BREAST CANCER DECODED By: Robert L. Bard, MD
CONCEPT
AND APPROACH
Drastic
changes in the incidence, diagnosis and treatment of breast cancer and benign
breast disease highlight a singular need for an up to date source on the early
detection and proper therapy of breast tumors.
The age of occurrence of breast cancer, formerly only a problem of older
women, is now at a median age of 45 years.
This means that women in their twenties are developing breast
cancer. Although risk factors have been
identified, the jeopardy to life is unchanged.
The increasing use of estrogen for osteoporosis and other female disorders
may elevate the risk of breast cancer.
One out of every eight women will develop breast cancer. Fortunately, the vast majority of tumors in
younger women are benign and can be diagnosed by simple, safe non surgical
tests. Jewish women, prone to breast
cancer, are further plagued by the concomitant presence of fibrocystic breasts
that are lumpy and mask a growing breast cancer.
increases markedly in younger patients and those with "mastitis" or
"cystic" breasts. A paper from
the University of Indiana Medical Center on the mammographic diagnosis of
fibroadenomas (benign tumor of young women) demonstrated that in 35 surgically
proven biopsies, the mammogram missed every mass. A non x ray exam, called the
sonogram, was able to diagnose every tumor in this study. Another non-x ray
test, called Doppler ultrasound, according to DIAGNOSTIC IMAGING (1988) and
CLINICAL RADIOLOGY (1990) may detect breast tumors not seen by all other tests.
Light scanning is another procedure that uses computers and fiberoptics to
visualize tumors.
The
latest text book on Breast Disease, BREAST ULTRASOUND by Thomas Stavros (Lippincott,
2002) mentioned that most abnormalities of the breast may be better
characterized or even detected only by diagnostic ultrasound procedures. JAMA
(May 1993) noted mammography readings were highly variable with many false
positives. Moreover, one expert missed 67% of cancers on high quality
mammograms. Indeed, top mammographers disagreed clinically in 1/3 of
readings.
cancers may lie dormant for up to ten years and that mammography is less
accurate in younger women, one realizes that sonography becomes necessary for a
complete workup in the detection of invasive. Mayo Clinic computer program
shows sonograms capable of 99% accuracy. The latest malpractice newsletters
warn physicians that they are liable if they miss a breast cancer because they
have not performed a sonogram. In fact, the PIAA Data Sharing Report shows that
the patient found the tumor in 69% of cases, mammography missed or was
equivocal in 49% and the median age of breast cancer was 43 years of age. False
negatives were highest in the under age 40 group comprising 40% of claims.
BREAST
IMPLANTS
year over 150,000 women have breast implants. Recent press has pointed to the
problem of breast cancer development in the augmented breast and the inability
of mammography to see it.
Mammography
has also long been used as the primary diagnostic imaging study for
complications of breast augmentation in the over one million women who
currently have breast implants. However, lack of accuracy of both mammographic
information and clinical interpretation have necessitated the application of
the non x ray imaging modalities of light scanning, sonography and duplex
Doppler ultrasound.
Every
plastic surgeon has received a radiologist's mammogram report on a patient in
whom a long standing implant has been removed for various complications that
referred to the ovoid shaped density as a "prosthesis in
position." Radiographically, the
hard capsule that forms after a year cannot be differentiated from certain
implant devices. Also, a leakage of silicone gel that is restricted to the
fibrous capsule is not separately distinguishable. Thus, x rays are inadequate
for the diagnosis of implant rupture except where the silicone has extruded
physically through the capsule. Even then, the routine views may not
demonstrate leakage that is close to the surface of the capsule so that it will
only be identified by a tangential x ray beam. An irregular outline of an
implant may be positional, caused by adjacent breast pathology, resultant of
fibrous septation or actually due to implant rupture.
A sonogram identifies an implant much the same as a cyst. Thus the size, shape, position, peripheral
envelope, wall contour and internal echo pattern are readily demonstrable.
Rupture of an implant, whether from structural failure, interoperative damage,
penetrating trauma or blunt trauma such as closed capsulotomy, is quickly and
accurately diagnosed by routine high frequency sonography.
Sonography
is also important in breast cancer diagnosis since the implant masks most of
the breast from the x ray. Dr. Levine, in the 1990 article: DEFINITIVE
DIAGNOSIS OF BREAST IMPLANT RUPTURE BY ULTRASONOGRAPHY in "Plastic and
Reconstructive Surgery" states that sonography is the best imaging
modality for the augmented breast.
Perhaps
more interesting are the roles of light scanning and duplex Doppler imaging in
the diagnosis of the cause of the implant rupture. Spontaneous failure of the
envelope will be accompanied by fluid extravasation. If recent and localized,
light scanning and Doppler flows will be unremarkable. A long standing leakage
may become secondarily infected, thus producing unilateral light absorption.
Similarly, trauma, intraoperative or external, may be associated with bleeding
which will also absorb light rays. Thus, a normal light scan exam in
transillumination suggests the probability of structure failure of the implant.
