Primary Care Physician
Dr. Orrange received her BA in Biology at the University of California, San Diego, and a Masters Degree in Health Sciences at the Johns Hopkins University School of Public Health. She received her MD from the USC Keck School of…
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Breast ultrasound, mammogram, MRI or all three? Where are we now with Breast Cancer Screening?
Posted in Breast Cancer by Dr. Sharon Orrange on May 08, 2009

As much as we hear about breast MRI and other new modalities for breast cancer screening it gets confusing for people to sort out what is best for them. To keep it simple, for most of us mammogram is still the best imaging study.  Screening mammograms start for most women at age 40 and that's where the debate begins. Every year or every other year mammogram between the age of 40 and 50 depending on your risks, then at the age of 50 we all go to once a year mammogram.  Let's start with the most common questions I am asked and get updated on the latest in breast cancer screening.

Which is better Digital or Analog Mammogram?  Digital mammography has only been available at most facilities for the last 5 years. For most people the effectiveness is equivalent HOWEVER in pre-menopausal women, women with dense breasts, and women under 55 digital mammography fares better in the diagnosis of breast cancer.

What also matters with mammography? The person reading the mammogram matters!  You want a radiologist who spends most of their time doing breast imaging. You can ask who is reading your mammogram and what percentage of their time they spend reading screening mammograms.

Who should get more than just once a year mammogram? ENHANCED SCREENING is recommended by the American Cancer Society for women at high risk for breast cancer. Women at high risk for breast cancer are:

  • Those with the BRCA 1 or 2 mutation, or a first degree relative with BRCA 1or 2 mutation and not tested
  • A Lifetime risk of breast cancer 20% or greater
  • Radiation to the chest between the ages of 10-30 years

 

How do I find out if I am considered high risk? You can assess your risk using a well known risk assessment tool. It is published on The National Institutes of Health website (http://www.cancer.gov/bcrisktool/Default.aspx) and this will give you your risk for the next five years. Always discuss your results with your healthcare provider as well.

 

Who should be tested for BRCA 1 and BRCA 2? These are the inherited mutations in the genes that are involved in hereditary forms of breast and ovarian cancer. The US Preventive Services Task Force recommends screening for BRCA 1 and 2:

  • Those with known family members with BRCA 1 or 2 mutations,
  • Known Ashkenazi Jewish Heritage WITH one first degree (mom, sister) or two second degree relatives with breast or ovarian cancer. Additionally
  • Two first degree relatives with breast cancer, of whom one received the diagnosis at 50 or younger.
  • One first degree relative with bilateral breast cancer regardless of age of diagnosis.
  • A combination of three first or second degree relatives with breast cancer regardless of age of diagnosis.
  • Breast cancer in a male relative
  • A combination of breast and ovarian cancer among first and second degree relatives, or 2 or more first or second degree relatives with ovarian cancer.

 

Is it better to get an ultrasound and a mammogram together? This question was asked and answered in a study published in 2008 which looked at screening ultrasound + mammography vs. mammography alone for certain women at risk for breast cancer.

How was high risk defined in this study? BRCA 1 or 2 (+), history of chest, mediastinal or axillary radiation,25% lifetime risk of breast cancer or 5 year risk > 2.5% or > 1.7% and extremely dense breasts. Women with a personal history of breast cancer, atypical ductal or lobular hyperplasia, DCIS, or lobular carcinoma in situ were also included.

 

What did they find? The good news was that adding a SINGLE screening ultrasound will detect 1.1-7.2 additional cancers per 1000 women with increased breast density.  The bad news was this study used physician-performed ultrasound so it s not clear if the results would be the same with non-physician technicians. The other bad news was that the number of false positives increases with ultrasound which results in unnecessary biopsies.

 

Conclusions about Breast ultrasound + Mammography for screening in high risk women: When physician performed, breast ultrasound increases sensitivity but decreases specificity of cancer screening in high risk women with dense breasts. No guidelines currently recommend screening breast ultrasound.

What about Breast MRI?  For those who need "enhanced screening" (criteria listed above) annual screening MRI as adjunct to mammography and clinical breast examination is recommended.  Again, there is insufficient evidence for or against the addition of screening ultrasound.

