Tag Archives: Breast Cancer

Mammogram Nonsense is Keeping me up at Night -by Ryan Polselli, M.D.

Last night I read the following question on a public Q & A forum:

Why are doctors still ordering mammograms when I’ve seen it reported in several reputable sources that mammograms don’t reduce cancer risk via early detection, and may cause cancer?

The question, from a non-medical professional, I thought, was fair. I understand that there is a lot of confusion among patients and the public about screening mammograms. However, one of my colleagues, an oncologist, attempted to answer this question and actually agreed with the premise! I was floored by his answer. What nonsense! I couldn’t sleep. How could any physician hold this belief? I tossed and turned for an hour. At 3 AM I went into my office to write my own answer. Here it is…

element-of-confusion

Screening mammography is one of the biggest successes in modern medicine. Period. It is the poster child for a successful screening program. There is not an educated person in the world that can argue or would even attempt to argue that mammograms don’t save lives.

If you are a woman and you want to increase your chances for living longer, wear your seat belt, eat well, exercise, and…get your mammogram.

All major organizations in the United States and countries of the modernized world that have repeatedly analyzed the data have all come to the same conclusion and continue to recommend mammograms in order to save lives.

This includes the American Cancer Society, the United States Preventative Services Task Force, The American College of Radiology, Society of Breast Imaging, the American Congress of Obstetricians and Gynecologists, and the National Comprehensive Cancer Network, among others.

Unfortunately, to answer part of your question, for reasons that are hard for me to understand, it seems that lately harmful hysteria and disinformation that flies in the face of science and logic have been shamefully making their way into cult culture and even to a degree mainstream medicine.

With all due respect, look no further than the former answer by one of my oncology colleagues. He says, “Routine mammography has resulted in a huge increase in the number of women diagnosed with breast cancer but no corresponding decrease in mortality.” This could not be further from what the overwhelming majority of evidence demonstrates.

For example, randomized controlled trials of women invited to screening mammography (traditional screen film) from 1963 to 2000 demonstrate early detection and treatment of breast cancer have reduced the proportion of late stage breast cancer and led to a 20–30% decrease in mortality among these women.

Additionally, more recent data using more modern equipment and techniques have demonstrated even larger gains. In some age groups and demographics, this results in a near 50% decrease in mortality. This data is now well established and has been reproduced multiple times in multiple studies in several countries throughout the world including the United States, Canada, and Europe. (Broeders, et al. 2012; Lee, et al. 2010; Oeffinger et al 2015; Siu 2016).

So why is there any confusion about this subject at all?

One possibility is that the ideal frequency and timing when women should obtain mammograms is not as clear cut as their well established effectiveness. That is not because they may not be doing their job, but that at some point, the more you screen, the less the screening returns any significant results and the more that screening may begin to result in harm.

For example, it does no good to screen for breast cancer with a mammogram every day, every week, or even every month. As the author of this question rightfully points out, a small dose of radiation is given to the breast with every mammogram and it’s very unlikely that anything will change on a daily, weekly, or even monthly basis. Additionally, mammograms can sometimes result in extra biopsies which turn out to be nothing to worry about. So a few organizations have started to try and tweak the traditional yearly mammogram recommendations. However, this does not mean in any way that mammograms don’t work and don’t save lives!

The first organization to tweak the traditional recommendations was the United States Preventative Services Task Force (USPSTF). This organization is the somewhat “rogue” group that for better or worse likes to challenge the status quo in the medical world. In 2009, they changed their recommendation to state that a woman should have a mammogram every other year beginning at age 50 instead of every year beginning at age 40.

Their recommendation was based largely on the fact that they didn’t feel the extra cancers that would be detected or the advantage of earlier detection with an annual regimen were worth the extra biopsies that would be needed and the anxiety that they would produce. It was not based on the number of lives saved nor focused on radiation to the breast. In fact, their data acknowledged that more women would die from their recommendations, but that the number was acceptably small and not worth what they consider harm largely in the form of anxiety from extra biopsies.

You can now understand why this recommendation sent shockwaves through the medical community and became (and remains) one of the most hotly debated decisions in modern medicine. If you are interested in more detail about this decision, read an article I wrote here:

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

One final note in conclusion to try to completely answer the question. It is true that mammograms do give a dose of radiation to the breast. The best data I have available to put this into perspective in terms of risk benefit for a patient is as follows:

The potential risk from radiation to the breast is the risk of inducing a fatal breast cancer. For a woman at the age of 65 this risk (from a single mammogram) is estimated to be 0.3 in 100,000 (Hendrick 2010).

However, the benefit is the detection and treatment of cancer before it is clinically apparent. In this age group the likelihood of this is about 1 in 500. Furthermore, the chance that this detected cancer would be fatal without a mammogram is about 1 in 4.

In short, if you do the math, the benefit to risk ratio for a mammogram in this age group is somewhere between 90:1 and 180:1.

