FOCUS ON THE CURE

October is Breast Cancer Awareness

Month

One in eight women will develop invasive breast cancer over the course of her lifetime. Educate yourself and your loved ones about awareness and detection. Learn about treatment options available in our community.

Early Detection of Tubular Breast Carcinoma Saves Lives

Mike Ratliff, MD

Memorial Hermann

Aparna Surapaneni, MD

Memorial Hermann

Women who get routine mammograms know the drill: Before the exam, you’re typically asked if you have experienced any changes in your breasts – including pain or changes in appearance – since your last mammogram. Those questions prompted 55-year-old middle school principal Andrea Denee’ Cain to recall a “very weird, piercing pain” in her left breast six months prior, which at the time she dismissed as a fluke. And a blemish on that same breast, which she “didn’t think much of” either.

The signs were there, yet she had been too busy to pay them much heed. The day of her mammogram was New Year’s Eve 2018. It was her birthday, and Cain – Dr. Cain – had just received her PhD from Texas A&M University.

Cain says that she has received annual mammograms and ultrasounds since her early 20s, given she has dense breast tissue and a history of non-cancerous breast issues. She underwent a needle biopsy for fibrocystic breast disease in 1995 and surgery to remove a benign tumor in 2006, both performed by Memorial Hermann-affiliated general surgeon Mike Ratliff, MD.

That day, in addition to her ultrasound, Cain requested a 3-D mammogram, an option which had recently become available to her. A few days later, she was called back for a needle biopsy, which, she says, she didn’t think much of because she had had biopsies before. She went to the appointment alone.

“At the end of the biopsy appointment, the radiologist showed me on my image what he called a radial scar, a benign breast lesion. He said they can be tricky because they can hide growths beneath them,” Cain says.

A week after the biopsy, Cain was referred to Dr. Ratliff for a surgical biopsy to determine the diagnosis. “Still, at this point, the word cancer had never been spoken,” says Cain.

Dr. Ratliff referred her to radiation oncologist Aparna Surapaneni, MD, and oncology hematologist Kevin Hude, both affiliated with Memorial Hermann.

In her surgical follow-up appointment – to which she took her mom, who is a retired nurse, and two of her sisters – Dr. Ratliff explained that he had indeed found something beneath the radial scar. “He said it was very small, but it was cancer,” she remembers. “And I froze. I don’t remember anything he said after that. From that point on he was talking to my mom and my sisters.”

Cain was diagnosed with tubular breast cancer, a rare form of invasive cancer that accounts for approximately one percent to two percent of invasive breast cancers. Dr. Ratliff subsequently performed a lumpectomy and sentinel lymph node biopsy to completely remove the tumor.

“Tubular carcinoma is rare but is, fortunately, a less aggressive cancer than the most common form of breast cancer, invasive ductal cancer,” says Dr. Ratliff. “Her nodes were negative, as is expected with tubular cancers. As a result, her overall outlook is excellent.”

Dr. Surapaneni told Cain that while she didn’t need chemotherapy, she recommended radiation therapy “as standard of care,” to prevent recurrence of her cancer. “Radiation treatment for breast cancer is, in the vast majority of cases, used in conjunction with definitive surgical treatment for best outcomes,” says Dr. Ratliff.

Cain underwent three weeks of full breast radiation, followed by a boost, which she completed in May 2019. From the moment she received her diagnosis, she never attended a treatment alone. She describes her experience as “very positive,” saying, “Dr. Surapaneni always asked us if we had any questions. Everyone was so nice.”

“This is the outcome you want,” says Dr. Surapaneni. “Because Andrea was vigilant about getting her regular screenings, her cancer was caught at an early stage and was small. She tolerated treatment really well and has a very good prognosis. She had great support from her family. And she is very willing to advocate for the importance of breast screening.”

After finishing her treatment, Cain shared her news at a large school district event. Afterwards, she says, several women came up to her and said they were so moved by her story they were going to schedule overdue mammograms. “I totally trust God that this was meant to be an opportunity for me to be there for someone else,” she says.

Don’t Be Alarmed if You Need Another Mammogram or Ultrasound

Dr. Richard Oria OakBend Medical Center

There are numerous reasons why a radiologist may elect to ask for additional views or ultrasounds after reading your mammogram. They are viewing a three-dimensional object in two dimensions. Overlapping tissue can create densities on the mammogram that appear as a mass or area termed “architectural distortion.”

The main reasons a patient may be called back are for areas of architectural distortion, masses or grouped microcalcifications, which are tiny spots of calcium in the breast.

Mammograms are categorized into groups termed BIRADS, or Breast Imaging Reporting and Data System. BIRADS 1 is negative; BI-RADS 2 is benign; BI-RADS 3 is probably benign; BI-RADS 4 is suspicious; BI-RADS 5 is highly suspicious and BI-RADS 0 is incomplete, requiring additional imaging including additional views, with or without spot compression, spot magnification views – typically for microcalcifications – and ultrasound. The focus here is on the BI-RADS 0.

