BREAST CANCER DECODED By: Robert L. Bard, MD
CONCEPT AND APPROACH
Drastic changes in the incidence, diagnosis and treatment of breast cancer and benign breast disease highlight a singular need for an up to date source on the early detection and proper therapy of breast tumors. The age of occurrence of breast cancer, formerly only a problem of older women, is now at a median age of 45 years. This means that women in their twenties are developing breast cancer. Although risk factors have been identified, the jeopardy to life is unchanged. The increasing use of estrogen for osteoporosis and other female disorders may elevate the risk of breast cancer. One out of every eight women will develop breast cancer. Fortunately, the vast majority of tumors in younger women are benign and can be diagnosed by simple, safe non surgical tests. Jewish women, prone to breast cancer, are further plagued by the concomitant presence of fibrocystic breasts that are lumpy and mask a growing breast cancer.
The incidence of miss by mammography increases markedly in younger patients and those with "mastitis" or "cystic" breasts. A paper from the University of Indiana Medical Center on the mammographic diagnosis of fibroadenomas (benign tumor of young women) demonstrated that in 35 surgically proven biopsies, the mammogram missed every mass. A non x ray exam, called the sonogram, was able to diagnose every tumor in this study. Another non-x ray test, called Doppler ultrasound, according to DIAGNOSTIC IMAGING (1988) and CLINICAL RADIOLOGY (1990) may detect breast tumors not seen by all other tests. Light scanning is another procedure that uses computers and fiberoptics to visualize tumors.The
latest text book on Breast Disease, BREAST ULTRASOUND by Thomas Stavros (Lippincott,
2002) mentioned that most abnormalities of the breast may be better
characterized or even detected only by diagnostic ultrasound procedures. JAMA
(May 1993) noted mammography readings were highly variable with many false
positives. Moreover, one expert missed 67% of cancers on high quality
mammograms. Indeed, top mammographers disagreed clinically in 1/3 of
readings.
BREAST
IMPLANTS
Mammography
has also long been used as the primary diagnostic imaging study for
complications of breast augmentation in the over one million women who
currently have breast implants. However, lack of accuracy of both mammographic
information and clinical interpretation have necessitated the application of
the non x ray imaging modalities of light scanning, sonography and duplex
Doppler ultrasound.
Every plastic surgeon has received a radiologist's mammogram report on a patient in whom a long standing implant has been removed for various complications that referred to the ovoid shaped density as a "prosthesis in position." Radiographically, the hard capsule that forms after a year cannot be differentiated from certain implant devices. Also, a leakage of silicone gel that is restricted to the fibrous capsule is not separately distinguishable. Thus, x rays are inadequate for the diagnosis of implant rupture except where the silicone has extruded physically through the capsule. Even then, the routine views may not demonstrate leakage that is close to the surface of the capsule so that it will only be identified by a tangential x ray beam. An irregular outline of an implant may be positional, caused by adjacent breast pathology, resultant of fibrous septation or actually due to implant rupture.
A sonogram identifies an implant much the same as a cyst. Thus the size, shape, position, peripheral envelope, wall contour and internal echo pattern are readily demonstrable. Rupture of an implant, whether from structural failure, interoperative damage, penetrating trauma or blunt trauma such as closed capsulotomy, is quickly and accurately diagnosed by routine high frequency sonography.
Sonography is also important in breast cancer diagnosis since the implant masks most of the breast from the x ray. Dr. Levine, in the 1990 article: DEFINITIVE DIAGNOSIS OF BREAST IMPLANT RUPTURE BY ULTRASONOGRAPHY in "Plastic and Reconstructive Surgery" states that sonography is the best imaging modality for the augmented breast.
Perhaps
more interesting are the roles of light scanning and duplex Doppler imaging in
the diagnosis of the cause of the implant rupture. Spontaneous failure of the
envelope will be accompanied by fluid extravasation. If recent and localized,
light scanning and Doppler flows will be unremarkable. A long standing leakage
may become secondarily infected, thus producing unilateral light absorption.
Similarly, trauma, intraoperative or external, may be associated with bleeding
which will also absorb light rays. Thus, a normal light scan exam in
transillumination suggests the probability of structure failure of the implant.
Duplex Doppler may shows linear fluid filled structures to be adjacent arteries
or veins. Additionally, this procedure may detect cancers adjacent to the
implant.
It is obvious that too few women are getting the message about the importance of early breast cancer detection since they fear that it will be too late or the therapy will be too deforming. The purpose of the book is to show that CHANCES ARE ITS BENIGN, AND, PROPER TREATMENT CAN SAVE YOUR LIFE AND NOT DISFIGURE. The work reaches out to the reader to reassure her with dramatic evidence that taking control of her breasts' health in a planned, stepwise manner can mean the difference between the words: "The scan shows it's a cyst. Don't worry" and the chilling sentence, "we could have helped you if you come in earlier." Women walk out of my office, knowing that their lump is benign and that their fears are nothing, looking ten years younger.
REVIEW OF CURRENT MEDICAL LITERATURE
Fleisher's
DIAGNOSTIC SONOGRAPHY (Saunders 1989) states that a sonogram is the best method
for diagnosing benign disorders and that a mammogram is the better tool for
diagnosing malignant diseases. He quotes the sensitivity of sonograms in cancer
detection at 69% as compared to the mammographic detection rate at 74%. The
author's own series using a hand held real time unit (same as Dr. Bard's) shows
an accuracy in detecting palpable lesions of 85% for sonograms and 70% for
mammograms. Both modalities yield a rate of 89% and he recommends both tests be
used in combination.
