Breast Cancer Basics: Second in a Four Part Series

Who Needs Additional Imaging?

Last month I outlined the benefits and importance of Screening Mammography, which has been demonstrated as a safe, harmless and inexpensive way to find early tumors in women age 40 and older. Screening Mammography clearly save lives.
But when is a mammogram not enough? Who needs more than a Screening Mammogram to stay out of trouble? And what other tests can be done?
Simply put, there are two categories of women who need additional breast imaging to be sure that a tumor is detected early:

1. Women with dense breasts
2. Women at increased risk of developing breast cancer

Breast Density and Increased Risk

Women with category C or D density on mammograms (heterogeneously dense or extremely dense breasts) are considered “dense,” and are candidates for additional imaging. The mammograms are less reliable, as subtle changes can be overlooked, and density in itself is a risk factor for developing cancer. Women with dense breasts are more likely to develop “missed” or “interval” breast cancers, those that pop up between annual mammograms.

Additional Risk Factors for Breast Cancer

Besides increasing age, other factors that increase your risk of developing cancer are: Hereditary Breast Cancer Syndrome (BRCA1 or BRCA2 mutation), mother, sister, or daughter with breast cancer, or atypical cells on a breast biopsy. There are various tools and programs for determining breast cancer risk, but if any determine you have a greater than 20% lifelong risk for developing breast cancer – which is about 2-3 time that of the average risk – you should undergo additional imaging.

Other Breast Imaging Methods Besides Mammograms

Since mammograms are not perfect at finding all cancers, instead of simply doing more frequent mammograms, it makes sense to use other breast imaging methods, especially those that can find breast cancers that mammograms cannot see.

The most common secondary screening technique used today is Magnetic Resonance Imaging. MRI penetrates dense breast tissue without difficulty and is very effective at finding cancers not seen on mammograms

However, there are several drawbacks to MRI. It requires insurance authorization and is expensive – especially when this cost is applied to your deductible! It is invasive, and the intravenous contrast medium Gadolinium that is used during the exam may accumulate in the nervous system. This is especially relevant if the MRI is repeated every year over the course of your life. In my experience, many women just don’t like MRI.

Ultrasound uses high frequency sound waves to visualize breast tissue. It is non-invasive, painless and inexpensive, and is also effective as a supplemental screening tool. However hand-held ultrasound is not easily reproducible, and the pictures taken depend on the skill of the technologist. Breast screening with hand-held ultrasound is not offered in most breast imaging centers in Atlanta.

There is a newer type of ultrasound device that overcomes these limitations. Automated Whole Breast Ultrasound (ABUS or ABVS) is a non-invasive and relatively inexpensive exam that captures all the breast tissue and creates a 3-dimensional display of the breast by ultrasound images. It is nearly as accurate as MRI at finding additional breast cancers, and is entirely reproducible, allowing for precise comparisons of the breast on serial exams. It is inexpensive, does not require IV contrast and there is no radiation.

At my center we have performed over 3,000 ABVS Exams, and I have found several breast cancers that were missed by mammography. We use this supplemental imaging technology instead of MRI for many women with dense breasts and those with increased risk factors. ABUS and ABVS are only offered at a few centers in Atlanta.

Other new imaging technologies including Molecular Breast Imaging, Positron Emission Mammography, and Contrast Enhanced Spectral Mammography, all of which are still investigational at this point.

When to Get an MRI or Ultrasound – Timing of Additional Screening Exams
In my practice I recommend “staggering” the additional imaging at six months or in between mammograms. In addition to looking at the breast with a different type of technology, getting an imaging exam every six months helps identify “interval” cancers and fast-growing tumors that otherwise might not be noticed until months later.

Remember that all the benefits of supplemental screening come from a reduction in stage at diagnosis, and all imaging technologies that detect cancers not seen on mammogram will improve this. Earlier stage at diagnosis correlates with less treatment, decreased cost, and reduction in suffering, pain and death.
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In the next article I will discuss what happens if your mammogram is abnormal, and how we use these various technologies in diagnosing breast cancer.
If you have questions or wish to contact me, please call or email me, and I will be happy to respond.

Barry Roseman, MD
Advanced Breast Care / Surgical Oncology of North Georgia, Inc
www.advanced-breastcare.com
404-841-6262
barry.roseman@gmail.com