Architectural Distortion

This is a very common occurrence but a potential sign for a true lesion. Additional views with slightly different projections and particularly spot compression views are utilized for evaluation of this abnormality. The spot compression views spread the overlapping tissue and remove the summation artifact if there is no true lesion. If a persistent abnormality is seen, an ultrasound is commonly requested to exclude an underlying lesion in the breast. The majority of the time, there is no lesion, and routine follow-up may be performed.

Masses

Doctors typically ask for spot compression views and ultrasound on any new mass or enlarging mass from prior mammograms. The spot compression views give an idea of the borders of the lesion with smooth borders typically indicating benign lesions such as cysts and benign fibroadenomas (non-cancerous tumors), whereas irregular borders are more worrisome and may indicate a more aggressive lesion. Ultrasound is then performed after the spot compression views for evaluation of the consistency of the lesion, primarily cystic or solid.

In addition, the vascularity of the lesion can be assessed with the color Doppler with the more vascular lesions typically being more aggressive. Cysts do not contain internal vascularity. Cysts typically do not require any further followup unless they are painful or they may be aspirated under ultrasound guidance. The vast majority of solid lesions are benign fibroadenomas, but an ultrasound guided biopsy may be necessary for confirmation of the pathology. Short-term ultrasound follow-up may also be performed.

Microcalcifications

The vast majority of microcalcifications are benign and typically either secretory or dermal (within the skin). Vascular calcifications in the arteries of the breasts may also present as microcalcifications. Spot magnification views are performed to determine the number and shape of the microcalcifications. Rounded, well-defined calcifications are almost always benign and compromise the vast majority of our findings. Irregular sharp or serpiginous microcalcifications – particularly if they are numerous and tightly grouped – generally require a biopsy, which may be performed with stereotactic technique and local anesthesia or may be performed with open technique with needle localization for the surgeon, who then completely removes the microcalcifications for pathologic evaluation. Stereotactic technique is much simpler and is used the vast majority of the time for these calcifications.

Over 95 percent of the BI-RADS 0 mammograms turn out to be benign. Having said this, it is crucial not to ignore the recommendations of returning to the radiology department for additional views or ultrasounds, as early detection and treatment of the worst case scenario – breast cancer – results in cure.

Prioritize Your Health with Comprehensive Breast Care

Michelle O’Shea, M.D. Houston Methodist Breast Surgery Partners at Sugar Land

Many of us spent the past year focused on preventing COVID-19, and although we are still dealing with it, it’s time to re-focus on our total health. Making time for an annual mammogram is an important part of maintaining overall wellness and protecting yourself from breast cancer.

One in eight women will develop breast cancer over the course of their lifetime, but early detection improves the overall prognosis and often results in less aggressive treatment options.

Starting at age 40 (or younger if you have family history of breast cancer), you should talk to your doctor about getting an annual mammogram. If you have questions about your breast cancer risk, talk to your primary care doctor or obstetrician-gynecologist.

“Getting a mammogram is an important part of good breast health management and should be part of your health care priorities” said Dr. Michelle O’Shea, breast surgeon at Houston Methodist Breast Surgery Partners at Sugar Land.

When you come to Houston Methodist Breast Care Center at Sugar Land for your annual mammogram, you’ll be taken care of from start to finish. You’ll benefit from our high-tech approach to breast cancer screening with 3D mammography, which is one of the most effective tools in detecting the smallest lumps and abnormalities. And if your mammogram shows something abnormal, you have a trusted team ready to guide you through options for treatment and care. We have also made breast surgeons more accessible for women with abnormal results through extended weekday and weekend hours for reassurance and maintaining priorities for better health.

“Having everything a patient needs under one roof is a major benefit for our patients and gives us an advantage in diagnosing breast cancer at the earliest stages, which provides the best chance for complete recovery – all at one location close to home,” said O’Shea.

The breast care team works together and communicates frequently to customize each treatment plan. This collaboration helps everyone stay informed and ensures the best possible outcome.

If you have family members with cancer, you might feel that getting cancer yourself seems like a matter of time. But thankfully, family history does not mean cancer is inevitable.

“Some cancers are caused by an abnormal gene that’s passed down from generation to generation,” said O’Shea. “But it’s the abnormal gene that’s inherited, not the disease.” In any case, only 5% to 10% of all cancers are referred to as inherited cancers and may include some breast and ovarian cancers.

“Mutations occurring in the BRCA1 and BRCA2 genes are common causes of inherited cancers. Women with these mutations are more likely to develop hereditary breast and ovarian cancer syndrome,” O’Shea shared. “Most breast cancers, however, even among close relatives, are not due to these mutations.”

Genetic testing is a good idea for some people and can help with treatment options. First, research your family’s cancer history. Enlist other family members and aim to get three generations’ worth of information. For each instance of cancer, note the person’s sex, age when diagnosed, other medical conditions, diet and exercise habits, age, and cause of death. Ask your doctor about genetic testing, if you have: • Several first-degree relatives (parents or siblings) with cancer, especially the same type. • Family members who developed cancer at a young age. • Close relatives with rare forms of cancer. • A family member known to have a genetic mutation.

Houston Methodist Sugar Land Hospital’s breast care team is committed to ensuring that your experience is as stress-free as possible. The personal touch begins with your mammogram and continues throughout every aspect of care, for as long as needed.