The Importance of Screenings

by Paul Fry, MD

This is a tale of good news and bad news. The bad news: most women can quote the statistics, 1 in 8 women will develop breast cancer. Let us look a little closer at these statistics to find some good news. It is true that 1 in 8 women will develop breast cancer, but that is in the span of a lifetime. By age 20, the risk is 1 in 1,760, by age 30 it rises to 1 in 229, and by age 40 it goes up to 1 in 69. Though not zero risk, these are not statistics one should be overly concerned about. It does start to rise to 1 out of 42 at age 50, 1 out of 29 at age 60, and 1 out of 27 by age 70. The lifetime risk is 1 out of 8. Clearly, breast cancer risk rises with age. The significant rise begins between the ages of 40-50.

More bad news: the main risk factor for developing breast cancer is one’s sex followed by one’s age. These are both things women have no control over. Other factors include early menarche, late menopause, and increasing times of unopposed estrogen from fewer children and then choosing not to nurse. These are factors in which today’s women still have little control over. There have been studies linking obesity, alcohol, tobacco, and lack of exercise to breast cancer. Though not statistically relevant, living a healthy lifestyle is always helpful. There is some good news that has been found over the last decade, 10% of breast cancer is genetic in origin. The BRC-1 and BRC-2 genes can be tested for and if present, can lead to lifestyle choices and further strategies to detect and treat.

Breast cancer is the second most common cancer in women just behind skin cancer. Breast cancer accounts for 1 out of every 4 cancers detected in women. It is no longer a death sentence diagnosis. Cancer survival is statistically monitored by what is called 5 year survival by which one colloquially can call a ‘cure”. Depending on the staging of breast cancer, the difference in survival is primarily a factor of the size of the tumor. Ductal carcinoma-in-situ, kind of like a pre-cancer, has a 100% 5 year survival with proper surgical treatment. Remarkably a tumor up to 2 cm or a Stage 1 Cancer also has a 100% 5 year survival. A tumor up to 5 cm, about the size one would start to palpate a “lump”, the 5 year survival is near as high, 97%. Stage 3 Cancer, usually a tumor larger than 5 cm or with lymph node involvement, the 5 year survival is still good, 72%. Sadly, once metastatic, the 5 year survival falls to 22%. These statistics are indeed a tale of good and bad news. Compared to other cancers, the survival rate is much better. For instance, Lung Cancer 5 year survival is only 10-15%. Colon Cancer is at 40-50% but falls to only 5% if metastatic. Pancreatic Cancer has only a 5% 5 year survival.

Clearly the earlier and ultimately smaller the tumor is detected, the better the survival. The key is early detection. The goal is to detect a tumor before it could be detected by self-exam or physician exam. Screening mammography is the main tool for this early detection.

Screening mammography began to be implemented in the late 1980s to the 1990s. Since 1990 there has been a 38% decline in mortality from carcinoma. Though beyond the scope of this article there have been studies directly linking the decrease in mortality to the increasing utilization of screening mammography. Though one of the most common cancers, we are fortunate in that breast cancer is one of the slowest growing cancers. This has allowed us to implement a screening program with a frequency calculated to detect new cancers or changes in size of a cancer between screening tests. The average breast cancer “doubling rate”, the time to double the number of cancer cells, is 282 days, this is just under one year. This is the amount of time one should be able to see interval changes in breast densities or to first detect new lesions. Ideally, with yearly mammograms, a new or growing tumor would be detected in this interval.

Mammography is a low dose X-Ray of the breasts. Mammograms are only performed at special facilities that meet both government regulatory and professional society accreditation. A radiologist who is specially

certified in mammography interprets these images. If there is a suspicious finding on the screening mammogram, this can happen up to 10% of the time, the patient returns for further imaging. This does not in and of itself mean one has breast cancer, this is important as it is a common misunderstanding not only of patients but of other medical personnel. It does mean that further imaging is needed. This may mean further compression or magnification views or the utilization of ultrasound and even MRI. The large majority of patients that return for further imaging are shown to not have suspicious abnormality. They are shown to be benign findings or simply artifacts usually from “overlapping” glandular tissues. If there is a finding on the mammogram that cannot be proven as benign, a biopsy may be needed. All mammograms are placed into a category called the BIRADS (Breast Imaging Recording and Data System). If BIRADS 4, “possibly” cancer, the chance of cancer is 30%; If BIRADS 5, “probably” cancer, the risk is 95%. Most suspicious findings are in the BIRADS 4 classification so a minimally invasive biopsy can be performed to detect cancer without resorting to more invasive surgical excision biopsies.

If a cancer is indeed detected by mammography, it is usually early and therefore small enough to receive near complete cure rate treatment. The advancements in surgery, chemotherapy, hormonal therapy and breast reconstruction, have made it so even advanced breast tumors or even metastatic tumors have better 5 year survival rates than most other cancers. Clearly, this is good news when faced with the bad news of breast cancer in general. Many, if not most, women given a diagnosis of breast cancer can now expect to live.

The American College of Radiology is tasked with certifying facilities and those radiologists that interpret screening mammograms. What follows is the latest Position Statement by The ACR concerning Screening Mammography:

“The American College of Radiology recommends annual screening mammography for women starting at age 40. This affords the maximum benefits of reduced breast cancer deaths, less extensive treatments for cancers that are found, decreased chance of advanced disease at diagnosis, and discovery and treatment of high risk lesions. Breast cancer incidence increases substantially around age 40 and even earlier for high risk women and women of color.

All health insurers, including the Centers for Medicare and Medicaid Services, should cover women ages 40 and older for annual mammograms as a preventative service, without additional cost sharing or co-payments. Extensive scientific research shows a 40 % reduction of breast cancer deaths with regular screening mammography screening. The greatest mortality reduction, the most lives saved and the most life years gained occur with yearly mammograms starting at age 40. There is no established age for women to stop screening as long as they are healthy and desire to remain so. Therefore, health care coverage for screening should not have an upper limit.”

The Good news of mammography is indeed remarkable. The bad news is in the State of Alabama, the utilization of mammography is still not ideal. From age 40-49 only 63% of women have had a mammogram. From age 50-64, only 72% of women have had a mammogram over the last two years. This falls to only 64% after 65. If you have not had a mammogram, please do. If you know someone who has not had a mammogram, please encourage them. Let us turn bad news into good news.

Paul J Fry, MD is Board Certified in Diagnostic Radiology and is a full partner with Radiology of Huntsville. He presently serves as Medical Director of the Department of Radiology at Athens-Limestone Hospital.