As you can see, like I said in the beginning of this article, if you are a woman and you want to live longer, do not bet against odds like this and get your mammogram. I hope this helps clarify some of the mammogram nonsense floating around out there.

Ryan Polselli, M.D., Diplomate of the American Board of Radiology, Fellowship Trained Breast Imaging Radiologist

Please note that this blog is intended for general informational purposes only and is not intended to be medical advice.

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Breast Implants and Anaplastic Large Cell Lymphoma (ALCL): Should I be Concerned? —by Ryan Polselli

There are an increasing number of reports in the media lately about a new relationship between breast implants and an extremely rare form of cancer showing up in the breasts. Notice that I did not say breast cancer. That is because although this cancer is found in the breast, it does not appear to arise from breast tissue.

ALCL
ALCL surrounding the breast implant in the right breast

This cancer, known as Anaplastic Large Cell Lymphoma and commonly referred to as ALCL, started showing up in cases of women that had persistent fluid accumulation within the fibrous capsule that the body forms when the implant is placed within the breast. Although fluid collections around the implant sometimes occur when the implant is initially placed, this fluid was showing up years after placement and seemed to persist despite typical treatment. As a result, some of these women underwent a second surgery in an attempt to correct the problem. When the fluid was sent for analysis, the cancerous cells were detected.

Reports of this phenomena started showing up in the literature until there were enough eyebrows raised to launch an official investigation by the FDA. Until recently, ALCL was known to be an extremely rare cancer that could involve the breast, but was better known for showing up in other areas of the body. Although it was known to occur in approximately 1 in 500,000 women each year, it only showed up in the breast 3 times for every 100 million women each year. The compilation of all the cases reported however, showed that it had shown up in the breasts of women with implants approximately 60 times worldwide when the total number of implants was estimated between 5 and 10 million.

So what has been concluded from these 60 cases worldwide? Only 34 of these cases had data reported that was deemed reliable enough to be included in the FDA’s study of cases from 1997 though 2010. From a statistical standpoint, there was not enough data to reliably determine any defining characteristics. ALCL occured in both implants with silicone and saline that had been placed for the purpose of reconstruction and augmentation.

There are some reports in the media stating that it is likely that the cancer is being caused by implants that are textured. This is because of the 4 cases of cancer in which the implant shell texture was known, they all happened to be textured. However, this could still be coincidence. We still don’t know what type of shell was involved in the remaining 30 cases.

Because more information is still needed, the FDA has formed a registry in association with the Society of Plastic Surgery to record all cases of ALCL. The FDA is requesting all confirmed cases of ALCL in women with breast implants to be reported to the FDA. The FDA has agreed to keep the reporter and patient’s identity confidential.

So what does all this mean for the average woman with breast implants. In short, don’t be alarmed. The incidence is so low and still so little definite information is known at this point that there is no need to run to your local surgeon to have breast implants removed. In fact, it is the official recommendation of the FDA at this point that implants should not be removed unless there is medical reason. The FDA continues to stand by the overall safety of breast implants when used appropriately.

Ryan Polselli, MD, Diplomate of the American Board of Radiology, Fellowship Trained Breast Imaging Radiologist

Note, this article is for general informational purposes only and is not intended to be medical advice

What is Breast Tomosynthesis and 3D Mammography?

Breast Tomosynthesis is better known by most patients and physicians as 3D mammography. However, the use of the term “3D” is a bit misleading. There are no 3D glasses to wear as one would typically expect when viewing a 3D image or movie and nothing “pops” out of the screen in the traditional “stereoscopic” sense.* The images actually appear as “flat” 2D images but are taken at multiple angles relative to the breast and then synthesized to appear as numerous thin traditional 2D images of the breast. This enables the radiologist to look at a single picture for essentially every millimeter of thickness through the breast. Depending on how thick the breast is when compressed, there can be 70 or more images for each view of each breast. In total, there can be 300 or more images created for each mammogram. The term 3D was initially introduced for the purpose of marketing directly to the consumer and to a lesser extent the medical community, but has since become so entrenched in our vocabulary that it’s here to stay.

Ryan Polselli
2D mammogram and 3D mammogram from same patient. The 3D mammogram on the left shows the breast cancer more clearly.

A useful way to understand the concept is to imagine superimposing all the individual tomosynthesis images.  The resulting image would be very similar to the traditional 2D digital mammogram that has been the mainstream of mammographic screening for the last 10 years or so. The advantage of separating the images with tomosynthesis is that it allows the breast imaging radiologist to “see through” the normal breast tissue which can traditionally “overlap.” The image above is a good example. This traditional “overlap” causes 2 main problems. It can hide underlying cancer and it can occasionally overlap in such a way to look suspicious for cancer when there is actually no cancer present. These two problems with the traditional 2D mammogram result in decreased cancer detection rates and more patient recalls for additional imaging to look for cancer that is not there. In other words, 3D mammograms (breast tomosynthesis) detect more breast cancers and results in less false alarms.

