy to evaluate fetal viability and to exclude life threatening tubal pregnancies (ectopic pregnancy).
Why do I need both a transabdominal and endovaginal pelvic ultrasound?
The transabdominal ultrasound utilizes the full bladder as a “window” to look at the pelvis. This gives the “big picture” of all the pelvic organs. The endovaginal scan gives a more limited but detailed image of the uterus and the ovaries. Most of the times both types of scans are needed to fully evaluate the pelvic organs.
If I have excessive menstrual bleeding, bleeding between periods, or postmenopausal bleeding what could cause this?
Abnormal or excessive bleeding also known as dysfunctional bleeding is overwhelmingly due to benign causes such as hormonal fluctuations, thickening of the uterine lining (endometrial hyperplasia), benign polyps of the uterine lining. Rarely, dysfunctional bleeding can be caused by a malignancy. This is why your gynecologist may recommend a pelvic ultrasound.
In addition to blood tests and pelvic ultrasound, how else can “dysfunctional bleeding” be evaluated?
There is a relatively noninvasive exam we perform called SONOHYSTEROGRAPHY. It involves the injection of saline into the
lining of the uterus (also known as the endometrial lining). Results can show a normal lining, a single or multiple benign polyps, endometrial hyperplasic and rarely endometrial carcinoma. These different findings can help the gynecologist formulate a plan for treatment.
Why would I need an ultrasound of my thyroid?
The thyroid gland produces hormones that regulate metabolism; they can’t be seen in a physical examination. Ultrasound can check a lump to determine if it is a solid nodule or simple fluid-filled cyst, or see if the thyroid is enlarged due to disease.
What is osteoporosis?
Osteoporosis is a silent, progressive disease characterized by decreased bone density and increased bone fragility with a consequent susceptibility to fracture. Up to 1.5 million fractures a year are attributed to osteoporosis. Osteoporosis may progress silently for decades. There may be no symptoms until fractures occur. Osteoporosis used to be considered an inevitable consequence of aging. Today, there are techniques for early detection and treatment options.
I’ve seen bone density studies offered all over the place even the mall. Why should I go to your facility?
As with all our imaging studies, we use the very latest state of the art technology. The Lunar Prodigy Advance is extremely accurate and measures the density in both hips (many measure only one hip). In addition our machine has the capability to do a lateral view of the thoracic-lumbar spine. With the addition of Total Body Composition Analysis software, we can also check your muscle to fat ratio.
What is the benefit of examining the lateral spine?
Imaging the spine in a side view (lateral view) in addition to the standard frontal view, allows the radiologist to evaluate for compression fractures of the spine. Compression fractures of the spine can cause false negative bone density readings without the lateral view. This is important because patients with spinal compression fractures are at a much higher risk for osteoporosis and future fracture risk. Lateral views also help to determine if osteoarthritis is present.
Why would I need Total Body Composition Analysis; isn’t BMI good enough?
Total Body Composition Analysis measures the ratio between muscle and fat. BMI measures how you look but not what’s inside. A person may appear overweight but have a healthy amount of muscle, not fat. Conversely, a patient with anorexia may not appear dangerously thin but is in danger of developing osteoporosis due to loss of muscle. Body composition analysis can help anyone develop a more targeted plan for exercise and nutrition by pinpointing problem areas in the body.
SCREENING FOR HEREDITARY CANCERS
My mother passed away from breast cancer at age 75. Does that mean I should have genetic testing?
You are a candidate for genetic screening if you have a first degree relative on your mother or father’s side you had the disease under age 50. See the chart in the genetic screening section of this website for more specific criteria.
Why should I be tested for a breast cancer gene when I get annual mammograms anyway?
Women who carry the genetic mutation for breast cancer are at high risk of getting the disease. If you know you are a carrier, you can choose a preventive strategy.
If I test positive for a genetic mutation, what are my options?
You may choose to add additional types of imaging, and more frequent screening. Chemoprevention is the use of medication shown to reduce the incidence of breast cancer. Some choose the route of actress Angelina Jolie who had a double prophylactic mastectomy. Genetic counselling along with genetic screening at WDI will help you choose the right course of action.
If I have a family history of breast cancer on my father's side, does that count as significant?
Yes! Whether the history is maternal or paternal the genetic implications are the same.
I tested negative for BRCA1 and BRCA2 mutations ten years ago. Should I be retested?
Definitely. We now know that additional genes are implicated in breast cancer and mutations in some of these genes also put you at risk for other cancers. We can screen with multi-gene panels to look for mutations in genes beyond BRCA 1 and BRCA 2.
ABOUT WOMEN’S DIAGNOSTIC IMAGING
How is your facility different?
Women’s Diagnostic Imaging strives to offer a rare blend of expertise, the latest technology, compassion and quality service. Dr. Weinstock gives all mammography patients immediate results following their exams to reduce the anxiety of waiting. If additional testing is required, it is done as soon as possible, often the same day. Dr. Weinstock will guide you if you need treatment after getting your results. Your comfort is important; our office is designed to be a tranquil and soothing environment.
If I switch to your facility, do I need to retrieve my old films and records?
We prefer to have your previous images before your exam. Breast imagers look for subtle changes in tissue patterns of the breast which could signify an early developing cancer. These findings often are not appreciated without the benefit of comparison.
If you had prior studies at another facility, you should request the images before your appointment at WDI. You may need to sign a release form before the images are released to you, mailed or sent electronically to WDI.
Do you take my insurance?
WDI participates with Medicare and will process all insurance claims directly for Medicare patients.
For all other patients with private insurance, the Practice is “fee for service.” This means that you will be asked to pay for your breast imaging study at the time of your visit. We will provide you with all the necessary paperwork for you to submit to your insurance carrier for direct reimbursement. WDI is considered an out-of-network provider and your reimbursement will depend on your out-of-network screening mammography spending account. Some insurance carriers have “WELLCARE” policies which cover out-of-network screening mammograms. To date, most patients with out of network benefits who have met their deductible have been reimbursed between 80-100%. The best way for a patient to know what reimbursement to expect is to contact the insurance carrier directly. If you need help getting information about your insurance coverage, please call our office. The staff will be happy to help you in any way they can.
Is your facility ACR (American College of Radiology) accredited?
WDI is an ACR accredited center for excellence. In addition, we have passed our MQSA (Mammographic Quality and Standards Act) yearly since opening in 2004.