Duplex Doppler may shows linear fluid filled structures to be adjacent arteries
or veins. Additionally, this procedure may detect cancers adjacent to the
implant.
treatment of breast disease has also changed from the days of deforming radical
mastectomies. Simple removal of the
tumor followed by mastectomy, chemotherapy and radiation therapy are now
available. Post mastectomy
reconstructive surgery will often restore a woman to her former natural
shape. In
and
where breast ultrasound and Doppler analysis are routinely used, exploratory
surgery has decreased 90%. The American
Cancer Society stresses self examination and mammography. Unfortunately, the survival rate of breast
cancer has not changed in the past 25 years.
Clearly, other diagnostic exams are needed, since the cure rate is
related to the early detection of the disease. Alarmingly, despite many years
of ongoing, improved and massive breast cancer screening, the US National
Center for Health Statistics now sates that the incidence of number of cases of
this disease is actually increasing.
women are overwhelmed with the variety of medical tests and their safety.
Recent articles in the NY Times stated that the female patient is
psychologically ill equipped to deal with the emotional trauma of breast cancer
at the time of diagnosis. These reports suggest that women be well informed
prior to the discovery of a tumor, so that they may make a better informed
decision. The book addresses the
specific type of exam for both early detection of breast disease as well as the
optimal test for specific disorders for each individual woman in an orderly,
sequential and safe format. The pro's
and con's of treatment protocols are also formatted. The author, a radiologist specializing in new
methods of breast imaging, has been lecturing for the Ultrasonic Institute on
new methods of breast cancer detection since 1973 at medical centers around the
nation and at international conferences and mentions in this book all types of
exams and therapies. The reader chooses
for herself what modality may be most suitable.
Methods used in
find acceptance in American medicine twenty or thirty years later. Some medical regimens may be generally
unsuitable for patients, yet may be ideal or the only possibility for an
individual woman. Diagrams of the
various exams are available for better appreciation of the visually oriented
test. As a ready reference format, each
chapter is preceded by a one page summary for quick review. The overall aim of the work is to be a health
"bible" for breast disorders for the 1990's woman.
It is obvious that too few women are getting
the message about the importance of early breast cancer detection since they
fear that it will be too late or the therapy will be too deforming. The purpose of the book is to show that CHANCES
ARE ITS BENIGN, AND, PROPER TREATMENT CAN SAVE YOUR LIFE AND NOT
DISFIGURE. The work reaches out to the
reader to reassure her with dramatic evidence that taking control of her
breasts' health in a planned, stepwise manner can mean the difference between
the words: "The scan shows it's a
cyst. Don't worry" and the chilling
sentence, "we could have helped you if you come in earlier." Women walk out of my office, knowing that
their lump is benign and that their fears are nothing, looking ten years younger.
the simple techniques used when tumors are small. Even men develop breast cancer at a rate approximately
1% that of women. Most women do need to know that CHANCES ARE ITS BENIGN. Since the age range of breast cancer is now
from the teens to the hundred's, women of all ages need to become actively
involved in managing their health just as they do their finances. Since all
women are at risk of breast cancer, all families must know the facts and the
choices involved. Jewish women, successful women, women on hormones, women with
breast implants and the growing number of health conscious people of all ages
will want to know thee available regimens so they have the data necessary to
knowledgeably take charge of the their own lives.
REVIEW
OF CURRENT MEDICAL LITERATURE
Fleisher's
DIAGNOSTIC SONOGRAPHY (Saunders 1989) states that a sonogram is the best method
for diagnosing benign disorders and that a mammogram is the better tool for
diagnosing malignant diseases. He quotes the sensitivity of sonograms in cancer
detection at 69% as compared to the mammographic detection rate at 74%. The
author's own series using a hand held real time unit (same as Dr. Bard's) shows
an accuracy in detecting palpable lesions of 85% for sonograms and 70% for
mammograms. Both modalities yield a rate of 89% and he recommends both tests be
used in combination.
Hagen-Ansert's
TEXTBOOK OF DIAGNOSTIC ULTRASOUND (Mosby 1989) states sonogram is clinically
useful in a) dense breasts b) younger
patients c) uncertain mammographic
findings d) pregnant patients e) implants
f) differentiation of cystic from solid in a known mass
Kopan's
BREAST IMAGING (Lipincott 1989) states that sonography should not be used for
cancer screening. However, he quotes studies by Sickle's, Cole, and Egan
showing respectively that sonogram detects cancers at the following rates: 58%,
78% and 79% in the general population
Britton's
article in CLINICAL RADIOLOGY (1990) demonstrates duplex doppler having a sensitivity
of 91% and specificity of 89%.
Levin's
paper in PLASTIC AND RECONSTRUCTIVE SURGERY (1991) mentions that mammography is
unreliable in the post augmented breast and that ultrasonography is the test of
choice for evaluation of breast prostheses.
sensitivity and 100% specificity for carcinoma using duplex Doppler.
Adler’s
abstract in ULTRASOUND MED BIOL (1990) has 82% detection rate of malignant
neovascularity with duplex Doppler.
