October is National Breast Cancer Awareness Month and many women may feel relieved after their annual mammograms come back clear, but what if finding a tumor on a mammogram was like trying to find a polar bear in a snowstorm? According to the American College of Radiology Imaging Network, 40 percent of women who have mammograms have dense breast tissue (DBT), which is harder to read than fatty breast tissue. Unlike fatty tissue, which appears black on a mammogram, both dense tissue and tumors appear white.
A new law passed in New York, and 11 other states, requires mammography providers to inform women if they have dense breast tissue, a charge led by Nancy Cappello of Connecticut. Cappello, now 60, started getting annual mammograms at 40. When she was 51, a doctor found a lump in her breast just six weeks after a mammogram appeared normal. A follow-up mammogram did not detect it and she was told she had dense breast tissue, but the cancer had already spread to 13 lymph nodes. Cappello underwent a mastectomy, chemo and radiation. She believes that if she’d known about the density, she would have had ultrasounds and/or MRIs and the tumor might have been found earlier.
In addition to the digital mammogram, the high-priced MRI and the diagnostic ultrasound, the FDA has cleared several adjunctive tests that expand the options.
Automated Whole Breast Ultrasound
Radiologist Kevin Kelly wanted to do for breast cancer what the pap smear did for cervical cancer when he created the SonoCiné Automated Whole Breast Ultrasound (AWBUS) screening test. The goal: Finding cancer early and avoiding chemotherapy. The AWBUS is able to find tiny, fast-growing invasive cancers (5-10mm in size) in dense breast tissue using sound waves. An attached computer slowly moves the transducer (held by the technician for pressure and alignment) across each breast, taking three or four thousand images per scan to capture all the tissue. The test takes about 20 minutes and can be read by the radiologist in five (as opposed to the labor intensive manual screening ultrasound). Studies have shown that AWBUS as an adjunct to mammography may be 100 times more effective in finding cancers in dense breasts than can be found by mammography alone.
Benefits: No radiation, no compression, no injected dyes, safe for pregnant women, helpful for high-risk women with dense breast tissue or implants, false positives have decreased over time.
Downsides: Costs range from $250-$400 per test, not shown to be as effective as the mammogram for detecting calcified cancers like DCIS, not widely available yet.
Insurance: Not covered by many companies.
Available at: Central Park Women’s Imaging in Manhattan.
Approved by the FDA in 1982 as an adjunct to mammography, the thermogram is a physiological screening test as opposed to an anatomical one. It monitors changes in an individual’s thermal pattern, which is as unique as a fingerprint, years before lesions develop. Tumors need blood and nutrients to grow, thus blood vessels increase around compromised areas causing the surface temperature of the breast to rise. An infrared camera records the skin’s temperature by way of a colored digital image detecting vascularity, inflammation and asymmetries.
It is then read by a radiologist who might recommend the patient for further testing if something appears suspicious. Long Island physician assistant/thermographer Kristine Blanche applauds the preventative aspects of the test with regard to issues like fibrocystic breast disease. “We teach the patients, based on research, what areas we can maximize in their lives to decrease the risk factors for breast cancer,” she said. “Then these women get to return and see the changes they’ve made in their own breasts in as little as three months. What I love most about thermography is watching women, especially with a family history, transform from being afraid to being empowered.”
Benefits: No radiation, no compression, no injected dyes, safe for pregnant women and for implants, good for young women with dense breast tissue, has an average sensitivity of 90 percent (95 percent when used with other tests), can detect the rare but aggressive inflammatory breast cancer (IBC).
Downsides: Costs about $200, not good at detecting some small cancers or the exact location of a tumor, not standardized.
Insurance: Not covered by many companies.
Available at: The Integrative Healing Center in Port Washington.
Touted as the “next generation of mammography,” the MicroDose Full Field digital mammogram has been used in Europe and Asia for years. The MicroDose has 18 to 50 percent less radiation than other digital mammograms, which is good for those who get tested annually (along with other X-rays) as the effects of ionizing radiation are cumulative.
A photon detector minimizes shadows, allowing for higher quality images and the machine has a curved and warmed surface.
Benefits: Low-dose radiation, better image quality, more comfortable, five-minute exam time.
Downsides: Radiation, compression, may not be able to read dense breast tissue, not widely available yet.
Insurance: Many insurers cover the tests.
Available at: Bergen Regional Medical Center in Paramus, NJ.
Tomosynthesis (3D mammography)
This test is an extension of a digital mammogram and is sometimes ordered for women with dense breast tissue. The machine takes multiple images—25 exposures with up to two pictures per second—that can be combined into a three-dimensional picture in hopes of finding more tumors than the standard test. The jury is still out on whether or not it finds more cancers than the traditional mammogram. For one, Dr. Susan Love, nationally recognized women’s health expert and surgeon, questions if avoiding a few false positives is worth two to three times as much radiation.
Benefits: Overlapping tissue doesn’t obscure the inside of the breast, less repeat testing when standard mammograms are questionable.
Downsides: Two to three times more radiation than a standard mammogram, compression, density can still be an issue.
Insurance: Not always covered.
Available at: Good Samaritan Hospital in West Islip.