Numerous scientific studies have now demonstrated the benefits of 3D mammogram. Among them, a study published in the Journal of the American Medical Association (JAMA) in 2012 involving nearly half a million women demonstrated a significant increase in the breast cancer detection rate and the simultaneous decrease in the recall rate with breast tomosynthesis when compared to standard 2-D digital mammography.

In January of 2015, Medicare was the first insurer to begin reimbursing for breast tomosynthesis. More recently, in August of 2016, Cigna, inspired by the mammogram recommendations of the National Comprehensive Cancer Network (NCCN), became the first private insurer to begin reimbursing for breast tomosynthsis.  More recently, as of April 2017, Anthem and UnitedHealthcare have also reported that they will reimburse for 3D mammogram. Largely as a result of recent studies documenting cost saving and increased breast cancer detection rates, several states including New York, Texas, New Jersey, New Hampshire, and Maryland have introduced bills seeking mandated insurance reimbursement for patients seeking to undergo breast tomosynthesis in their states.  In the future, as the technology becomes more widespread, there will likely be an increasingly larger network of insurance companies that reimburse for breast tomosynthesis.

From the patient perspective, there is nothing noticeably different from having a 3D mammogram when compared with the 2D mammogram other than the “arm” which takes the mammographic “picture” will rotate slightly when obtaining the exposure. Unfortunately compression is still required and the experience is still uncomfortable. Patients that are pre-menopausal can minimize any discomfort by obtaining a mammogram approximately 1 week after a period or if medically appropriate, taking an anti-inflammatory before the procedure.

Ryan Polselli, M.D., Diplomate of the American Board of Radiology, Breast Imaging Radiologist

Please note, this is for informational purposes only and is not intended to be medical advice.

*Note, Fujifilm does market a traditional stereoscopic 3-D viewer, but the technology has not yet been adopted into mainstream clinical practice.

What Every Woman Needs to Know about Breast Thermography

Fluoridation of water exists to mask bad dental care to the poor. Vaccinations cause autism but the proof has been suppressed by a massive pharmaceutical company cover-up. HIV is an artifical disease created by the CIA. Condensation trails from aircraft represent the emission of biological and chemical agents into the atmosphere.

If you believe in any of the above or similar conspiracy theories, this article is not for you. However, if you believe in the scientific method and that properly applied scientific knowledge can improve health and prolong life, stick around.

Ryan Polselli

 

There is an increasingly popular trend in the field of breast cancer screening. Many patients are turning to Thermography as an alternative to traditional mammography. Thermography is an older technology that uses a special camera to take infrared pictures of the breast looking for relative hotspots which are supposed to correlate with breast cancer. There is no ionizing radiation involved and it’s painless.

The theory being used to support it’s effectiveness is that tumors have increased metabolic activity and vascular recruitment which produces heat. This heat can then supposedly be detected in the form of a visual hotspot. While the gross concept is generally sound and it is true that some tumors produce more detectable heat than the surrounding tissues, many don’t.

But what do the scientific studies show? A complete review of the scientific literature demonstrates that Thermography does not reliably detect breast cancer or prolong life. In essence, Thermography is no more effective at detecting the important forms of breast cancer than throwing darts in the dark. The lack of effectiveness is likely due to the fact that breasts have a natural variation in background heat levels which mask or minimize any potential detectable heat difference between breast cancers, espeically when the cancer is small or slow growing.

So for those women wishing to improve chances of survival for a disease that shows up in 1 in 8 women, stick with traditional mammography and ignore the anecdotal stories of Thermographic success which can be found throughout the internet…along with the stories of chemtrails and vaccination cover-ups.

Note, this is post IS intended to be medical advice.

Ryan Polselli, M.D.

Diplomate of the American Board of Radiology

Fellowship Trained Breast Imager

Breast Cancer Screening: Technology or Radiologist

There’s a lot of press about the importance of a 3-D mammogram (breast tomosynthesis) and how much better it is in terms of detecting cancer than the traditional 2-D (standard digital) mammogram.

Here’s a little known secret:

While it is true that there is a difference in the cancer detection rate between the two technologies, what I notice on a daily basis is that the most important consideration for a patient should actually be who interprets their study.

A mammogram is one of the most subjective radiological studies in the field of radiology and there are huge differences in the breast cancer detection rates between radiologists.

I often see breast cancers that were missed (on both 2-D and 3-D mammograms) that would have been detected if a different radiologist had interpreted the study.

Interestingly, most of these statistics are recorded and regularly reported for radiologists. However, they are rarely made public. In part, there is resistance to releasing data such as this because of the potential for misinterpretation by patients and the public in general.

However, today’s patients are increasingly sophisticated and it is my personal opinion that it may be time to bring awareness to this topic.

-Ryan Polselli, M.D.

Fellowship Trained, Breast Imaging Radiologist

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

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

Ryan Polselli
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.