Dr. Norton’s Mammography Blog

Since the onset of regular screening mammography in the 1990’s, breast cancer mortality in the US, which had been unchanged in the previous 50 years, has decreased by 30%.  However, in November of 2009 the US Preventive Services Task Force (USPSTF) issued new mammography recommendations that sent shockwaves throughout the US medical community and created a great deal of confusion amongst American women. In contrast to prior mammography guidelines the federally supported USPSTF recommended:  1) against routine screening in women aged 40 to 49, 2) against previously recommended routine screening for women 75 years and older, 3) against annual screening for women 50 to 74 years (USPSTF recommended screening every other year as opposed to annually), 4) against teaching breast self examination, and 5) against clinical breast examinations.

This federally funded and staffed Task Force did not include a single radiologist, oncologist, breast surgeon or any other clinician with expertise in breast cancer diagnosis or treatment.  Despite demonstration by their own analyses that screening beginning at 40 saves the most lives and years of life, the Task Force blatantly stated that the new recommendations were the most “efficient” (i.e., least expensive).

American women should be given the straight facts:

1. The use of annual screening mammography has reduced the breast cancer death rate in the US by 30% since 1990
2. Several international studies have demonstrated the benefit of screening mammography in women aged 40 and older (example:  Swedish study showed 40% reduction in mortality in screened population).
3. Based on data on the current performance of screening mammography in the United States 1 invasive cancer is found for every 516 mammograms performed in women in their 40s.
4. Mammography performed only every other year in women 50 to 74 would miss 19-33% of cancers that could be detected by annual screening.

The Task Force also cited potential harms of screening which included discomfort, anxiety and the chance of a false positive reading requiring additional imaging or biopsy. Again, current imaging data shows that 90% of screening exams are normal and out of the remaining 10% most will require only limited additional imaging to clarify whether a cancer is present.  Only 2% of women who receive screening mammography will require biopsy (most often a minimally invasive needle biopsy).

The new USPSTF guidelines were strongly opposed by the American Cancer Society, American College of Radiology and Society of Breast Imaging all of whom continue to endorse regular mammography after age 40. Despite assurances from HHS’ Secretary Kathleen Sebelius that the federal policies for mammography “remained unchanged” and that she “would be very surprised if any private insurance company changed its mammography coverage as a result of the USPSTF action”, a survey conducted by the Avon Foundation in February 2010 demonstrated that “USPSTF recommended guidelines combined with other factors such as budget cuts, have resulted in fewer mammograms or the elimination of early screening programs for women under 50 offered through state administered breast cancer screening programs”.

Although there continues to be widespread confusion among women regarding breast cancer screening guidelines, recent events have provided some clarity. In May 2010, Senator David Vitter (R-LA) sent a letter to the US Department of HHS Secretary Sebelius demanding that in compliance with recently passed healthcare reform legislation that HHS remove any reference to the discredited November 2009 USPSTF mammogram recommendations. Section 2713 of the recently passed national healthcare bill requires the federal government to put aside the November 2009 recommendations related to breast cancer and mammography. Senator Vitter wrote “the fact that these recommendations are still being presented to the general public as “current” is only serving to further confuse women on this critical issue.

The recommendations were ill conceived from the start-developed by a process without transparency, without input from those with experience and expertise in the field and without due regard for the thousands of lives that could be impacted by the recommendation”. Subsequently, on July 14, 2010, the US Department of HHS released new regulations requiring that new healthcare plans cover evidence-based preventative services and eliminated the cost sharing requirement for patients for such services. Regarding screening mammography, this HHS announcement specifically uses the prior USPSTF guidelines from 2002 which recommends that mammograms screening begin at age 40. The Task Forces’ controversial guidelines released in 2009 recommending that screening begin at 50 were labeled as “not considered to be current” in the new HHS rules.

In summary, in November 2009 the USPSTF released screening guidelines for mammography that were ill conceived and not supported by science. This led to considerable confusion in the medical community which resulted in decreased utilization of screening mammography which is the most accurate screening tool for lowering breast cancer mortality. Fortunately, these recommendation have been amended such that screening mammograms are once again recommended to begin at age 40. Furthermore, all women over age 50 should have yearly screening mammography as recommended by the American Cancer Society, American College of Radiology and Society of Breast Imaging.

