Deborah Howell (Host): Hello and welcome to the show. You’re listening to the Weekly Dose of Wellness brought to you by MemorialCare Health System. I’m Deborah Howell, and today’s guest is Dr. Richard Reitherman, the medical director of Breast Imaging at the Memorial Care Breast Center at Orange Coast Memorial Medical Center and also at Saddleback Memorial Medical Centers. Dr. Reitherman is well known for his clinical role in the early adaptation, promotion and refinement of breast MRI, with more than 20 years of experience in breast imaging and intervention. He’s also very involved in improving screening for high-risk women less than 40 years of age. Welcome, Dr. Reitherman. Dr. Richard Reitherman (Guest): Good morning. Deborah: Glad to have you on this show. Today we’re talking about the latest technologies for women who want to be screened in order to protect their health. So, can you tell me, please, what is automated whole breast ultrasound and who benefits from it? Dr. Reitherman: Sure. The basic issue of any modality other than mammography is that mammography does not detect all invasive breast cancers, so additional imaging technologies were done to mitigate that. Whole breast ultrasound is dedicated to screening procedures. It acquires hundreds of images of each breast to compliment the limitations of mammography. Now, in distinction, the inner breast ultrasound is designed to evaluate the specific area of one breast where there’s a lump or a mammographic abnormality and we take maybe a dozen images. The woman who benefits from whole breast ultrasound screening is a woman who has what we call mammographical dense breasts. The purpose of the screening test for breast cancer is to detect it at an early stage. Let me give you an example of mammographically dense breasts. Deborah: Okay. Dr. Reitherman: The woman who does not have mammographically dense breasts, the task of looking for cancer is like looking for the North Star on a cloudless night, say, in Denver. Deborah: Wow. Dr. Reitherman: And a woman with mammographically dense breasts, the task of looking for cancer is like looking for the North Star on a cloudy night in San Francisco. Now, there is a spectrum. Basically, women with dense breast issues are harder to detect invasive breast cancer. Deborah: Is there any typical woman who has dense breast? I mean, is there a profile for a woman with dense breast? Dr. Reitherman: A basic profile is pre-menopausal woman, regardless of the age, so this must pick around 50 and under, the pre-menopausal; they tend to have the majority of dense breast issues. As menopause comes and aging, the breast density in a given woman decreases, so the sensitivity of mammography increases postmenopausally and is less good in women pre-menopausally. Deborah: That’s a very concise answer, I appreciate it. So, what I’m understanding is, a normal mammography you get what, three or four images taken? Dr. Reitherman: Correct. Deborah: And so, now you have hundreds of images and from those you call dozens for any problem areas, is that correct? Dr. Reitherman: Correct, the difference in physics of X-ray mammography, including tomosynthesis, as opposed to ultrasound. Deborah: Okay, let’s talk a little bit about tomosynthesis because you hear the words now in commercials. You know, you think you know what it means, but let’s get your definition of it. Dr. Reitherman: Okay. Tomosynthesis, also called 3D mammography, is an additional mammographic procedure that’s used in combination to the traditional two-view, 2D mammography that I think everybody is used to. After the two pictures of each breast are taken, an additional picture or acquisition of each breast is taken with multiple images with the acquisition in a panning [point], so you can kind of re-format and get by the dense breast issue. So, it’s a mitigation process for dense breast issue. Deborah: Okay, all right. And what about women with implants? Would that be considered, obviously, dense? Dr. Reitherman: Well, basically, even though that’s not the intrinsic dense breast patient, anybody with the prosthesis in their breasts, saline or silicone, definitely has limitations in terms of our ability to find cancer using mammography alone. Deborah: Does the automated whole breast ultrasound have more success than a standard mammography? Dr. Reitherman: A whole breast ultrasound is effective in looking at entire breast volume, each breast, no matter what’s in the breast. But if there is prosthesis in the breast, a silicone implant, we can see the difference between the breast tissue and the implants and go around the implants, which mammography does not have the ability to do. Deborah: I see. So I understand that the Memorial Care Breast Center at Orange Coast is one of only a handful in Orange County to have the new technology. Is that right? Dr. Reitherman: That's correct. Deborah: Okay. So, if you want the full procedure, if you want hundreds of images, if you want to be as sure as possible that you are breast-cancer-free, you might want to check out whole breast ultrasound. Let’s talk a little bit about ASBD algorithms for managing dense breast patients. Dr. Reitherman: Okay. ASBD stands for American Society of