Dr. Ari Brooks, Professor of Surgery; Chief, Endocrine and Oncologic Surgery; Director of the Breast Center, Pennsylvania Hospital, offers insights to help women make more informed decisions about early detection technologies.
3D Mammograms: Who Needs Them?
As you drive around our region, listen to the radio, or read the paper, you may notice that many of our hospitals and radiology centers are now advertising 3D mammogram technology as the next best thing in breast screening. Also this year, if you are a woman over 40 who got a screening mammogram, you may have received a letter stating that your breasts are dense and that breast density limits the ability of mammograms to find cancers. But wait, didn’t we just hear last year in the news that mammograms don’t make a difference anyway?
Are you confused yet? If so, don’t feel bad; you are NOT alone! I will do my best to help clear up what I can. It’s important to remember Susan G. Komen’s clear message that early detection saves lives!
What is the real deal on mammograms?
A mammogram is an X-ray of the breast. X-rays travel through the body. They are blocked by dense parts and pass through less dense parts, making a picture that shows white for bones and black for air or fat. If your breast is mostly fat, the X-ray will be mostly black and small spots of calcium (calcifications) show up clearly. These calcifications can be a marker of early breast cancer. If your breast is not mostly fat, and has more glandular tissue (younger or firmer) your X-ray will not be mostly black: it will be a shade of gray or even white. This makes finding small spots of calcium harder, and makes finding tumors, which are white or grey, really hard to do. So mammograms are easiest to interpret (work best) on mostly fat breasts, and harder to interpret (not as effective) on mostly dense breasts. For this reason, the states of Pennsylvania and New Jersey have passed laws requiring that your doctor notify you about your individual breast density and that your mammogram may not be as effective as it would be in someone with less dense breasts. That information is good to know, but we don’t have a great test to use that is proven effective in women with dense breasts. Some insurance companies will pay for a special screening breast ultrasound test or even a breast MRI in women with dense breasts (but most will not).
What about 3D Mammograms?
This summer, two of our local health systems (Penn and Einstein) joined 11 other institutions around the country in publishing an article about their large-scale evaluation of 3D mammograms in practice. This is the largest study looking at the benefits of 3D mammograms to date. In short, after looking at over 300,000 mammograms, the authors found that 3D mammograms have fewer false positives (meaning you get called back for more pictures and they don’t find anything to biopsy) and found more invasive (dangerous) cancers than regular digital mammograms. Sounds great, right? It is a great technology, and it makes finding small tumors easier, especially if they are not associated with calcifications.
So what is the down side?
1. It is twice as much radiation as a regular digital mammogram.
2. It is more expensive for the radiologist to buy and read, but is not paid for by insurance at a higher rate than a regular digital mammogram. (That means that it won’t be feasible for most radiology centers to replace all their machines with 3D machines).
3. It is still a breast X-ray, and it is not proven to be better in dense breasts than regular digital mammograms.
OK, who should get a 3D mammogram?
Because 3D mammograms reduce the false positive rate, women who are going for their first mammogram should consider getting a 3D mammogram. These are the women who are most likely to get called back for more pictures (false positives). Women who have had issues with multiple call backs in the past may also benefit from this technology. Possibly, women ages 40-55 may get the most benefit from a reduction in false positives and a slightly higher cancer detection rate, as this is the age range where breast cancer incidence is lower making false positive test results more likely.
SO why are we hearing that Mammograms don’t make a difference?
Over the past 3 decades many, many investigators have devised studies and published papers trying to determine the best way to screen for breast cancer. Most have concluded that a screening system like the one set up in the USA will detect more cancers at an early stage that the alternative, which is to wait until you, the patient, feel (or see) a lump and come to the doctor. Most of these studies have found that the treatment for early stage breast cancer is less invasive, easier to tolerate, and survive than the treatment for late stage breast cancer. What has been hard to prove, however, is that finding and treating a breast cancer when it is so small or even in the “pre cancerous” stage, translates into a survival advantage over finding the cancer in stage II when it is a lump you can feel. Some investigators have calculated that routine mammogram screening is “too expensive” or “not financially sustainable.” That may be true from a statistician’s point of view but our society has avoided placing a price tag on our mothers, wives, sisters, and daughters.
I would pay any price to avoid their suffering. Wouldn’t you?
Please continue to spread the word that early detection saves lives! If you are over 40, get a mammogram every year (3D or regular, dense or fatty. It doesn’t really matter).