Screening for Breast Cancer – Dr. Julia I. Flukinger, MD

well I’m a radiologist I did my fellowship in breast imaging so I do almost exclusively breast imaging I look at mammograms and ultrasounds and MRIs all day long I do biopsies of the breasts and so I wanted to talk to you today about screening for breast cancer mammography and other tools there was a new law which was enacted this week in the state that I am also going to inform you about so let’s see so our objectives are we’re going to talk about what is breast density what does that mean I’m going to tell you about the new legislation and I’m going to hopefully give you an idea of how limiting breast density truly is we’re gonna talk a little bit about supplemental imaging screening breast ultrasound and tomosynthesis and the benefits and limitations of breast MRI and also I’m gonna try to touch on call backs and the busy breasts which some women are told that they have why do we do screening mammography in the 1980s mammography was shown to detect breast cancer before it could be felt leading to earlier treatment and reduced number of deaths and this is one of the best studying tests we have in medicine over and over and has been proven to reduce the deaths from breast cancer so all women despite some things you may have heard in the in the news over the last couple of years which have maybe debated this the reputable agencies still recommend screening mammography and all women 40 and older every year so what are we looking on the man on at on mammograms this is just a diagram of breast anatomy and breasts are composed of glandular tissue which is this kind of purplish stuff supportive tissue which is this lighter yellow stuff sort of like the fibrous divisions and in orange orange sections kind of supporting the tissues of the breast fats which is this yellowish stuff and then the glandular structures which are tubes that leave the milk to the nipple when your lap tating so what is dense in case you don’t remember from high school physics or science classes a rock is dense a marshmallow is not dense so in the breast the the glandular structures are more dense and the fat is less dense if you were looking at a chest x-ray which many people have seen on TV and that kind of thing the bones are dense the lungs are very black or not dense the heart is kind of in between it’s kind of gray so breast density is defined by the mammogram and it’s not something you can detect on physical exam some patients have very fatty breasts and they feel very firm and hard when you’re palpating them so this is mammographic definition of the diagram I’ve shown you before the glandular and the fibrous supportive tissues are when it’s dense on the mammogram and individuals have different proportions of fat and fiber glandular tissues leading to difference appear different appearances on mammography now of note also breast cancer is dense and in many patients it’s a similar density to the glandular and fibrous structures and that’s one of the things we have to sort through as we’re reading mammograms so we assigned one of four density categories to each patient’s mammogram and these are the official categories oh this is in federal law so every mammogram has one of these statements on it the breasts are almost entirely fat scattered fibre glandular elements heterogeneous lis dense or extremely dense so the dense breasts you may hear about in the news is the last two categories and roughly half of people are in these two categories and half of people are in these two categories and it’s sort of like one fifth and four fifths when you divide the the dense people up so here’s some examples I wanted to show you some pictures today so you get an idea of what it is we’re looking at so this is a patient that would be considered almost entirely fat what we use to define it on the on those categories is the percentage of the breast that’s occupied by glandular or white dense structures so this patient has less than 25% of the breasts occupying a glandular structures this patient has maybe between 25 and 50% of the breast is occupied by

glandular structures this patient is dense 50 percent or more between 50 and 75 percent of the breast is occupied by dense glandular structures I want to tell you really quick what scent what the word sensitivity and specificity mean a test that is sensitive if a mammogram is sensitive it’s easy to find the cancer and in more dense breasts sometimes it’s harder to find a cancer because they can hop that a cancer can hide in this dense tissue it looks similar to the tissue right next to it so you can’t see it as well so arguably mammograms are a little bit less sensitive and someone with more breast density and a little bit more sensitive with someone who’s more fatty this patient is also categorized by as dense in these technical categories she’s about 50% dense but this is a pretty easy mammogram to read I wouldn’t say this patient’s mammogram is significantly limited they’re still you know you can see through the glandular tissue here it’s not it may be dense structures occupying that volume of the breast but it’s not really really dense and these categories are somewhat you know they’re supposed to be defined perfectly but it is sort of subjective this patient is also heterogeneous lead us in that third category and in her you can see this tissue is very dense whereas this huge section of the breast is