Wake Radiology Women’s Imaging Breast imaging specialists lead the way T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
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October is National Breast Cancer Awareness Month
Wake Radiology Breast Services Leading-edge Women’s Imaging in the Triangle are not negative and require additional workup. “In all medical screening tests, whether for prostate-specific antigens or occult blood in the stool, unfortunately, there are a number of false-positives or indeterminant results for individuals who do not have any disease. For a screening mammogram, this means there is a finding on the mammogram that requires me to get additional imaging to be able to be more specific about the diagnosis. This does not mean that the woman has a malignancy. It just means the woman cannot be diagnosed as
PHOTO BY BRYAN REGAN PHOTOGRAPHY
Screening mammograms form the first line of defense In her 23 years of experience, Kerry Chandler, director of women’s imaging services at Wake Radiology, says that she has lost track of exactly how many mammograms she has read. She does know that she has read close to 24,000 mammograms in the last three years alone. Last year, tens of thousands of screening mammograms were performed at Wake Radiology’s six breast imaging locations throughout the Triangle, including Wake Radiology Comprehensive Breast Imaging
consolidating all reading at one location and establishing a reading team of radiologists with special expertise in mammography. Specially trained clerical staff dedicated to screening mammogram readings ensure that all relevant history and images are at their fingertips. She strongly believes this is a better process than promising women their results before they leave the office. Reading a screening mammogram is too vital a task to be done hurriedly or when distracted; it is challenging to find relatively small and sometimes very subtle signs of cancer. Having a team of radiologists consistently reading the mammograms promotes an additional level of quality control. For technologists, there are both formal feedback processes and a training program, beyond continuing medical education, that is led by breast imaging specialist Richard E. Bird, MD, FACR, one of the breast mammography icons in the US, who has been with Wake Radiology since 2004.
Dr. Danielle Wellman discusses her findings with a patient at Wake Radiology Comprehensive Breast Center in Cary.
Services in Cary, the area’s first center dedicated exclusively to breast imaging. Almost all mammograms are digital—an advantage over analog films for patients with dense breasts, patients who are younger, and patients who are pre-menopausal. “Some patients don’t realize the difference between screening mammograms and diagnostic mammograms, and this difference becomes important in reducing patient anxiety,” Chandler notes. Screening mammograms, by definition, are for patients who have no symptoms, and they allow the radiologist to separate out patients who are definitely negative or benign from those who The Triangle Physician
negative based on our typical image screening protocol. Many patients do not understand this and react with a significant amount of alarm when told they need a diagnostic exam after a screening mammogram. “Wake Radiology has a screening recall rate of around 5 percent; optimal range is between 4 and 6 percent. This recall rate has been shown to be one indicator that the least number of disease-free women are being called back for additional imaging while still maintaining optimal sensitivity in finding small cancers.” Chandler has lifted to an advanced art the process of reading screening mammograms,
“We are trying to find cancers when they are less than 15 mm. That seems to be a cutoff of frequency of metastasizing to the local lymph nodes,” Dr. Chandler says. And she adds, “that process requires consistent highquality standards in screening mammogram interpretations.” Diagnostic mammograms and breast ultrasound aid diagnosis and evaluation Diagnostic mammography and/or breast ultrasound are complementary in the diagnosis and evaluation of a breast problem, and they are strongest when the same physician evaluates the patient, takes the history, reads the mammogram, and then performs or supervises the ultrasound, Chandler believes. The choice of modality is customized to each clinical situation. For a woman in her 20s with a palpable mass, an ultrasound in skilled
Almost all patients who come to Wake Radiology for diagnostic evaluation receive their results before leaving. “Women who have been called back for a diagnostic evaluation are very anxious. I spend time with them; that is critically important. It makes for a much better experience for the patients. They know where they stand in terms of what happens next,” Dr. Chandler says. “I directly supervise every ultrasound, so I usually use that opportunity to explain her exams to the patient. I often review findings on the diagnostic mammogram with the patient as well. The patients then know my thought process when I’m looking at their studies. “It is important to reassure a patient—to explain, for example, that breast calcifications are very common and very likely to be benign. I also want to make sure that I discuss what next steps need to be taken to fully work up any finding so each patient understands the rationale for what we do and has the opportunity to ask questions.
