3D Mammography: Hype or Hope?

3D Mammography represents one of the most significant advances in breast cancer screening and prevention for all women in nearly 4 decades (when mammography was first adopted in 1969).
The American Cancer Society’s estimates for breast cancer in the United States for 2014 are:

About 232,670 new cases of invasive breast cancer will be diagnosed in women.
About 40,000 women will die from breast cancer.
Conventional 2D digital mammography is the most common screening method for breast cancer. But researchers say this technique may flag findings that turn out to be non-cancerous. These findings, known as “false positives,” lead to higher patient callback rates, meaning some women are required to return for further scans or biopsies that may be unnecessary. Early detection is the most effective tool in approaching breast cancer. Tomosynthesis technology, also known as a 3D Mammogram, allows radiologists to see cancer more easily, and sooner than ever before. Studies have shown that with 3D Mammograms, 35% more cancers are found earlier.*

Another great advantage of 3D mammography is that it helps avoid follow-up imaging and biopsies and the anxiety that comes along with those call back appointments. The study shows a significant drop in the need to be called back – 38% lower recall rates* – and an 11% drop in biopsy rates.*

3D Mammography may also be particularly useful for detecting cancer in women at high risk of developing breast cancer including those with dense breast tissue and/or a family history.

In another study at the Perelman School of Medicine at the University of Pennsylvania, results revealed that, compared with 2D digital mammography, tomosynthesis (3D) reduced the average patient recall rate from 10.4% to 8.78%, and it increased the cancer detection rate by 22%. Furthermore, the proportion of positive screening mammograms from which breast cancer was diagnosed increased by 46% with tomosynthesis, from 4.1% to 6%.

Retrospective studies published in 2014 in The American Journal of Roentgenology (AJR) and The Journal of the American Medical Association (JAMA) confirm previous studies that 3D mammography finds significantly more invasive cancers and reduces unnecessary recalls.

The studies focused on the impact of 3D mammography and demonstrated the following key findings:

AJR KEY FINDINGS (1) JAMA KEY FINDINGS (2)
44% increase in invasive cancer detected with 3D mammography 41% increase in invasive cancer detected with 3D mammography
16% decrease in recall rate from screening mammography 15% decrease in recall rate from screening mammography
29% increase in the detection of all breast cancers 29% increase in the detection of all breast cancers
(1) AJR 2014 Jun 13 [Epub ahead of print] (2) JAMA. 2014;311(24):2499-2507. doi:10.1001/jama.2014.6095.

Bottom Line: 3D Mammography is the new gold standard in screening for breast cancer. 3D mammography increases cancer detection rates by finding more invasive cancers and reduces unnecessary recalls.


“Dense” Breasts on Your Mammogram Report? What next?

You just had your annual screening mammogram and the summary report provided to you states you have “dense” breasts but this is a BENIGN FINDING and there is no evidence of breast cancer. The language used in the report may be mandated by law, and say something like, “Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer. This information about the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor. Together, you can decide which screening options are right for you. A report of your results was sent to your physician.”

What are dense breasts?

Basically it describes the amount of glandular tissue in the breast, meaning dense breasts have less fatty tissue than normal breasts. Here is the classification system used by radiologists interpreting your mammogram:

densebreast

Why is this important?

High breast density, as seen on a mammogram, is linked to an increased risk of breast cancer. Women with very dense breasts are four to five times more likely to develop breast cancer than women with low breast density (1-2). Approximately 10-20% of breast cancers are missed by standard mammography – that percentage can approach 40-50% in women with dense breast tissue.

What does this mean?

No need to be alarmed. Your breasts are like a majority of US women. Based on the American Journal of Roentology, seventy-four percent of patients between 40 and 49 years old had dense breasts. This percentage decreased to 57% of women in their 50’s. However, 44% of women in their 60’s and 36% of women in their 70’s had dense breasts as characterized on their screening mammograms.

This notification in your report is meant to increase your understanding of your mammogram results. So far, at least 12 states have enacted laws requiring breast imaging centers to add information about breast density in the result notification letters they mail to patients. Legislatures in several other states are considering breast density notification laws, and federal legislation has been proposed.

What should you do?

If you are found to have dense breasts, the decision on additional screening and about which test—ultrasonography or MRI—should be based on the your lifetime risk of breast cancer. The American Cancer Society recommends that patients with a lifetime risk of 20% or greater should be screened annually with breast MRI regardless of breast density. This lifetime risk assessment includes those patients who carry the BRCA gene mutations and their untested first-degree relatives. Also considered are women who underwent chest radiation between the ages of 10 and 30, and patients who have more than one first-degree relative with breast cancer but who do not have an identifiable genetic mutation. Patients with dense breasts who have an increased lifetime risk but who do not meet these criteria and those who are at average risk may be offered breast ultrasonography. If risk factors are unclear, genetic counseling can help determine the lifetime risk and thus help the patient choose the additional screening test.

