It's that time of year again - October is breast cancer awareness month. My key words in 2017 for breast cancer awareness are individual risk assessment based on breast density and family history.
I tell all my patients about their breast density results and make recommendations for supplemental imaging if needed. We also screen our patients to see who may be at risk for hereditary cancer. A simple saliva test will let you know if you have one of many genes implicated in cancer. Counseling gives women with positive results many treatment options. Forewarned is forearmed!
The good news this year is that 30 states now have breast density notification laws. Radiologists in these states are required to tell mammography patients that their exams can be less accurate in dense breast tissue and advise them to discuss results with their doctors. Some states, including New Jersey, require health insurance providers to cover supplemental imaging for women with dense breasts.
Mammograms are 98 percent accurate in finding tumors on fatty tissue. But 50 percent of cancers in dense tissue are missed on mammograms because the glandular and fibrous tissue - that's what dense means - obscures the cancers, which also appear white. A mammogram on dense tissue is like a car with a blind spot - the cancer might be there, you just can't see it.
Studies have shown that having dense breast tissue is in itself a risk factor for developing breast cancer - up to 4-6 times the risk when compared to women with fatty tissue which appears black on a mammogram in contrast to the white cancer. Supplemental screening is helpful in dense tissue because the images show tissue and tumors differently. Ultrasound, Magnetic Resource Imaging (MRI) and Molecular Breast Imaging (MBI) are excellent at finding cancers in dense tissue.
Mammography is still the gold standard because it has been proven time and again to save lives. Women with dense breast tissue still need mammograms because there are abnormalities that are only seen in mammogram images such as micro calcifications.
Your breast cancer awareness starts with a mammogram - but it's just that - a start. Here is a review of the imaging modalities I recommend and why you may or may not need to consider them. I hope this will help you navigate through the sometimes confusing and conflicting information that you read:
Digital Mammography - Mammography is excellent at finding cancers in women who don't have dense tissue. Briefly, breast tissue is made of glandular (dense), fatty and fibrous tissue. The percentages of each vary in women mostly based on genetics. As women get older, the percentage of dense tissue may decrease and be replaced by fatty tissue. However this is not always the case.
At this time, almost all radiology centers have replaced the older film screen mammography with digital mammography as digital provides images that can be analyzed faster and stored and shared more easily.
3D Mammography (Breast Tomosynthesis) - 3D mammography is an enhanced mammographic technology that acquires images at multiple angles. The images are then reconstructed, reducing or eliminating tissue overlap in areas of concern on dense tissue. Tomosynthesis has been found to decrease patient call backs by 30 percent.
WDI began using 3D Mammography when Low Dose C-View imaging software was developed. This technology cuts the radiation level of the exam and time in compression in half. We introduced Low-Dose 3D Mammography to Bergen County.
Ultrasound - I have been an early proponent of Ultrasound screening for women with dense breasts. Studies dating back to 1998 have demonstrated that adding breast ultrasound to mammography in women with dense tissue doubles the numbers of early cancers found. Since the introduction of Breast Density Notification Laws, many states, including New Jersey, now require health insurance providers to cover screening ultrasounds for women with dense breast tissue. Breast ultrasound may also be used to guide a needle during a breast biopsy. If a breast lump is found during an exam or something abnormal is seen on your mammogram, an ultrasound can help show whether it is a solid mass or a cyst.
In untrained hands, cancers are missed (false negatives) and too many insignificant findings wind up being biopsied (false positives). In recent years, as health care professionals have been getting better training and more experience performing Ultrasound, results have improved.
Molecular Breast Imaging (MBI) - MBI examines the ACTIVITY of the breast tissue. This is a great technology for women with dense breast tissue, high risk patients and women with breast implants. I use Breast Specific Gamma Imaging (BSGI) from Dilon Technologies in my practice. A Mayo Clinic study comparing MBI with mammography, found that MBI detected three times as many cancers in women with dense breast tissue. MBI also demonstrated fewer false positives than Breast MRI. MBI is also more sensitive in finding invasive lobular cancers which are often hidden on mammography, Ultrasound and in physical exams.
Magnetic Resonance Imaging (MRI) --Magnetic Resonance Imaging (MRI) looks at both structure and blood flow, with cancers showing increased areas of blood flow.
MRI is very sensitive and so can reveal tumors not found on mammograms or ultrasound. The disadvantages are high false positive rate, high cost and for some women, claustrophobia. In addition, MRI cannot be performed in women who have certain metals such as pacemakers. While WDI does not perform MRI exams, I will refer patients to facilities I know have expertise in reading the images when I think they should have this test.
Genetic Testing for Hereditary Cancer - If you have a family history of cancer, you may be a candidate for genetic testing. We use MyRisk from Myriad Genetics, a 28 gene panel that evaluates genes associated with 8 cancer sites including breast, ovarian, pancreatic, prostate, endometrial, colon, gastric and melanoma. If you were tested for BRACA1 and BRACA2 and the results were negative, you may be eligible for the rest of the MyRisk panel.
Pink is great for ribbons, bracelets and tee-shirts. But to really raise breast cancer awareness, become AWARE of your breast density and family history. It may save your life!