Category Archives: Breast Cancer

Should You Get a Mammogram?

Leda Derderich wishes she had.

Dederich had stage IV breast cancer diagnosed at age 45, two years after she and her doctor discussed and dismissed the need for a routine screening mammogram while breastfeeding at age 43. That decision to delay screening mammograms may have meant that she lost the chance to find and treat her breast cancer before it had spread beyond the breast. It’s a decision she regrets now, and blames on the confusion around mammogram guidelines.

I have had a much harder time accepting that I was not screened for breast cancer before it was too late. Not because I couldn’t be bothered, was too anxious, or didn’t have health insurance, but because the guidelines for screening women in my age range are one hot mess of a controversy, and I fell through the cracks.

Two years before my diagnosis, when I was 43 years old, I asked my doctor if I should get a mammogram. I had a vague understanding that breast cancer screening protocols were in flux, but I wanted to be sure. My risk profile for the disease was very low. I was nursing my infant daughter, and I really did not want to stick my breasts in a vice grip (it’s not really that bad, but that’s how I was imagining it). My doctor told me that if I didn’t want a mammogram, I didn’t need to get one.

Her counsel was based on a set of widely used guidelines at the time that say having a mammogram is an “individual” decision for women under 50 at average risk for breast cancer. She had no reason to believe I was at risk, and I had no reason to believe I should question her judgement.

What I didn’t know, at the time, was that there are multiple and conflicting breast cancer screening guidelines for women between the ages of 40 to 49.

Dederich is right. There is controversy around what’s best for women in terms of screening mammograms, a controversy that began in 2009 when the US Preventive Services Taskforce rocked our world with their recommendation against knee-jerk, routine mammogram screening in all women between ages 40 and 49.

Now, almost a decade later, the guidelines for mammogram screening still vary, though not as much as you might think. With one notable exception. Allow me to summarize for you.

Screening Mammography Guidelines – Not as Out of Sync as You Think

With some minor differences in wording and nuance, the US Preventive Services Taskforce, American College of Physicians (ACP), American Academy of Family Physicians and 2017 ACOG guidelines in essence recommend that women at average risk for breast cancer be offered mammogram starting at age 40, but make informed, individualized decisions about having mammograms depending on their individual risk, personal values and concerns. The frequency of mammograms, if women choose to have them, varies between one and two years. The American Cancer Society guidelines recommends individualized choice between ages 40 and 45, with all women starting screening at age 45.

Wrapped into those guidelines is the fact that delaying mammograms to age 45 or age 50 accepts a small but real increase in breast cancer deaths – on the order of around 1-2 extra deaths per thousand women. In return for delaying mammograms, women get less false positives and less unnecessary biopsies. It’s estimated that if you have an annual mammogram starting at age 40, you have a 60% chance of a false positive and a 7% chance of having an unnecessary biopsy, compared with a 40% chance of false positive and 5% chance of biopsy if you wait to age 50 to start routine mammos.

Also considered in the guidelines are the fact that mammograms do not prevent breast cancer and do not find all breast cancers at an early, curable stage. They miss about 10% of cancers, and may not detect rapidly growing cancers that arise between routine mammograms and spread beyond the breast almost from the get go. In addition, the cancers mammograms do find may be the slow growing kind that would never kill you anyway, or are not really cancer (we’re talking DCIS), but can lead to surgery, radiation and even mastectomy.

The American College of Radiologists continues to recommend annual mammograms for all women starting at age 40

The one group still recommending routine annual mammograms for all women starting at age 40 (ie, no individual choice) is the American College of Radiology (ACR). The ACR is now on a campaign to re-inform women about mammogram screening, putting their own spin on the data to get their message out to the public that the everyone else’s guidelines are just plain wrong.

Is the ACR right? Should the US medical profession just go back to telling all women to have a mammogram starting at age 40 ? If so, we’d be at odds with most of Europe, where women at average risk of breast cancer are not invited to screening till age 50, and where breast cancer deaths are not higher than those in the United States.

As a compromise, the ACP and ACR in 2012 issued a joint statement on points of agreement designed to ensure that mammograms remain affordable and available to all women starting at 40 who want them regardless of risk. But the differences in recommendations between the ACR and other organizations remains.

Which brings us back to the fact that when it comes to mammograms, for now, women have a choice to make.

It doesn’t matter what the guidelines say if the decision you make about having a mammogram is the wrong decision for you.

Dederich regrets the decision that she and her doctor made, and feels that she did not have the information she needed to make the right choice for herself.  She feels that because the medical community is conflicted, our patients are confused and therefore misinformed.

Smart, dedicated people are deeply engaged in this issue. But while they compare data sets, grapple with the statistical significance of lives like mine, and churn out conflicting guidelines, far too many women are left confused and misinformed about what is best for our health and long-term survival.

This is exactly why my colleagues and I created Breast Screening Decisions*, a free website and Iphone App designed to help women make an informed decision about screening mammograms. Using BSD, a woman can determine her own risk of breast cancer (which, even among low risk women, is not zero), explore her own personal values around screening, learn about the benefits and harms of screening mammograms, and see for herself what the difference is between starting annual mammograms at 40 vs waiting till 50 or having them every other year vs. annually. There is a real difference in mortality, but it’s small, and we’ve created visuals to help you see it accurately.

Some women don’t care a hoot about false positives or unnecessary biopsies or the fact that their mammogram might detect a cancer that would never kill them but results in them undergoing surgery, even mastectomy. It will all have been worth it if they catch a cancer early. And even if they don’t catch it early, at least they feel they did everything they could have done to do so.

On the other hand, there are women who want to avoid mammograms at all cost. Perhaps they or a loved one had a bad experience with a false positive, or a biopsy that resulted in complications, or they just believe they will not get breast cancer and don’t want the harms of mammography.

What’s important is that women feel they’ve been given the information they need to make the choice that’s right for them.

