For an audio version of this post, please click on the speaker icon (top left).

 

 

Today marks the first day of Breast Cancer Awareness Month.

As it is women that keep us guys in check and make the world go around, it is important that precautionary steps be taken to ensure that you do not leave prematurely (having the  XY component of our population left to our own devices is a quite sobering thought).

As a radiologist, I have given several presentations in the past regarding mammograms and try to answer any questions that tend to arise.

I thought it would be good to share some of the more frequent questions I receive and my answers so that you can be better informed managing your breast health.

What is the difference between regular 2D mammography and 3D mammography (Tomosynthesis)?

For decades 2D mammography was the only method available to screen for breast cancer.

In 2D mammography each breast is imaged in 2 planes (CC (craniocaudal) and MLO (mediolateral oblique) views).

Similar to a chest x-ray, the resulting product is displayed as one fixed image.

Because of this there will be overlapping structures which may obscure underlying pathology.

If 2D mammography can be likened to an x-ray, 3D mammography can be thought of along the lines of a CT scan.

3D mammography will acquire images by scanning an arc over the breast and that data is then reconstructed into a series of images that allow the radiologist to scroll back and forth through in order to analyze a particular structure of concern.

 

 

[Forgive the shakiness of the video, it was hard to scroll and film at the same time.

The above video shows striking architectural distortion from a prior surgery seen on 3D mammography.

More subtle findings where 3D mammography is even more beneficial did not translate well from the high resolution monitors I use to the standard video (the principles remain the same however).]

 

I came up with a more layperson explanation that seemed to go over well with the crowd so I will share it with you now.

I want you to picture yourself making a large bowl of Jello Fruit Salad.

 

 

You have various types of fruit cut in all shapes and sizes.

During the creation process your toddler accidentally threw a pea into the mix and the dessert set without you realizing it.

Now you know there is a pea in your creation and it is your job to find it.

If this was a 2D mammogram you are only allowed to look from the top of the container and from ONE side to find the offending object

You might be lucky and the pea is not obscured and easy to spot.

If you are unlucky, however, the pea will be obscured from both of these views by fruit in the way.

Now to simulate a 3D mammogram using this model, I now allow you to take the Jello out of the container and then slice it from top to bottom AND you also have the ability to make an exact duplicate of the fruit salad and slice it from side to side.

You are then allowed to examine each slice individually for that pea.

It’s a lot easier, isn’t it?

Even this is not a true simulation of what happens in my reading room.

The fact is that you knew going in that there was a pea in the mixture.

 

 

Unfortunately as radiologists we are not told ahead of time that there is a cancer (pea) in the study in front of us.

Initially insurance companies did not reimburse on the 3D mammography component and the difference was an out of pocket expense charged to the patient.

Fortunately insurance companies have realized that 3D mammograms were beneficial (picked up malignancies earlier or potentially decreased the need for call back diagnostic mammograms) and the majority, if not all, will now reimburse for this extra charge.

How often do I need a mammogram?

This is where it gets a bit interesting.

Traditionally after the age of 40 a screening mammogram was recommended annually.

There have been some organizations, most notably the American Cancer Society, who have suggested an alternative screening protocol (with every other year screening after the age of 55).

Currently insurance companies do allow for annual screenings after the age of 40 and that is what my practice adheres to.

I have been told I have dense breasts.  What should I do?

As a quick overview, there are typically 4 classifications for breast density:

• Fatty Breasts.
• Scattered Fibroglandular Tissue.
• Heterogeneously Dense.
• Extremely Dense.

 

Dense breasts (the last two classifications) can obscure pathology making it difficult for the radiologist to pick up potential cancers on mammogram.

 

 

 

Although 3D Mammograms improve the detection rate, it still is not perfect.

Typically in these instances the radiologist will recommend a breast ultrasound which can pick up mammographically occult lesions.

Therefore combining the two modalities of mammogram and breast ultrasound help give the best chance of picking up pathology from screening methods.

If Ultrasound is so great and can pick up lesions mammograms can’t, why can’t I just do annual Ultrasound screenings?

I get it.

Women do not like having their breasts compressed in a mammogram machine as it can be uncomfortable.

The reason why compression is necessary is twofold:

1. Prevents motion artifact by “locking in” the breast in a fixed position.
2. Compression will help spread the tissue over a greater surface area and result in less obscuring overlapping tissue.

 

Ultrasound does not require this kind of compression and is thus more tolerable.

Unfortunately ultrasound falls short in detecting microcalcifications, which are a concerning sign for potential cancer.

This is where mammograms shine over ultrasounds as they can pick up these tinier than a pin tip calcifications which require ultra high definition reading monitors to visualize (12 Megapixel).

[For reference a 4K High Definition TV has 8.5 Megapixels.]

So unfortunately the answer to the question is you still do need a mammogram.

I just got a letter saying I have to come back for a diagnostic mammogram.   Does this mean I have cancer?

I am sure the anxiety level goes through the roof when you open the mammogram result letter and it indicates that you need to come back for more imaging.

It is natural to think of the worst and immediately jump to worrying about breast cancers.

I am here to assure you that these types of requests are quite common and it merely means that there is an area on the mammogram that we would like to explore a little more.

• According to statistics, 1 in 10 women will get called back for additional imaging (10%).
  • Of those women who get called back, 1 in 10 will proceed to undergo a biopsy (1%).
    • Of those women who undergo biopsy, 2 in 10 will be diagnosed with malignancy (0.2%).

WebMd, “After Abnormal Mammogram Result.”

 

Caution:

Even with annual mammograms and/or ultrasounds it is important that you continue undergoing physical exams by you and your clinician.

Imaging is not perfect by any means and there are cases where a physical exam was the first to alert to the presence of cancer.

 

 

I hope that this article allays some of your fears and trepidation about getting a mammogram.

 

 

 

Note:

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