To summarize about Breast MRI (since I am asked about it quite a bit) Current guidelines recommend MRI with mammography in some high risk women. There are no studies of the effect of screening breast MRI on breast cancer mortality that have been published as of yet.  Routine breast MRI in everyone is NOT recommended because of the high false positive rates and unnecessary biopsies, in addition to being very expensive. Again, breast MRI is recommended in combination with mammography in women at very high risk of breast cancer.

What about for women with saline or silicone implants? There is still no evidence to suggest that any screening test is better than digital mammogram for those with implants. For questions of whether an implant has ruptured MRI is helpful.

 

Thoughts? Experience?

Dr O.

 

 

 



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27
I'll never get another one of these damned things. I just went yesterday for this and I have bruises all over my chest and can barely move my left arm as I have a torn rotator cuff/ruptured tendon in the arm. Assholes!
By hope4acure  Jul 22, 2009
26
Dr. O, thank you for responding to my comment. I have a further qestion. I am currently uninsured, do to this I am unable to obtain a digital mamogram at this time. What can I do to still keep on my breast health checks, Like I stated earlier? I have anual and bianual clinical exams through a free health department program. I am very worried, not being able to get a digital mamogram at this time.
By christinaC  Jun 25, 2009
25
Hi there, I am just wondering when a baseline mamogram should be done.... I mean what age? Thanks
By DeniseDies  May 31, 2009
24
I "lucked out" so to speak.
My mom,2 of her sisters and a Great Aunt on my mothers side,all had breast cancer.

A lump was found in my right breast at age49.A biopsy revealed it to be an LCIS (do I have the terminology correct).Anyway,a pre cancerous growth.

With my family history,and finding I had BRAC 1 BRAC 2 Gene,I opted to have a phrophalatic Dble mastectomy.

I felt it was the logical choice,instead of mamograms every 3 months,and even then the chance of it sneaking up on me wasn't a pleasant thought.I didn't want the specture of breast cancer hovering over my everyday life.

So now,I never have to worry about breast cancer.
I'm not entirely pleased with reconstruction,done with saline inflatable implants.....I think the plastic surgeon wasn't really straight forward with how they could turn out looking ,not really like breasts at all.
By dancingd  May 15, 2009
23
ChristinaC: Yes at 32 with a mother who was PREMENOPAUSAL when she was diagnosed with breast cancer you can have digital mammgram +/- ultrasound depending on findings.

Medusa08: You sound like you have fibrocystic breast changes which are VERY common and digital mammography tends to be better than analog for you..so find a place that can screen you with a digital mammogram. Implants are fine and you can still get screened for breast cancer even with implants.

Kandyland2001: not only can you ask for early screening but you can ask for BRCA testing given that your mom had BILATERAL breast cancer. Find a breast surgeon near you for appropriate testing and screening if your primary care doctor can't take care of if for you.

DR O.
By DrOrrange  May 13, 2009
22
I have more of a question. I am a thirty two year old woman, My mother died of ductal cell carcinoma at 52. She was diagnosed at age 46, at stage three. My question is, should I go ahead and start having yearly mammograms? I have my routine clinical exams , twice a year already.

Thank you,
Christinadukie@yahoo.com
By christinaC  May 12, 2009
21
not sure how to move this off this thread to the one regarding the specialty clinics So Norma rather than continue to clutter this thread with issues that are not related I am going to reply to you on that thread. Hopefully we will all do so, Breast Cancer is a seperate and serious issue and doesn't need to be caught in the other argument
By doalan  May 12, 2009
20
Dr. I have a question. I do not see that I am at high risk according to the guidelines described. Is it true?
I have not had a mammogram in 3 years since after my divorce and move from the small town I lived in. I need to have a mammogram badly, since I remember my previous Dr. said that I had cystic breasts for the past 15 years. Nothing came up positive for cancer and just water and vitamin E was reccommended, not much caffeine, and also I am sup. to have a mammogram every 6 months. I am almost 50. 1)Am I not at risk having cystic breasts, 2)is that the same as having dense breasts, 3)can I have breast implants with cystic breasts (smaller implants), and 4)what type of mammogram is good for cystic breasts?