not very dense at all so it might be harder to find a tiny cancer and if it were to arise here as opposed to if it were to arise here and then here’s the final current category extremely dense where 50 I mean over 75% of the volume of the breast is occupied by these dead structures glandular structures and this patient has some little biopsy clip she’s had lots of lots of things looked at further this patients also extremely dense so the breast density awareness bill maybe you have heard about this but about a dozen states have enacted laws requiring disclosure regarding breast density to women undergoing mammography so the idea is you get a letter in the mail after you get a mammogram and initially this was in response to one woman I think she was in Connecticut whose breast cancer was not seen on her mammogram it was mammographic ly occult and she had dense breast tissue and her cancer was the the diagnosis was delayed because it wasn’t seen on the mammogram so she became very vocal about it and this kind of began the events leading to some states enacting laws about this so Maryland’s law was in effect as of October 1st and it requires a general letter be sent to alma mater fee patients on the subject of breast densities the laws vary a little bit from one state to the next our law does not require that we tell you the breadth of your breast density in the letter it just requires that we inform you that there is such thing as breast density and if your dense there are certain limitations and we decided an advanced radiology that we would include in the letter a category for the patient of dense or not dense so dense would be those bottom two categories I showed you and would be the top to fatty and scattered fibre glandular elements so that’s what this letter will say that you’re going to get in the mail now whenever you have a mammogram no start anything that’s starting this week no your prior mammograms have a breast density assigned it’s just that you don’t get a letter saying anything about it so you’re you can always look back on your prior reports or your doctor can and see what your breast density is so why is this issue of density awareness an issue well the main thing is masking and that’s what I was trying to describe before that the density of the normal structures and the density of cancer are usually similar and therefore a cancer can hide in those denser structures and not be visible on the mammogram because it’s blending in with the background there is a second claim that there is a higher risk of cancer and patients with dense breasts that they actually develop more cancers and that those claims are exaggerated once those numbers were studied and the studies were studied basically it’s it’s not a very significant difference what when we’ve talked about this at the Society of

breast imaging and lots of experts have looked at it and sort of they were taking the densest breast and the least dense breast and making a generalized number off of very small numbers of patients and it just is not very accurate so there is not a significant increase in breast cancer in patients with dense breasts over patients with fatty breasts and there is not an increase in breast cancer deaths and patients and breath with dense breasts so it is not a significant inherent risk factor and a lot of us are concerned that patients are going to get very worried about these things you know much more than would be warranted so tidbits on density awareness so first of all I want to comment on the accuracy of the density read categorization Dan cope ends is the probably the foremost expert in country on mammography and he says that you cannot precisely characterize the volume of dense tissue in the breast for lots of reasons and basically we have these categories just to give an idea of what the picture looks like factors such as the shape of the patient’s breast the dose of radiation going through the breast can you know make something look less dense or more dense and complicate this so this is not a scientific volumetric it’s just not a hundred percent accurate these numbers but then they just give us an idea of what this mammogram looks like and it’s based on the radiologists judgment and it can change over time in an individual most of the time patients start off more dense when they’re young and as time goes on the density issues kind of involute inand they become the breasts become more fatty so is this law a good idea in my opinion and in the opinion of most other breast imagers I’ve talked to about it it’s likely to lead to a lot more panic and confusion than live scene and the other problem with it is we don’t yet have good scientific data to guide us what to do with this information so I mean it would be nice if we could say we’re gonna enact this law and we’re gonna tell Freddie their breast density and then when they say okay I’m I’m dense what should I do then we say well you should get this test because studies have shown that this will you know do you talk to more cancers in you we don’t have a definitive answer to tell you what to do with this information so I don’t know how helpful this additional information is so I’m going to show you a few cases of cancer just so you get an idea of what it is we look for um this patient has a mammographic vehicle of breast cancer she has a palpable lump in her right breast and you might say if your radiologists is that a mass