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I saw in the news recently that the government
has said that women under 50 should not get
mammograms. What do you think?
I have heard that some digital mammograms are
better. Is that true?
I have a lump, but my mammogram is normal, so
it's not cancer, right?
I had a routine mammogram and it showed
"calcifications", or a "nodule". I have been
referred to a surgeon. Does this mean I have
cancer?
I went for my routine screening mammogram, and I
was told to come back in 6 months for another
mammogram. Is it okay to wait that long if
there’s an abnormality on the mammogram now?
I had an abnormal mammogram and have been told
to see a radiologist or surgeon to have a biopsy
done. What does that involve?
I was seen by a surgeon because of an abnormal
mammogram, and was scheduled to have surgery.
They are going to put a wire in my breast, and
then take me to the operating room for the
biopsy. Is there a simpler way to do the
biopsy?
Why isn't ultrasonography used for screening for
breast cancer?
Is an MRI better than a mammogram for finding
breast cancer?
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I saw in the news recently that the government
has said that women under 50 should not get
mammograms. What do you think?
There is an agency that evaluates a wide range
of preventive and screening services on behalf
of the Agency for Healthcare Research and
Quality (AHRQ). It is called the
United States Preventive Services Task Force
(USPSTF), and has been in existence since
1984. Presumably it is an independent panel of
private-sector experts in prevention and primary
care. Of interest, there are no specialists in
mammography or breast surgery on the panel.
They comment on a vast array of medical issues,
and specifically in this case about when
mammograms should be done. They last gave
recommendations on screening mammography in
2002, at which time they supported it for women
in their 40s. They have now reversed that
recommendation in their
revised recommendations, just published in
November 2009. This change was based
primarily on additional information from results
of a study in the United Kingdom, which compared
two groups of women between the ages of 39 and
41, and another updated study from Sweden. In
these and other studies, there was a
decrease in mortality in women undergoing
screening, anywhere from 15-31%. The studies
also took into consideration the potential down
side of screening, in the form of pain from the
test, anxiety about results, “false positive”
studies (in which there is an abnormality seen
on the mammogram that requires a biopsy, but
there is no cancer found), and “false negative”
studies (there is a cancer present, but it is
not seen on the screening mammogram). After
taking all this into consideration, they decided
the benefits in lowering mortality were not
worth the costs of screening in this age group.
Many organizations, including the American
Cancer Society, the American College of
Surgeons, the Commission on Cancer, and the
American Society of Breast Surgeons, among
others, have denounced the new recommendations,
and have encouraged women in their 40s to
continue annual screening mammograms. We agree
with continuation of screening in these women,
but it is worthwhile to understand that
mammography is less than ideal for finding
breast cancer at an early stage. It is the best
screening test we have right now, and we have
seen many many women in our practice who were
diagnosed with early breast cancers based solely
on an abnormal mammogram. But we must do quite
a few biopsies to find the smaller number of
women with cancer.
There are some factors that can affect the
advantage of screening mammograms. If the films
are of poor quality or are read by an
inexperienced radiologist, or if any recommended
biopsies are done by inexperienced physicians,
there may be more harm than good done. So we
highly recommend annual, or at the very least
biannual (every two years) screening mammograms
for women in their 40s, done at a reputable
facility such as the Breast Center at DeKalb
Medical; if a biopsy is required, be certain the
physician is highly skilled in the technique. Our
surgeons at DeKalb are members of the American
Society of Breast Surgeons, and have extensive
experience in biopsy techniques.
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I have heard that some digital mammograms are
better. Is that true?
There are some advantages to digital
mammography, but the pictures obtained with
“film screen” are quite good. Some very large
comparison studies have shown that digital
mammography is slightly better for women with
very dense breast tissue, and this typically
would be younger women, before menopause. For
all others, the image quality is no better, in
terms of identifying abnormalities which might
be a sign of an early breast cancer.
Just like the digital cameras so prevalent
today, digital mammography has advantages in
terms of storage and retrieval of images, and in
taking good pictures to start with. Most women
will note that the time necessary to have the
mammograms done is much shorter, and therefore
more convenient. The image can be adjusted for
contrast, brightness, and magnification, without
having to repeat the study. And it can be
stored electronically, making it much more
accessible for comparison with future films, or
for copying for other physicians who may need to
review them. So, if your mammogram center is
NOT using digital technology, don’t be too
concerned. The training and experience of the
radiologist is of much more importance than the
type of image used.