Thank you, Dr.
By medusa08  May 12, 2009
19
Is there somewhere that I can force to do an early mammogram/MRI/ultrasound? I went in a couple of years ago to get a baseline mammogram at age 27, I got undressed and in the room and the technician refused me although the doctor ordered it. I have constant tenderness, prior to that I had some strange discharge, however her reasoning was I was too young. I told her my history and the fact that my mom was diagnosed pre-menopausal. She said that since my mother was in her late 40's at the time that it didn't matter that she was pre-menopausal. Even though my family experiences very late menopause (60's). My mother actually had bilateral breast cancer, two seperate diagnoses two years apart. She had a double masectomy and a year later it returned metastasized, spread to her liver, brain, lungs, etc.. and killed her. I think I should be able to get tested. How can a technichian overrule a doctor's order??? Where can I go?
By kandyland2001  May 12, 2009
18
> Equality for men is (hopefully) coming!!
> By the way: June is Men's Health Month.

Thank goodness. I'm sick of one group over the other competing for attention and saying they are not equal when they many times have always been more than.
Men ARE more important* than women they do more and complain less, they should be given more funds and consideration for all their needs.
* they are stronger
* they are more beautiful
* more polite
* more intelligent
* etc.
: )
By NormLNorma  May 12, 2009
17
Equality for men is (hopefully) coming!!
By the way: June is Men's Health Month. Will you be focusing on men's health next month, Doctor O?

Contact: Susan Mosychuk (202) 225-2301
Murphy Brings Men’s Health Issues to the Federal Stage
Drafts Bipartisan Legislation to Create Office of Men's Health within HHS

Washington, Thursday, April 30, 2009 -

Congressman Tim Murphy (R-PA) and Congressman Barron Hill (D-IN) today introduced H.R. 2115, the “Men and Families Health Care Act of 2009.” This bipartisan legislation would establish an Office of Men's Health within the Department of Health and Human Services for the purpose of improving the health of men and their families in the United States. This Office will mirror the existing Office of Women’s Health, established in the early 1990s, which has improved the quality of life for women nationwide.

“The goal of this bill is to raise awareness about men’s health issues, and ways we can prevent and detect men’s health problems. The Office of Men’s Health will bring this issue to the federal stage and result in more men getting the treatment they need, which will save lives,” said Congressman Murphy. “For too long the health needs of men have gone unaddressed. This bill will help men’s health take its rightful place in our federal government’s healthcare priorities.”

“I try to take good care of myself by exercising and watching what I eat. But, I know I need to go to the doctor more often. I think men often need a little extra push when it comes to taking care of their health, and I think this bill is one way to do just that,” said Congressman Hill.

The office will be designed to monitor and coordinate efforts to improve the health and well-being of men by streamlining government efforts on the federal and state levels in the areas of prevention, health education, outreach, and research. You can learn more and take action by visiting the Men’s Health Office Resource Center at www.menshealthoffice.com
By ESF  May 11, 2009
16
There is a new machine that doesn't squeeze the breast and uses no radiation. It is automated ultrasound and produces a 3D image in 10 minutes. The patient lies prone on a table and the breast lies naturally in a solution. It is a modest procedure with a towel laying over the patient's back. The entire process can be done in a doctor's office. The machine became available in the U.S. this year and received FDA approval last year. Anyone of any age can use the machine. This company was formed to save lives and provide comfort to the patient. 100% of the women who have used this machine said they would NEVER get a mammogram again. The cost is much less than MRI and comparable to a mammogram. Generally, it can be done for the price of a copay. For more info, email me at paul@kpimaging.us.
By paulbrian  May 11, 2009
15
I have breast cancer and im only 15 i was wondering how i can get ride of it at a young age
By Starlee3  May 11, 2009
14
You can assess your risk using a well known risk assessment tool. It is published on The National Institutes of Health and this will give you your risk for the next five years. Always discuss your results with your healthcare provider as well..http://www.globalreplica.com/">replica rolex submariner
By Alise  May 11, 2009
13
Dr. Orange, Big time help needed!!!I have had to have mammogrames since the age of 27 due to the family history of Breat cancer. Luckly I have only been called back once for a ultra sound which was just fine. But I have had a problem with leaking from the nipples for over 10 years. And it isn't just me it is me and both of my sisters. Antibiotics haven't done anything to clear it up. And the doctors say there are to may to go in and seal them using a wire during a ultrasound(OUCH)!!! Would you might a have any ideas to what might be causing it??? The one thing the doctors have never done is to test the fluids. So I don't know how to handle this as I go in at the end of this month for my regular Mammogram. Thank you for any advice you can offer!!
By pepsiaddict77  May 10, 2009
12
Mixi: There are mobile mammography units in most areas...i just looked online (Im not sure where you live) but it looks like you can find one to come to your house in most areas. Look under "mobile mammogram units"
Dr O.
By DrOrrange  May 10, 2009
11
I'm 52 and, earlier this year, I was invited to attend for my first mammogram.

