The month of October is Breast Health Awareness Month when we, as physicians, remind the women of our community that breast cancer is the most common cancer and second leading cause of cancer-related deaths in women and, further, that screening mammography is a crucial part of their preventative health maintenance.
Since the controversial recommendations of the United States Preventative Services Task Force (USPSTF) were published and widely publicized by the media, there has been some confusion for physicians and patients alike. Issues regarding mammography, such as actual mortality reduction, reasons for mortality reduction, detection sensitivity in dense breasts and radiation risk vs. benefit may have added to indecision or refusal of many women to have a mammogram.
Screening mammography is, by far, the best studied preventative medical exam and has demonstrated a reduction in breast cancer deaths, approximately by 30 percent. Although there is some argument regarding the actual reason, such as the screening mammogram, greater breast cancer awareness or therapies for breast cancer, all have very likely played a significant role in preventing breast cancer related deaths. No other screening modality or alternative for breast cancer can claim superiority to a mammogram. As a community radiologist practicing mammography, I can attest that mammography has allowed for the detection of smaller malignancies, which results in improved therapy outcomes with less morbidity and fewer deaths.
The women of our community deserve to know that, although mammography is the best preventative measure we have for detecting breast cancer at a treatable level, it is not perfect. There are shortcomings because of the nature of the imaging technique and the variable density of women’s breasts. While our ability to detect cancer in fatty or low-density breasts is excellent with sensitivities of 80 to 98 percent, our ability is more limited in denser breasts — between one-third to one-half the sensitivity in fatty, less dense breasts. The reason for this is because there is overlap of the glandular tissue when imaging a three-dimensional breast and projecting it onto a two-dimensional mammogram image. The denser the breast, the greater the overlap and potential camouflage of cancers. Despite this shortcoming, it should not deter women from screening, because even in dense breasts, cancers are detected at a treatable level compared to alternative, less proven technques such as thermography or simple physical exam. The good news is that there is a new technology, called breast or mammographic tomosynthesis, which allows for the unraveling of the overlapping breast tissue, much like peeling and exposing layers of an onion, thus improving the radiologist’s ability to see cancers in dense breasts.
Radiation risk should be a concern for all of us. However, the levels women are exposed to for mammography are minescule compared to daily environmental exposures and other medical exams, which many patients routinely and willingly undergo at the drop of a hat, such as head CT for headaches and abdominal CT for abdominal pain. The misconception of radiation risk impacts women’s health, because many women choose not to screen for fear of radiation-induced cancer. Many of these women choose less reliable or unproven alternatives to screen. Unfortunately, I eventually see these patients when the tumor is large enough to be seen by the alternative methods, which then require mammography in order to provide a valid and official diagnosis required by the treating surgeon and oncologist. Women should know that these alternative exams can detect cancer, albeit and very likely, at larger, more advanced and less treatable stages. I have personally diagnosed cancer in a number of women who rely solely on thermography and alternative techniques until such time as the cancers are larger than those detected by mammography. These are cancers which typically demand greater therapeutic regimens with potentially increased morbidity and mortality. Don’t let unrealistic fear of radiation have you miss out on the benefit and greater preventative potential available with screening mammography.
As I mentioned above, the newer modality of tomosynthesis allows for better imaging of dense breasts, which accounts for approximately half the population of adult women. Other advantages of tomosynthesis address concerns of radiation exposure and cancer detection, because it has been shown in several medical studies to provide better discrimination of normal overlapping tissue and real cancers. Recalling women for additional mammograms, called diagnostic mammograms, can be an anxiety-provoking experience and in turn may deter these women from even wanting to get a mammogram. Tomosynthesis addresses this issue in part by reducing the number of recalls for additional views. This reduces both the radiation exposure and perceived or real anxiety of being recalled from screening.
Radiologist training and performance parameters are issues that patients may be less familiar with but are equally important to women’s health. Radiologists are required to complete continuing education and to read a minimum number of mammograms to practice proficiently. I participated in a study in which the agreement of mammographic interpretations by community radiologists with consensus interpretations of an expert radiology panel was undertaken to identify approaches that may improve mammographic performance. The multicenter trial identified mammographic asymmetries and architectural distortions as areas in which improved identification will result in greater accuracy and reduced recalls, hence a positive impact by decreasing false positive biopsies, morbidity and reduction of unnecessary radiation exposure. Capable breast imagers are aware of and maintain performance benchmarks in their screening practices and should be cognizant that proactive patients and referring physicians may inquire about the interpreting radiologists’ performance.
Radiologists who are breast imaging physicians not only work as medical diagnosticians but also serve as patient-care centered advocates who interact directly with the patient, allowing valuable patient contact and enabling encounters that lead to informed and empowered patients who may have to face significant health decisions.
It is with great satisfaction, tinctured with humility, that I practice my profession, knowing the impact it has upon on the lives that I touch. I endeavor to continually fine tune the skills of mammographic screening, persevering in my optimism of the modality, and remain forward-looking to better imaging modalities and algorithms with which to better serve my patients.
Dr. Martin Ruocco is a breast imaging/MSK radiologist at Innervision Medical Imaging at Grove in Greenville.