Health Watch: Breast Cancer & Oncology | Early Detection

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From the July 2012 issue of Columbus CEO
  • Courtesy the Stefanie Spielman Comprehensive Breast Center at James Cancer Hospital and Solove Research Institute

Breast cancer, like other cancers, is a disease that causes cells to grow uncontrollably and invasively. It accounts for nearly one in three cancers in American women, and strikes more than 200,000 women each year in the United States alone. According to the American Cancer Society, approximately 40,000 of those 200,000 women will die from the disease. Those who beat cancer still may have a tough battle, facing chemotherapy, radiation treatment, surgeries and sometimes mastectomy (removal of the breast).

The very mention of the word cancer strikes fear, but there are encouraging statistics. The National Cancer Institute estimates that in 2008, more than 2.6 million U.S. women with a history of breast cancer were alive; while some were still undergoing treatment, most were cancer-free.

Doctors say the key is early detection, and the most effective detection tool is the mammogram, in which radiology is used to look inside the breast and detect even the tiniest of abnormal growths.

Technology Saves Lives

“There are two types of mammograms,” says Dr. Corinna Chang, breast radiologist and medical director of the Dublin location of Solis Women’s Health. “Screening mammograms are performed for asymptomatic women to detect unsuspected breast cancers. If an abnormality is seen on the screening mammogram, the patient will be called back for a diagnostic mammogram and possibly an ultrasound of the breast for further evaluation.”

A diagnostic mammogram may also be performed when a patient experiences a new lump, area of pain, redness or nipple discharge, Chang says. Diagnostic mammograms may include special spot compression or magnification views in addition to the standard views typically performed for a screening mammogram.

The breast is made up chiefly of milk-producing glands (lobules) and the ducts that connect the glands, as well as connective tissue, fat and lymphatic tissue. According to the American Cancer Society, most masses discovered in women’s breasts are benign, so they do not grow uncontrollably and will not spread to other parts of the body. Many of those masses are located within a duct or lobule, and that’s where they’ll stay.

However, when a mass is cancerous, it is most typically an aggressively invasive type of cancer. The cancer cells break through the walls of the duct or lobule and spread to the surrounding tissue. If not caught early, the cancer can spread throughout the breast and even travel through the body to distant organs.

A woman’s first line of defense is the monthly self-exam to check for lumps within the breast. Dr. Mitva Patel, a breast-imaging specialist with the Stefanie Spielman Comprehensive Breast Center at Ohio State University’s James Cancer Hospital and Solove Research Institute, says self-exams are absolutely recommended, but technology can detect things the human hand cannot.

“Most of the masses that can be detected in a self-exam are around 2 centimeters in diameter,” Patel says. “Our goal in mammography is to find cancers when they are as small as possible. The average size of a cancer detected by mammography is under 1 centimeter, but we routinely detect cancers that are just a few millimeters.”

Controversy

Doctors have traditionally recommended that women have a mammogram every year beginning at age 40. For a while, many doctors recommended having a baseline scan done at age 35, but some say there are a few drawbacks to that approach. While the radiation delivered in the course of a mammogram is small, there is still some radiation exposure. “You have to weigh the risk of that additional exposure,” Patel says.

In addition, women’s breasts lose density as they age, with much of the tissue converting to fat over the years. In younger women’s breasts, a mammogram is less effective because the tissue may be too dense for the imaging equipment to penetrate.

In 2009, the U.S. Preventative Health Task Force issued a recommendation that women delay mammograms until age 50, and then receive them only every other year. Part of the rationale was that the screening process causes undue emotional and psychological stress on a patient, so the test should be performed less frequently.

“For every 1,000 women who have a mammogram, about 100 will get a call back,” Patel explains. “Most of them will end up having additional tests, and the tissue is fine.” She says there can be stress on the patient in the time that elapses between test and results, but adds the pain of waiting far outweighs the risk of letting cancer go undetected.

Amy Behrendt is a firm believer in mammograms. Her mother is a breast cancer survivor, having undergone a successful lumpectomy a number of years ago, and she knows other women who have been diagnosed with breast cancer. “I had two close friends and a cousin on my husband’s side die of the disease, so I am affected more mentally than physically,” she says.