The process of going through a diagnostic evaluation and possible biopsy is very anxiety producing for the patient, and that impacts the ordering physician. This is why we try to complete the process as quickly as possible. We know that the majority of people, even if they go to biopsy, are not going to have cancer. For biopsies, our positive predictive value is around 40 percent; 40 percent of people we ask for biopsies have a positive biopsy. That is an optimal value we strive for. So you see, even for those women who get a full workup and then go on to biopsy, results are still negative 60 percent of the time. “If a patient has breast cancer, some referring doctors prefer to be the one to communicate that diagnosis to their patient while others prefer that we tell the patient her positive breast biopsy results. If the physicians at Wake Radiology discuss positive results with a patient, we do so in person rather than on the telephone. We believe that we are best able to communicate this extremely upsetting news face to face.” Close communication and a high degree of expertise – hallmarks of Wake Radiology’s practice – are much appreciated by referring physicians. “Wake Radiology has excellent physicians with a world of experience. We know we are getting quality films and quality readings,” says Sheppard McKenzie III, MD, of Kamm, McKenzie Ob-Gyn of Raleigh.
“If there is a mass or a lump in addition to an abnormal mammogram, we will refer a patient on to a general surgeon. But if it is a subtle finding, and Wake Radiology could do a directed biopsy with the mammogram, we utilize that. They are very good at getting in touch with us. Sometimes with the patient there, they will call to say there is a suspicious area, so we can order the other study right then, if it is convenient for the patient,” McKenzie says. “They are just very good at communicating with our physicians. It makes a huge difference. If the news is good, I like the fact that they will tell the patient. They’ll say ‘Findings discussed with the patient.’ I know patients want to know yesterday that everything’s okay.” Ultrasound plays important role in examining abnormalities The primary use of ultrasound is for the further examination of a mammographic or a palpable abnormality in the breast, according to Dr. Bird, MD, FACR. “It is a very good tool, and we use it frequently.” Improvements in technology have increased the sophistication of this modality, and it plays an integral role in breast imaging at Wake Radiology. Indications for breast ultrasound include: matrix characterization of palpable or clinically occult masses detected on mammogram; characterization of solid masses; evaluation PHOTO BY BRYAN REGAN PHOTOGRAPHY
hands may identify a simple benign breast cyst with no need to proceed to any further imaging. Because an older patient in her 30s is more likely to have occult cancer, a diagnostic mammogram is the first imaging choice. For the radiologist to see extremely small breast calcifications, a diagnostic mammogram would include magnification views, and for a palpable mass, special mammogram views are used to show the margin of any corresponding mass that could be present.
“My goal is to help solve the problem of what the patient has, and also to mitigate the anxiety that the patient has about the evaluation. I communicate to the patient at any level the referring physician wishes. “If we believe a finding needs to be biopsied, some referring doctors want us to go ahead and do that. Others prefer we send their patients to another practitioner. I show every patient who needs a biopsy all the imaging findings and explain why I think she needs a biopsy. I also try to give each patient an idea of what the possible final diagnostic possibilities are including how suspicious I am that the finding could be breast cancer.”
Dr. Duncan Rougier-Chapman, one of four breast MRI specialists who read and render 3D images of the breasts when cancer is detected. The Triangle Physician
ACR guidelines for annual breast MRI Published guidelines by the American Cancer Society recommend breast MRI and mammograms once a year starting at age 30 for certain women who are defined as high risk if they have: • a greater than 20 percent calculated lifetime risk of developing breast cancer • the breast cancer gene BRCA1 or BRCA2 • a first-degree relative with a breast cancer gene • the TP53 or PTEN gene mutation • a rare genetic syndrome including Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba, or if a first-degree relative has such syndromes Help your patients assess their breast cancer risk To calculate a patient’s risk for breast cancer, you need answer only seven simple questions. Simplicity and accessibility are at the heart of the National Cancer Institute’s online Breast Cancer Risk Assessment Tool, known as the Gail Model. It estimates a woman’s risk of developing invasive breast cancer over specific periods of time, using data from more than 280,000 women aged 35 to 74 years and National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program.