Breast Disease, the national society, and they’ve established kind of a protocol to help patients and physicians navigate this dense breast issue. Traditionally what we do is we stratify women into different risk groups based on family history. If the woman has no family history of breast cancer, she has less of a chance of getting breast cancer during her lifetime, than the woman with the high family history, such as her mother had breast cancer. Deborah: Okay. Dr. Reitherman: So the ASBD algorithm first categorized its patients into three groups: The highest risk group, which is greater than 20 percent and includes the patients with gene positive breast cancer, are recommended to have mammogram and a breast MRI annually. The middle risk group, which is11 to 19 percent lifetime risk, is recommended to have a mammogram and a whole breast ultrasound every year. Deborah: Okay. Dr. Reitherman: The third group, which is a normal risk group, the women under 10 percent lifetime risk, are recommended to have a mammogram alone. And this is evidence-based, meaning scientifically based, recommendation. Deborah: So, do all physicians have access to the algorithms? Dr. Reitherman: Well, they do, but one of the confusing parts about breast screening is that there are multiple societies who have multiple ideas on how breast cancer should be screened. Deborah: Okay. So what are some of the alternative forms of imaging used to detect breast cancer? Dr. Reitherman: Certainly we have pre-validated forms for detecting breast cancer: The mammography, the traditional way, which is the most widely available – We have breast MRI, which is proven to be the most sensitive in detecting invasive breast cancers. Deborah: Okay. Dr. Reitherman: And we have ultrasound, which in combination to traditional mammography is the next best to breast MRI in detecting breast cancers. And mammography, with or without tomography, is the third best, compared to mammography and ultrasound alone. Deborah: Lots of choices out there. If you’re a woman in your middle 50s, which route do you go if you’re basically a healthy woman and you’re not genetically predisposed to it, what do you think you do? Dr. Reitherman: Well, it’s really a conundrum because there’s so much information. But I think there are two sources: One is you go to a reputable breast center that’s understands the integration of all these things, or you go to your primary care physician or gynecologist and ask their advice in terms of how to navigate this. It is confusing. Deborah: Yes, it’s, as you say, too much information, TMI. So, leave it up to the professionals. Just go to someone you believe in and, like you say, a reputable place of medicine and you should be in good shape. Dr. Reitherman: Correct Deborah: Now, I understand there’s a new breast density law in the State of California. So, how does this automated whole breast ultrasound play a role? Dr. Reitherman: Okay, here’s the deal with the law. It’ll go into effect April 1st of 2013. At that time there will be five states in the United States that have that law in place, which will now encompass a third of the women in the United States under this law. Now, a lot of states are following. Previous to this law, the patient received a letter by law telling her whether her mammogram was normal or abnormal and what to do. Deborah: Okay. Dr. Reitherman: And number two, that there are alternative forms of imaging, specifically breast ultrasound, whole breast ultrasound, and MRI, which can mitigate the issue. And thirdly, the mammography cannot detect breast cancer in patients with dense breasts as well as it can in women who do not have dense breasts. Deborah: Wow. Dr. Reitherman: So, that's by law. Deborah: Do you think it’s a good law? What are the pros and the cons? Dr. Reitherman: Well, that’s a good question. The cons are, the additional whole breast ultrasound or MRI to mammography really requires the dedication of a facility in terms of physicians, technologies and equipment to perform an integrated study. And this is not as widely available as the ability to perform good mammography. Deborah: And may or may not be covered by insurance. Dr. Reitherman: Exactly. The second thing is who is going to pay for it? Deborah: Yes Dr. Reitherman: Will it be covered by insurance or not? Deborah: Wow, changing scope of things for sure – so, ladies, information is power. Dr. Reitherman: Can I give you that – the cons, the pros? Deborah: Absolutely. Dr. Reitherman: Okay, the pro is that mammography plus whole breast ultrasound will detect almost twice as many invasive breast cancers in women with dense breasts than mammography alone. And it will detect it at a smaller size and in the lower scale. And those are scientifically validated specs. Deborah: All right. Well, Dr. Reitherman, I wish we had more time. This is a fascinating study and such a changing landscape. Thank you so much for your time today. It’s been really interesting; we learned a lot. We’ve been speaking with Dr. Richard Reitherman about early breast cancer detection with automated whole breast ultrasound. Join us again next time as we explore another Weekly Dose of Wellness brought to you by MemorialCare Health System.