Decisions are Not Easy

The hard thing about making decisions is that the decision we make today might be different than the one we’d make in hindsight, when we know how those odds we considered actually played out. I try when I can to tell my patients who are making choices to project themselves into future, having either a false positive, DCIS or a breast cancer diagnosis, and ask themselves if they would then regret the choice they are making today, whatever that may be. If their choice remains the same, it’s probably the right choice for them. If not, then they may want to rethink it.

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* Breast Screening Decisions (BSD) is completely free as well as ad-free, was built using funding from the NIH, and is maintained using private unrestricted institutional donations.  I have no financial interest in BSD. 

More from TBTAM on Mammograms

What Women Want – How and When to Deliver the News of a Breast Cancer Diagnosis

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If you’re going to have to tell a woman that she has breast cancer, she wants to hear the news as quickly as possible, preferably face to face, ideally within 1-2 days of the biopsy being done, and have an appointment set up to deal with the diagnosis either that day or the next.

That’s what Dr Deanna Attai and colleagues found out when they surveyed over 1000 women, including 784 breast cancer survivors, to find out how and how soon they wanted to get their breast biopsy results, and compared that to what actually happened when they got their results.

It’s no surprise that in almost all cases, when it comes to hearing results, what women got did not match what they wanted. For example, while 40% of women heard their diagnosis within 1-2 days of biopsy, 80% would have wanted their results within that time frame.  Fifty four percent heard their mammogram results within 2 days, but 84% wanted them the same or next day.

A few important nuances emerged from the data – given a choice between hearing results face-to-face and getting them faster over the phone, women opt for speed. If it’s a mammogram or blood test result rather than a biopsy, face-to-face is not as important.

Most interesting were the comments women made on their surveys, which should be required reading for anyone having to give bad news. Here are just a few –

  • “Use the same compassion and candor you would use if you had to give this info to your loved one”
  • “Nothing is worse than calling a patient and telling them to bring someone with them but not telling them why.”
  • “Please remember that a bad test result may throw a person off, so much so that they cannot really hear what you are saying. Be clear and be careful. Ask the person to reflect back what you have said, so you are sure they got it!”
  • “We were starving for reliable information when I was diagnosed. Wish there was information provided with the results that further explained everything.”
  • “Always present situation with hope.”
  • “My oncologist was exceptionally kind. He said ‘I’m sorry this is happening to you’. He was the only one of several doctors to do so’”

The study population by design sampled internet-saavy women, and Caucasian women were over-represented in the sample, so these results may not extrapolate to all women.

But the message is loud and clear – when it comes to breast cancer screening results, we are not meeting our patient’s desire for timeliness or preferred method of communication.

Prophylactic Mastectomies Increasing Despite No Survival Benefit

fight like a girlOne of the more concerning trends in breast cancer treatment is the growing use of bilateral mastectomy to treat breast cancer that is present in only one breast. We call this prophylactic contralateral mastectomy – or removal of a normal breast in order to prevent future breast cancer.

A new study of almost half a million women with breast cancer reports that in 2009, 12.7% chose to treat cancer in one breast by removing both breasts, a rate almost triple that in 2002. Unfortunately, the additional surgery added no benefit, as survival rates were no better among women who had bilateral mastectomy compared to those who chose to keep their healthy breast.

The trend towards prophylactic contralateral mastectomy (PCM) is most pronounced among women diagnosed with breast cancer prior to age 55. PCM Rates are highest among women with more advanced disease, the group it is least likely to benefit, but also increasing among those with stage 0 or 1 breast cancer. Other factors associated with use of prophylactic contralateral mastectomy are Caucasian race, higher income and education, larger tumor size, use of breast MRI, family history of breast cancer and increased anxiety and fear of recurrence.

While prophylactic mastectomy does decrease the chance of a new primary breast cancer in the unaffected breast, that risk is less than 1% to start with. The study did not address mastectomy of the affected breast, but in most cases, mastectomy does not improve survival when compared with lumpectomy and radiation therapy.

Why?

Why are so many women opting for bilateral mastectomy, when local treatment with lumpectomy and radiation therapy will in most cases be more than sufficient treatment, and allow for women to keep both their breasts?

Some are crediting Angelina Jolie, who famously underwent bilateral mastectomies for prevention of breast cancer due to a genetic mutation she carries in the BRCA gene.  Yet only about a third of the increase in PCM seen in this study occurred in genetic mutation carriers, so something else is at play here.

I think that something else is the desire for that elusive “peace of mind”, combined with mandatory insurance coverage of reconstructive surgery and the widespread acceptability of breast implants in the general population. Add in a really good nipple tattoo or nipple reconstruction and you’re set to move on from your diagnosis into a breast-cancer free future.

Because nothing says “I’m done” more than a set of new, cancer-free breasts.

Forget that the odds were already well in your favor before the procedure. Or that the procedure does nothing to improve those odds. Or that your peace of mind comes at quite a price – loss of breast sensation, inability to breast feed, and higher cost and complication rates.

I’m not sure what the right answer is to this obvious conundrum.

We’ve done so much to move away from aggressive treatment to allow for improved quality of life and breast preservation compared to the old days, when the Halsted Radical Mastectomy was standard over-aggressive treatment for what in most cases is a localized disease.  Now it seems we are going backwards, but this time at the behest of women themselves.

I suppose that all we can do it take it on a case by case basis, and try to be sure that women are making this important treatment choice with the best data we can give them. In that vein, studies like this provide important information.

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More Reading 

 

 

False Positive Mammograms & Subsequent Breast Cancer Risk

breast ca risk and false pos mammo
A recent study points to a higher risk of breast cancer in women with a history of a false positive mammogram.

Investigators examined the number of breast cancers occurring over 10 years with whose routine screening mammogram had resulted in either a “call back” normal mammogram or a benign breast biopsy (false positive mammograms), and compared it to the number of cancers in women whose mammogram was normal on the first go round (true negative mammogram.)