Access the Breast Cancer Risk Assessment Tool at wakerad.com
of tissue potentially excluded on routine mammographic views, and characterization of masses that are incompletely demonstrated in mammography; evaluation of women with inflammatory symptoms to distinguish a mastitis from an abscess; and guidance for interventional procedures. Typically, ultrasound follows a screening or a diagnostic mammogram and is complementary to it. In general, it is not a screening tool for cancer, Bird observes. While studies confirm that ultrasound can find cancers not found by mammography, ultrasound is not specific enough, with the resulting cost a large number of false-positives. It is notable that ultrasound is operator dependent. The quality of the examination greatly depends upon the experience and expertise of the person performing the exam. At Wake Radiology, a women’s imaging radiologist experienced in ultrasound directly supervises each breast ultrasound.
dilemmas and often can uncover occult disease. “We see the benefits of breast MRI all the time,” says Duncan Rougier-Chapman, MD, co-director of breast MRI imaging for Wake Radiology. “On a daily basis, we are seeing cancers that are not known—cancers of the opposite breast and cancers thought to be one centimeter in size that are found to be five centimeters in size. Breast MRI detects metastases in the spine, chest, or liver that were not known beforehand—or never would have been known. The patient could fail therapy, as appropriate therapy cannot be administered unless the extent of disease is recognized.” Rougier-Chapman is one of the practice’s four breast MRI specialists. Since introducing breast MRI in 2005, they have performed more than 5,500 exams and approximately 150 MRIguided breast biopsies.
Risk Calculator (Click a question number for a brief explanation or read all explanations.) 1. Does the woman have a medical history of any breast cancer or of ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS)?
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2. What is the woman’s age? This tool only calculates risk for women 35 years of age or older.
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3. What was the woman’s age at the time of her first menstrual period?
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4. What was the woman’s age at the time of her first live birth of a child?
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5. How many of the woman’s first-degree relatives – mother, sisters, daughters – have had breast cancer?
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6. Has the woman ever had a breast biopsy?
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6a. How many breast biopsies (positive or negative) has the woman had?
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6b. Has the woman had at least one breast biopsy with atypical hyperplasia?
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7. What is the woman’s race/ethnicity?
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The Breast Cancer Risk Assessment Tool, also known as the Gail Model, is an online interactive tool designed by scientists at the National Cancer Institute (NCI) and the National Surgical Adjuvant Breast and Bowel Project (NSABP) to estimate a woman’s risk of developing invasive breast cancer.
For certain women at high risk for breast cancer, the American Cancer Society recommends annual breast MRI screenings as an adjunct to mammography. Among them are women who have a greater than 20 percent calculated lifetime risk for developing breast cancer, as defined by a risk calculator such as the Gail Model. Also included are those who have the breast cancer genes BRCA1 and BRCA2 and those with a first-degree relative who carries the gene. “We probably are seeing only the tip of the iceberg of those who would qualify for breast MRI screening,” Rougier-Chapman says. They include both men and women whose families have a very high predominance of breast malignancy. “If a patient is genetically positive for the breast cancer gene, he or she should be screened with a breast MRI.”
Highly accurate breast MRI is the best study for screening and staging of high-risk patients Magnetic resonance imaging (MRI) of the breast is the most accurate imaging method to detect and stage breast cancer, and for women and men at high risk, it is the most effective screening modality. Research shows this three-dimensional imaging study has 91 to 100 percent sensitivity. Used in conjunction with mammography and ultrasound, breast MRI can solve diagnostic The Triangle Physician
BSGI images (left) of a woman with a very difficult mammogram (due to extreme density, multiple calcifications, and numerous previous benign surgical biopsies) and the completely normal BSGI exam of the same woman.
It is important to understand that breast MRI does not preclude the need for mammography or ultrasound, he continues. “Mammograms and ultrasound can answer the question in the majority of cases. A mammogram can show precancerous conditions such as abnormal calcifications and often can obviate a need for additional imaging such as MRI. MRI can show a broad spectrum of disease, but we try to use the most cost-effective and simplest tools first.” For women with breast cancer, the extraordinary detail of breast MRI makes it the most accurate means available today for staging. “Current research suggests that in approximately 30 percent of cases staged with breast MRI, the information will in some way change management of that patient. And in 75 percent of those cases, it does so in a manner that benefits the patient,” RougierChapman says. The national standard for staging includes a bilateral breast MRI to evaluate the extent of the disease within a breast with a known cancer, and it also has been proven to detect occult disease in the contralateral breast that has been missed by mammography and clinical evaluation. Moreover, the detail of a breast MRI can reveal accurate tumor volume, which is vital to assessing patients pre- and post-therapy, specifically useful in neo-adjuvant therapies. And for women who have undergone surgery, breast MRI is able to distinguish scar tissue from disease recurrence. This can help patients avoid unnecessary biopsies. The negative predictive value of breast MRI is 99 percent. New advances in breast-specific gamma imaging (BSGI) With the addition of breast-specific gamma imaging (BSGI), Wake Radiology now has the most comprehensive approach to the diagnosis of breast cancer in the area. “BSGI has essentially the same indications as breast magnetic resonance imaging (BMRI). It is almost as sensitive and somewhat more specific and can be used in place of BMRI for women who cannot have BMRI for a variety of reasons. It is considerably less expensive, and pre-certification has not been a problem,” explains Dr. Bird, MD, FACR, who introduced the BSGI program to the area in 2007.