there it looks a little distorted there this looks a little denser but when you look at multiple prior mammograms she looked exactly the same for many years so we don’t see any evidence of cam are on this mammogram this is this patient’s MRI I know she also had an ultrasound and that led to her biopsy but I just wanted to give you an idea of what cancer can look like on an on an MRI and so this is a little burned out I don’t know if you can see the contour of the entire breast but for MRI the patient lies on their stomach their breasts go in these two holes and the MRI machine you get an IV contrast injection and that contrast lights up areas that are cancerous it’s very very sensitive it is not as specific as other tests in basically as mammography but so in other words things will light up and look bright sometimes in some people’s breasts that are not cancer but it’s very very sensitive it’s the most sensitive test we have for breast cancer so I just used this case to illustrate here this this MRI picture looks a little more like the mammogram looks you can see all that dense tissue you can’t quite tell what’s the cancer and what’s not this contrast shows you that this is her cancer and you and it’s a pretty big cancer it’s about I think about three centimeters hidden on her mammogram so that is an impressive case but more unusual here’s what we would prefer to find a small cancer detected on the mammogram this is a lymph node which has been there for many years so although that might get some of your attention in this patient it wasn’t to worry about but this was new and here’s how she looked a year or two prior you know this mass was not was not evident so this is a nice tiny little cancer and here’s what she looked like on MRI that is that lymph node again and there’s the mass everything else is black in the breast now we know this patient doesn’t look like she has any other cancer in that breast or in the other breast and she’ll

go to surgery and have that small cancer treated here is a case of patient with dense breasts who has a pretty obvious breast cancer although I’m not sure how well it’s projecting this little triangle means that she felt alone unfortunately this patient had never had a mammogram before so we don’t know how long this has been developing but can you see all these little white dots in this area how there’s little white dots that are brighter than everywhere else not sure if you can see that but those are calcium deposits and they have funny shapes and there aren’t calcium deposits up here in this lady’s breast and also it’s kind of denser down here it’s a little distorted it kind of looks like the tissues are pooled in so if you were to see this on one of our really good mammography monitors it would be pretty obvious that there’s a abnormality here that’s much different from up here and and that this isn’t cancer so my point in showing you this is not all cancer is a mass it’s not a big lump it’s a kind of diffuse area and the calcium deposits really help us to to find it and this is this patient’s MRI so she has I mean almost her entire breast is is lighting up and so this tells us that you know that cancer doubt this is maybe fooling us making it look a little bit worse because that’s a picture of the whole breast looking from the top to the bottom it’s more the bottom half when you look at these slice images but in any case the cancer is more extensive on the MRI then you might expect on the mammogram yes yes it has to do with these specific calcium deposits some cancers have calcium deposits some do not lots and lots of women have calcium deposits in their breast that are not cancer and so we look at the distribution in the shape of the calcium deposits to to tell if they’re suspicious or not and in this case they’re kind of in a they’re in a segment of the breast along the breast Anatomy they’re not diffused throughout the whole breast and they have these funny shapes which you probably can’t appreciate I mean I can’t really see it on this will be a very high resolution monitors which can show like each one is a different shape they’re not round they’re like triangles and angles and lines and all different shapes so sometimes calcium deposits are the only thing that we see when we detect a cancer and this is one of the reasons that even if patients undergo MRI for screening it’s always recommended that they also have a mammogram because mam of mammography is the only modality which reliably detects calcium deposits so what are other screening options if you’re dense or if you’re high-risk screening ultrasound whole breast ultrasound is one option Thoma synthesis is an is a newer modality which is basically like a 3d mammogram it’s or like a CT scan of the breast where we can go through with slices of the breast instead of a sum sum of summation picture of you know when you get a mammogram your breast is squashed and you get the radiation goes from one side to the other and you’re getting a picture of that whole flat area this cuts that into multiple slices it looks like a mammogram machine and it does involve radiation slightly more than the radiation of a typical mammogram and then there’s MRI so these are the other reliable screening options none of these has been scientifically shown to reduce breast cancer deaths as mammography has and each has its strengths and limitations so what about ultra Sun a major study was published a few years ago that showed a small but real increase in cancer detection when ultrasound whole breast ultrasound was combined with mammography but the drawback was there were many false positives so patients where you found lots of little nodules and things to look at in their breasts that required either follow-up or sometimes we would recommend a biopsy and then the biopsy would be negative so additional cancers were detected that weren’t seen on the mammogram but there was lots of extra things the patient had to go through and for some patients this causes a lot of anxiety another limitation of ultrasound is that the images can look different if they’re taken on one machine versus another