Women who had a false positive mammogram had a higher risk of breast cancer in the subsequent 10 years compared to women with a true negative mammogram. How much higher? As you can see in the graph above, for every 1/000 women with a true negative mammogram, 3.9 breast cancers occurred within the subsequent 10 years. This is in contrast to women with false positive mammograms who had 5.5 breast cancers for every 1,000 women, and women with a false positive biopsy who had 7 cancers per 1,000 women.

Thought the relative risks between groups is statistically significant, it’s extremely important to realize that ALL these risks are under 1%, so we are making distinctions between very small numbers.

Here’s what the study results looks like in an icon array, a useful tool for illustrating comparative risks that are under 1%. Among the 1,000 women pictured in each array below, the pink ladies are the ones who developed breast cancer within the 10 years, while the grey ladies remain cancer free.

true neg

False pos

biopsy

Further stratifying results by breast density, the researchers found that 10 year subsequent breast cancer risk was highest in women with extremely dense breasts and a false positive biopsy (9.01 per 1,000 women), and lowest in women with fatty breasts and true negative mammograms (2.22 per 1,000 women), with the rest scattered in between according to density.

breast ca risk by density

The investigators uses data from the Breast Cancer Surveillance Consortium (BCSC) from 1994 to 2009, studying over 2 million mammograms done in over 1 million women. It’s a robust database that the US Preventive Services Task Force used to advise their recommendations for mammogram screening. They adjusted risk data for age, race/ethnicity, menopausal status, history of breast biopsy, and family history of breast cancer, all factors that are associated with breast cancer risk.  The study results are consistent with those of other studies, adding to a growing body of literature linking false positive mammograms with breast cancer risk.

Now What?

A history of a prior breast biopsy is a known risk factor for subsequent breast cancer, and is already incorporated into the Gale Model and other breast cancer risks assessment tools. It may be time to consider incorporating a history of a prior false positive mammogram into these tools. At this point, breast density has not been incorporated into these risks assessment tools, primarily because it is such a subjective measure with not great reproducibility, and because it changes over time.

How to Use This Information

Women and their doctors may want to use this information to help them decide how often to have mammograms, or whether or not to begin to incorporate sonograms into their breast cancer screening regimen.

That said, it’s important to understand that although the risks for breast cancer are increased by a false positive mammogram, the absolute increase in risk is modest – still less than 1% in even the highest risk group.

More on Breast Density Notification Laws

mammo fatty and dense 2There’s a nice discussion of the practical considerations around breast density notification laws in this week’s NEJM.

The editorial and accompanying podcast summarize what we do and don’t know about breast density, and give practical suggestions for incorporating breast density into the discussion around mammography screening for individual patients.  Online access to both the editorial and podcast discussion is free, and I encourage you to read and listen.

Bottom line  

Most women under age 60 will have dense breasts on mammography. Breast density is subjective, and we do not as yet have a computerized way of standardizing breast density readings. Breast density can also vary in a given women across the menstrual cycle and with age.

Breast density may increase breast cancer risk from 1.2-2 times, but it is not clear if that increased risk is additive to other factors that already increase breast cancer risk – family history, lifestyle, reproductive history – or just a manifestation of that risk.  No current breast cancer risk model incorporates breast density.

At this point in time, mammography is the only breast cancer screening that has been shown to reduce breast cancer mortality. There is little evidence to support routine supplemental screening sonograms in women at average risk of breast cancer who have dense breasts.

In women at average risk for breast cancer with dense breasts, screening breast sonograms will detect less than 1 additional cancer per 1,000 women screened. In this group of women, supplemental sonography has not been shown to decrease breast cancer mortality and carries high rates of false positives. (Only 6% of biopsies will show cancer.)

In women at higher than average risk for breast cancer, sonograms in those with dense breasts pick up an additional 3.2 cancers per 1000 women screened.  How this may translate into reduce breast cancer mortality is not known. Women with a lifetime risk of breast cancer >20% are advised to consider breast MRI , which identifies an additional 8.5 cancers per 1000 women screened and has been shown to be cost effective in this population.

My take

Breast density notification laws, while well-intentioned, unnecessarily alarm women with normal mammograms by telling them they “may be at increased risk of breast cancer”.

A better approach would be to simply notify women that breast density may obscure masses that mammograms miss but sonograms may detect, albeit with higher rates of unnecessary biopsies and no proven efficacy in reducing breast cancer mortality in women at average risk for breast cancer.  Then let women make an informed choice about sonograms based on this information and their own risks.

One of the arguments made for screening sonograms  is that they allow for earlier diagnosis of masses that evade mammography, leading to less need for advanced treatments such as chemotherapy. Given that chemotherapy is now being targeted to tumor type and not just stage, this advantage of earlier stage diagnosis may not prove as large as some would hope.

The best approach to breast cancer screening at this time is to target it based on risk.

You can learn your breast cancer risk here.  Talk with your doctor about the benefits and harms of mammography, when to start screening, and how often to be screened. If your breasts are dense, and you are at increased risk for breast cancer, you  may consider additional screening with sonogram, although its benefits are not known. If your lifetime breast cancer risk is >20%, consider supplementing mammograms with breast MRI.

Age is one of the strongest risk factors for breast cancer, and it’s why mammograms are recommended every 1-2 years starting at 50 in all women, regardless of other risk factors.  Some groups, including the American College of Obstetricians & Gynecologists, recommend annual mammograms starting at age 40 for all women.  Others, including the US Preventive Services Task Force, recommend individualized screening schedules for women ages 40-49 based on risk and personal preference.   We’ve developed an online decision aid for women ages 40-49 that can help you and your doctor come to a screening decision that’s right for you.

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More info on mammograms and breast density

Breast Screening Decisions – A Mammogram Decision Aid

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I’m proud and excited to introduce you to Breast Screening Decisions, an online Mammogram Decision Aid designed to provide individualized, unbiased information that can help women ages 40-49 decide when to start and how often to have screening mammograms.