PAT I E N T P R O F I L E Marian Sichel Breast Cancer Survivor from age 43 At 43, a breast self-exam saved Miriam Sichel’s life, and when she hears suggestions that women discontinue breast self-exams or delay screening via mammogram until age 50, she becomes nearly speechless. At 41, the Raleigh clinical social worker, wife, and mother of three boys already had begun annual screening mammograms on her doctor’s recommendation. She felt that was wise; although she was negative for the breast cancer genes BRCA1 or BRCA2, her paternal grandmother and paternal great aunt both had died of breast cancer. Then one day in late 2008, about eight months after her latest mammogram, she learned that a childhood friend had breast cancer. She did her own breast self-exam, just in case, and felt a lump. That was Friday; Monday, she contacted her obstetriciangynecologist and soon was at Wake Radiology for a diagnostic mammogram and ultrasound. “The lump did not show up clearly on the mammogram, but it showed up on the ultrasound,” she recalls. “The way they put it was that this doesn’t have typical cancer characteristics, but we can’t take a chance. To be safe, I was referred to Richard Bird, a women’s imaging radiologist at Wake Radiology Comprehensive Breast Services, for a needle biopsy. Dr. Bird and Wake Radiology were absolutely wonderful. I had the biopsy on Tuesday, and by Thursday, we had the results.” To stage Sichel’s disease, Bird performed breast-specific gamma imaging (BSGI), a nuclear medicine study. This modality was chosen because Sichel had a metal prosthesis in her ear and could not have magnetic resonance imaging (MRI). The results suggested that the known carcinoma was unifocal and without microscopic disease in the lymph nodes, and the other breast was negative. “I remember Dr. Bird telling me how thorough the BSGI was. He was so reassuring,” Sichel says. After successful treatment with chemotherapy and surgeries that included double mastectomy and reconstruction, Sichel is back to her active life. She lauds two persons in particular who positively impacted her recovery. Her physical therapist, Todd Erbst from Avante Physical Therapy, was able to explain which tissues and muscles were going to be affected and stressed, helping her understand what was happening physically and feel more assured. The second person is friend and breast cancer survivor Debbie Horwitz, who developed the photographic portrait of her own breast reconstruction in the booklet, Myself: Together Again. “She was diagnosed with breast cancer at 32,” Sichel notes. “There were no photographs of the step by step reconstruction process out there before this. She put this out there so women wouldn’t be left in the dark as well as to be an educational tool for doctors to pass along to their patients. I felt much more in control, knowing what was going on and what to expect.” As for forgoing regular breast self-exams and not having screening mammograms until age 50, she takes a moment. “I’m getting choked up. Obviously, it saved my life. How do you answer that, with all the people I know under 50 who have been diagnosed with breast cancer?” Such a recommendation, she says, “is life threatening. I’m not a physician, and I don’t know the specific risks, but I know what I see around me.”
