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PrintDon't Give Up Your Mammogram
Lucy Adams
A woman’s breasts can quicken the pulse, sustain life, symbolize femininity and represent fertility. Some are large. Some are small. Some are significantly altered from their original rendering. All of our efforts to display, control, contain and augment indicate the breast’s importance to men and women, alike. A woman’s breasts probably elicit more complex spontaneous emotions than any other outwardly visible body structure.
But juxtapose the words “breast” and “cancer” and the result is the makings of a perfect emotional maelstrom. The debate that began in 2009 over breast cancer screening did nothing to quell the fear while creating confusion. Early in November of 2009, women awoke to the news that the U.S. Preventive Medicine Task Force recommended against routine mammograms for women under age 50, recommended against teaching women breast self-exam and touted biennial mammograms for women ages 50 to 70. The basic message was that the benefits of these screening exercises did not outweigh the costs.
Very likely when hearing the 60-second sound bite on their commute into work or while washing the breakfast dishes or during the daily carpool schlep, many women who had been putting off a mammogram felt bolstered in their procrastination. The conflict between urgency and avoidance abated, though the dread of contracting cancer probably did not. The American College of Obstetrics and Gynecology (ACOG), however, continued to hold fast to its recommendations for yearly mammograms for every woman age 40 and over as well as its recommendations for breast self-exam. Multiple other organizations such as the American College of Radiology, the Society of Breast Imagery and Susan G. Komen for the Cure support ACOG’s recommendations.
“The problem with what [the Task Force] recommended,” says Dr. Randy Cooper, co-medical director of University Hospital’s Breast Health Center, “is that if you find a cancer on a mammogram and you cannot feel it, the survival is probably going to be 90-plus percent. Whereas, if you present with a palpable breast cancer, a lot of times the survival drops down to 60 or 65 percent.” Citing a 10-year study out of the University of Missouri, Dr. Cooper explains that mammograms are able to detect very small cancers of about two centimeters or less. Breast cancers detected by a physician during a clinical exam tend be larger, in the three-centimeter range. The larger the mass, the more likely lymph nodes are to be involved, making not only the cost and complexity of treatment increase, but also the mortality rate. He says, “There’s no question that you can cut mortality by finding cancer on mammography.”
By no means, however, is he suggesting that women place all of their confidence in technology and skip monthly breast self-exams (BSE). Though there has also been controversy over the need for and effectiveness of BSE, another sound bite that relieved some reluctant women from that to-do list duty, it is a screening technique that may catch some of the 15 to 20 percent of breast cancers that do not show up on mammography. While he acknowledges that the research, when considering sample sets in the thousands, doesn’t result in overwhelming support of the effectiveness of BSE, he maintains that for the individual woman who finds a suspicious lump in her breast it makes all the difference. “There’s one thing for sure,” says Dr. Cooper. “Checking your breasts is not going to hurt you. It just doesn’t make sense to tell people not to check their breasts.”
The news report most women probably did not hear was that a recent study out of Norway demonstrated about a 10 percent reduction of death due to breast cancer as a result of routine mammograms, study results that many physicians, including Dr. Suzanne Thigpen, contend ended the debate that the U.S. Preventive Services Task Force ignited. “Mammography is not perfect,” says Dr. Thigpen, a seasoned radiologist and former lead mammographer at the Breast Health Center at Georgia Health Sciences University. “We’ve known that. It’s the best tool, however.” Routine mammograms enable a physician to identify new masses, areas of distortion or calcifications. General change in the size of the breast, skin thickening and increase in the total amount of breast tissue also become apparent when images from each year are compared across time. And with mammogram technology rapidly improving, odds are that mortality rates will continue to drop.
A mammogram, which is a four-view X-ray, two views of each compressed breast—a top to bottom view and a view diagonally from the upper inside quadrant to the lower outside quadrant—that reveal what the glandular tissue looks like all the way back to the chest muscle plus lymph nodes, was originally read on X-ray film. Developed in 1969, these images provided a breakthrough in early diagnosis of breast cancer and are still used. The combined cost of performing and reading a film mammogram is approximately $180.