Hagen-Ansert's TEXTBOOK OF DIAGNOSTIC ULTRASOUND (Mosby 1989) states sonogram is clinically useful in a) dense breasts b) younger patients c) uncertain mammographic findings d) pregnant patients e) implants f) differentiation of cystic from solid in a known mass
Kopan's BREAST IMAGING (Lipincott 1989) states that sonography should not be used for cancer screening. However, he quotes studies by Sickle's, Cole, and Egan showing respectively that sonogram detects cancers at the following rates: 58%, 78% and 79% in the general population
Britton's
article in CLINICAL RADIOLOGY (1990) demonstrates duplex doppler having a sensitivity
of 91% and specificity of 89%.
Levin's paper in PLASTIC AND RECONSTRUCTIVE SURGERY (1991) mentions that mammography is unreliable in the post augmented breast and that ultrasonography is the test of choice for evaluation of breast prostheses.
Adler’s abstract in ULTRASOUND MED BIOL (1990) has 82% detection rate of malignant neovascularity with duplex Doppler.
Scatarige's note in THORACIC RADIOLOGY (1989) shows high accuracy of staging internal mammary lymphadenopathy.
Jones review in CLINICAL ONCOLOGY (1990) had sonograms picking up axillary nodes missed by other methods in 27% of cases.
Levin's paper in PLASTIC AND RECONSTRUCTIVE SURGERY (1991) mentions that mammography is unreliable in the post augmented breast and that ultrasonography is the test of choice for evaluation of breast prostheses.
Parker's lecture at the NYU BREAST CANCER UPDATE (1993) showed sonography's ability to detect unsuspected cancers as small as 0.4 cm and determine whether the associated lymphadenopathy was malignant or benign. Mendellson's 1992 talk at DOWNSTATE MEDICAL CONFERENCE showed sonograms to be able to discover occult lesions.
Barth's 1993 study showing sonograms detected more than twice as much multicentric breast cancer than mammography.
Stavro's 1997 paper shows accuracy in detecting benign disease solely by ultrasound at 99.7 %.
Bard's paper in 1993 NY STATE JOURNAL OF MEDICINE revealing mammographic misses in breast implant imaging.
Bard's 1994 lecture at the MAYO CLINIC highlighted the accuracy of multimodality imaging.
Bard's
1996 FEMALE PATIENT paper showed 99% accuracy in benign disease diagnosis
CONCLUSION
Although
mammography is the only generally accepted screening modality, it is clearly of
limited use in younger patients or those with fibrocystic breasts. The inaccuracy of sonograms is true if one
considers the total population to be screened will predominate in older age
groups. Kopan's, in his textbook, admits that he chooses to do sonograms on
women under 28 because of anecdotal evidence that it works best. Dr. Bard's
suggestion is that sonograms be the screening procedure of choice in younger
women and those with fibrocystic breasts. Mammography should remain the gold
standard in women over 40 or those with fatty breasts of any age. The
combination of light scanning, Doppler ultrasound and standard sonograms of the
breast often mean the difference between delayed diagnosis and immediate
surgery. Multimodality imaging, the emphasis of this book, offers the patient
the difference between weeks of worry for the mammogram to be repeated for
"interval change" or for an immediate answer that the problem is
benign.
Aside from a few books on cancer and women's diseases, there are no non-medical books on the spectrum of new tests and therapies for breast disease. Given the epidemic proportions of breast cancer, the time is right for a new and comprehensive manual for today's concerned and aware women.
Books
on personal health include THE DOCTOR BOOK, by Wesley Smith (Price Stern Sloan,
L.A. 1987) which has one paragraph on breast exam by a physician and one
paragraph on mammography.
The
NY TIMES GUIDE TO PERSONAL HEALTH by Jane Brody (
HORMONES,
by Lois Jovanovic, MD (Fawcett, 1987) includes 26 pages on breast disease,
mentioning the fact that 90% of breast cancers are detected by women
themselves, leaving the reader to wonder at the value of the
"gold-standard" exams of
mammography and 2 pages on hormone therapy for breast cancer.
CHOICES,
by Marion Morra and Eve Potts (Avon 1987) also titled: Realistic alternatives in cancer therapy, has
one chapter on breast cancer, with 6 pages on mammography, one paragraph each
on ultrasound, computed tomography, transillumination and thermography. There are 16 pages on surgery and
radiotherapy and 29 pages on post operative care.
Gross's WOMEN TALK ABOUT BREAST SURGERY (Harper 1991) has 2 pages mentioning a particular cancer was missed by mammogram and sonogram.
Levy's YOUR BREASTS (Noonday 1990) says one 1 page that benign cysts that are not palpable or show on x ray may be imaged with sonograms.
Thompson's EVERY WOMAN'S HEALTH (Prentice Hall 1990) says on one page that sonograms are useful in cyst detection.
Better Homes and Garden's FAMILY MEDICAL GUIDE (1989) mentions that sonogram is useful if mammography is unclear.
Harvard's YOUR GOOD HEALTH (HARVARD 1987) says on one page that sonogram is good for cyst detection.
Love's DR. SUSAN LOVE'S BREAST BOOK (ADDISON WESLEY 1990) has one half page each on sonogram and transillumination.
Hirshaut's BREAST CANCER: THE COMPLETE GUIDE (BANTAM 1992) has one half page each on sonogram and transillumination.
Many
private practice radiologists are currently routinely screening women with cystic
breasts or those under fifty with sonograms even though the