Nuclear imaging of the breast has been around since the 1990s, initially using a standard gamma camera that imaged the breast in anterior and lateral projections. This technique, however, produced poor resolution because of the large size of the detector, which limited the proximity of the breast tissue, and the nonstandard views, which did not correlate with mammographic views. Today, new equipment and technology allow close proximity of the detector to the breast and positioning that correlates precisely with mammographic positioning and allows mild compression of the breast. The result is a significant increase in sensitivity for small malignancies. “Previously, only lesions greater than 1.0 cm could be identified,” Bird explains. “Now, lesions as small as 2 mm to 3 mm can be detected. According to recent literature, the sensitivity is approximately 85
percent to 95 percent (depending on tumor size), and the specificity is approximately 75 percent to 85 percent.” BSGI is functional imaging of the breast dependent on hypermetabolic tissue with a high concentration of mitochondria in the cells. Following the intravenous injection of the isotope, each breast is imaged in the CC and MLO projections. Axillary views also may be obtained, if indicated. The examination is done with the woman comfortably seated and takes 30–45 minutes to complete. The radiation dose is approximately the same as that for an upper GI series. This exam is done only at Wake Radiology Comprehensive Breast Services in Cary. Like MRI, BSGI is unaffected by scar tissue and implants. It can be used for staging of newly discovered breast cancer and for evaluation The Triangle Physician
of questionable recurrence after breast conserving therapy, although MRI generally is used in those situations. “BSGI provides an important alternative to MRI for women who otherwise would qualify for MRI reimbursement, but cannot have MRI because of claustrophobia or incompatible metal implants or devices,” Bird explains. “Because of the high negative predictive value, the primary use of BSGI in our practice is for screening women with mildly increased risk (less than 20%) and dense breast tissue, and for screening of women with normal risk, but very difficult mammograms. It is used in place of whole-breast ultrasound for screening because of slightly better sensitivity and much better specificity. It is adversely affected by high estrogen levels and should be done between days three and ten of the menstrual cycle, when practical.” Practice offers mammogram-, ultrasound-, and MRI-guided breast biopsy By providing breast biopsy guided by ultrasound, by mammogram (stereotactic), and by MRI, Wake Radiology helps make the diagnostic process more comprehensive and efficient. In stereotactic breast biopsy, ionizing radiation is utilized to help guide instruments. With ultrasoundguided core needle biopsies, images are viewed in real time while the patient lies comfortably. MRI-guided biopsies are an important capability when a breast MRI reveals areas of concern or abnormalities, especially those that cannot be seen on ultrasound or mammogram. These biopsies require specialized instrumentation. “I urge physicians to ensure they send a patient for a breast MRI to a facility that is able to perform an MRI-guided biopsy. Otherwise, if they do find something, they have no means to access it,” says Rougier-Chapman. For the patient, the process of going through any type of breast biopsy can produce anxiety, and Wake Radiology strives to make the procedure less so by going over images with the patient and PET-CT staging and restaging March 2010
August 2010
explaining why a biopsy is needed. For breast biopsy, the practice’s positive predictive value is 40 to 45 percent, Chandler notes. This means that patients who receive a biopsy are negative for cancer 55 to 60 percent of the time. PET increasingly utilized in evaluation of breast cancer Positron emission tomography (PET) is the most recent addition to the imaging studies available for the evaluation of patients with breast carcinoma. Unlike anatomic imaging modalities, which depend on a change in the morphology of normal structures to detect pathology, PET produces functional images based on differences in metabolic activity. This nuclear medicine study utilizes a short-lived radioactive tracer, F-18, which is attached to fluorodeoxyglucose (FDG), an analog of glucose. In general, malignant cells demonstrate greater metabolic activity and increased utilization of glucose compared to normal structures. The F-18 labeled FDG is actively taken up by malignant tissue and is displayed as hypermetabolic foci of increased activity on the PET images. One significant advantage of FDG PET imaging, explains Wake Radiology’s David Ling, MD, a body imaging radiologist and PET-CT specialist, is that PET can demonstrate increased metabolic activity in a malignant lesion before there are any apparent morphologic changes. PET images are co-registered with low-dose computed tomography (CT) images acquired during the same scanning session on the same hybrid PET-CT scanner. The CT images allow for more precise anatomic localization of the foci of increased metabolic activity detected by PET.
PET·CT images of 57-year-old female with metastatic breast cancer. First PET-CT in March 2010 (left images, top and bottom) show the conglomerate of adjacent nodes. After cancer therapies, on the follow-up PET-CT in August 2010, the conglomerate of adjacent nodes clearly decreased in both size and number. The Triangle Physician
PET currently does not have a role in the detection of primary breast cancer, Ling notes. This is because the limited spatial resolution of the current PET scanners does not allow for the detection of small breast cancers. In the initial staging of patients with suspected early stage disease, while PET has not replaced CT, MRI, and bone scintigraphy, PET can help clarify findings that are equivocal on the initial staging studies. Compared to sentinel node biopsy, PET has a high specificity for axillary nodal metastases, but a lower sensitivity, and thus does not replace histologic evaluation of the sentinel nodes.