machine if they’re taken by different technologists in contrast to mammography where it’s the appearance from one Center to a net to the next one technologist to the next appearance is more consistent and oftentimes breast ultrasound is not covered by insurance I’m talking about screening breast ultrasound now not not the ultra Sun some of you may have had if you had a call back mammogram and we used it for problem-solving in a specific area so here’s just to give you an idea of what this looks like here’s one image from a normal ultrasound now many of you had an ultrasound of some part of your body if not your breast and you probably recall there’s a little probe that you hold in your hands like a little rectangle and only thing we’re seeing is what’s directly under that probe okay so you can imagine that the technologist has to slide the probe Oliver your breast and take pictures of anything of interest so I as a radiologist reading it if the technologist slides it all over the breast and doesn’t something then you know they’re not going to take a picture of that particular spot they can’t take a zillion pictures of the entire breasts so it’s not like a mammogram where I can look back and see a picture of the whole breast what they look like last year two years ago but anyway there it is so this is a normal all breast ultrasound the dense tissues tend to look white on the ultrasound the fatty tissues tend to look black here’s the skin and then back back here would be the chest while this is the patient’s pectoralis muscle so this is all you just kind of get used to the way it looks and it’s hard for people to look at it first and here’s some nodules and on an ultrasound so these are things that that we we find when we look in people’s breasts this is the same patient she has one two three four five six nodules this one if you see a good picture of it looks almost certainly like a cyst which is definitely benign but a lot of these things are sort of like I can’t they don’t look too suspicious like a cancer but I can’t say for sure that it’s not and they’re not definitely a cyst so we better follow them so this lady will you know have to come back and have these things remeasured andrey looked at every six months until we decide that they’re stable so i just want to give you an idea of what that looks like because it is a little tricky for radiologists to read you know next year when she gets this followed up I’m gonna rely on the fact that the technologist wrote right breast eight o’clock eight centimeters from the nipple that they estimated that correctly and labeled it correctly to know that this is the same lesion so it is it’s more tricky to make comparisons than mammography is all right what about tomosynthesis I’m sorry that I don’t have any Tomo synthesis images with me today it is newer and less extensively studies it’s not new new it’s been around for I don’t know ten years maybe I mean probably longer the preliminary version so it was sort of not-ready-for-prime-time not for Ponton finally people think it’s ready for primetime and we have it in one of our centers now we just started using it it is not covered by insurance patients have to pay out of pocket for it and we’re using it mostly for problem-solving patients who have an abnormality on the mammogram they’re screening mammogram and they come back to have it further looked at so preliminary data shows that it has a similar sensitivity to ultrasound so that adds a few additional cancers detected over our screening mammography and it has fewer false positives as opposed to ultrasound which like I showed you you find more things that are false positives it does use radiation a slightly higher dose than is in standard digital mammography it’s not covered by insurance and the availability right now is limited but I have a feeling it’s going to become more so what about MRI MRI is our most sensitive imaging test for breast cancer there are lots of false positives it’s very expensive it’s not covered by insurance for most patients but it is for some it utilizes an IV contrast agent so some patients have risk factors that make it a little bit more risky for them to get the IV contrast rate agent it’s generally very safe though and I should probably also mention that some patients are claustrophobic and can’t tolerate being in the tube of the magnet very well currently we use MRI to screen very high-risk patients in whom there is such a high look likelihood of finding a cancer that all these other drawbacks are worth it and for example Braca one patients have an 80% lifetime risk of developing a breast cancer in bracket two patients have a 40 percent lifetime risk so in those patients the insurance generally will