DeKalb Medical has been using digital technology
for mammograms for about 5 years. All our
radiologists are trained and experienced in
reading mammograms, with each reading thousands
of mammograms annually. The equipment is
upgraded routinely. If you would like to
schedule a mammogram at DeKalb, you can call
404-501-2660.
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I have a lump, but my mammogram is normal, so
it's not cancer, right?
You
must understand that not all cancer shows up
on mammography. Any lump needs to be
examined by a qualified physician, whether it
shows up on mammography or not. If the lump is
not seen on mammography, it may be still need to
be biopsied. An ultrasound may be helpful. But
the most important thing to remember is that if
you have a lump, it should be evaluated
promptly, regardless of what the mammogram might
show.
I had a routine mammogram and it
showed "calcifications",
or a "nodule". I have been
referred to a surgeon. Does this
mean I have cancer?
Screening
mammograms have become an important method to
screen for breast cancer. We have learned that
mammograms can often detect the earliest signs
of breast cancer, at a point in time when it can
not yet be felt. Early breast cancer often
shows up as a small cluster of calcifications,
which look like a small grouping of tiny white
flecks on the mammogram, or as a small nodular
area which is more white than the surrounding
breast tissue. But, these same
abnormalities can be caused by breast changes
that are not breast cancer as well. Only
about one in six of these abnormalities end up
being cancer when they are biopsied. But the
only way to be sure is to sample the tissue with
some sort of biopsy. This means that most of
those who have a biopsy will find out that there
is no evidence of cancer.
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I went for my routine screening mammogram, and I
was told to come back in 6 months for another
mammogram. Is it okay to wait that long if
there’s an abnormality on the mammogram now?
It’s good that you are having annual mammograms
done. Of course, every woman hopes that nothing
abnormal will be seen, and in fact about 90% of
women do indeed have a “normal” mammogram. And
of the other 10%, even though the mammogram
may show something abnormal, most of these women
don’t have cancer.
Abnormalities seen on mammograms fall for the
most part into 2 categories; suspicious
calcifications, or densities. Not all
calcifications are suspicious, and it would be
too complicated to go into all the subtle
distinctions that are considered in evaluating
any calcifications. Generally speaking, the
calcifications which are small, clustered (and
multiple), and variable in shape and size (this
is called pleomorphic), are the ones that should
be biopsied. Now if the radiologist sees
just one or two calcifications, or if they are
not that variable in size, or if for some other
reason, they aren’t that suspicious, he may
recommend a “short term followup”, which usually
means, a repeat mammogram of just the involved
breast in 6 months. It doesn’t really make
sense to recommend a biopsy when the findings
are not that suspicious, since it would require
doing biopsies in 50 women to find the 1 of 50
who actually has a cancer. As it stands, only
about 15% of the abnormal calcifications which
are biopsied (BIRAD 4 cases) are cancer; the
other 85% of suspicious calcifications are due
to benign changes in the breast tissue.
It
is important that the radiologist reviewing your
films has lots of experience reading
mammograms. At our institution, all the
radiologists who read mammograms are reading
thousands of studies every year. Our
facility is accredited by the American College
of Radiology. We use the most up to date
technology for digital mammography, which
provides high resolution images, and with much
less inconvenience for the patient (rarely do
the pictures need to be “done over”).
Those women who are requested to return for
followup films in 6 months in most cases will be
given further reassurance with the 6 month film
and then return to an annual schedule. A few
women may be advised to have a biopsy based on
the followup. If you feel anxious about
being told to come back in 6 months, you should
ask your primary care physician for a referral
to DeKalb Surgical Associates for a breast
consultation. We are experienced in
evaluating breast abnormalities and will
carefully review your specific case, including
the findings on physical exam, and on
mammography. If appropriate, ultrasound can be
performed at the time of your visit for
additional information (though for
calcifications, ultrasound rarely is utilized).
