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Melanie Cole, MS (Host): We know mammograms can seem scary for some women, but breast cancer is scarier. If you're a woman over 40, it could save your life. Joining the show to discuss early and regular screenings for breast cancer and 3D mammography is my guest Dr. Emily Norman. She’s the radiology director at Stoughton Hospital. Dr. Norman, explain a little bit about breast cancer. What are you seeing as far as incidents and awareness? Are you noticing that more women are getting screened?

Dr. Emily Norman (Guest): Absolutely. There’s a lot more awareness now than there ever was before. We have community efforts. We have screening days where you can come in for a mammogram without being scheduled at quite a few of our local hospitals. I think just in general whether it’s for Race for the Cure or other ideas like that. Women are becoming more aware of the importance of being screened for breast cancer.

Melanie: Who’s at risk for breast cancer? I mean I know that there’s so many women that are, but are there certain risk factors that would predispose a woman and really make it just that much more vital?

Dr. Norman: Well, there are some risk factors. In general, we look at things like your family history. Women who have had other family members, especially their close family members such as a mother or a sister. Those women who have family members getting breast cancer at an early age, premenopausal age, are definitely at a higher risk for developing cancer over their lifetime. Usually if they have that family history, they’ll work with a geneticist to determine their own risk. That’s one of the strongest risks we know of is just looking at your family history and seeing what’s going on.

Overall, breast cancer does remain the second leading cause of cancer death. One in eight women do have a risk of having breast cancer over their lifetime. It’s important for everybody, whether or not they have that family history, to come in and be screened.

Melanie: So, let’s talk about screening then. Who should get screened, at what age, and why, Dr. Norman, is there confusion over the current recommendations for screening mammography?

Dr. Norman: Right. There definitely is a lot of confusion. Currently the American College of Radiology, which guides the radiological statements, has remained at their recommendation of starting at age 40 annual screening for an average risk woman. In general, within the radiology world, we see women who still get caner at a younger age. So, we feel strongly that they should start being screened at age 40; and, especially in the younger years, they should come on a yearly basis. The cancers that you get at a younger age are, in general, more aggressive. So, you want to catch those early, and when they're small, get them out of there and make sure that the patient then has every best chance for survival and a normal life afterwards.

There is some confusion. Other societies, I think specifically maybe family practice. Some of the other medical specialties are saying to go to every two years. A lot of that is because they’ve looked at cost reduction. Yes, it does save some money on the outset as far as save the money for screening. However, our worry is that then if a cancer is detected, it would be detected at a somewhat more advanced stage after two years rather than one. The outcomes may not be quite as good.

So, there is still a lot of ongoing research with this. We want people to receive screening in a reasonable manner. Not to have exams that they don’t need. However, we do want to be careful and not let anyone slip through the cracks who maybe would have had a better outcome if they were screened yearly. So ACR still recommends beginning at age 40, yearly screening.

Melanie: Then tell us about digital mammography or tomosynthesis, 3D mammograms; and what’s the difference between the standard, what we used to be using, and this 3D?

Dr. Norman: So, Stoughton Hospital is very excited that we now have 3D mammography, which is also known as digital breast tomosynthesis. So, you may hear that term. Basically, your routine digital mammogram was two pictures of each breast. Now, with 3D mammography, we basically take many more pictures of each breast. Thin sliced images, sort of like if a patient has had a CT scan where they have multiple images through one part of the body. We now use a 3D mammogram machine, and instead of just taking two projects, we basically can create a 3D picture of the breast.

Why this is exciting is that we then get a much better overall picture of the breast tissue. 3D tomosynthesis has been shown to significantly decrease the rate of people being called back. So, it also decreases the chances that when we do call you back, that there’s nothing there, or what we call false positives. So, when we do call someone back after a 3D image, we are noticing—and studies have shown a significantly improved rate—of actually finding a cancer. So, it’s improved our accuracy, but it’s also decreased the overall number of studies that women have to have. So, it’s a much better test, especially for younger women or women with dense breast tissue. 3D mammography does a much better job of looking through that breast tissue and finding true cancers.

Melanie: Speak about dense breast tissue for a minute doctor because some women have gotten a letter, and it’s a law in some states that they have to be alerted if they have dense breasts. What does that mean and what does that mean for our risk for breast cancer?