In 2008, over 355,000 breast augmentation surgeries were performed in the U.S.  It was the most frequent cosmetic surgery in the U.S. followed by liposuction, eye lid surgery and rhinoplasty (nose job).  Currently, women of all ages, including those in the mammography screening population are undergoing this procedure and it is, therefore, important that they not only be aware of its potential complications, but also the effects it may have on their breast imaging. 

Although most women fair well after surgery, early and late complications can include infection, breast pain, changes in breast sensitivity, capsular contraction, implant leakage or breakage, and possible need for additional surgery due to patient dissatisfaction.   

Once a woman begins screening mammograms or undergoes diagnostic mammography, it is important that the procedure be performed at a facility which is experienced in providing mammography for the augmented breast.  This examination will require that additional implant displacement views (Eklund Views) be performed so that visualization of breast tissue is maximized.  Women undergoing breast augmentation should understand that oftentimes less breast tissue is seen even with the additional “implant displacement views”.    Depending on the relative sizes of the woman’s native breasts and her implant anywhere from 20-70% of breast tissue can be obscured.   Also, capsular contraction which occurs with the “aging” implant and implant leakage can contribute to suboptimal visualization of the breast.  

An FDA study published in 2000 estimated that most women had at least one “broken implant” within eleven years of implant placement and that the likelihood of rupture continues to increase over time.   If rupture or leakage is suspected then this is best evaluated with a specially tailored MRI exam.    

In summary, a woman’s experience with breast implants is usually, but not always, uneventful for at least the first 10 years after surgery.  However, it is important that women with implants remember that their lifetime risk of developing breast cancer is one in eight, just as in the general population.  For this reason, it is mandatory that all women with implants receive their breast imaging at a facility experienced with the nuances of optimal imaging of the augmented breast. 

We know the importance of regular mammograms. But are you aware of Uterine Fibroids and the fact that the same age group of women is often affected? If you’re a women over 35 years of age and don’t have uterine fibroids, chances are you know someone who does.   Uterine fibroids or leiomyomas are so common that 20-40% of women over 35 years old have them and over 70% of women will develop fibroids during their lifetime.  The good news is that fibroids only cause symptoms or problems for 30% of the women who have them.  Stay tuned.  Next I’ll discuss what Uterine Fibroids are.

According to data from the 2004 Behavioral Risk Factor Surveillance System (BRFSS) only 58% of US women aged 40 and older had a mammogram within the last year.  The percent of women aged 40 and older who had a mammogram within two years increased from 29% in 1987 to 70% in 2000 and remained stable through 2003.  However, since that time mammography utilization has decreased.  In 2005, the screening rate was 4% lower than in 2000.  How can this be when we know from large international studies that annual mammography performed on women over 40 reduces breast cancer mortality up to 40%?

There are multiple reasons for this decreased utilization.  Socio-economic status affects screening rates.  Women with less than a high school education; those without health insurance; and immigrants are less likely to undergo regular mammography.  Access to services is also a problem.  The number of breast imaging facilities has not kept up with the growing U.S. population of women over 40.   Additionally, many breast imaging facilities have closed due to lack of personnel, financial constraints and malpractice concerns.  This has occurred in a face of a screening population that grew by 24 million between 1990 and 2000.  Finally, many women remain fearful of the mammogram examination itself with some complaining about discomfort and a few even believing that the exam itself can cause cancer.

The solutions to the problem of falling utilization will not be easy and will require not only increased education regarding the benefits of mammography, but also the need to provide more convenient access for all eligible women must be addressed.

Postmenopausal hormone replacement treatment (HRT) has been used for many years to help relieve postmenopausal symptoms and slow or prevent osteoporosis. However, in the last several years many studies have raised concerns about the association of HRT and the increased risk of developing breast cancer. Although the specifics of these studies show some variability, the consensus is as follows.

It is clear at this time that long-term use of combined hormone therapy (estrogen plus progesterone) increases the risk of breast cancer and may increase the chance of dying of breast cancer. The use of estrogen alone and its effect on breast cancer incidence is less clear, but some studies have found that long-term use of estrogen (more than 10 years) increases the risk of ovarian and breast cancer.