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I
was told that my mammogram was read as a BIRAD
4. What does that mean?
When your mammogram is read by the radiologist,
he will categorize the findings according to
whether anything looks suspicious or not. The
American College of Radiologists set up
standards for rating mammograms, which is called
BIRADS (Breast Imaging Reporting and Data
System). Here is a table of the possible
designations.
|
Category |
Diagnosis |
Number of Criteria |
|
0 |
Incomplete |
Your mammogram or ultrasound didn't give the radiologist enough
information to make a clear
diagnosis; follow-up imaging is
necessary |
|
1 |
Negative |
There is nothing to comment on; routine screening recommended |
|
2 |
Benign |
A definite benign finding; routine screening recommended |
|
3 |
Probably Benign |
Findings that have a high probability of being benign (>98%);
six-month short interval follow-up |
|
4 |
Suspicious Abnormality |
Not characteristic of breast cancer, but reasonable probability
of being malignant (3 to 94%);
biopsy should be considered |
|
5 |
Highly Suspicious of Malignancy |
Lesion that has a high probability of being malignant (>= 95%);
take appropriate action |
|
6 |
Known Biopsy Proven Malignancy |
Lesions known to be malignant that are being imaged prior to
definitive treatment; assure that
treatment is completed |
You
can see that the BIRAD 4 classification refers
to findings for which the radiologist feels
biopsy should be considered, even though it
might not be cancer.
This designation covers a wide range of
suspicious findings, and for this reason, some
radiologists will further categorize the
findings as 4a, 4b, or 4c, indicating
progressively higher suspicion. For example, if
he sees a group of three tiny calcifications,
not very tightly clustered, and all rounded, he
may feel biopsy is appropriate, even though
these are most likely benign, and so may
designate this as a BIRAD 4a. If he sees a
“tight” cluster of numerous tiny calcifications
that are variable in shape and size, and perhaps
showing branching, he would predict that these
are much more likely to indicate cancer, and may
designate these as BIRAD 4c. In most cases,
both of these situations are going to require a
biopsy, even though the level of suspicion is
quite different.
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I
had an abnormal mammogram and have been told to
see a radiologist or surgeon to have a biopsy
done. What does that involve?
It
is important that in addition to annual
screening mammograms after age 40, you should
have an annual breast exam by a physician who
does a thorough physical exam of your breasts.
This is especially important if your mammogram
is abnormal. If you are referred for a biopsy,
and no breast exam is done beforehand, you might
not have the proper biopsy method, or there may
be findings missed that would alter the
recommendations for biopsy. The surgeons at
DeKalb Surgical Associates are highly trained
and skilled in the assessment of breast
problems, particularly mammogram abnormalities.
In most cases of BIRAD 4 abnormalities, you
would be scheduled for a stereotactic biopsy.
But if the abnormality corresponds to something
the surgeon can feel, or can see on ultrasound,
a core needle biopsy with ultrasound guidance is
usually a better option, and this can usually be
done on the same day as your first visit.
A
stereotactic biopsy is a clever method designed
to obtain a small but sufficient amount of
tissue from the breast for biopsy when the area
of suspicion cannot be felt, but is seen on the
mammogram. It requires some sophisticated
equipment, and a skilled physician, but usually
is relatively easy for the patient. You will
lie on your stomach on a special flat table that
can be raised up; your breast drops through an
opening in the table. A mammogram plate holds
your breast stationary while digital images are
taken at two slightly different angles. This
allows the physician to precisely localize the
abnormality in your breast, using a computer
that is hooked up to the table. After injecting
some local anesthesia in the skin of your
breast, a core needle is advanced through the
skin to the target, and several cores of tissue
are removed. An x-ray of the removed tissue
will immediately confirm that the suspicious
area has been removed. The procedure usually
only takes about 20 minutes, and is usually
painless after the local anesthetic injection.
In
most cases, the physician will place a small
metal marking clip in the area where the biopsy
was taken. This clip is about the size of a
tooth filling, and will not be felt, will not
move around, and will not set off any metal
detectors. This marker is important whether you
have cancer or not. If the biopsy shows cancer
(results will usually be available in 2-3 days),
your surgeon will need to remove more tissue
from around the biopsy area. Since the original
suspicious abnormality may have been completely
removed with the biopsy, the marker will be a
certain way of knowing precisely where the
biopsy was done. If you don’t have cancer, the
marker will remain permanently in your breast,
documenting that the suspicious area has been
adequately biopsied.
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I was seen by a surgeon because of an abnormal
mammogram, and was scheduled to have surgery.
They are going to put a wire in my breast, and
then take me to the operating room for the
biopsy. Is there a simpler way to do the
biopsy?
In most cases, the initial biopsy can be done
without placing a wire, and without having to go
to the operating room. Since most such
abnormalities on mammogram are benign, it’s
usually better to do a less invasive biopsy
initially, rather than going to the operating
room for a surgical biopsy. There are
exceptions to this, but the surgeon should have
given a logical explanation for why a less
invasive procedure was not chosen. If
you don’t feel comfortable with the
recommendation for an open surgical (excisional)
biopsy, you could always request a second
opinion.
