Transcription:
The Benefits of Mammography

Melanie Cole (Host): According to www.breastcancer.org, about 1 in 8 women will develop invasive breast cancer over the course of her lifetime, and many experts are saying that starting at age 40, most women should have a mammogram every year that can help catch breast cancer early on when it's most treatable. My guest today is Dr. Lisa Schneider. She's a radiologist and the Medical Director of Imaging at Piper Breast Center, part of Allina Health. Welcome to the show, Dr. Schneider. So, women hear that word “mammogram” and they recoil. What do you want to tell them about a mammogram and not to be afraid of it and then let's talk about when they should start getting it?

Dr. Lisa Schneider (Guest): Oh, all great things to talk about, Melanie. Good morning. It's so good to be here again with you. First of all, I want women not to be afraid of mammograms. I understand the fear; I understand the anxiety and I often say that part of what I do in my job is treat anxiety as well as read the mammograms. I know it's an understandably concerning and can be a very scary time. But, what I want to share with women is that it's been a success story. Since women have started getting screening mammograms in the United States, starting in the 1980s, we've seen the death rate from breast cancer go down about 30%. So, we have proven the test over time that it does decrease our death rate because we are able to detect breast cancers on screening mammography before they have a chance to spread and potentially kill and be the cause of your death. So, it's been just a real win. It can be uncomfortable. I always recommend that women go to a place that they're near--that's near to them—and that they're comfortable with. The other message I like to tell women is any mammography center in the United States that has its doors open has already had to kind of cross a high bar in terms of having their doors open. In 1992, Congress passed an act that said any place in the country doing mammography has to meet certain Federal guidelines and regulations and they are inspected once a year to make sure those things are met--everything from the training of the technologists to the physicians who read them to the equipment. So, they should be assured that number one, there's a very high quality of mammography that's done in the United States and that screening mammography works because of early detection.

Melanie: So, Dr. Schneider, there has been some controversy. People hear ACOG saying one thing and people are going back and forth about when we should start our screening mammography and how often after that we should get it. What do you say?

Dr. Schneider: Right. So, I am a member of the Society of Breast Imaging, full disclosure, I am also a member of the American College of Radiology and I'm a radiologist who works in a breast center who deals with women with breast cancer every day and I'm very active clinically and I see the benefits of screening mammography. That being said, there is controversy. The American College of Radiology and ACOG recommend age 40. The American Cancer Society recently changed their guidelines to starting at 45, and then the United States Preventative Task Force Services recommend 50. So, there's all of this confusion of these different organizations and women don't know who they should believe and I always tell women, “Know the facts. Talk it over with your doctor and kind of go from there.” So, one of the facts that women will sometimes say is "Well, there's nothing like that in my family history and therefore, I probably don't need to start screening until I'm 50." I will tell women that the majority of breast cancer occurs in women who don't have a family history. So, I just simply arm women with the facts about it, and that there's no scientific or biological reason to delay screening until the age of 50--because no decade of life, the 40s, the 50s, the 60s, or the 70s, account for more than 25% of the cancers diagnosed each year.

Melanie: So, okay. So, women hear this, they hear all these different sort of recommendations and if they start, and then there's difference between diagnostic and screening. They wait for that letter or that word from you and it's a very scary time, Dr. Schneider. Women sit there and you talked about anxiety before, and so we sit there and we wait to hear. What do you want women to know about that waiting to hear whether you have to come back for the diagnostic?

Dr. Schneider: Right. So, I want women to know that the majority of women don't need to come back for a diagnostic mammogram. You know, nationwide, it's about 10% of women that we call back and out of those 10%, the majority of those, it will just simply be a couple of extra pictures that will resolve the problem and they don't have cancer, and then we say "You've passed your screening test now, we'll throw you back in the pool and you can come back and have a screening in a year.” A very small percentage of those will have something abnormal in their mammogram, and we will need to do a biopsy, perhaps, and it's a needle biopsy, okay? It's not an open biopsy. The majority of biopsies done today in the United States in the breast are done with a needle. It's a percutaneous procedure, a little bit of local anesthetic. Women should also know that by law, they have to receive the letter within a certain amount of time, okay? Stating whether or not their mammogram was normal or abnormal, and then, there is a guideline, particularly within Allina, that once we tell a woman that her mammogram is abnormal, we adhere to a standard of getting that woman in as quickly as we possibly can for that diagnostic workup and so at that time, she can consult with the radiologist an she can kind of know a little bit more information. So, two things we try. Number one, it's not a lot of women that get called back. Some women that get called back are getting called rightfully so, because there is a cancer that needs to be detected and treated, and potentially cured. And then, the rest of the women that have that anxiety about they don't know or they do know, or the don't know, we just try to get in and work them through the system as quickly as possible and communicate with them, all along the way.

Melanie: Can you tell, as a radiologist, whether something looks benign, like a papilloma or something, or whether you suspect that it is cancer? Can you see that on the picture?

Dr. Schneider: Sometimes, yes. Of course. So, sometimes I can look at a screening mammogram and I can say from the doorway that's cancer until proven otherwise. I need to put a needle in that and prove to her doctor and to her that it's cancer and it needs to be treated. The challenge of my job--and that's the challenge of any radiologist--is trying to sort out those in-between cases. You know, is this concerning enough? Is there something sneaking around or hiding in there that could be a cancer and it concerning enough that I should call her back? Or, is it something that's you know, benign and I don't need to call her back? Where it's really helpful for a radiologist is having a track record on this woman. By “track record”, I mean her old exams. If she has got her old exams and she's been faithfully getting mammograms for a long time, that really helps us out a lot. An old teacher of mine once said "Old films make you smart," meaning old images make us smart so that we have the previous exams to say, “Everything has been there before. This clearly isn't a cancer; it's benign,” and we can dismiss it.

