Is it Time to Move on from the Preoperative Wire Localization?

For those unfamiliar, preoperative wire localization is the procedure performed on the overwhelming majority of patients undergoing lumpectomy or excisional biopsy prior to surgery. The general idea is that one or more needles and wires are inserted into the area in question before surgery with imaging guidance to assist the surgeon in removing the correct area of the breast that could not otherwise be felt or seen by the surgeon. The procedure remains essentially unchanged from its development in the 1970s and has been performed on millions of women and thousands of men across the United States. Although without question this method is cheap, reliable, and effective, it also suffers from some limitations.

One limitation is that the wire must be inserted on the day of the procedure, most often immediately before surgery. This not only creates an inconvenient rate-limiting step for all parties working the patient through the modern day surgical process, but more importantly it can become a safety issue. The pressure to rapidly move patients through the procedure on the day of surgery can be a source of latent errors. I have witnessed at least one sentinel event root cause analysis committee list an impatiently waiting surgical team and “time-crunch” as a reason for the wrong area of the breast being localized and subsequently removed.

Another important limitation often overlooked is patient comfort. At best, following the procedure a wire (and sometimes needle) is left dangling out of the breast with an awkward tape-job which sometimes includes a styrofoam cup or other device taped to the patients’ chest in order to secure the wire and or needle in an attempt to keep them from becoming dislodged and out of site. In patients requiring more than one wire for surgical planning, it can leave the patient looking like some awkward form of radio-frequency receiver. Both cases leave the patient feeling uneasy, sometimes even grossly nauseated while looking at their breast with wires hanging out of it prior to surgery. Quite simply the look and feel from the patient perspective is “barbaric.”

Throughout the years there have been numerous devices and procedures to improve on the traditional needle localization, but none have ever taken root in mainstream clinical practice patterns. There is a newer method however, which appears in my mind to potentially hold enough promise to prompt change from years of habit it in the breast imaging and surgical community. Specifically, the new device implants special reflectors in the breast that allows for radar localization. This allows for placement many days before surgery if needed and does not make the patient feel as uncomfortable. This month, original research was published about this method in the journal of Radiology that examined the effectiveness of this method using the Scout device in 100 women over the course of a year. The results showed that it was effective for localizing breast lesions even when reflectors were placed closely together to “bracket” the lesions.

Beyond Wires and Seeds: Reflector-guided Breast Lesion Localization and Excision. 

Given this evidence and the above considerations, I think this is an excellent time for the breast imaging and surgical community to start seriously considering changes or at least alternatives to the traditional wire localization procedure.

Ryan Polselli, M.D.
Fellowship Trained, Breast Imaging Radiologist

What Really was Said at the Water Cooler in 2009: USPSTF Breast Cancer Screening Recommendations and Current Physician Practice Patterns

In 2009 the United States Preventative Services Task Force (USPSTF) updated their now infamous breast cancer screening recommendations. In their report, the so-called experts (many of whom had no direct affiliation with patient breast cancer screening) voted that a total of 12 mammograms throughout a woman’s lifetime should be enough to effectively screen women for a disease that is the second leading cause of death among women in the United States and kills an average of 40,000 women every year.

These new recommendations came at a time when studies throughout the world were repeatedly confirming annual screening mammograms reduce breast cancer deaths anywhere between 30-45% with newer advances in screening and treatment decreasing the death rate an additional 2.5% each year. In essence, the recommendation to cut back on screening mammograms was made by the USPSTF at a time when mammography was being hailed as the poster-child of a successful cancer screening program.

Not unexpectedly, when the report was originally released, most of the medical community and media gathered around the report like co-workers around the water cooler—everyone expected to discover the missing piece of evidence—perhaps there was some flaw in the system and perhaps mammograms were not as useful as we thought?

However, a review of the report still left most of the medical community scratching their heads. The report contained no evidence that mammograms were not doing their job or saving lives. There was actually evidence to the contrary. In fact, the USPSTF data even acknowledged that if their recommendations were followed, additional women would die. Some experts even estimated that up to 100,000 more women would die over time if the recommendations were adopted into mainstream clinical practice. Sure, most of the medical community understood the report was trying to make an argument for the potential harms that a woman could endure as a result of over-diagnosis from too many mammograms, but they couldn’t justify the lives lost. As a result, most in the medical community left the water cooler that day and returned to their desks unswayed from their decision to recommend annual mammograms. Most believed the task force simply voted the wrong way and that ultimately there was no more to the story.

