Dr. Benjamin Pettus
As the first Breast Center of Excellence on the Peninsula, Riverside is committed to providing the highest level of care available within the bounds of current technology.
Mammography remains the “gold standard” method, proven to detect the majority of cancers at the earliest stages. The best data available supports a 30-60% reduction in woman’s chances of dying of this horrible disease (based on changes in the whole population including women not being screened – effect for screened women is likely greater). This means that 3-6 out of every 10 women with breast cancer in our entire population would not be alive if it were not for the advent of screening!
Despite this, only 6 out of 10 women choose to undergo recommended ANNUAL screening. Sadly, the majority of women dying of breast cancer were not getting annual screening at the time of diagnosis. While no test is perfect, mammography remains the only test proven to reduce the risk of dying from breast cancer. One in eight women get breast cancer at some point in their lives, please get screened somewhere.
Among women getting screened annually, we believe in a personalized approach to care. We believe in providing access to testing and we believe in education so women can make decisions with which they are most comfortable. We are sympathetic to the tremendous anxiety generated by the process of screening and early cancer detection. Part of this simply has to do with the nature of the disease. As a progressive disease, a woman’s chances of survival are dramatically improved the earlier the disease process is arrested. Cancer starts as normal tissue that then changes. Every woman’s tissue is unique and not all cancers look the same. Many cancers are difficult to detect until they look different from normal tissue. This means that there is a threshold below which detection is possible. Our efforts to detect very subtle changes can result in many “false positives” requiring additional workup i.e. “call backs”, and even biopsies. This is particularly true with the more sensitive/more costly tests such as breast MRI which is why we use them judiciously and predominantly in the most high risk women most likely to obtain benefit. Read more.
But we all still agree: this is not “good enough”. The women under our care are precious. We have to look them in the eye when we tell them the “news”. We all want to know in our hearts that we provided every possible tool and the best care possible. Who you trust to read your mammogram is every bit as important as the tool itself.
Of all the options under active investigation, Tomosynthesis holds the most promise and is increasingly available. But we do a tremendous disservice to women by overstating this promise. A more honest assessment is necessary so that women can make an informed decision. Read more
Tomosynthesis is an imaging technique that has been used since the 1930s but only recently applied to the breast because of radiation exposure issues that required significant retooling. It does not generate “3D” images in the strictest sense though that description has gained favor due to ease of description/corporate marketing. An x-ray beam sweep generates an image “slice” in the tissue of interest by blurring surrounding tissue with the exception of the focal point of the arc. As one of the difficulties with breast imaging detection is “superimposition” of tissue, this technique has the most theoretical potential for women with denser tissue.
Initial studies, however, failed to show an improvement over conventional “2D” mammography, particularly for detection of calcifications that often are scattered through imaging planes. “Change from prior studies” is also more difficult to assess – as some cancers do not look “mass-like” or have “spiculations”, there is a risk that the readers may have even more trouble detecting some cancers if they over-rely on the “tomo” images. Read more
Subsequent research efforts since this initial set-back have focused more on using this test as a supplement to regular mammography. When utilized in a “combo mode” both images are generated at a single compression such that women may feel that only one exam was performed, but in fact a supplemental test was added to their exam.
Newer advances have improved the technology such that an equivalent dose can now be expected and prior pitfalls avoided by use of reconstructed 2D images.
Several studies have shown an increase in cancer detection and some have shown a decrease in call-back rates when used this way, but these are not always the same study.
In our hands we are seeing a decrease in the call-back rates, further confirming this in an incremental step forward.
1) Tomosynthesis is still mammography. It does not replace mammography, rather it is a supplemental test acquired at the same time as a conventional “2D” mammogram.
2) It is not “more gentle” – compression is still required and if not performed will reduce the quality of the exam.
3) It is not “faster”- the length of time in compression is longer for both tests.
4) Secondary to recent advances including the ability to reconstruct 2D data from 3D data, it is now the “same dose” as a mammogram though possibly higher in women with larger breasts if additional pictures need to be taken for full coverage.
5) It is not really “3D” people say that to make description easy.
6) Even if not a “revolutionary” step forward it is at least an “incremental” improvement.
7) It is sometimes covered by insurance so out-of-pocket expenses may be higher.
Read more here.
We believe this is an incremental step forward. Consider choosing this option especially if you are a woman with dense tissue, complex breast pattern, and intermediate to high risk.
To your health!
Benjamin J. Pettus MD, PhD Fellowship Trained Mammographer for Riverside