MRI, and certain forms of ultrasound, especially automated whole-breast ultrasound, can be very helpful in evaluating women with very dense breast tissue. Mammography and ultrasound together has been shown to be up to 97% sensitive (5). Kelly et al. demonstrated that supplementing mammography with automated breast ultrasound resulted in doubling the cancer detection rate. The ACRIN 6666 trial showed that supplementing mammography with screening ultrasound in women with an elevated risk of developing breast cancer and dense breast tissue increased the detection rate by 55%.

While DMS does recommend these studies for some patients, realize that there are no formal guidelines by either the American College of Radiology or the American Cancer Society regarding breast imaging for women with dense breast tissue, unless the woman is also considered to be in a high-risk category (for example those with a strong family history of breast cancer). Some of these tests are not covered by insurance. Also realize that MRI and ultrasound also have some limitations when imaging dense breast tissue – there is no perfect method of evaluation.

Newer methods of mammography such as tomosynthesis and contrast-enhanced mammography are showing promise, but studies are still being performed; these exams may also expose a woman to higher doses of radiation and/or a contrast material injection.

The Bottom Line

Increased breast density makes it harder for a radiologist to detect early stage (read: treatable) breast cancers, which have a tendency to spread faster within dense breasts. If you have dense breasts, know your family history and speak to your primary care doctor about your risk factors and whether an ultrasound or MRI might be helpful in further screening for breast cancer.

Remember, the best way to fight breast cancer is through early screening and detection. DMS recommends:

Have a mammogram every year starting at age 40 if you are at average risk.
Have a clinical breast exam at least every three years starting at age 20, and every year starting at age 40.
Further information: The Gail Model calculates a woman’s breast cancer risk over the next five years, in addition to her lifetime risk (www.cancer.gov/bcrisktool/). The model considers age, ethnicity, history of breast cancer in first-degree relatives, age of menarche, and previous history of breast biopsies and benign breast disease. This Risk Assessment Tool can be used by physicians to determine if you are at higher risk for developing breast cancer.

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA area.

References:

(1) Boyd NF, Guo H, Martin LJ, et al. Mammographic density and the risk and detection of breast cancer. N Engl J Med. 356(3):227-36, 2007.

(2) Tamimi RM, Byrne C, Colditz GA, Hankinson SE. Endogenous hormone levels, mammographic density, and subsequent risk of breast cancer in postmenopausal women. J Natl Cancer Inst. 99(15):1178-87, 2007

(3) Checka CM, Chun JE, Schnabel FR, Lee J, Toth H. The relationship of mammographic density and age: implications for breast cancer screening. AJR Am J Roentgenol. 2012 Mar;198(3):W292-5. doi: 10.2214/AJR.10.6049.

(4) Saslow D, Boetes C, Burke W, et al., American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007; 57:75–89.

(5) Kelly KM, Richwald GA. Automated Whole Breast Ultrasound: Advancing the Performance of Breast Cancer Screening. Semin Ultrasound CT MRI 2011; 32:273-280


Confused about When to Start Getting A Screening Mammogram? Age 40 or 50?

Confused about when to start getting a mammogram? You are not alone. In the past year, there have been several conflicting reports of scientific studies recommending annual screening mammogram at age 40 or age 50, depending on which study you read. Furthermore, there is confusion about whether to get your screening mammogram every year or every two years. Why all the confusion and where is it coming from?

Not all organizations agree on mammogram guidelines. For instance, the U.S. Preventive Services Task Force (USPSTF) mammogram guidelines recommend women begin screening at age 50 and repeat the test every two years. The American Cancer Society and other organizations recommend screening begin at 40 and continue annually.

The USPSTF recommendation is valid under the argument that women between the ages of 40 – 50 years derive only a small benefit from annual screening mammograms. But, ask yourself if you were the one person to get that “small benefit” would it matter to you? While there is the risk of false positive exams and further workups that put patients through further testing, no one disagrees whether the trouble was worth it when breast cancer is detected early and can make the most difference between life and death. No one disputes that screening mammograms saves lives. The key is early screening. While the benefit may be small, the benefit outweighs the perceived risks.

Ultimately, Digital Mammography Specialists (DMS), along with the National Cancer Institute, The American Cancer Society, the American College of Obstetricians and Gynecologists, the American Medical Association, and the U.S. Preventive Services Task Force encourages all women to discuss the risks and benefits of getting a mammogram with their doctors. No one should make this decision for a woman; it should always be her choice when to start screening for breast cancer.