Breast Screening Decisions (BSD) was created in the wake of the 2009 US Preventive Services Task Force recommendations that every woman in her 40’s make an individual decision about when to start and how often to have mammograms. Not all medical groups agreed with the USPSTF recommendation, adding to the confusion many women feel about the mammogram decision and putting providers in the difficult position of having to steer each patient through the controversy to a decision that feels right for her.

Breast Screening Decisions is a support tool for shared mammogram decision making between women and their health care providers. Women ages 40-49 can access BSD online at their own convenience, then bring in the BSD summary to a preventive care visit, where an informed discussion can occur, leading to a decision about screening mammograms that both patient and her provider can feel good about.

Breast Screening Decision is not designed to influence mammogram decisions, but to inform and reduce anxiety around the decision-making process for both women and their providers. We want to help women make the decision that is right for them, whatever that decision may be.

Who Should Use Breast Screening Decisions?  

  • Breast Screening Decisions is for women ages 40-49. Women outside this age group should not use the site, as the data presented will not apply to them
  • Breast screening Decisions is for women at low to average risk of breast cancer. BSD starts with a breast cancer risk assessment – a series of questions to help women find out their own breast cancer risk. Women at higher than average breast cancer risk based on personal or family history are then advised NOT to use BSD, but instead to speak to their doctor about which breast cancer screening modalities are best for them – usually annual mammogram, but sometimes with the addition of sonogram or breast MRI.

A Tour of Breast Screening Decisions

Breast Screening Decision starts with a breast cancer risk assessment – a series of questions to help women find out their own breast cancer risk, which is then shown to her visually –

BSD YOUR RISK

The user then sees possible mammogram screening outcomes for women such as herself –

mammo bsd

including information about both the benefits as well as possible harms of screening mammogram. BSD also includes lots more info on breast cancer and mammograms that women can access through pop ups and link outs.

The heart of BSD is the option array – where BSD users can scroll through the various screening options available to them, using a a grid which displays the breast cancer mortality outcomes for each possible mammogram screening schedule – every year vs every other year or starting at age 40 vs  starting at age 50. (I love this page of the website…)

bsd mortality

The user then is shown a summary page of their breast cancer risk and possible outcomes –

bsd summaryBSD concludes with a series of questions to help women clarify their concerns and personal values around breast cancer screening.

bsd values

And finally, BSD users are given a summary to save or print out, and bring to their appointment with their health care provider.

bsd summary

An Invitation

If you are a woman ages 40-49 or her provider, we invite you to use Breast Screening Decisions, and hope it will prove to be a valuable resource in making individualized decisions about mammograms.

We welcome collaborators interested in studying the effectiveness and impact of BSD in clinical practice. If you’re interested in collaborating with us, please contact us – Margaret Polaneczky, MD (mpolanec@med.cornell.edu) or Elena Elkin, PhD (elkine@mskcc.org).

The BSD Back Story

It all started in December 2009 with a blog post I wrote explaining the United States Preventive Services Task Force Recommendations on Screening Mammograms. I was as confused as my patients were about the recommendation that the decision as to when to start and how often to have screening mammograms be an individualized one that takes into account a woman’s risk for breast cancer, as well as her personal values and concerns about breast cancer and mammography.

How the heck was I going to accomplish that in a 15 minute office visit, let alone be confident that the choice my patients made was indeed an informed one? My knee jerk response was just to ignore the recommendations and tell everyone to get an annual mammogram, regardless of who they were or what they may have wanted to do. I would certainly be supported in that tactic by my own ACOG, as well as the National Cancer Institute and of course the American College of Radiology.  Not to mention, it’s the fastest way to get off a controversial topic in the midst of busy office hours and the safest choice medio-legally.

But as I wrote that blog post and started to wrap my head around the facts about mammography as we know them today, I began to understand why some women might make a choice different that I would be recommending. In fact, I already had more than a few women in their 40’s ask me if they could skip their annual mammograms – healthy, low risk women, with no family history of breast or breast-linked cancers, some of whom had already had one or more false positive mammograms.  They wanted to back off the annual screening, and they wanted my support.  I stumbled through an office counseling session, doing what I could to confirm their low risk status, and we usually ended up compromising on an every other year schedule, while I remained worried that I was setting myself up for a lawsuit.

This was not going to work long term – not for me or for my patients. They deserved my support in making this choice, and I deserved some support in making sure their choice was an informed one, and in supporting them when they chose an option other than annual screening.

The blog post I wrote on the topic had received so much positive press (The Washington Post called it the “clearest assessment of the controversy you’re likely to find”) that I knew I was onto something. So I approached Al Mushlin, Chair of Public Health at Weill Medical College where I work, and told him I wanted to build a web-based mammogram decision aid. He hooked me up with Elena Elkin, brilliant outcomes researcher at Memorial Sloan Kettering and grant writer extraordinaire. We (well mostly Elena) wrote a grant and got funding from the Cornell CTSC. And together with our amazing research coordinators Paige Nobles and Val Pocus (both of whom unexpectedly turned out to also be web-savvy, graphically-minded visual artists), with input from Al and from experts in mammography and breast cancer, along with feedback from beta users in our target population, we build the first version of BSD (Thank you, Marwan Shouery) and piloted it with over 150 women and their providers at the primary care and Ob-Gyn practices at Weill Cornell Medical Center. We hope to publish the results of our pilot study soon, but suffice it to say that BSD was well received by women and providers alike.

For reasons related to firewalls and such (lessons learned), we had to rebuild BSD from scratch for public access (Thank you, Mohammad Mansour and colleagues), and that is the site we are releasing today.  Other than some new colors, prettier formatting and a new font or two, BSD is the same site as the one we researched. The research site will remain behind a very tight firewall for use in future research.

So now..

Almost four years, many many hours of collaborative work and thousands of dollars later, Breast Screening Decisions is finally live to the public.  