Melanie: Should women with breast implants still have screening mammograms? Or, if they've after a mastectomy, if they've had reconstruction, do they then still get mammograms?

Dr. Schneider: Good question. Women with implants, if they're over the age of 40, should absolutely be screened for breast cancer. Again, there's a special mammographic view that we do where the technologist will gently push the implants back and pull the breast tissue forward so that we can get an optimal view of that. I will say they do get a little bit more radiation when they have a mammogram versus women who don't have implants, because we need to take extra pictures to screen them to make sure we're doing an adequate job of seeing all of their breast tissue. That extra radiation that they're getting, I think over a lifetime of just getting one screening mammogram a year is negligible and not likely to cause them any harm. Your other question was about once you've had a mastectomy. So, once you've had a mastectomy, it depends on the kind of reconstruction that you get. If you have a mastectomy and you get reconstruction with an implant, that breast no longer needs to be screened, but we would screen your other breast if you still have your native, other breast. If you get a reconstruction with what we call a “tram flap”, which is a mound of tissue that the surgeon places over the breast, it can sometimes be difficult to detect a recurrence in that breast and a lot of plastic surgeons like us to go ahead and just gently do a mammogram on that lump of tissue that has been used to reconstruct the breast.

Melanie: Are there different types of mammogram? We hear now that there's 3D digital mammography, tomosynthesis, we've heard about a whole breast ultrasound, and MRI. Speak about those other types of mammograms that people may want to ask their doctor or radiologist about and then what's on the horizon for mammography?

Dr. Schneider: Right. So, screening mammography, number one, has been the only examination that has been shown to have an impact on the mortality rate of breast cancer. That's the screening test that we recommend women get every year. For women who are at higher risk, and we have documented that they are higher risk, be it family history, previous biopsy, personal history of breast cancer, if you meet sort of a 20% threshold, then we recommend that there is another screening test that be thrown into the mix, either whole breast ultrasound to look for cancer, or breast MRI to look for cancer. Mammography itself is evolving. You touched on 3D, or digital tomo breast synthesis, which is the same thing. What that is is a new mammogram that not only gets kind of the two-dimension look at the breast, but it takes tiny little slices, like a CT scan, through the breast. It allows me, as a radiologist, to uncouple the tissue and cancers that are hiding within that tissue, a lot of times become more conspicuous. And then also, that tissue overlap is sometimes the reason we call women back because we're not certain if there's something hiding in there. This new modality has saved us calling women back. So, it's increased specificity and increased sensitivity for a screening test that's already been shown to decrease mortality rate. I think with this added tool of the 3D technology, we're going to see the mortality rate hopefully drop a little bit more and our anxiety rate drop even more since we will have to call women back less frequently.

Melanie: And, what about women with dense breast tissue? What do you tell them? Again, this is something we're getting letters about now, and there's requirements in certain states that you be notified about dense breasts. So, what do you want to say about that?

Dr. Schneider: Right. So, dense breasts, the reason people get concerned about dense breasts is that it can hide a breast cancer in your mammogram. It can make detecting a breast cancer more difficult in a woman that has dense breasts versus a woman that has more fatty breasts. The law came into being in different states after a woman who had breast cancer didn't have any idea about the density of her breasts and she said, "If I would have known I had these dense breasts, and that was hiding my breast cancer, I would have done something else in addition to getting a mammogram. There ought to be a law." So, indeed now, many states have passed a breast density law stating that in addition to informing women of the results of their mammogram, we need to inform them whether or not they have dense breast tissue. So now, that's what we do and Minnesota now has this law, and it states something to the effect of the letter, “You have dense breast tissue. This can make cancer more difficult to detect. It also places you at a little bit higher risk of developing breast cancer. Talk it over with your doctor if you want another screening exam.” And that screening exam, there's no consensus on which other screening exam would be the best fit. You can do breast ultrasound or you could do breast MRI. There is, however, a test coming out, it is out right now, and it's being utilized across the country, it's called an “abbreviated breast MRI” and instead of a full diagnostic breast MRI, which take up to half an hour or 40 minutes, this abbreviated test for women with dense breast takes about seven minutes. It takes the radiologist a lot less time to read and it will probably be a lot less money once it's implemented than the full diagnostic MRI.

Melanie: What great news for women to hear, Dr. Schneider. Wrap it up. Best advice about all the controversy surrounding mammograms, what you want women to know about them getting that baseline mammogram so that you have those old films, as it were, and you can look at it and give us a better diagnostic tool to catch breast cancer early.

Dr. Schneider: You know, just talk it over with your physician when you turn 40 about having a mammogram. Really consider strongly about having a mammogram in your 40's. I think that's a time when women are very productive, very active and if they were to develop breast cancer, give yourself every opportunity for that cancer to be caught early when it is very treatable and curable.

Melanie: Thank you so much for being with us today. You're listening to The WELLcast with Allina Health and for more information, you can go to www.allinahealth.org. That's www.allinahealth.org. This is Melanie Cole. Thanks so much for listening.