But the story didn’t actually end there.

The majority of the media and a few impressionable souls in the medical community remained gathered around the water cooler that day. While the concept of mortality in the setting of breast cancer screening was perhaps the “real” news of the day, it wasn’t “exciting” news and quickly became overshadowed by discussion of the relatively new and intriguing concept of “over-diagnosis.” By 6 o’clock, all major networks became pseudo-educators for the masses and carried stories about the “harms of over-diagnosis” from annual screening mammography. In some circles, knowledge of the concept even became a surrogate marker for supposedly intelligent discussion of breast cancer screening. 

All of this occurred without significant mention of the fact that more of the women we love—wives, mothers, and friends would die if these recommendations were adopted.

This month, JAMA Internal Medicine published a research letter showing that most practicing clinicians continue to recommend annual screening mammograms contrary to the USPSTF recommendations. While that’s no surprise, you wouldn’t know it by the recent headlines. You would think most doctors have lost their minds. I even read one article that went so far as to suggest insurance companies should take the lead and quit paying for yearly mammograms. Think about that for a moment. In any event, it seems that now is a good time to remind a majority of the media and some in the medical community about the original takeaway from the “water cooler discussion” in 2009.

Ultimately and always—Do no harm.

Ryan Polselli, M.D.
Breast Imaging Radiologist

How Reliable is Breast MRI compared to Mammography and Ultrasound?

This is one of the most important questions in the field of breast imaging today.

It is important to keep in mind that there are widely varied opinions about this question depending who you ask. As a breast imaging radiologist, my opinion may differ from physicians in other specialties. My opinion, however, is formed from all prior studies and current research, as well as personally interpreting hundreds of thousands of mammograms, tens of thousands of ultrasounds, thousands of breast MRI’s, and diagnosing hundreds of breast cancers each year.

I could spend significant time discussing the relative “reliability” of breast MRI in scientific terms of sensitivity (how likely breast MRI is to detect breast cancer when it is present) and specificity (how likely breast MRI is to be correct when it shows what looks like breast cancer), but I think the message would be lost, so I will do my best to answer the essence of this question based on my opinion in the simplest terms.

First, mammography saves lives. Independent studies in the United States and several countries throughout the world have demonstrated time and time again that annual screening with mammograms reduces the number of deaths from breast cancer anywhere from 20–48%. Recent studies have demonstrated that the newer 3-D technology is even better than the traditional 2-D mammogram in terms of detecting more cancers.

As a result, annual screening mammograms are generally recommended by the majority of major health organizations such as the American Cancer Society, The American College of Radiology and the Society of Breast Imaging, The National Cancer Comprehensive Network, the American Medical Association, and others. However, in addition to mammography, breast ultrasound and breast MRI are increasingly playing large roles in breast cancer screening.

Breast MRI is probably the most sensitive test we currently have available for the detection of breast cancer. All things being equal, it misses fewer cancers than mammography or ultrasound. While it is more common that a breast cancer cannot be seen on mammogram but shows up on breast MRI, it occasionally happens that a breast cancer cannot be seen on breast MRI which shows up on a mammogram. For this reason, breast MRI and mammogram are considered to be complementary tests.

It is currently recommended by the American Cancer Society, the American College of Radiology and other organizations that women with high risk for breast cancer undergo annual breast MRI in addition to annual mammogram. If you want more detailed information about breast MRI see this recent article I wrote for SW Florida Health and Wellness Magazine:

What Every Woman Should Know About Breast MRI 

Recent research however, is demonstrating that breast MRI may even be useful for women at average lifetime risk of developing breast cancer. If you want more information about this research see this article from one of my earlier posts here:

Screening MRI Benefits Women at Average Risk of Breast Cancer

Although breast MRI is extremely powerful, one of the criticisms is that it can occasionally be difficult to differentiate some forms of active but normal breast tissue (and other findings) from certain forms of breast cancer (usually low grade breast cancers). This becomes more of an issue when someone who does not have extensive experience reading breast MRI attempts to interpret a study, or when the facility performing the study, does not do a sufficient number of breast MRI’s to produce consistent or high quality images.

Breast ultrasound can also be a useful supplement to mammography, but is highly dependent on the ultrasound technologist and equipment and can be a worthless test in the wrong hands. It will undoubtedly miss more cancers than breast MRI, but occasionally demonstrates cancers that cannot be seen on mammogram. However, there are several forms of breast cancer which are not seen on ultrasound and therefore ultrasound should never be substituted for a mammogram.