PET has proven to be of great utility in the staging of patients with suspected locally aggressive neoplasm at the time of initial diagnosis, in the assessment of response to therapy, and in the restaging of patients following treatment. This is because PET is able to assess for locoregional spread more precisely than CT, and it can detect metastatic lesions in areas that may not be optimally evaluated by other imaging modalities, such as the hilar nodes and the internal mammary chain nodes. Not infrequently, PET demonstrates more widespread disease than expected in patients with suspected recurrence. This is especially important in the clinical management of patients for whom aggressive local therapy is being considered. One study, Ling observes, showed that PET imaging altered therapeutic options in up to 44 percent of patients with suspected locoregional recurrence by demonstrating more widespread disease than CT. In another study of patients with elevated levels of tumor markers, PET-CT affected clinical management in 51 percent of patients. In the evaluation of osseous metastatic disease, bone scintigraphy remains the initial imaging study for surveying the entire skeleton. PET appears to be superior, however, in the detection of lytic and intramedullary metastases. An important application of PET is in treatment monitoring. PET images can assess the metabolic response to treatment, and they have been able to discriminate between responders and nonresponders more accurately and earlier than other imaging modalities. PET has been used to evaluate the efficacy of neo-adjuvant chemotherapy, sometimes after a single cycle of treatment. Studies have shown that a decline in a primary tumor FDG uptake by approximately 50 percent or more is predictive of a good response to neo-adjuvant systemic therapy. After completion of chemotherapy, residual activity on PET images is predictive of residual disease, but absence of activity is not a reliable indicator of complete pathologic response since residual microscopic disease is not excluded. “The introduction of FDG PET has changed patient management in breast cancer,” Ling says. “PET imaging represents early clinical application of molecular imaging. Research into other positron emitting isotopes and dedicated positron emission mammography scanners is ongoing.” USPSTF recommendations Last winter, the United States Preventive Services Task Force published new guidelines for screening mammography that surprised and perplexed Dr. Chandler. For years, various researchers and groups have considered at what age, and how often, women should have screening mammograms. The mammographers of Wake Radiology support yearly mammograms for women ages 40 to 80. These are the recommendations of the American Cancer Society and the American College of Radiology, and breast self-examination also is included. But the USPSTF, in contrast, recommended that women wait until age 50 to begin regular mammograms, that they need not continue after age 74, and that they could wait twice as long— two years—between mammograms. Breast self-examination was out altogether. The issue is critical,
Positive breast cancer findings from screening mammogram exams
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Female Patient Ages Wake Radiology data from Jan 2008 to December 2009
The Future of Breast Imaging What does the future hold in the fight against breast cancer? Here are just three examples. An association between inflammatory breast cancer and viral sequences Could breast cancer, like cervical cancer, be associated with a virus? Is a breast cancer vaccine on the distant horizon? In an intriguing yet very small study of 67 patients with inflammatory breast cancer, 44 were positive for viral sequences resembling mouse mammary tumor virus (MMTV). The 72 percent of cases that were positive was significantly more than the 40 percent positive in non-inflammatory breast cancer patients. See Levine, Paul H. et al. Increased Detection of Breast Cancer Virus Sequences in Inflammatory Breast Cancer. Advances in Tumor Virology 2009, Vol 1 pp 3–7. 3D tomosynthesis This promising new digital technology produces unmatched image quality and could help find tumors that otherwise could be missed. Moving in an arc around the breast, tomosynthesis acquires a series of images and creates a high-resolution image from the raw data—without increases in radiation exposure over standard mammography. Already available in Europe and Canada, tomosynthesis is in clinical trials in the US in preparation for US Food and Drug Administration pre-market approval. Elastography A new procedure related to ultrasound, shows promise in helping distinguish benign from malignant solid tumors. The technique estimates tissue stiffness, adding another dimension of specificity in characterizing lesions, and Wake Radiology’s expertise includes participation in a clinical trial of elastography. “Elastography has been helpful and has been quite accurate,” says radiologist Richard E. Bird, MD. While one day, elastography may help reduce the need for biopsies, Bird indicates that currently it is not used in making decisions regarding biopsy because there have not yet been enough clinical studies.