Since the FDA approved the first digital mammogram machine in January of 2000, digital mammography has increasingly, if not nearly altogether, replaced film. A digital mammogram is superior to the film version for multiple reasons. Using digital equipment, patients are exposed to less radiation and have more detailed images that are digitally recorded. Radiologists can then manipulate the images to see any questionable spots under greater magnification and with altered contrast. Often digital mammograms eliminate the need for a patient to return for tests, like a repeat mammogram, an ultrasound or a biopsy, just to rule a suspicious area as non-cancerous. The cost of an annual digital mammogram screening, about $275, includes the technician and physician fees and is covered by most insurance plans for women over 40.
Advances in breast screening technology continue to be explored. One of several screening technologies being researched is tomosynthesis, or 3-D imaging. It enables radiologists to see through breast tissue to examine structures in relation to one another, according to Dr. Thigpen. GHSU is on the front lines of employing this breakthrough technology approved by the FDA last February. “Tomosynthesis allows the radiologist to see through the tissue and between layers of the tissue,” Dr. Thigpen explains. Exposing a woman to even less radiation than digital mammography, it provides a clearer picture of what is happening inside the breast, resulting in fewer false-positives, thus fewer patients being called back for further exam, Dr. Thigpen says.
These are thrilling times in the battle against breast cancer. Dr. Thigpen’s tone reveals her excitement as she says, “I project that [tomosynthesis] is the new state-of-the-art. We are on the cusp of something wonderful.” Because it is so new, 3-D imaging currently has no billing code for insurance companies. The FDA will review the use of the technology by institutions such as GHSU over the course of one year to determine the technical and professional costs and set a consumer price.
Commonplace use of tomosynthesis in doctors’ offices for routine screenings is, nonetheless, not in the imminent future. For now, digital mammography remains the technology that most doctors use to screen their patients for breast cancer. Dr. Ron Eaker, obstetrician and gynecologist with Women’s Health of Augusta, says, “Digital mammography has essentially become the standard in most communities. Many offices offering mammography either already do the digital imaging or are in the process of converting to that.” Women whose physicians’ offices only offer film mammography may request a referral for a digital mammogram. Insurance companies generally reimburse for either. Dr. Eaker warns, however, “It is important to realize that digital is not a panacea nor does it detect all cancers.”
With an incidence rate of 30 percent in pre-menopausal women and 50 percent in post-menopausal women, proper screening methods are essential for early diagnosis. Digital mammography, according to the National Cancer Institute (NCI), is significantly better at detecting breast cancers in three groups of women: (1) those under age 50; (2) those of any age who have very dense breast tissue (meaning tissue that has a high ratio of connective tissue to fatty tissue); (3) those who are pre-menopausal or peri-menopausal. For a woman who is over age 50, has fatty rather than dense breast tissue and is no longer menstruating, digital and film are equally accurate, according to the NCI.
American Cancer Society (ACS) guidelines recommend that women in their 20s begin monthly breast self-examinations, get a yearly clinical exam by a physician and, beginning at age 40, have an annual mammogram. Some women should have a periodic breast MRI, based on family history, genetic tendency or other factors, according to the ACS. Early detection results in treating smaller cancers. Treating smaller cancers results in a higher cure rate. A higher cure rate results in fewer deaths due to breast cancer.
Though the chance of developing breast cancer is much lower for young women than for older women, the risk of mortality is much higher. Dr. Thigpen warns that younger women tend to get more aggressive cancers than do older women. Discussing the risk factors with your doctor may lead to a recommendation to initiate mammogram screenings before age 40. Women who have never had children, had a first child after age 30, started menstruation before age 12, began menopause after age 50 or who have a mother or a sister diagnosed with breast cancer are at greater risk. If a woman’s sister or mother has a history of pre-menopausal breast cancer, advises Dr. Cooper, she should begin annual mammograms at an age 10 years younger than the age at which the sister or mother was diagnosed.
Some women may find comfort in knowing that there are things they can do, other than identifying risk factors and attending to routine screenings, to preserve and protect their breast health. Daily exercise, maintaining a healthy weight and avoiding excessive alcohol use are within a woman’s control. A diet that includes adequate amounts of folate (0.4 mg per day) and vitamin D (400-800 IU per day), as well as nutritious foods, also aids in buffering her against breast cancer. Above all, be smart. Don’t ignore a lump. Don’t let fear trump the power of technology. Don’t put off until next year what you should be doing today.