Just in time for the next USPSTF update on mammogram screening …

 

Dense Breasts on Mammogram – No Need to Be Afraid

Mammogram Fatty and Dense

Only in America can we find a way to scare the bejesus out of a woman with normal breasts and a normal mammogram. But that’s exactly what happened when NY Times reporter Roni Caryn Rabin read her normal mammogram results letter –

A sentence in the fourth paragraph grabbed me by the throat. “Your breast tissue is dense.”

I can’t really blame Rabin for being afraid. The information about breast density in her mammo letter was mandatory verbiage crafted by legislators as part of a law that all women be told if they have dense breasts on mammogram.

“Your mammogram shows that your breast tissue is dense. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to find cancer on a mammogram and may also be associated with an increased risk of breast cancer. This information about the result of your mammogram is given to you to raise your awareness. Use this information to talk to your doctor about your own risks for breast cancer. At that time, ask your doctor if more screening tests might be useful, based on your risk. A report of your results was sent to your physician.”

Raise awareness? More like raise the alarm. The information mandated by the law is just enough to scare any women who happens to have dense breasts, but not enough to help her understand what this really means.

If you’ve gotten a letter telling you your breasts are dense, don’t be afraid. Having dense breasts is entirely normal, especially if you are under age 60.  Here’s what you need to know –

What is Breast Density? 

Breast density is a radiologic assessment of how well x-rays pass through the breast tissue. It is a surrogate for how much of the breast is composed of glandular tissue and how much is fat. The radiologist reading the mammogram classifies the breast composition as one of the following –

  • Almost entirely fat (<25% glandular)
  • Scattered fibroglandular densities (25-50%)
  • Heterogeneously dense breast tissue (51-75% glandular)
  • Extremely dense (> 75% glandular)

Breast density is subjective.

Different radiologists may give the same mammogram different ratings. Use of computerized density measurement could alleviate inter-observer variability, but there is not yet a standardized computer rating system. For the purposes of the law, dense breasts are defined as those that are heterogeneously dense or extremely dense.

Breast density can vary across a woman’s menstrual cycle and over her lifetime.  

The same women being scanned at a different time of month or at a later year can land into a higher or lower breast density category, and may or may not get that extra statement in her mammogram letter. Recent research suggests that a single breast density reading may not be the best way to predict breast cancer risk, and that the risk may be confined to those women whose breast density does not decrease with age.

Dense breasts are extremely common, especially in younger women. 

According to a recent report of mammograms here in New York City, 74% of women in their 40s, 57% of women in their 50′s, 44% of women in their 60′s and 36% of women in their 70′s have dense breasts.

Increased breast density may be a risk factor for getting breast cancer. 

The mechanism is unknown, but it may be that breast density is just the end result of other factors that increase breast cell proliferation and activity – factors like genetics and postmenopausal hormone use.

How much of a risk? Well, it depends on what study you read and who you compare to whom. If you compare the two extremes of breast density in older women, those with extremely dense breasts have a three to five-fold higher cancer risk than those with mostly fatty breast. The risk is lower than that in those in the middle category of breast density and in younger women, though not well-defined.

The truth is, we really have no way to translate individual breast density into individual risk. Researchers are trying to see if breast density can be incorporated into current risks assessments such as the Gail Model, but at this point, breast density has not been shown to add much more than we already know about a woman’s risk from using these models.

The problem with breast density as a risk factor is that most women at some point in their lives have dense breasts. Should we really consider 75% of women in their 40’s to be at increased risk for breast cancer?

I don’t think so.

Dense breasts can obscure a cancer on mammogram.

This makes mammogram less reliable in women with dense breasts. Digital mammograms may be better at finding breast cancers in women with dense breasts who are also perimenopausal or < age 50, but it is not known if this translates into better outcomes. Additional testing with ultrasound and MRI can find cancers that mammograms miss in women with dense breasts. Unfortunately, breast ultrasound and MRI screening tests are less specific than mammograms – three times as many biopsies will be done, most of which will not be cancer.

Breast cancer patients with dense breasts are not at increased risk of death.

In a study of over 9,000 women with breast cancer, no association between increased density and death from cancer was found. In fact, it was obese women with lower breast density who had the higher risk of death, possibly because their fatty breasts may be a more favorable environment for tumor growth.

We do not know if additional breast cancer screening beyond mammograms saves lives.

Sonogram and/or MRI for breast cancer screening is currently not recommended based on breast density alone. Additional screening beyond mammography is only used in women at highest risk for breast cancer – those with cancer in a first degree relative with a high risk gene mutation, a family history suggesting one of these mutations, a Gail model or other combined lifetime breast cancer risk assessment >25% or a history of chest irradiation. Even in this group, declines in morality with the additional screening have not yet been shown, and the false positive rate of this additional testing is extremely high – only 20% of abnormals are cancer when biopsied.

There are no recommendations to use sonogram and MRI in otherwise low risk women, and none that have shown that using it based on breast density alone saves lives.

Additional screening beyond mammograms adds significant costs to breast cancer screening.

For some women, this additional cost may not be covered by insurance. While Connecticut has passed a law mandating that insurers cover additional sonograms, New York State has not.

What should you do if you’ve been told your breasts are dense on mammography? 

If you are at increased risk for breast cancer due to personal or family history, you may want to consider adding ultrasound or MRI screening.

Otherwise, at the point there is no recommendation that you do anything other than continue screening at whatever interval you and your doctor have decided is right for you. If you decide you want a sonogram, understand that you will need to accept the additional false positives and biopsies that may result and that the additional screening has not been shown to decrease deaths from breast cancer in women at average risk.

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More info on mammograms and breast density

Early Mammograms – New Study Misses the Mark

mammogram2A recent study has concluded that women with breast cancer who failed to get annual mammograms are more likely to die from their disease than those who had annual mammograms, and argues that more frequent mammograms are warranted in women under age 50. Unfortunately, despite all the media attention this study is getting, I don’t think the researcher’s conclusions are supported by the study results.