Chandler feels, because of the numbers. The National Institutes of Health estimates that breast cancer affects one in eight women over the course of their lives, and the disease kills more women in the United States than any cancer except lung cancer. “If the USPSTF recommendations are adopted by the government and insurance carriers, the reality is that more women will die each year from breast cancer,” Chandler wrote in letters to patients and a posting on Wake Radiology’s website, wakerad.com. The early detection of breast cancer through routine screenings, she believes, has driven the mortality rate down at least 20 percent, and perhaps 30 percent. To her, it’s a success story of modern medicine. “Our patients are asking us about these recommendations, so I’m sure primary care providers are also getting many questions The Triangle Physician
from their patients,” Chandler says. “I would tell every provider that it is his or her duty to look critically at these recommendations and the data that the task force used to make these recommendations. By my own evaluation, it seems that the task force did not look at all the data.” Chandler points to landmark studies in Sweden conducted by radiologist and researcher Lázló Tabár, MD, a randomized trial of breast cancer screening of more than 130,000 women aged 40–74 years with a 13-year followup of more than 2,450 cancers.1 “The data was very clear that mammography performed even in 40- to 50-year-old women brought about a statistically significant decrease in mortality,” she says. “Screening mammograms allow us to identify small breast cancers of 15mm or less,
and for those patients, the prognosis is very favorable.” “I am confused about the reasons the USPSTF is making recommendations that essentially say no screening mammography for women between ages 40 and 50, because it is not unusual for me to find small cancers on screening mammograms on completely asymptomatic women in this age group. The USPSTF recommendations fly in the face of what I see and in the face of the data that I know. (See graph on previous page.) “I understand the USPSTF’s frustration with false-positive mammograms that lead to subsequent benign biopsies, but as of yet, we do not have a good alternative screening test.”
The interval between mammograms also is of concern. “The optimal interval between screening mammograms has not been proven to be two years (as the USPSTF recommends). In the best studies that have looked at this parameter, the optimal interval between screening mammograms has been shown to be about 16 months. The current yearly screening protocol was developed since this interval is the closest to the optimal interval that can easily be remembered by the patients and the referring providers.” 1 The Swedish Two-County Study found a reduction in mortality of 34 percent of women ages 50 to 74, and a reduction of 13 percent for women 40 to 49. The lower mortality reduction among the younger women, the researchers concluded, was due to faster progression of tumors and rapid increase in incidence during that decade of life. The researchers concluded the interval between screenings should be shortened and that annual screenings would increase the reduction to 19 percent. Tabár L, Fagerberg G, et al. Efficacy of breast cancer screening by age. New results from the Swedish Two-County Trial. Cancer. 1995 May 15. PubMed PMID: 7736395. http://www.ncbi.nlm.nih. gov/pubmed/7736395.
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Wake Radiology Breast Imaging Physicians Kerry E. Chandler, MD Women’s Imaging Radiologist Director of Breast Imaging Services
Richard J. Max, MD Women’s Imaging Radiologist
Paul A. Haugan, MD Body Imaging Radiologist PET·CT Imaging Specialist
Elizabeth A. Rush, MD Women’s Imaging Radiologist
Richard E. Bird, MD, FACR Women’s Imaging Radiologist
Holly J. Burge, MD Body Imaging Radiologist Director of PET·CT Services
Carmelo Gullotto, MD Body Imaging Radiologist Breast MRI Specialist
David Ling, MD Body Imaging Radiologist PET·CT Imaging Specialist
Duncan P. Rougier-Chapman, MD
William G. Way Jr, MD Body Imaging Radiologist Director of Diagnostic Imaging PET·CT Imaging Specialist
Claire M. Poyet, MD Women’s Imaging Radiologist
Bryan M. Peters, MD Neuroradiologist Women’s Imaging Specialist
Eithne T. Burke, MD Women’s Imaging Radiologist
Danielle L. Wellman, MD Women’s Imaging Radiologist Breast MRI Specialist
Body Imaging Radiologist Co-director of Breast MRI Services
G. Glenn Coates, MS, MD Body Imaging Radiologist Co-director of Breast MRI Services
David I. Schulz, MD Body Imaging Radiologist PET·CT Imaging Specialist
Susan L. Kennedy, MD Women’s Imaging Radiologist
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