TUMOR DETECTION FOR DENSE BREASTS

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.

 Since cancers may lie dormant for up to ten years and that mammography is less accurate in younger women, one realizes that sonography becomes necessary for a complete workup in the detection of invasive. Mayo Clinic computer program shows sonograms capable of 99% accuracy. The latest malpractice newsletters warn physicians that they are liable if they miss a breast cancer because they have not performed a sonogram. In fact, the PIAA Data Sharing Report shows that the patient found the tumor in 69% of cases, mammography missed or was equivocal in 49% and the median age of breast cancer was 43 years of age. False negatives were highest in the under age 40 group comprising 40% of claims.

 

BREAST IMPLANTS                

Every year over 150,000 women have breast implants. Recent press has pointed to the problem of breast cancer development in the augmented breast and the inability of mammography to see it.

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.

 The treatment of breast disease has also changed from the days of deforming radical mastectomies.  Simple removal of the tumor followed by mastectomy, chemotherapy and radiation therapy are now available.  Post mastectomy reconstructive surgery will often restore a woman to her former natural shape.  In England and Australia, where breast ultrasound and Doppler analysis are routinely used, exploratory surgery has decreased 90%.  The American Cancer Society stresses self examination and mammography.  Unfortunately, the survival rate of breast cancer has not changed in the past 25 years.  Clearly, other diagnostic exams are needed, since the cure rate is related to the early detection of the disease. Alarmingly, despite many years of ongoing, improved and massive breast cancer screening, the US National Center for Health Statistics now sates that the incidence of number of cases of this disease is actually increasing.

 Many women are overwhelmed with the variety of medical tests and their safety. Recent articles in the NY Times stated that the female patient is psychologically ill equipped to deal with the emotional trauma of breast cancer at the time of diagnosis. These reports suggest that women be well informed prior to the discovery of a tumor, so that they may make a better informed decision.  The book addresses the specific type of exam for both early detection of breast disease as well as the optimal test for specific disorders for each individual woman in an orderly, sequential and safe format.  The pro's and con's of treatment protocols are also formatted.  The author, a radiologist specializing in new methods of breast imaging, has been lecturing for the Ultrasonic Institute on new methods of breast cancer detection since 1973 at medical centers around the nation and at international conferences and mentions in this book all types of exams and therapies.  The reader chooses for herself what modality may be most suitable.  Methods used in Europe, for example, find acceptance in American medicine twenty or thirty years later.  Some medical regimens may be generally unsuitable for patients, yet may be ideal or the only possibility for an individual woman.  Diagrams of the various exams are available for better appreciation of the visually oriented test.  As a ready reference format, each chapter is preceded by a one page summary for quick review.  The overall aim of the work is to be a health "bible" for breast disorders for the 1990's woman.  

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.  

Women with cancer can be helped because of the simple techniques used when tumors are small.  Even men develop breast cancer at a rate approximately 1% that of women. Most women do need to know that CHANCES ARE ITS BENIGN.  Since the age range of breast cancer is now from the teens to the hundred's, women of all ages need to become actively involved in managing their health just as they do their finances. Since all women are at risk of breast cancer, all families must know the facts and the choices involved. Jewish women, successful women, women on hormones, women with breast implants and the growing number of health conscious people of all ages will want to know thee available regimens so they have the data necessary to knowledgeably take charge of the their own lives.

 

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.

Dixon's paper in BRITISH J SURGERY (1992) showed 78% sensitivity and 100% specificity for carcinoma using duplex Doppler.

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

As breast cancer strikes younger women due to lowering of the median age of occurrence, screening procedures become imperative.

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.

 

 COMPETITION

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 (Avon, 1982) has 7 pages on breast cancer with 2 paragraphs on diagnostic tests. 

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.

 Lauersen's IT'S YOUR BODY (Berkely 1983) on p.418 states that sonograms will be effective in the future. Indeed, Dr. Lauersen routinely now performs sonography on his patients semiannually or more often in his private office.

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 American College of Radiology does not recognize this as a screening tool. However, there is no other acceptable alternative choice for the patient or better diagnostic tool for the physician other than the non specific MRI exam. Every finding (30% specificity) must be biopsied to be verified.