At DMS, our expert women’s imaging radiologists recommend annual mammograms starting at age 40. The Joint Statement from the American College of Radiology and Society of Breast Imaging clearly spells out the compelling reasons to get a screening mammogram every year beginning at age 40.

It is well known that mammography has reduced the breast cancer death rate in the United States by 30 percent since 1990 ─ hardly a small benefit.
Based on data on the performance of screening mammography as it is currently practiced in the United States, one invasive cancer is found for every 556 mammograms performed in women in their 40s.
Mammography only every other year in women 50-74 would miss 19 to 33 percent of cancers that could be detected by annual screening.
Starting at age 50 would sacrifice 33 years of life per 1,000 women screened that could have been saved had screening started at age 40.
Eighty-five percent of all abnormal mammograms require only additional images to clarify whether cancer may be present (or not). Only 2 percent of women who receive screening mammograms eventually require biopsy. The USPSTF data showed that the rate of biopsy is actually lower among younger women.
DMS supports screening beginning at age 40 because screening mammograms can detect breast abnormalities early in women in their 40s. Findings from a large study in Sweden of women in their 40s who underwent screening mammograms showed a decrease in breast cancer deaths by 29 percent.

But mammogram screening isn’t perfect. Another study concluded that despite more women being diagnosed with early breast cancer due to mammogram screening, the number of women diagnosed with advanced breast cancer hasn’t decreased. The study suggested that some women with early breast cancer were diagnosed with cancer that may never have affected their health.

Unfortunately doctors can’t distinguish dangerous breast cancers from those that are non-life-threatening, so annual mammograms remain the best option for detecting cancer early and reducing the risk of death from breast cancer.

DMS will continue to evaluate new data on mammography and breast cancer detection as information is made available. But at this time, until a validated method exists that can identify tumors that are slow growing and non-lethal from those that are aggressive, DMS physicians feel it is in the best interests of their patients to offer routine screening mammography. And while they further acknowledge that reducing the number of mammograms offered to women, along with follow-up testing, would save healthcare dollars, they do not believe that denying quality care is the way to do it.

If you’re concerned about screening mammograms, discuss your concerns with your doctor. Together you can decide what’s best for you based on your individual breast cancer risk.

Talk with your doctor about:

Your personal risk of breast cancer.
The benefits, risks and limitations of screening mammograms.
The role of breast self-exams in helping you become more familiar with your breasts, which may help you identify abnormalities or changes.
The role of a clinical breast exam, which is an examination of your breasts by your doctor and is offered annually at Digital Mammography Specialists.
About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA area.


Reduce Your Breast Cancer Risk by 40%! Here’s how.

Can exercise really help decrease your risk for breast cancer? Research and retrospective studies published in the last few years suggests there is a truly significant benefit from exercise. Aside from the benefits to your cardiovascular system and your overall health, exercise can reduce your risk of dying from breast cancer.

According to research published in December 2013 in the Public Library of Science, even small amounts of regular exercise, such as regularly going on short runs or walks, potentially lowered a woman’s risk of dying from breast cancer by more than 40 percent.

For the study, researchers at the Lawrence Berkeley National Laboratory followed 79,124 women, all of whom were either runners or walkers, for 11 years. None of them had been diagnosed with breast cancer at the start of the study, and they all reported the distances they ran or walked each week, as well as their bra cup size, body weight, and height.

Researchers found that the women who met the Centers for Disease Control and Prevention’s current aerobic exercise guidelines (that’s two and a half hours of moderate activity or an hour and 15 minutes of vigorous activity a week) were 42% less likely to die of breast cancer during the study than those whose exercise fell short of the guidelines—even after adjusting for body mass index (BMI).

What’s the secret? Exercise reduces estrogen’s effect on cancer by altering how the body breaks down the hormone into either harmful or benign byproducts, according to previous research in Cancer Epidemiology, Biomarkers & Prevention.

Similarly, researchers in France looked at studies that involved more than 4 million women around the world who participated in prospective studies from 1987 to 2013. They found that the more active a woman is, the better her odds of avoiding breast cancer. Women who were most active, with more than an hour a day of vigorous activity, got the most benefits, lowering their cancer risk by at least 12 percent. Women who were overweight or obese benefited a little less, but still lowered their risk by 10 percent overall.

While the study in the Public Library of Science found breast cancer risk reductions as high as 42 percent from physical activity, the huge number of women included in the retrospective study performed by the Strathclyde Institute for Global Public Health suggests that the 12 percent reduction in breast cancer risk is more accurate. More activity was better, but anything was better than nothing.

So, if you want to significantly reduce your risk for breast cancer, moderate exercise such as walking briskly for a total of two hours per week will do the trick. If you’re strapped for time, about an hour of running each week will be just as effective. Running and walking offer the same breast cancer protection. At higher intensities, it just takes less time to expend the required amount of energy.