However, the location was too far fom my home for me to be able to attend.

I'm disabled, you see, unable to walk more than a few yards.

To get to the clinicwould have involved a four bus journey, which I wasn't able to undertake.

I phoned thre clinic, asking if it would be possible for my appointment to be re-scheduled to a day when my husband was off work and would be able to drive me......

It wasn't possible.

Ergo, I had to cancel the appointment and won't be eligible for another for three years.

I'm not convinced of the efficacy of mammograms, anyway, since a friend was given the all-clear, yet died of a carcinoma that couldn't have been detected by mammogram.
By mixi  May 10, 2009
10
Dr. O.,

Thanks so much for your article. Considering I am pre-menopausal, have had radiation treatments to the neck and chest, breast densness, and come from a known background of the Ashkenazai Jewish tribe, (I have Gaucher's disease), this was a very appropriate article. I am calling the OBGYN to get a mamogram and testing for BRCA 1 or 2 in the morning.

You may have saved my life.
By daisymom  May 10, 2009
9
Dr. Orrange, if I read your post on specialty clinics wrong I apologize but it appears that you seem to have no problem with female specialty clinics but question the need for male specialty clinics. All of the things that are stated as reasons for female clinics including gender specfic issues combined with screening are there for males, yet you seem to question is there a need, you question whether the needs for males could are not being met in general medicine...yet the same question is not proposed for female care. I would prefer to carry this conversation on the specialty clinic site so as not to diminish or take away from the importance of Breast Cancer, that is not the intent. However, it seems obvious you feel differently about the need for mens and womens clinics. At least part of the benefit and focus of womens clinics...at least from the advertising is to provide a environment for women, focused on women....would not men benefit from the same? That is the way I read your post....was I reading that wrong....it seems I am not alone if I did...but if I did, I apologize...If you would respond on the specialty site perhaps ESF & I would be best leaving this thread for its purpose...
By doalan  May 09, 2009
8
ESF: I will continue to post on issues relating to men and women.
Doalan: When have I ever made a point that it is "wrong when the attention is skewed toward men but justify it when it is skewed toward women."
Andromeda7: Some receive their first baseline between the age of 35 and 40 but for most who are low risk the recommendation is for your first annual screening mammogram at 40...assuming you have been receiving annual breast exam.

Tadlem: Great point about breast self exam...because most early breast lesions are NOT paplable on breast self exam it is most important in women under 40 who are not yet getting annuals. Also evidence has shown that breast self exam twice a year is equivalent to monthly.

Breast cancer is rare in men and annual screening mammogram is not recommended. Breast self exam in men (and your doctor can do this annually) is recommended as men can more easily palpate a nodule or abormality given they dont have the fatty tissue women have.

Calcifications are common and your radiologist will decide if they find them worrisome (worth a biopsy) or are stable and unchanged...that is where a good radiologist and close follow up is helpful.

For those after breast reduction surgery it is still recommended the first line screening test is mammography.

In premarketing studies on continuous oral contraceptives there was not an increase in mammogram abnormalities or breast atypia or cancer.

Dr O.
By DrOrrange  May 09, 2009

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