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Monday, Oct 15, 2018
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Breast cancer awareness: From mammograms (2-D and 3-D) and MRIs to risk factors, here’s what you should know

Jenna Johnson expects to reach a major milestone next month: five years cancer free following a diagnosis of breast cancer.

The now 56-year-old executive assistant and office manager was diagnosed in November 2013, after reporting a few months late for her annual mammogram. Thatís when she first learned about a newer type of mammogram, one that provides doctors with more detailed images than standard two-dimensional mammography.

Known as breast tomosynthesis or 3-D mammography, it sometimes costs more than 2-D screening, but Johnsonís insurance would cover the cost so she opted to give 3-D a try. Good thing she did. Her cancer was so small and early stage that it might not have shown up on standard two-dimensional images.

"It was a bit of a shock when they found something," said Johnson, a mother of two who lives in Citrus Park. "But because they caught it early, I was able to keep a positive attitude. Thatís what helped me get through it all."

The radiologist who read Johnsonís films that day, Dr. Mia Jackson, medical director of imaging at the Shimberg Breast Center at St. Josephís Womenís Hospital, confirms that a 2-D mammogram may not have picked up the cancer.

"I refer to that now as my ĎA-ha!í case," Jackson said. "The cancer was much more evident with 3-D. It was less than a centimeter in size. It popped right out."

3-D mammography has been in widespread use since receiving FDA approval in 2011, but not all insurance companies cover it and not all screening centers offer it. Because it takes more images of the breasts, 3-D takes a few minutes longer than traditional screening. If available, patients can usually pay out of pocket an additional $40 to $80 for the newer technology.

3-D mammography takes pictures in thin slices, giving doctors a look at breast tissue one layer at a time, often making abnormalities stand out more than with 2-D mammography.

"Iím a big fan of it," said Jackson, whose full-time job is looking at images for breast cancer. "It should be the standard of care for all women."

Looking at 3-D images is like flipping through the pages of a book versus searching for something in that book by just looking at the cover, or looking for a bird in the forest. With 3-D, Jackson said, "you can walk through the forest to find the bird, versus standing on the edge of the forest and looking."

Because doctors can see more detail with
3-D imaging, there are fewer false positive results so fewer women are called back for additional screening and invasive procedures such as biopsy, also saving them from the
anxiety of waiting and returning for re-screening or additional tests. And 3-D imaging picks up slightly more cancers than 2-D.

"We should use 3-D mammography on every woman," Jackson said. "We certainly offer it to all our mammography patients."

But about 20 percent of patients at the Shimberg Breast Center donít opt for it, usually because of the cost.

"I think that within the next five years it will be available to all women, that all insurance companies will cover it," Jackson said. In the meantime, she recommends that women who can afford it ask for 3-D imaging when itís time for their annual mammogram.

Another, more advanced technology for screening is magnetic resonance imaging, or MRI. It is generally used in addition to mammography because MRI may miss some cancers that mammography picks up. Because MRI is highly sensitive (and prone to picking up anomalies that may not be cancer) and is significantly more expensive than 2-D or 3-D mammography ($1,000 or more versus around $50 for a 2-D mammogram), it is usually reserved for a very limited group of women who have greater than average risk for breast cancer.

In March, the American College of Radiology and the Society of Breast Imaging released new guidelines for breast cancer screening in women at greater than average risk. The guidelines single out several specific groups of women for MRI screening, including those who carry a gene associated with breast cancer such as BRCA1 or BRCA2; those who havenít had genetic testing but have a parent, sibling or child with a known BRCA mutation; those with a 20 percent or greater lifetime risk of developing breast cancer (determined by a credible breast cancer risk assessment or genetic testing); those with a history of chest radiation therapy before 30; those who have dense breasts and a personal history of breast cancer; and those diagnosed with breast cancer before 50. In most cases, women in these high-risk groups should begin screening for breast cancer no later than 30, with a combination of mammography and MRI.

Most women begin getting mammograms at 40 or 50, depending on which screening guidelines they and their health care providers choose. Women at high risk for breast cancer need to begin screening sooner, sometimes as early as 25, and may need to be screened more than once a year.

"Everyone agrees that mammography saves lives," said Dr. Bethany Niell, section chief of breast imaging at Moffitt Cancer Center. "What we want to do is identify those women at high risk (for breast cancer) so they can benefit from earlier screening and supplemental screening with MRI."

Some women believe having dense breasts alone should qualify them for MRI screening. Most doctors disagree.

"Having dense breasts ó along with other risk factors ó may make MRI necessary," said Niell. But if thatís your only risk factor, "it is not an indication for supplemental MRI screening."

Who would be a good candidate for supplemental MRI screening? One example, according to Niell, is a 28-year-old woman whose mother had ovarian cancer and a BRCA mutation; she should begin screening no later than 30 with MRI. Or, a 55-year-old woman with a 20 percent or greater estimated lifetime risk of breast cancer. She may also benefit from breast MRI along with mammography.

The American College of Radiologyís new guidelines also recommend all women have a breast cancer risk assessment by 30, especially if they are African-American or of Ashkenazi Jewish descent, because of their unusually high risk for the disease.

There are a number of different tests for assessing risk, but the Gail model and the Tyrer-Cuzick model are among the most commonly used. They ask a range of questions, such as age, race, ethnic background, age of menstruation onset, number of pregnancies, history of breast disease and first-degree female relatives with breast or ovarian cancer. The Gail questionnaire may take just a few minutes; the Tyrer-Cuzick is more comprehensive and requires a lot of detail about your own health and medical history and that of certain family members.

The idea is to determine your lifetime risk of developing breast cancer. For the average woman, itís about 12.5 percent; for high-risk women, itís 20 percent or higher. Those are the women who need to talk with their doctors to see if they would benefit from breast MRI in addition to screening mammography.

"We should be evaluating every woman for breast cancer risk," said Dr. Robert Gabordi, a breast surgical oncologist and genetic specialist at St. Josephís Womenís Hospital. "A lot of women who are high risk donít even know it."

Contact Irene Maher at [email protected]

     
     
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