It is almost always best to know there is cancer
present BEFORE going to the operating room.
If it is not yet determined whether there is
cancer, a less invasive core needle biopsy
(either a stereotactic biopsy or ultrasound
guided biopsy) is almost always preferred.
|
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Why isn't ultrasonography used for
screening for breast cancer?
Although ultrasound is vital for the
diagnosis and management of breast
cancer, and for the evaluation of breast
lumps, its role in breast screening is
not clear. Mammography has been
demonstrated to identify many early
breast cancers before anything might be
palpable, that is, before the cancer is
big enough to feel like a lump. The
mammogram films show essentially the
entire breast, and any abnormalities
seen will be studied further. If the
mammogram shows something that looks
like a nodule, ultrasound is almost
always utilized to focus on that
specific area. If calcifications are
seen on mammography, ultrasound would
rarely be beneficial, such
calcifications are not well seen by
ultrasound.
Since microcalcifications are one of the
main abnormalities that help us find
early breast cancer by screening,
ultrasound is not helpful, since
microcalcifications are rarely seen on
ultrasound images. In addition, there is
no standardized method for recording
ultrasound images of the breast.
The ultrasound is extremely valuable to
focus on one particular area in the
breast, once an area of concern has been
identified either by palpation, or by
detection of a nodule on mammography. In
this case, the ultrasound is excellent
at distinguishing between solid and
cystic lesions, and also is very good at
characterizing solid lesions as likely
benign or malignant (cancer).
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Is an MRI better than a mammogram
for finding breast cancer?
This is one of those questions that has
a very complex answer, and the answer
may change over the next few years.
MRI stands for “Magnetic Resonance
Imaging”, and is a very
sophisticated method of viewing anatomy
in the body. It probably first
found a valuable niche in medicine for
evaluating the back part of the brain,
where CAT scans sometimes were lacking
in the desired detail. As time has
passed, MRI has been applied to
virtually all body parts, and now has
many daily uses, particularly in
evaluating joints and other
musculoskeletal abnormalities,
particularly the spine, and the pelvis
and back part of the abdomen. The
breast has been evaluated with MRI as
well, and no doubt will continue to have
important applications. But doctors
are not yet agreed as to how best to
utilize MRI for breast problems.
The benefit of MRI in breast
problems is its extremely high
sensitivity, which means that it can
show a very high level of detail, and
some hidden cancers (a very small
percentage) will not be seen with any
other imaging study. The down
side
of MRI has to do with its relatively
low specificity, meaning that not
everything it “sees” is bad.
With screening mammograms, less than 10%
of women will have abnormalities that
require more evaluation, and of all the
women who have a cancer hiding somewhere
in their breast, about 95% of them will
be in that small 10% group. So
mammography does a very good job of
sorting out which women have silent
cancers, but it does not find 100% of
the cancers. With mammography, out
of about every 5-6 women for whom we
recommend a biopsy, we find 1 cancer.
With MRI, about 25% of women will have
abnormalities that require more
evaluation, and in many cases, there
will be two, three, or even more
abnormalities that might require a
biopsy. Of all women with a cancer
hiding in their breast, about 98% will
be in that group of 25%. But you
can easily see that the number of women
undergoing biopsies is 2½ times that
required based on the mammograms.
There are a few more cancers found,
but it is hard to decide whether it’s
worth the cost, inconvenience, and
anxiety for all the women who don’t have
cancer, who now are undergoing biopsies.
At DeKalb Surgical, MRI is used in
selected cases, primarily in women who
are already diagnosed with breast
cancer.
In addition, women who have a distinctly
higher breast cancer risk, due to strong
family history (e.g., either a
documented carrier of one of the BRCA
genes, or two immediate family members
with breast cancer, etc.), may be
screened with MRI. In cases where
the likelihood of developing a cancer is
extremely high, the use of MRI, even
with its low specificity, makes more
sense. (If you are interested in
more information, here is a
table put out by the American Cancer
Society in 2007 that lists their
indications for using breast MRI, and a
link to the full article from which
it came.)
As I said above, the role of MRI is
evolving, so our use of MRI may also
change as time goes on, and as more data
is published about the specific
situations which may benefit from its
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