So I have been told by several people that I should put new items in the front and not the back of this section, so this will be my new way to present new items.
The newest thing in breast issues, as I am sure you are all aware of, are the recommendations for Mammograms and breast self exam. I have waited for some time before writing anything to let my anger resolve. I did not want to rant and rave as I have probably done to many people since then. So I will try to be calm in my discussion.
Let me start by saying that no one that I know who deals with breast problems agrees with the report. The report did not involve anyone who cares for patients with breast problems. They are only looking at population statistics, which only looks at the cost to save a life. I have a problem putting a "price" on a life, especially a young life. The report agrees that every study that has looked at mammograms, shows that yearly mammograms save lives. They just do not feel that the number of young lives saved, justifies the number of mammograms needed, and the false positive readings that will happen. I disagree. We certainly have many false positive studies, that may require extra xrays or ultrasounds and even biopsies. By responding to these abnormalities, we miss fewer serious problems. This is not a perfect system, no one thought it was, but we would rather do too many biopsies than miss too many cancers. Do we over treat some cancers? Probably, but we would rather excise a small cancer that may never cause a problem, than leave one that will grow and potentially impinge on someones life. We have no way today of knowing which cancers, if any can be ignored. The report only used the end point of death, which is not a bad endpoint, but early detection can effect many other issues besides death. With early detection, we can save more breasts. We can avoid more toxic treatments such as chemotherapy. The report did not look at either of those endpoints.
In addition the idea of breast self exam is not one that should be thrown out. No one forces women to do breast self exam. Many women do continue to do breast self exam and statistically about 20% of breast cancers will be picked up by the patient between their routine breast exams. It is hard to imagine that this is not helpful. So to try to take away something from this report......I prefer to ignore it. I continue to recommend mammograms starting by age 40 with yearly mammograms. We may start earlier depending on the patients risk. If a women is willing I still recommend breast self exam. Unfortunately I think this report will be the first in many as health care rationing is likely to be in our future. We see it in the Canadian system. We see it in the British system. We will likely see it in the USA. My best recommendation is to contact your Senators and Congressmen to try to protect us. I feel we are living in interesting times.
|Wow, this has been an interesting month for breast news. Several major issues hit the news: CAD Readers, Breast MRI, decrease in breast cancer incidence, and American Cancer Society breast screening guidelines. Due to the number of calls and questions I have received recently I thought it was a good time to review these items. Unfortunately as is so common, the news does not quite explain these issues accurately so there is much confusion. Perhaps I can explain these somewhat more clearly.
CAD readers are computers that have been programmed to review a mammogram and highlight areas on the xray that the radiologist needs to review more closely. The computer does not read the mammogram ,it has only been programmed to pick up subtle abnormalities that a person might miss. They again do not read the mammogram, they just assist the radiologist. A study looking at the CAD readers found that by using them it was noted that there were more negative biopsies being done, likely being caused by abnormalities seen by the CAD reader. Thus by more negative biopsies being performed, the accuracy of the test has gone down. Of note while the accuracy may have been decreased it was not by abnormalities being missed, but by a few extra biopsies being done. In my opinion if the CAD reader has caused a few extra biopsies, while that is not great it is not causing missing of significant areas. As with any test, with experience the accuracy will increase and the fact that it has not caused lesions to be missed to me is more important. In my experience I think the CAD reader is helpful in reading of mammograms when it is done with an experienced mammographer. Most facilities in the Chicago area do use these CAD readers and I think with time they will be shown to be helpful.
Breast MRI is a very sensitive radiologic test for looking at breasts. It is probably the most sensitive test we have. It is not as affected as much by breast density as mammograms are. Breast MRI is a very involved test, lasting 60-90 minutes, requiring very special MRI hardware and software, and requiring very special training to read the study. Only a few facilities can properly perform this test. The MRI is not a routine screening test but has very specific indications It should only be recommended by a Breast Specialist who would know the appropriate patient to refer for the test. Insurance companies are often not willing to pay for this very expensive test.
In the news this month was a study on patients who were diagnosed with breast cancers and had their opposite breast negative on both mammogram and physical exam. These woman(1000 patients) were given breast MRI, and in 3.1% of these patients, another cancer was seen, although about 1/2 of these were non-invasive breast cancers which may have never become significant for the patient. This study shows that MRI can occasionally pick up cancers in negative breasts, but not at a very significant rate.
In my opinion breast MRI has a very special indication. I do not routinely order it in woman who have been diagnosed with breast cancer, but I do recommend it in woman with breast cancer who have very dense breasts, who can likely be hiding something in either breast. By focusing the test on patients who are likely to benefit from the test, we will make it a more impressive test and will increase the likelihood that the insurance companies will pay for it.
