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.
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.
This image demonstrates the consequences of injecting free silicone into the breast.
Patients looking for a quick and cheap fix to enlarge their breasts sometimes resort to injecting silicone (frequently automotive grade silicone from a tube).
For patients that are lucky enough to avoid some of the initial risks such as infection, the initial breast enlargement is short-lived. As the breast tissue reacts to the free silicone, it always forms an extremely lumpy, marble-like appearance that is essentially permanent. Patients that wish to correct the appearance must undergo extensive surgical reconstruction that still leaves the breasts disfigured.
Although this practice has been around for several years, it is surprising that it continues.
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.
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.
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.
The discussion resulting from Angelina Jolie’s decision to undergo elective mastectomy has generated a few questions that should be clarified.
Angelina Jolie has a known defect in her genes that puts her at a higher risk for developing breast cancer than most women. The defect occurs in a part of her genetic makeup that has been labeled BRCA1. The BRCA1 genetic defect carried by Angelina Jolie gives her up to an 80% chance of developing breast cancer at some time in her life.
There are many other known genetic defects that can put a person (including males) at a higher risk for developing breast cancer. All of these defects are relatively uncommon. Roughly, the defects occur in less than 2-3% of the population, although there is variation between different races. The presence of the genetic defect does not imply that a patient will definitely get cancer. Likewise, the absence of any known genetic defect does not imply that a patient will not get breast cancer.
Genetic testing for the presence of the more common known genetic defects in the sequence BRCA1 (and BRCA2) can be determined with a blood test. However, this test typically costs several hundred to a few thousand dollars. Without a very strong family history of breast cancer (breast cancer in multiple first degree relatives) or breast cancer diagnosed at a young age (typically under the age of 40-50), it is very difficult to get insurance to pay for the test.
One option to manage this high risk is known as prophylactic bilateral mastectomy. A breast surgeon can remove the majority (but not all) of the breast tissue in both breasts. Because the majority of the breast tissue is removed, there is significantly lower risk for developing breast cancer. However, breast tissue that is too close to the skin, muscle or other vital structures cannot be completely removed. Therefore, there is still a small risk of developing breast cancer after the surgery. Also, the surgery is much more complicated than most breast surgeries such as breast augmentation and carries a higher risk of serious complication.
Once the majority of breast tissue has been removed and the area has healed (many months), there are options to reconstruct the breast and give a more normal appearing breast contour which include breast implant augmentation. However, this reconstructive process is much more complicated than typical breast augmentation and the end result is never as aesthetically pleasing.
I commend Angelina Jolie for publicly sharing her experience with us and undoubtedly inspiring many women facing similar decisions.