The researchers did a retrospective medical record review on deaths that occurred among breast cancer patients receiving care at Mass General or Brigham & Women’s Hospitals in Boston between 1990-1999 and followed until 2007. They call this a Failure Analysis.

Invasive breast cancer failure analysis defined 7301 patients between 1990 and 1999, with 1705 documented deaths from breast cancer (n = 609) or other causes (n = 905). Among 609 confirmed breast cancer deaths, 29% were among women who had been screened (19% screen-detected and 10% interval cancers), whereas 71% were among unscreened women, including > 2 years since last mammogram (6%), or never screened (65%). Overall, 29% of cancer deaths were screened, whereas 71% were unscreened. Median age at diagnosis of fatal cancers was 49 years; in deaths not from breast cancer, median age at diagnosis was 72 years

The authors concluded that because most deaths from breast cancer occur in un-screened women under age 50, initiation of regular mammograms before age 50 years should be encouraged.

Where this Failure Analysis Fails

Despite its strongly worded conclusions, the study raises more questions than it answers, and has a number of severe limitations.

  • The study fails to tell us what percent of women who did not die got annual vs not annual mammograms. This is akin to reporting that 80% of auto accident deaths occur among those who started their trip at home vs a public parking garage, without telling you what percentage of all car trips originate from home.
  • The study did not compare breast cancer treatments between women who died and those who did not die. The researchers just assumed that all women got standard of care at their medical center for their cancer. That’s a huge assumption to make without any proof.  It would have been actually quite easy to review a statistical sampling of charts to determine if this assumption was correct, but the researchers did not do this.
  • Women who don’t get regular mammograms may differ from those who do in other ways that increase the risk for death from breast cancer death, including low socioeconomic status, lack of health insurance, and distrust of medical treatments.
  • The researchers try to make the point that among those who died of their cancer, those who had not had mammograms prior to diagnosis had later stage cancers. Given that this analysis was confined to patients died of their cancer, I’m not sure stage at diagnosis mattered.
  • The entire analysis is conducted among women who died, either from breast cancer or from other causes. Since death from non-cancer causes is rare in women under age 50, breast cancer deaths will be over-represented in younger women in the sample. Older women not getting mammograms may be not getting screening because they are ill from other causes and are also more likely to die from these other causes during the follow up period, making breast cancer deaths less common in this group.  Who knows which way the data ultimately skewed as a result of these biases, but regardless, it is skewing every which way as far as I’m concerned. All of which muddies the conclusions.
  • The study was conducted at a Mass General and Brigham and Women’s Hospital using records from their breast cancer registry. Both these hospitals are referral centers likely to attract younger women with more aggressive cancers for treatment, who may not be representative of the general population of women presenting for mammogram screening or who are diagnosed with breast cancer. Indeed, the study population was over 90% white and of high socioeconomic status, pretty standard for a referral population if I ever saw one.

One thing that is evident is that breast cancers in younger women tend to be more aggressive than those in older women, an idea that would support more aggressive screening in younger women since each life saved carries more years of life saved. However, this is countermanded by the argument that breast cancer, despite being more aggressive, occurs much less frequently in younger than older women. Add in that mammograms are much better at detecting slower growing, less fatal breast cancers than the more aggressive cancers, and that screening is less effective in the denser breasts of younger women, and you have a sense of the screening conundrum we face for this cancer that claims so many women’s lives each year.

Unfortunately, this retrospective analysis is not going to solve the issue.

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Webb, M. L., Cady, B., Michaelson, J. S., Bush, D. M., Calvillo, K. Z., Kopans, D. B. and Smith, B. L. (2013), A failure analysis of invasive breast cancer. Cancer. doi: 10.1002/cncr.28199

More on mammograms –

Angelina, BRCA, Mastectomies, etc…

Angelina_Jolie_Cannes_2011

In a beautifully written editorial in the NY Times entitled “My Medical Choice” Anjelina Jolie has come out publicly as a carrier of the BRCA 1 gene, which places her at high risk for both breast and ovarian cancer.  She has undergone a prophylactic nipple-sparing mastectomy with plans for future removal of her ovaries to prevent ovarian cancer.

I choose not to keep my story private because there are many women who do not know that they might be living under the shadow of cancer. It is my hope that they, too, will be able to get gene tested, and that if they have a high risk they, too, will know that they have strong options.  Life comes with many challenges. The ones that should not scare us are the ones we can take on and take control of.

Kudos to Jolie for choosing to tell her story in such a measured and informative manner. Having referred dozens of high risk women for BRCA testing, only to see them avoid it year after year, I for one  hope that Jolie’s story will encourage women at high risk to get screened.

But I also recognize that not every woman with a suggestive family history wants to know her BRCA status.

And that, too, is a choice.

What Most of You Need to Know

For the overwhelming majority of the rest of the women I see, and for almost  all of you reading this, the most important thing you need to know is buried within Jolie’s  editorial, and it is this –

Only a fraction of breast cancers result from an inherited gene mutation.

About 2% of women have a family history that suggests the possibility of BRCA mutation,  and only about 1/10  of one percent of women carry a BRCA gene mutation.

Thus, Jolie’s story, while compelling, is medically irrelevant to almost all women. But for a very few, it may be lifesaving.

Should you consider BRCA testing?

Not unless you yourself have had pre-menopausal breast cancer or have had ovarian cancer, or  have a strong family history of breast/ovarian cancer.  From the NCI, here are the recommendations for screening based on family history –

For women who are not of Ashkenazi Jewish descent:

  • two first-degree relatives (mother, daughter, or sister) diagnosed with breast cancer, one of whom was diagnosed at age 50 or younger;
  • three or more first-degree or second-degree (grandmother or aunt) relatives diagnosed with breast cancer regardless of their age at diagnosis;
  • a combination of first- and second-degree relatives diagnosed with breast cancer and ovarian cancer (one cancer type per person);
  • a first-degree relative with cancer diagnosed in both breasts (bilateral breast cancer);
  • a combination of two or more first- or second-degree relatives diagnosed with ovarian cancer regardless of age at diagnosis;
  • a first- or second-degree relative diagnosed with both breast and ovarian cancer regardless of age at diagnosis; and
  • breast cancer diagnosed in a male relative.