Although Behrendt has suffered through the waiting period after a few false positives, she finds the test well worth the worry. At age 38, she had her first mammogram at an OhioHealth facility after finding a suspicious mass during a self-exam. After the mammogram revealed something was amiss, she underwent an ultrasound and a biopsy, then three days of waiting before finding out it was just fibroadenoma, a benign growth. She has been through the process three times in the past six years. Now, Behrendt gets an annual mammogram and undergoes additional scans six months later if a benign mass is detected.

In spite of the 2009 recommendations, most physicians and related groups—including the American Cancer Society, the American College of Radiology and the Society of Breast Imaging—still recommend annual mammograms beginning at age 40. Women who have a family history in the first degree—that is, a mother or sister who had the disease—are encouraged to begin mammograms 10 years prior to the relative’s age at the time of diagnosis. “If you have one relative who had breast cancer, you have double the risk of developing it,” Patel says. “If you have two first-degree relatives who were diagnosed, your risk is three times that of the typical woman.”

Doctors encourage all women to stick to the screening plan regardless of family history. “Three-quarters of the women we diagnose do not have a family history of breast cancer,” Patel says. “Lack of family history of the disease is no reason for a woman to skip her annual exam.”

New Developments

Experts agree that early detection through mammography saves lives. Now, women’s odds of survival are getting even better as researchers develop better ways to see what’s going on inside the human body. Dr. Jeff Hawley, a breast imaging specialist and assistant professor of radiology at OSU, says technology is continually improving.

“It has been getting progressively better since it began,” he says. “It started out almost like Xerox images, and we moved through analog technology into digital imaging. There is no perfect test, but it has become increasingly more sensitive.”

The newest technology in breast imaging, called tomosynthesis, is a 3-D imaging process that uses an older science called tomography, which was once used to scan for kidney stones and other ailments, but fell by the wayside as new technology became available. Now the science is being revived for a new purpose.

Breast experts predict that tomosynthesis will make a big difference in the efficiency of mammography, reducing callbacks for additional scans by about 30 percent—saving women money, stress and potentially reducing their cumulative radiation exposure.

One of the problems in mammography is that overlapping tissue sometimes presents as a mass when, in reality, there’s nothing there but breast tissue. “Women get calls back about something that’s not necessarily real,” Hawley says. In tomography, the radiologist is able to view the breast from more angles—up to 64 images are generated instead of the traditional two—giving a much more accurate picture.

Dr. Tom Buse of Riverside Radiology and Interventional Associates says OhioHealth went live with the new technology in July 2011, soon after it was approved by the U.S. Food and Drug Administration.

“With conventional mammography, we’ve always had 2-D imaging at two different angles, from bottom to top and from side to side,” he says. “Tomosynthesis does a sweeping arc through the breast. It gives us a look from many different angles instead of being trapped in just two views, and it allows us to tell if something is just overlapping tissue or if it is actually an underlying mass.”

When a mass is present, doctors can characterize it more quickly and accurately. The margins and regularity of the mass’s shape give doctors an idea of the nature of the potential problem.

OhioHealth was the second hospital group in the country to use tomosynthesis units, and as of early June was the only group to offer the technology in Ohio. OSU will implement tomosynthesis this summer.

Those who run medical offices are hashing out how to pay for the units, which typically cost about $500,000 as opposed to $300,000 for a traditional mammography machine. “It’s not a cheap proposition to get it started,” Hawley says. He says OSU hasn’t determined whether patients will pay a nominal fee or whether the cost will be built in some other way.

“Right now, most insurance companies do not cover it,” Buse says. “We do think it will be covered as it becomes more commonplace, but for now, we’re not charging anything extra.”

For the time being, traditional 2-D mammography remains the gold standard. “Probably in 10 years, tomosynthesis will have become much more common,” Buse says. “Right now, there is only anecdotal evidence. I’m sure in the future there will be studies linking the technology to a reduction in mortality, and that’s when it will become the standard of care. That’s when it will really have an impact.”

Mammography is one of the most studied tests in all of medicine, Hawley says, and it has been proven that there is a significant reduction in mortality among women who participate in the screening process.

“It’s always kind of sad to see a woman who had a mammogram, and then you don’t see her again for three or four years and she has developed a large cancer,” Hawley says. “You always wonder how much better you could have done for that patient if you had caught it earlier.”

Kristin Campbell is a freelance writer.

 Reprinted from the July 2012 issue of Columbus C.E.O. Copyright © Columbus C.E.O.