cover this as a yearly test and in those patients you can imagine any little finding is going to be more suspicious because this you know this patient has a higher likelihood of developing a breast cancer and there are other parents who qualify as very high risk too those are just two examples um Baraka one abra├žo 2rg are known with genes that lead to increased risk of breast cancer and other cancers so like if you heard about Angelina Jolie she her mother died of breast cancer I believe at a young age and so they did some further family history and if they you discover that there are lots of people in your family getting breast cancer at a young age or men getting breast cancer this might prompt a genetic counselor to do the blood testing to look at your genes and see if you have one of these known genetic mutations that leads to a very high risk of breast cancer and ovarian cancer and other cancers there are other genes almost certainly but we haven’t identified them to be able to test for them as well so there are some patients where we think oh they almost certainly have some genetic mutation in their family but it’s not Braca one in Bracker two it’s something else that we haven’t quite see ones yet so I want to show you some screening MRIs so this patient would be dense heterogeneous Li dense on her mammogram not terribly dense I mean you this is definitely a very useful mammogram to read you can find cancer on this mammogram and here is her MRI and this is a great MRI because everything is black right her nipples light up that’s typical these squiggly lines are blood vessels veins but nothing else lights up in her breast so this is great for her she’s brought a positive you can use this MRI you know that if you get this every year and she gets a little white dot that’s new that dot is suspicious for cancer you’ll biopsy it it’ll be easy to find here’s a patient who has moderate background enhancement on her MRI so not only does cancer light up on MRI but like I told you it’s not incredibly specific and the lots of other things can light up or look bright on the MRI so this is all this patient does not have cancer but you can see bright stuff all over the place which is can be confusing for the radiologist to read it it makes it hard to you have to sort of debate is this suspicious to this blob stand out from the rest of all the other blobs everywhere and there are some other tools that we have on our workstation that show us color mapping and blood flow and things that help us and also if someone’s getting screening MRI they’re getting this every year so we can compare to their priors I wanted to make sure I didn’t forget to tell you something so if this were a high-risk patient we might you know if we say this area stands out a lot after looking at all the pictures extensively you might biopsy that in a in a Braca positive patient to say this this one part stands out more than anything else I can’t say for sure there’s no cancer there and in this patient there’s a really high risk she’s gonna get a cancer so so this might prompt an MRI guided biopsy and just to find out you know if that patient has cancer or not but these are not the things that we want to go through for your average risk patient it’s sort of too much time you know anxiety money everything here’s another patient with moderate background enhancement she kind of has gray blush everywhere and lots of little dots and I have seen cancer look like a little dot just like that but we also see lots of little dots that are not cancer so it can be tough to make that judgment and you know one thing that’s important we we find in reading MRI is just how many MRIs you read in our practice we have a small group of doctors who read all the MRIs I’m one of them and we find that the more you read you kind of hone in your ability to decide what’s suspicious and what’s not and this lady has marked background enhancement lots of white stuff everywhere so you can see it just similar to mammography MRI can be limited in some patients this patients also marked background enhancement oh the point I wanted to make about this patient she has so much background enhancement and she’s dents on mammography but not all of that dense I would almost argue in this patient her MRI is harder to read than her mammogram so busy breasts on mama on mammography and MRI probably some of you have been

told that you have busy breasts this just means that there are lots of things to look at on your mammogram or your ultrasound or both and in this patient maybe this catches your eye and you think is that a cancer yes cancer can look exactly like this but in this patient this is not cancer could that be a cancer yes cancer can look like that it can look like that it can look you know this looks like if you saw this by itself you would have lots of things to to look at but this is why we follow patients over time if you have five years prior mammograms and they all look exactly like this it’s not cancer the point is that you know to be patient if you get called back to sort these things out it’s our job to be very sensitive and bring back anything that we think could be a cancer so that we can study it further and decide if it needs a biopsy so if an abnormality is detected on your screening exam don’t freak out we call back about ten percent of patients who get screening mammography but most of them do not have breast cancer we will do additional