Bottom line: Regular exercise reduces a women’s risk of breast cancer, regardless of the type of exercise or the age when you begin exercising. Combined with getting a mammogram starting at 40, keeping your weight in check, and eating a mostly plant-based diet you can significantly reduce your risk of breast cancer.

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA area.


BRCA What?! Am I At Risk for Breast Cancer ?

BRCA1 and BRCA2 are human genes that produce proteins that help repair damaged DNA. When either of these genes is mutated or altered, DNA damage may not be repaired properly. As a result, cells are more likely to develop additional genetic alterations that can lead to cancer. A woman’s risk of developing breast and/or ovarian cancer is greatly increased if she inherits a deleterious (harmful) mutation in the BRCA1 gene or the BRCA2 gene.

Men with these mutations also have an increased risk of breast cancer, and both men and women who have harmful BRCA1 or BRCA2 mutations may be at increased risk of additional types of cancer.

About 12 percent of women in the general population will develop breast cancer sometime during their lives (1). By contrast, according to the most recent estimates, 55 to 65 percent of women who inherit a harmful BRCA1 mutation and around 45 percent of women who inherit a harmful BRCA2 mutation will develop breast cancer by age 70 years (2, 3). Men and women who inherit harmful BRCA1 or BRCA2 mutations, whether or not they develop cancer themselves, may pass the mutations on to their sons and daughters. If a person learns that he or she has inherited a harmful BRCA1 or BRCA2 mutation, this will mean that each of his or her siblings has a 50% chance of having inherited the mutation as well.

Because harmful BRCA1 and BRCA2 gene mutations are relatively rare in the general population, most experts agree that mutation testing of individuals who do not have cancer should be performed only when the person’s family history suggests the possible presence of a harmful mutation in BRCA1 or BRCA2.

Several screening tools are now available that doctors can use to help them with this evaluation (4). These tools assess family history factors that are associated with an increased likelihood of having a harmful mutation in BRCA1 or BRCA2, including:

A personal history of breast cancer at age 50 or younger
A personal history of triple negative breast cancer (breast cancer that is estrogen receptor-negative, progesterone receptor-negative and HER2/neu receptor-negative)
A personal or family history of male breast cancer
A personal or family history of bilateral breast cancer (cancer in both breasts)
A personal history of ovarian cancer
A parent, sibling, child, grandparent, grandchild, uncle, aunt, nephew, niece or first cousin diagnosed with breast cancer at age 45 or younger
A mother, sister, daughter, grandmother, granddaughter, aunt, niece or first cousin diagnosed with ovarian cancer
A family history of both breast and ovarian cancers on the same side of the family (either mother’s or father’s side of the family)
Ashkenazi Jewish heritage and a family history of breast or ovarian cancer
There is only a very small chance that your family carries a BRCA1/2 mutation if:
You or an immediate family member is the only person in your family with breast cancer
The breast cancers in your family all occurred at older ages
In most cases, genetic testing is not recommended when there is a low chance of finding a mutation. Remember that most breast cancers are not due to a BRCA1/2 mutation.
Genetic tests can check for BRCA1 and BRCA2 mutations in people with a family history of cancer that suggests the possible presence of a harmful mutation in one of these genes. The test can be performed on a blood or saliva sample. It takes about three weeks to get results. If a harmful BRCA1 or BRCA2 mutation is found, several options are available to help a person manage their cancer risk.

Digital Mammography Specialists recommends patients speak to their doctor or other health care provider to address any health concern and before making any health care decision. Our breast imaging radiologists are always available to answer any questions about BRACA genes and breast cancer.

About the author: Raja P. Reddy, MD is a board certified diagnostic radiologist specializing in breast imaging. He is also a contributing editor for Digital Mammography Specialists, a leading provider of outpatient women’s imaging services in the greater Atlanta, GA area.

References

1. Antoniou A, Pharoah PD, Narod S, et al. Average risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations detected in case series unselected for family history: A combined analysis of 22 studies. American Journal of Human Genetics 2003; 72(5):1117–1130.

2. Chen S, Parmigiani G. Meta-analysis of BRCA1 and BRCA2 penetrance. Journal of Clinical Oncology 2007; 25(11):1329–1333.

3. Howlader N, Noone AM, Krapcho M, et al. (eds.). (2013) SEER Cancer Statistics Review, 1975-2010. Bethesda, MD: National Cancer Institute. Retrieved June 24, 2013.

4. U.S. Preventive Services Task Force. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: Clinical Summary of USPSTF Recommendation. AHRQ Publication No. 12-05164-EF-3. December 2013.

DISCLAIMER: The information contained herein is not intended to be a substitute for professional medical advice, diagnosis or treatment in any manner. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding any medical condition.