A breast imaging specialist discusses breast cancer screening
If the pink ribbons on your co-workers' lapels don't jog your memory, perhaps the pink lights illuminating the Chicago skyline will.
That's right: October is National Breast Cancer Awareness Month. And while we all appreciate a reminder to show our support to those affected by breast cancer, the real measure of the campaign's success is action: getting women to schedule and undergo mammograms.
But unfortunately, due to mixed signals from various health care groups, scheduling a mammogram can be fraught with uncertainty and confusion. To help demystify and clarify issues surrounding mammograms and breast health, we talked to Peter Jokich, MD, director of the Rush Breast Imaging Center.
Q: What is the best way to detect breast cancer?
Jokich: The gold standard for detecting small, early-stage breast cancers is still mammography. Evidence from clinical trials over the last several decades has shown that screening mammograms — X-rays of the breast in women who have no symptoms of breast cancer — decrease mortality from breast cancer around 30 percent.
And a recently published case-control study from western Australia and a separate analysis of 10 other case-control studies show that women who undergo screening mammograms on a regular basis can expect a nearly 50 percent reduction of mortality from breast cancer. So, according to that study, mammography cuts the chances of dying from breast cancer in half.
Q: What about other technology such as ultrasound and MRI? Will these replace mammograms to screen patients for breast cancer?
Jokich: The use of ultrasounds and MRIs to screen for breast cancer is a hot topic among my medical peers. Screening ultrasound has been suggested for use in women with denser breast tissue, which potentially puts them at greater risk for developing cancer and also makes it harder to find the cancer; the density — or areas of whiteness on the mammogram — obscures the cancer, which also usually appears as a white area on the image.
While ultrasound may be less expensive and more adept at catching cancers in dense tissue, the health care community currently doesn't have the trained personnel and standardized practice guidelines and protocols in place to make this happen. And there's a problem with ultrasound producing too many false-positive findings (that is, findings that turn out not to be cancerous).
Although most breast imaging experts do not recommend screening ultrasounds for women with dense breast tissue at this time (based on the risk-benefit analysis of multiple studies, including the large ACRIN 666 trial), it does seem like something that could happen down the line. We need to figure out how to reduce the number of false positives first.
Breast MRIs are even more sensitive than breast ultrasounds, meaning they can detect even more breast cancers, even in the 2 to 3 milllimeter size range. The problem is they also find multiple spots that turn out not be cancerous, possibly even more than ultrasounds, producing more false-positive results.
MRI is also more expensive and requires an IV; the exam lasts about an hour. So, screening breast MRIs probably aren’t going to be for everyone. Currently at Rush, we use this technology in combination with mammography on patients with the BRCA gene mutations, which puts them at a significantly increased risk of developing breast cancer in their lifetime.
Why MRI for this group? Because women with BRCA mutations are about five times more likely to develop breast cancer than women who don’t have BRCA mutations, spots detected at MRI are more likely to be cancerous (as opposed to false alarms). While the screening test can be onerous, it could truly be lifesaving for this high-risk group of patients.
Q: There seem to be mixed messages out there regarding how often a woman should undergo screening mammograms and at what age she should start. What's your recommendation?
Jokich: In 2009, the U.S. Preventive Services Task Force (USPSTF) revised its guidelines, recommending that women at average risk of developing cancer undergo screening mammograms every two years beginning at age 50. These guidelines were very controversial, and came under attack from multiple fronts. In fact, the government quickly backed away from these recommendations.
The American Cancer Society, the American College of Radiology and the Society of Breast Imaging, as well as various other groups recommend that an average woman (a woman with no significant risk factors such as family history or testing positive for the BRCA gene mutation) should undergo annual screening mammograms starting at age 40.
While cost, access issues and the perceived harms of mammography (e.g., unnecessary additional tests and anxiety) seemed to have informed the USPSTF recommendations, I believe science and research support the latter recommendation of screening earlier and more often. We know from our own practice how often cancers are detected in women in their 40s, so it just doesn't make sense to wait until 50.
Many preventive services for women are now covered by the Affordable Care Act, including mammography screenings. If you have a new health insurance plan or insurance policy beginning on or after Sept. 23, 2010, breast cancer mammography screenings every one to two years must be covered without your having to pay a copayment or co-insurance or meet your deductible. This applies only when these services are delivered by a network provider.
If you have private insurance, I would advise checking with your provider to see exactly how often screening mammograms are covered. Yearly mammograms are also covered by Medicare if you are a member who is 40 years of age or older.
If you aren't insured, some states and local health programs — as well as some employers — provide free or low-cost mammography screenings. The National Breast and Cervical Cancer Early Detection Program, for example, provides such screenings.
Q: What do you see as barriers to getting mammograms?
Jokich: Lack of insurance, inconvenient hours and locations of mammography facilities. These are certainly barriers to getting regular screening mammograms, but they're only part of the story. Women with no symptoms or family history often don't see the need to get screened on a regular basis and many worry about radiation exposure.
The truth is that 80 percent of women who develop breast cancer have no significant risk factors for breast cancer or family history. As for the fear of radiation exposure during mammography, the dose is very low. The benefits of detecting breast cancer early far outweigh the risks of developing cancer as a result of radiation exposure (potentially up to four cases per 1,000,000 women).
Q: Does race or ethnicity play a role in terms of who gets breast cancer or who dies from it?
Jokich: There are certainly racial gaps when it comes to breast cancer. For example, while white women are more likely to get breast cancer, black women are more likely to die from it, with many black women first receiving medical attention during the later, more advanced stages of disease when it’s more difficult to treat.
In this study co-authored by David Ansell, MD, MPH, chief medical officer at Rush, investigators found that regular mammographic screening can contribute to the narrowing of differences among black and white women when it comes to when, or during what stage, they get medical attention for breast cancer.
These findings support the idea that more black women die from breast cancer than white women because of irregular screenings or the quality of the mammogram as opposed to the nature of the cancer itself.
By promoting access to routine and regular high-quality mammography screening, the health care community, government, insurance companies, private organizations, etc., can help ensure women get treatment for breast cancer in its earlier stages, and that could make all the difference.