I could go on and there are many other complex considerations to this question, but I feel these points are some of the most important considerations at the present time. With the amount of confusion there is out there regarding this question, I like to take the time and educate where I can. Hopefully, this has been helpful.

Ryan Polselli, M.D., Breast Imaging Radiologist

This answer is for general informational purposes only and is not a substitute for professional medical advice. Always seek the advice of your doctor before starting or changing treatment.

Should I Have a Mammogram Yearly or Every Other Year

I have written about this before, but I receive so many questions about this on a daily basis that I want to revisit the question.

There are organizations that advocate both.

Organizations such as the United States Preventative Services Task Force (USPSTF) advise mammograms every other year. They acknowledge that many cancers will be missed with this model, but they believe the number is “small” (it is estimated an additional 100,000 women will die as a result of the recommendations) but they believe this is outweighed by the anxiety, additional biopsies, and the potential for misdiagnosis that can occur by yearly mammograms.

Organizations such as the American College of Radiology (ACR), still recommend yearly mammograms because they believe the number of lives that will be saved by yearly screening far outweighs the anxiety, the extra biopsies, and the potential for misdiagnosis.

I personally want every important woman in my life to have a mammogram every year because I am more concerned that they could end up as one of the 100,000 women that will die from a missed cancer than I am that they could experience some anxiety, an extra biopsy, or misdiagnosis.

But this may not be the right decision for everyone and most importantly I believe in patients being given all the facts…and the freedom…to make their own choices.

-Ryan Polselli, M.D.

Fellowship Trained Breast Imaging Radiologist

Breast Pain

Ryan Polselli

Breast pain is one of the most common complaints heard by a breast imager.  It inevitably generates a lot of questions. Because it is so common, over time I have developed somewhat of a standard speech for patients that answers the most common questions and concerns. This is what I usually say:

The good news is…breast pain is almost never associated with breast cancer. Cancer almost always presents as a painless lump in the breast. Having said that, we don’t like to take any chances and we fully investigate the cause of the breast pain. Once we have completely evaluated the cause of the pain, and if we find nothing concerning with the history, the physical examination, and the imaging findings (mammogram and ultrasound), we are as certain as we can be that there is nothing to worry about from a cancer screening standpoint.

The bad news is…breast pain is not easily treated. There is one proven, tried and true therapy that will relieve some of the pain…anti-inflammatory pain relievers such as ibuprofen or naproxen (Advil or Aleve).  However, there are many patients that cannot and or should not take these medications so check with your referring physician first. There are a couple of other therapies that vary in their effectiveness depending on the patient. Some patients swear that eliminating or cutting back on caffeine intake significantly reduces or eliminates the pain while others say it has no effect. Some patients  also report benefit from vitamin E supplementation while others do not. Of all of the therapies that I have heard patients try, these are the only ones that are consistently mentioned to me to provide relief.

There are always specific questions and I do my best to answer them. After all questions have been answered I always like to express one final thought…I am always happy to have a patient investigate any breast concern no matter how “small” or “trivial” that a patient may think it is…because you never know…and in this field it can never hurt to exercise a little caution.

Ryan Polselli, M.D.

Should Women Have Regular Mammograms?

Ryan Polselli

In general, most women should have a screening mammogram once a year beginning at the age of 40. If a woman is at a high risk for developing breast cancer then earlier screening may be advised.

High risk is typically defined as a known genetic defect (such as with Angelina Jolie), a family history of early (before menopause) breast cancer, prior breast cancer, and a few others. There are risk calculators available on the web if you think you may be at a higher risk.

Also, there are many mammography clinics which do not require a referral for screening mammograms and some will accept walk-ins.

Ryan Polselli, M.D.

What Type of Breast Implant is Best for Reconstruction after Breast Cancer?

Ryan Polselli

There are multiple options available for reconstruction of the breast following breast cancer surgery (oncoplastic breast surgery). In the setting of augmentation required for symmetry of the breast, flaps of tissue from the patient’s own body (such as the abdomen) or synthetic implants can be used. Synthetic implants commercially available include saline, silicone/gel and combination products.

From an aesthetic perspective, the choice is best made in consultation with your plastic/breast surgeon. From the viewpoint of a breast imager (radiologist) in terms of future breast cancer screening, there are pros and cons to each of the options, but none overwhelmingly outweigh any other. Officially, there is no recommendation.

Ryan Polselli, M.D.