For women of Ashkenazi Jewish descent:

  • any first-degree relative diagnosed with breast or ovarian cancer; and
  • two second-degree relatives on the same side of the family diagnosed with breast or ovarian cancer.

What about prophylactic Mastectomy?

Mastectomy was not Angelina’s only choice.  Mastectomy is effective at reducing the risk for  breast cancer, but breast cancer mortality is not impacted due the effects of aggressive screening and excellent treatments for breast cancer when it is diagnosed in BRCA carriers who choose not to have a mastectomy on a preventive basis.  Thus, Jolie  could have opted for aggressive screening with breast mri and/or use of medication (tamoxifen or raloxifene) to cut her risk of breast cancer in half. But with the option for nipple sparing surgery, mastectomy appears less a barbaric operation than in the past, with only a small increase in risk for leaving the nipple behind.

The use of mastectomy is increasing, not just among BRCA carriers, but among women with early breast cancer or pre-invasive disease (DCIS and LCIS) that places them at higher risk for invasive cancer in the future.  I for one worry that mastectomy may be getting over-used, and hope that Angelina’s story will not result in more women having surgery than is necessary.

What about Ovarian Cancer Protection?

As a gynecologist, I’m particularly concerned about ovarian cancer in BRCA carriers.

Angelina’s decision to remove her ovaries and fallopian tubes offers her the best odds of avoiding ovarian cancer, the disease that took her mother’s life.  Unlike mastectomy, which prevents cancer but does not reduce mortality, oophorectomy does reduce mortality form ovarian cancer.  Because the truth is, we have nothing to offer to women to effectively screen and diagnose ovarian cancer at early stages  (although we offer it, ultrasound is not effective screening on a population basis), and treatments are just not as good as what we have for breast cancer.  So BRCA carriers are offered prophylactic BSO in their 40’s or once childbearing is completed.  The procedure itself can often be done as an outpatient  laparoscopic surgery.

We are beginning to understand that ovarian cancer may actually originate in the fallopian tubes. Research is underway to determine if removal of the fallopian tubes alone might provide similar protection as removing of both the ovaries and tubes.  It’s too soon to say how that will play out, but we are hopeful.

What most women do not realize is that we do have prevention for ovarian cancer.  It’s called the Birth Control Pill, and taking it can lower the risk for ovarian cancer by 80%.

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More reading

  • CNN – What Angelina Forgot to Mention.  A Must Read.
  • NYTimes – an excellent discussion on the rising use of mastectomy for breast cancer prevention
  • NPR Blog – Peggy Orenstein raises concerns about women generalizing Jolie’s experience to the average woman not at increased breast cancer risk.
  • LA Times – Anna Gorman, another BRCA carrier, tells her story
  • Prophylactic Oophorectomy in BRCA Carriers
  • Huffington Post – Good Video segment including interviews with breast experts and survivors.

Ms Jolie’s image used with permission from Wikipedia, Source: George Biard

The Truth About Mammograms

NYTImes cover

A  breast cancer survivor takes a long hard look at the myths and realities of mammography.

I used to believe that a mammogram saved my life.

Bottom line – Mammography is not perfect, and like all screening tests, has risks as well as benefits.  Mammograms lower breast cancer morality by 15%, but at a cost of over-diagnosis, and some believe, over treatment of cancers detected by screening that may never had caused death in the first place.  This is most evident in the increasing use of mastectomy to treat DCIS, a non-invasive form of breast cancer that is readily detected by mammography.

A must read for every woman considering having a mammogram.

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More on mammograms –

Flaxseed – Anti-cancer Properties in the Breast? An Interesting Question.

Flaxseeds
Flaxseeds

In a fascinating and well-done study, Swedish researchers found that in women undergoing breast reduction surgery, those who took Flaxseed (25 grams daily) had a significant increase in levels of IL-1Ra – an inhibitor of pro-cancerous inflammatory cytokines – in the breast tissue taken at surgery.

The effect of flaxseed was similar to that in women who before the surgery took Tamoxifen, an estrogen receptor modulator that lowers breast cancer risks and is used to treat estrogen-sensitive breast cancers.

Women who were exposed to estrogen before their surgery, on the other hand, had lowered IL-1 levels and an increase in pro-cancerous inflammatory cytokines on their breast biopsies.

Estradiol, Tamoxifen, and Flaxseed Alter IL-1β and IL-1Ra Levels in Normal Human Breast Tissue in Vivo.Annelie Abrahamsson, Vivian Morad, Niina M. Saarinen and Charlotta Dabrosin

Objective: The objective of this study was to elucidate whether estrogen, tamoxifen, and/or diet modification altered IL-1 levels in normal human breast tissue.

Design and Methods: Microdialysis was performed in healthy women under various hormone exposures, tamoxifen therapy, and diet modifications and in breast cancers of women before surgery. Breast tissue biopsies from reduction mammoplasties were cultured.

Results: We show a significant positive correlation between estradiol and in vivo levels of IL-1β in breast tissue and abdominal sc fat, whereas IL-1Ra exhibited a significant negative correlation with estradiol in breast tissue. Tamoxifen or a dietary addition of 25 g flaxseed per day resulted in significantly increased levels of IL-1Ra in the breast. These results were confirmed in ex vivoculture of breast biopsies. Immunohistochemistry of the biopsies did not reveal any changes in cellular content of the IL-1s, suggesting that mainly the secreted levels were affected. In breast cancer patients, intratumoral levels of IL-1β were significantly higher compared with normal adjacent breast tissue.