So what are the current recommendations?

Other than short-term relief of postmenopausal symptoms, there are few strong reasons for use of postmenopausal hormone treatment. If HRT is needed for relief of postmenopausal symptoms, each woman should work with her physician to find the lowest possible dose that works for her and for the shortest amount of time.

I recently interviewed Ruthie Bolton (formerly of the Sacramento Monarchs) who asked me if African American women had a higher risk of developing breast cancer.  This is an interesting and often
misunderstood topic.  First of all, irregardless of ethnicity all women over 40 should have annual screening mammography.  However, when one looks at breast cancer incidence as published by the American Cancer Society, some surprising data presents itself.  ACS surveillance review published in 2007 showed that breast cancer incidence was highest in Caucasian women (132 per 100,000), followed by African American women (118 per 100,000), Hispanic women (89.3 per 100,000), Asian American
women (89 per100,000) and finally American Indian women (69 per 100,000).

However, female death rates related to breast cancer in African American women (34 per 100,000) were highest amongst all ethnic groups followed by Caucasians (25 per 100,000).  Additionally, African American women are less likely than Caucasian women to survive 5 years:  77% versus 90% respectively.

The reasons for this lower survival are diverse. Aggressive tumor characteristics appear to be more common in African American women.  Additionally, presence of chronic illnesses, lower socio-economic status, and delayed access to medical care also contribute to this disparity.  Again, this scenario should reinforce that early detection is the single most important tool to identify and thus treat breast cancer at its earliest stage.  Access to services such as mammography should  not compromise a woman’s opportunity to receive this important service.

For many years, screening mammography has been the “gold standard” in detecting early breast cancer in all women regardless of underlying risk factors.   With the development of new breast imaging technologies, namely breast MRI, the screening strategy for women with especially high risk of developing breast cancer has changed.  MRI has been shown in numerous scientific studies to be the most sensitive test for detecting early breast cancer (greater than 95% in some studies).

As a result, of these studies the American Cancer Society (ACS) has revised its recommendations regarding breast MRI.  Its most recent guidelines published in 2007 recommend MRI screening in addition to mammography for women who meet one of the following criteria:

They have a BRCA1 or BRCA2 mutation

They have a first-degree relative (parent, sibling, child) with a
BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves

Their lifetime risk of breast cancer has been scored at 20%-25% or greater, based on one of several accepted risk assessment tools that look at family history and other factors

They had radiation to the chest between the ages of 10 and 30

They have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relative

As expressed by Christy Russell, MD, Chair of the ACS Breast Cancer Advisory Board, “These guidelines are a critical step to help define who should be screened using MRI in addition to mammography, a question of significant importance as we discover women at very high risk of breast cancer can be diagnosed much earlier when combining the two technologies rather than using mammography alone.”

It’s Breast Cancer Awareness month and what better time to schedule your annual mammogram. Mammography is the most reliable screening method for breast cancer detection available today. Combined with an annual clinical exam by your physician and monthly breast self-examination (BSE) it is the best way to detect breast cancer early and save women’s lives.

All too often we see women that come in to our imaging centers because their mother, sister or close friend has been diagnosed with breast cancer. Don’t let negative news get you to the doctor. Make a commitment to overall good health; schedule your mammogram today and make it an annual habit.

Magnetic resonance imaging (MRI) of the breast is an important new approach we use to diagnose and characterize abnormalities in the breasts. Because images produced by MRI are very detailed, this
technology can detect small changes or abnormalities. Breast MRI frequently can be used to determine whether or not an area is cancerous, thereby avoiding unnecessary biopsies and it is especially helpful for evaluation of very dense breasts.

The American Cancer Society has recently announced that Breast MRI may also  be useful as a screening exam for high risk women where there is a strong family history of breast cancer. Generally, Breast MRI should not replace your annual mammogram, but if you think you fall into the high risk category, you may want to ask your doctor if this exam is right for you.

RAS recently installed several new digital mammography units. What does this mean to you, our patient? This new state-of-the art equipment accommodates larger size women, provides a shorter exam time, and provides less radiation dose to the patient. With the exception of images that are recorded and stored on computerized media, the method of performing the exam is the same as traditional — or analog — mammography.