Shaping Up for Summer From the Inside – Part 2: Breast Exams
By Susan Hornik
With 40,000 deaths each year from breast cancer, it is very important for women over 50 to make sure they are vigilant about breast exams. And while a standard mammogram is strongly recommended, there is an increasing nationwide movement for women with dense breast tissue to undergo ultrasound technology.
While the American Cancer Society, the American College of Radiology, and the American College of Obstetricians and Gynecologists recommend that women in good health should receive an annual mammogram starting at age 40, mammography misses a substantial number of cancers, especially in women with dense breast tissue, said Dr. Judy C. Dean, senior radiologist at Santa Barbara Women’s Imaging Center.
“For those women, it may be as many as half of all cancers are being missed if they rely on mammography alone,” noted Dean. “Those cancers will have to grow large enough to be felt in the breast, or big enough to finally be seen on mammography, which may be too late. Breast cancer survival is directly related to size and stage of the cancer at the time of diagnosis. Clearly, a test that misses half of the detectable cancers in half the women tested is inadequate.”
Digital Breast Tomosynthesis, also known as 3D mammography, is the newest advance in breast imaging and replaces 2D digital mammography. It is accomplished similar to a traditional mammogram with the exception that the x-ray tube moves during the exposure, acquiring multiple “snap-shots” from different angles. The result is a stack of thin images, spaced just 1 mm apart, that are reviewed with and compared to standard 2D images.
A board certified Diagnostic Radiologist since 1984, Dean has specialized in women’s imaging and breast diagnosis since 1989. In addition to interpreting thousands of mammograms every year, Dr. Dean is actively involved in breast related endeavors on the local, state, and national level.
There are vast differences between a mammogram and an ultrasound.
“An ultrasound uses sound waves to make images,” said Dean. “A transducer slides over the skin and sends out sound waves, then listens for them to bounce back. The reflected sound is used to make an image of the tissue, sort of like sonar is used to locate fish. There is no radiation, no compression, and minimal contact pressure. In experienced hands, an ultrasound can be more sensitive than mammography, for the 40 to 50 percent of women who have dense breast tissue.”
Mammography, on the other hand, uses transmitted x-rays to make an image, explained Dean. “The breast has to be precisely positioned and partially compressed to make a quality image. Mammography is the gold standard for breast cancer screening, and is the only technology with long-term clinical trials that proves it can reduce deaths from breast cancer. I am not ready to abandon it, but it has some shortcomings, especially for women with dense breast tissue.”
How do you know you have dense breast tissue? “Breast density is noted in doctors’ mammography reports, so if you have had a mammogram that information is available,” said Dean. “You cannot determine breast density by physical examination. Lumpy breasts are not necessarily dense breasts. It takes imaging with mammography to determine breast density.”
Dean has excellent advice for women over 50 committed to protecting their breast health.
“We are beginning an era of more individualized medicine. This is why a one-size-fits-all screening is being replaced by a more nuanced approach, taking into consideration personal medical history, individual phenotype and heredity. Women are used to filling out medical histories that include how many pregnancies they’ve had, and at what ages, when they experienced menarche and menopause, etc., and all those things influence risk for developing breast cancer. To understand your individual risks and what to do about them, it’s also important to know your family history, especially for breast and ovarian cancer; and it’s essential to know your breast density,” added Dean. “know your family history so that you can have a frank discussion with your doctor. “
Hearing lifetime risk statistics for breast cancer can be frightening, acknowledged Dean. “Somewhere around 12 per cent of women in the United States will develop breast cancer at some point during their lifetimes, and that’s a big number. But, in any single year, the risk of breast cancer is very small for most women. For example, probably in the range of one chance in 250 for women in their 50’s. However, that changes for women with dense breast tissue; for those women it may be more than five times that high. It’s also higher for women with a family history of breast cancer, especially pre-menopausal breast cancer.”
Risk Factors For Breast Cancer
* The number one risk factor is simply being a woman; second is age—the risk is higher the older you are.
* Family history of breast cancer, especially pre-menopausal breast cancer or breast cancer in a first degree relative like your mother, sister, or daughter; family history of ovarian cancer.
* Dense breast tissue, which occurs in 40 to 50% of women, is also a significant risk factor for both development of breast cancer, and cancer missed by mammography. For these women we recommend Whole Breast Ultrasound and/or digital breast tomosynthesis in addition to standard mammography.
* First pregnancy and childbirth after age 30.
* Never having a full-term pregnancy.
* Early puberty and/or late menopause.
* Previous breast cancer, ovarian cancer, or breast biopsy showing atypia or other high risk tissue.
* Long-term use of post-menopausal hormone therapy.
* Alcohol consumption.