DECREASE IN BREAST CANCER INCIDENCE
In 2003 the results of the Woman's Health Initiative were presented showing that woman who had their uterus and were taking hormone replacement therapy of an estrogen and a progesterone had an increased incidence of breast cancer. Woman who have their uterus need to take both an estrogen and a progesterone for hormone replacement therapy. They cannot only take an estrogen as a woman taking estrogen without a progesterone who has a uterus will hyper-stimulate her uterus and cause uterine cancer. At the time the results of the study came out about 40% of women who had been taking hormones stopped. When breast cancer incidence data were recently reviewed, for the first time in over a decade, at the time of the study results the incidence of breast cancer had decreased. The decrease seems to be in the type of hormone positive breast cancers that are seen in woman talking postmenopausal hormones. While cause and effect can often be hard to evaluate it is certainly very suggestive that this decrease is related to the decrease in hormone usage. We will need to follow this in the future.
AMERICAN CANCER SOCIETY(ACS) BREAST CANCER SCREENING RECOMMENDATIONS
The main issue here is that the ACS is recommending screening breast MRI in high risk woman as defined by various breast cancer risk models. It will be interesting to see if the insurance companies will accept these recommendations and be more willing to pay for breast MRIs in these patients. Again a breast specialist is the best person to decide if you are someone who would benefit from these very involved and expensive test.
Well that's it for now, I will continue to monitor the world of breast issues and try to keep yo up to date
I recently have had many questions about a recent newspaper article about breast cancer and alcohol consumption. Over the last 10 years or so there have been a number of studies looking at this question. All the studies have come up with the same conclusions. Woman who average more than one drink per day, increase their risk of breast cancer by about 10%, and potentialy an even greater increase with greater consumption. It does not matter whether they drink beer, wine or hard liquor. All the studies have come to the same conclusion so this is probably truth. As for a mechanism, while no one knows for sure, it likely has to do with hormone levels.
|MAY 2008- WHOLE BREAST SCREENING ULTRASOUNDS
So in the last week a study has been in the news looking at whole breast ultrasound(US) for the diagnosis
of breast cancer in high risk women with dense breasts. This has been a very controversial area
in breast imaging for many years.
Breast US is an excellent diagnostic test. By a diagnostic test I mean a
test, which is meant to look at a specific area, such as an area seen on
mammogram, or an area felt on exam, which needs further evaluation. The question is can we use US as a
screening test, especially to evaluate high risk women, with dense breasts. US
is less bothered by the denseness of breasts than is mammogram. The problem though is that US is very
user dependent, meaning that it is critical who is performing the US. There are several other problems with
screening US. Especially in large
breasts, it can be very time consuming.
While it can pick up many things in a breast, it tends to lead to many
biopsies based on the abnormalities seen, most of which will turn out to be
benign. This was shown in the
study in the news, where many biopsies were done, which were probably not
necessary. It did pick up some
small cancers, which were not noted on other studies or physical exam, though. In addition it is unknown
if insurance companies will be willing to pay for this test. As it is likely to be a somewhat, long
and tedious test, it is likely to be sort of expensive. At this time I still think that Breast
MRI is a better screening test for high risk women, especially those with dense
breasts. I truly do not think the
answer for this test is in yet. We
will continue to watch.
July 2008-BREAST SELF EXAM(BSE)
So breast self exam(BSE) was in the news again. The Cochrane report says that is leads to more benign biopsies and does not affect mortality. So what does this actually mean? If you canvas breast experts, there is not a consensus, but most people who treat breast cancer still think BSE is worthwhile. We all know that the earlier a breast cancer is picked up, the better the results of treatment, and the more likely we can avoid mastectomy. At least 20% of breast cancers are picked up by woman. In the USA we do not only rely on BSE, but we also have breast imaging, as well as professional breast exams. I personally have seen many patients who have been able to pick up their breast cancers often at a very early stage. In addition BSE is free and available to virtually all woman. So what do I think? While I do not demand my patients do BSE, I do recommend it to most. I feel if a woman examines her breasts regularly, if there is a change she will likely find it. If a change is noted it should be brought to her physicians attention. A woman does not need to know if what she is feeling , feels like a cyst, a solid nodule, etc. That kind of evaluation is best left to the professionals. As far as timing of BSE, we recommend it monthly, but that again is up to the patient. If a woman is still menstruating, I do recommend she performs her BSE 7-10 days after her menstrual cycle has begun, as that is a relatively quiet period for the breasts. For those who get too scared examining their own breasts, then they should not do it. I hope this was helpful.