imaging to sort out the finding every exam is individually tailored to the patient do we need to do a focal spot compression on this one little area do we need to magnify it do we need to do an ultrasound do we need to do a bunch of those things maybe it’s not real but it’s just an artifact sometimes dense tissue even in a not very dense breast can kind of overlap in a certain way one year and make it look like there’s a little man there may be on extra pictures we can show that it just totally spreads out and it’s nothing to worry about maybe we can prove that it’s stable maybe we can prove that it’s benign let’s say you have a new sit a new mass on your mammogram we do an ultrasound and it’s a simple cyst which is known to be benign but lots of patients are put in this category almost certainly benign and I know this causes some patients excuse me anxiety it’s something that we can’t prove it’s benign but we’re pretty sure it’s not cancer so we watch it over time and oftentimes we watch these things for two years so if you’re put in this category be patient this means we think that whatever the finding is has less than 2% chance of being a cancer it really doesn’t require a biopsy or maybe we we couldn’t biopsy it and some patients particularly those with busy breasts are called back many times some patients develop lots of cysts they get a new sister get called back again and then they start to say I always get called back and it’s always nothing well I hope that it’s always nothing but even in patients who have busy breasts once sometimes they get called back and that time it’s something so don’t be complacent be patient and try to realize that if you get called back it’s probably not going to be a cancer but we it’s something that definitely needs to be sorted out further and we want you to be patient with the follow-ups so we can you know have all those imaging studies in a row to document that it’s benign and then reassure you that whatever it is is benign and remember the end goal is to detect your cancer as early as possible if one should arise this is that busy busy breasted lady where it looked like she had all those masses there on her left breast and the MRI was so she was so kind of busy and confusing someone decided to get an MRI to problem-solve for her not as a yearly screening but just to see what she looked like see if any of this was of suspicion and this whole area where it looked so distorted and dense on the mammogram is not right on me on the MRI so that is further evidence that it’s not cancer and this was a little lymph node which we can prove multiple different ways so just kind of a summation so she’s got busy breasts a little bit on MRI she’s got lots of dots but it’s different busyness than than the mammogram so anyway it’s you know a lot to look at in this lady and it’s a lot of work but she’s someone who has to kind of be patient she has a few biopsy clips here here here here so she’s had to undergo biopsies and fortunately for her none of them are cancer so back to the issue of dense breasts what should you do if your breasts are dense don’t freak out you should get your yearly mammogram just like every woman over 40 should get and comply with any follow-ups or callbacks that are recommended and considered discussing with your doctor your risk factors your doctor might suggest that you see a genetic counselor or another specialist who’s trained to really accurately assess your risk factors if you are at higher risk higher than average risk you could consider doing

extra tests like a screening ultrasound or maybe Tomo synthesis in addition to your mammogram if you are at very high risk twenty percent or greater lifetime risk then you should get a yearly MRI and a yearly mammogram breast density can limit the sensitivity of mammography to different degrees and new legislation mandates that you be informed of this and having dense breasts is normal and 50% of women have desperate dense breasts mammography reduces deaths from breast cancer and that’s true for patients in all density categories so if you are 40 or older get your mammogram every year breast MRI is a useful tool in screening for high-risk patients but it also has some limitations ultrasound and tomosynthesis are also useful in detecting breast cancer but unfortunately we don’t have very well established guidelines of when and how to use them as screening tools and for now like just when I said there are not validated guidelines on what to do with patients who have dense breasts so your radiologist and your primary care doctor can help you decide what screening tests are best for you these are some useful websites this breast density info is very useful it has little questions and answers that you can click on the question will give you the answer about different subjects very accurate and useful I like to tell people that the SBI online it’s more for breast radiologists but there is an area called resources so if you have questions about you know what does the one of them experts in breast imaging feel about you know other screening tests things that have happened in the news they usually have a response to the things that are going on and then you can read what the most respected experts feel about it and I just wanted you to know that I used I ACR guy’ll and the guidelines and Daniel Coe pans that mammography expert that I told you about to help me make this talk today you