Scatarige's
note in THORACIC RADIOLOGY (1989) shows high accuracy of staging internal
mammary lymphadenopathy.
Jones
review in CLINICAL ONCOLOGY (1990) had sonograms picking up axillary nodes
missed by other methods in 27% of cases.
Levin's
paper in PLASTIC AND RECONSTRUCTIVE SURGERY (1991) mentions that mammography is
unreliable in the post augmented breast and that ultrasonography is the test of
choice for evaluation of breast prostheses.
Parker's
lecture at the NYU BREAST CANCER UPDATE (1993) showed sonography's ability to
detect unsuspected cancers as small as 0.4 cm and determine whether the
associated lymphadenopathy was malignant or benign. Mendellson's 1992 talk at
DOWNSTATE MEDICAL CONFERENCE showed sonograms to be able to discover occult
lesions.
Barth's
1993 study showing sonograms detected more than twice as much multicentric
breast cancer than mammography.
Stavro's
1997 paper shows accuracy in detecting benign disease solely by ultrasound at
99.7 %.
Bard's
paper in 1993 NY STATE JOURNAL OF MEDICINE revealing mammographic misses in
breast implant imaging.
Bard's
1994 lecture at the MAYO CLINIC highlighted the accuracy of multimodality
imaging.
Bard's
1996 FEMALE PATIENT paper showed 99% accuracy in benign disease diagnosis
CONCLUSION
breast cancer strikes younger women due to lowering of the median age of
occurrence, screening procedures become imperative.
Although
mammography is the only generally accepted screening modality, it is clearly of
limited use in younger patients or those with fibrocystic breasts. The inaccuracy of sonograms is true if one
considers the total population to be screened will predominate in older age
groups. Kopan's, in his textbook, admits that he chooses to do sonograms on
women under 28 because of anecdotal evidence that it works best. Dr. Bard's
suggestion is that sonograms be the screening procedure of choice in younger
women and those with fibrocystic breasts. Mammography should remain the gold
standard in women over 40 or those with fatty breasts of any age. The
combination of light scanning, Doppler ultrasound and standard sonograms of the
breast often mean the difference between delayed diagnosis and immediate
surgery. Multimodality imaging, the emphasis of this book, offers the patient
the difference between weeks of worry for the mammogram to be repeated for
"interval change" or for an immediate answer that the problem is
benign.
Aside
from a few books on cancer and women's diseases, there are no non-medical books
on the spectrum of new tests and therapies for breast disease. Given the epidemic proportions of breast
cancer, the time is right for a new and comprehensive manual for today's
concerned and aware women.
Books
on personal health include THE DOCTOR BOOK, by Wesley Smith (Price Stern Sloan,
L.A. 1987) which has one paragraph on breast exam by a physician and one
paragraph on mammography.
The
NY TIMES GUIDE TO PERSONAL HEALTH by Jane Brody (
1982) has 7 pages on breast cancer with 2 paragraphs on diagnostic tests.
HORMONES,
by Lois Jovanovic, MD (Fawcett, 1987) includes 26 pages on breast disease,
mentioning the fact that 90% of breast cancers are detected by women
themselves, leaving the reader to wonder at the value of the
"gold-standard" exams of
mammography and 2 pages on hormone therapy for breast cancer.
CHOICES,
by Marion Morra and Eve Potts (Avon 1987) also titled: Realistic alternatives in cancer therapy, has
one chapter on breast cancer, with 6 pages on mammography, one paragraph each
on ultrasound, computed tomography, transillumination and thermography. There are 16 pages on surgery and
radiotherapy and 29 pages on post operative care.
IT'S YOUR BODY (Berkely 1983) on p.418 states that sonograms will be effective
in the future. Indeed, Dr. Lauersen routinely now performs sonography on his
patients semiannually or more often in his private office.
Gross's
WOMEN TALK ABOUT BREAST SURGERY (Harper 1991) has 2 pages mentioning a
particular cancer was missed by mammogram and sonogram.
Levy's
YOUR BREASTS (Noonday 1990) says one 1 page that benign cysts that are not
palpable or show on x ray may be imaged with sonograms.
Thompson's
EVERY WOMAN'S HEALTH (Prentice Hall 1990) says on one page that sonograms are
useful in cyst detection.
Better
Homes and Garden's FAMILY MEDICAL GUIDE (1989) mentions that sonogram
is useful if mammography is unclear.
Harvard's
YOUR GOOD HEALTH (HARVARD 1987) says on one page that sonogram is good for cyst
detection.
Love's
DR. SUSAN LOVE'S BREAST BOOK (ADDISON WESLEY 1990) has one half page each on
sonogram and transillumination.
Hirshaut's
BREAST CANCER: THE COMPLETE GUIDE (BANTAM 1992) has one half page each on
sonogram and transillumination.
Many
private practice radiologists are currently routinely screening women with cystic
breasts or those under fifty with sonograms even though the
of Radiology does not recognize this as a screening tool. However, there is no
other acceptable alternative choice for the patient or better diagnostic tool
for the physician other than the non specific MRI exam. Every finding (30%
specificity) must be biopsied to be verified.
