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Screening Mammography, Ultrasound, and MRI

 

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 was told that my mammogram was read as a BIRAD 4.  What does that mean?

 

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 use

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DeKalb Surgical Associates ©2013
2665 North Decatur Road
Suite 730
Decatur, Georgia 30033

980 Building, Suite 430
980 Johnson Ferry Road, NE,
Atlanta, Georgia 30342

Phone: (404) 508-4320
Fax: (404) 508-4112 

 

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