Dr. Norman: Right. So, what that means is… So, every time a radiologist opens up a mammogram to look at it, we have to notice how dense the patients breast tissue is. There are actually four categories that we use. The least dense we call fatty breast tissue. Up one level goes to scattered fibroglandular. Then we go to dense and then extremely dense. So, every woman should fall into one of the four categories. The importance of knowing what your density is is this kind of guides a radiologist or whoever’s looking at your study to know how easy or difficult it might be to find a breast cancer on your pictures.

So, in a woman with fatty breast tissue, a breast cancer normally stands out pretty obviously. However, if you're dense and you still have a lot of glandular tissue, a breast cancer can be somewhat more difficult to see. So, it’s not necessarily that a dense person would have a much higher chance or getting cancer, it’s just that their cancers are more difficult to detect by mammography. That’s where 3D mammography becomes so helpful. It reduces the chances that we’re going to miss a breast cancer in a dense patient.

So, when you get your letter and it tells you your density, what that’s gonna do is kind of guide you, as a patient, to seek the best kind of mammogram for you. A lot of hospitals now offer 3D mammography as a choice. They’ll say we have regular 2D, or we have the new thing, which is 3D mammograms. They’ll leave it up to you to choose which one you’d like to have. Now if you've had a letter that tells you that your breast tissue is dense or extremely dense, then you should definitely consider electing to have that 3D mammogram rather than going for the 2D mammogram. That’s why it’s important to kind of look at that letter and see what your breast tissue density is.

Melanie: Now you mentioned the call back. It’s something every woman fears. That fear of waiting to hear from you radiologists that we’re not getting the call back or we are. So, explain the difference of a diagnostic mammogram and what happens after that call back?

Dr. Norman: Right. So that’s a great question. What happens is once you have your screening mammogram, if the radiologist sees any questionable thing—whether it be a mass or a calcification—we will call you back and do a little bit more investigation. So, the call back doesn’t always mean that it’s something bad. Every now and then it’s nothing at all or it could be a benign finding such as a simple breast cyst. Or a fibroadenoma, which is another type of benign breast disease.

So, when you get your call back, you come back in. Sometimes a woman needs a couple more mammogram pictures, and we’ll do that. Often the woman will end up going to an ultrasound. The ultrasound just uses a different type of imaging to look at the soft tissues. So, we’ll look with either mammo or ultrasound. If we find something then, say if it’s benign, that’s great. Usually the radiologists themselves, most of the time, will be able to come in and talk with a patient that day and give them their results and say, “This looks benign, nothing to worry about. You can return to routine screening.”

Now if we find something that looks suspicious, we’ll come in. We’ll talk with the patient about that, and usually at that point we’ll recommend a biopsy. So, the difference between screening mammogram where you wait for your results and get those a few days later and a diagnostic, you will get your results and we’ll have a plan or action for you the day of that procedure. Whether it be no further follow up needed or we need to do something else. Whether it’s a follow up in six months or get a biopsy or sometimes get a breast MRI. So, the diagnostic is just a next step of working up a finding on your screening mammogram.

Melanie: Wrap it up for us Dr. Norman. You’ve explained everything so beautifully and let women really know the importance of a mammogram and really what it means and what the difference is with 3D and 2D. Wrap it up for us with your best advice about self-exams, a woman’s best health advocacy by getting her mammograms on a regular basis, and what you would like them to know.

Dr. Norman: Absolutely. We’ll I think the most important thing is to remember that the screening mammogram is just an excellent tool that we have. Whether you decide to come yearly or every other year, it’s important to be consistent. It’s important to come in because now we are seeing so much improvement on how breast cancer is treated. When we find a small breast cancer early before it’s spread anywhere else, it can be removed. The patient may receive a small amount of either radiation or sometimes chemo. In general, people are doing so much better. So, the early detection is just vitally important to that.

Digital breast tomosynthesis or 3D mammography has been kind of the way of the future, but now it is becoming available in many, many places around Madison and Stoughton. We are excited to have that because in general it should decrease the amount of times a woman is called back for something that turns out to be nothing. So overall, it should kind of decrease the level of worry as far as women won’t b getting those return for more picture letters as frequently as they used to. So, it’s definitely a great new tool.

I think that as many women as would like to should opt for the 3D mammogram when they come in. We highly encourage women to do it. That way we have the best chance out there to find any sort of problem in the breast.

Melanie: Thank you so much Dr. Norman for coming on today and sharing your expertise as a radiologist and letting us know what 3D mammography is really all about. This is Stoughton Hospital Health Talk. For more information, please visit stoughtonhospital.com. That’s stoughtonhospital.com. This is Melanie Cole. Thanks so much for listening.