Conclusion: IL-1 may be under the control of estrogen in vivo and may be attenuated by antiestrogen therapy and diet modifications. The increased IL-1β in breast cancers of women strongly suggests IL-1 as a potential therapeutic target in breast cancer treatment and prevention

It’s a very interesting study, though certainly not enough data to make any kind of statement about flaxseed for cancer prevention. Swedish women undergoing reduction mammoplasty are certainly not representative of the population of women at large.
And before you go stocking up on flaxseed, read this on the potential risks as well as benefits of flaxseed and its oil.

All that said, I still find this a very interesting study with a biologically plausible result, and hope there’s more data coming from this group an others on this approach to cancer prevention and treatment.

5-Hour Energy “Pinkified” for Breast Cancer – Really?…

The Komen Foundation set the bar low when it partnered with Kentucky Fried Chicken to fight breast cancer, urging women and their families to buy the fat-laden meals despite the fact that obesity increases the risks of breast cancer.

Now the Avon Foundation has slid right under that bar by teaming up with the makers of 5-Hour Energy Drinks to sell pink energy lemonade, with a portion of the proceeds going to fight breast cancer.

Really?….

This is, after all, the same Energy Drink that has been linked to 13 deaths over the past four years and is currently being investigated by the FDA. The drink that comes with a warning label stating “Do not take if you are pregnant or nursing, or under 12 years of age. If you are taking medication and/or have a medical condition, consult your doctor before use.” And despite claims that it only contains as much caffeine as a cup of coffee, the label also warns ” Do not exceed two bottles of 5-hour ENERGY® shots daily, consumed several hours apart”.

This is the drink we need to be buying to help fight breast cancer?

What’s next –  Pink cigarettes?

Can Eating Broccoli Prevent Breast Cancer?

It’s a question I found myself asking after reading that a diet rich in the natural plant compound phenethyl isothiocyanate (PEITC) has been shown to prevent the development of mammary tumors in mice.  PEITC is a compound found in watercress and in cruciferous vegetables such as broccoli and cauliflower.

The researchers found that administering PEITC for 29 weeks was linked with a 56.3% reduction in mammary carcinoma lesions greater than 2mm. “Although PEITC administration does not confer complete protection against mammary carcinogenesis, mice placed on the PEITC-supplemented diet, compared with mice placed on the control diet, clearly exhibited suppression of carcinoma progression,” the authors write. PEITC was also well-tolerated.

Although studies on PEITC in mice are quite promising, proving that PEITC works in humans is not so easy.  Dietary studies in humans are exceedingly difficult to perform, and studies of PEITC-rich foods and cancer rates have had mixed results to date. Still, we do know that people who eat a diet rich in fruits and vegetables have lower rates of certain cancers, as well as less heart disease, hypertension and diabetes.

Those are enough reasons to feel good about eating your broccoli.  Here’s my new favorite recipe for eating mine.

ROASTED BROCCOLI

Although there are many wonderful roast broccoli recipes out there (see links below), the simplicity of this preparation makes this it a versatile accompaniment to almost any meal.

Prep Time: 5 minutes
Cook time: 25 minutes
Yield: 4 servings

Ingredients:
– 1 head broccoli
– Extra virgin olive oil
– Sea salt & fresh ground pepper to taste

Instructions:

Preheat the oven to 450 degrees Fahrenheit. Cut the broccoli into large florets. Cut off the end of the stalk and discard, then slice the remaining center stalk into 1/8 inch thick rounds. Spread the broccoli out in a single layer on a large baking sheet. Brush with olive oil and season with salt and pepper. Roast 15 mins or so, till just tender and the edges are nicely browned, stopping halfway through to turn the broccoli and re-brush as needed with olive oil.

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NCI info on cruciferous vegetables and Cancer

More great broccoli recipes

Increased Breast Density Does Not Increase Breast Cancer Mortality – One More Argument Against Mandatory Breast Density Laws.

On the heels on NY State’s Breast Density Notification Law, which mandates that women with dense breasts be told they may be at increased risk for breast cancer, comes the reassuring news that having increased breast density does NOT increase the risks of dying from breast cancer.

In order to determine if higher mammographic breast density is linked to a reduced survival in breast cancer patients, Gretchen L. Gierach, Ph.D., M.P.H., of the Division of Cancer Epidemiology and Genetics (DCEG) at the National Cancer Institute in Maryland, and colleagues looked at data from the U.S. Breast Cancer Surveillance Consortium and examined 9,232 women who were diagnosed with primary invasive breast carcinoma between 1996–2005 with an average follow-up of 6.6 years. The researchers studied the relationships between mammographic breast density and risk of death from breast cancer and all causes. Mammographic density was measured using the Breast Imaging Reporting and Data System (BI-RADS) density classification.

The researchers found that density does not influence the risk of death once the disease has developed. They write, “It is reassuring that elevated breast density, a prevalent and strong breast cancer risk factor, was not associated with risk of breast cancer death or death from any cause in this large, prospective study.”

Studies such as these are point out that the most important factor in breast cancer survival is the behavior of the the tumor itself, and not necessarily the risk factors that led to development of cancer in the first place. The analogy I like to use is that of traffic density and accident mortality. The chance of your being in a car accident is of course increased as population and number of drivers, automobiles and passengers in them increases. But your chance of dying in an individual car accident is related more to the circumstances of that accident – the drivers involved, the speed, the road conditions that day, etc – than to the fact that the accident occurred.

One more argument against mandatory breast density notification laws

Presuming that the woman in this study had their mammograms done long before any state passed a breast density law, this study further begs the question as to what benefit these laws will have for women, especially those under age 50, most of whom have dense breasts. (See my previous post on why these laws are misguided.)

At this point, breast density laws are simply legislation based on uncertain science advocated for by women desperate to eradicate breast cancer deaths and passed by legislators who refuse to accept the uncertain state of medical science.

In my opinion, it would be better to focus our legislative efforts on funding research in to the possible environmental causes of breast cancer, and on reducing the levels of known carcinogens in our environment.

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CBS News does a great job reporting on this issue