Improvements in Breast Imaging

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:14latest information on cancer care
00:14 --> 00:15by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week, it's a conversation
00:21 --> 00:22about recent advances in breast
00:23 --> 00:24imaging with Doctor Kiran Sheikh.
00:24 --> 00:27Dr Sheikh is an assistant professor
00:27 --> 00:28of clinical radiology and biomedical
00:28 --> 00:31imaging at the Yale School of Medicine,
00:31 --> 00:33where Doctor Chagpar is a
00:33 --> 00:34professor of surgical oncology.
00:35 --> 00:37Kiran, maybe we can start off by
00:37 --> 00:39you telling us a little bit more
00:39 --> 00:41about yourself and what it is that you do?
00:41 --> 00:42Originally I was always
00:42 --> 00:44kind of interested in medicine.
00:44 --> 00:46My parents were both in
00:46 --> 00:48medical careers, so I was always
00:48 --> 00:49kind of going towards medicine.
00:49 --> 00:53But in general, I ended up in radiology
00:53 --> 00:55later on in my career.
00:55 --> 00:57I was in medical school and
00:57 --> 00:58gearing towards actually neurology,
00:58 --> 00:59neurosurgery.
00:59 --> 01:02And then as I kind of went down my path,
01:02 --> 01:04I met a lot of radiologists and
01:04 --> 01:05they were amazing mentors
01:05 --> 01:08and they introduced me to
01:08 --> 01:10the field of diagnostic imaging and
01:10 --> 01:12I kind of started figuring out that
01:12 --> 01:15besides being involved in the
01:15 --> 01:17care and the treatment of patients,
01:17 --> 01:20I actually started becoming a lot more
01:20 --> 01:22intrigued about just the initial
01:22 --> 01:24impact of diagnosing disease and
01:24 --> 01:27being a part of the forefront of
01:27 --> 01:29imaging and so that's kind of how
01:29 --> 01:32I ended up in radiology.
01:32 --> 01:35And then specifically within breast imaging,
01:35 --> 01:38it was actually when I was in medical
01:38 --> 01:41school I again I had those radiologists
01:41 --> 01:44that kind of were my mentors and
01:44 --> 01:47then ended up in radiology
01:47 --> 01:50residency and saw the unique
01:50 --> 01:53relationship that the radiologists
01:53 --> 01:56had with our breast patients and how
01:56 --> 01:58important breast imaging was for
01:58 --> 02:01population screening and the kind
02:01 --> 02:03of larger impact that they could have.
02:03 --> 02:05So that's how I ended up in breast imaging.
02:07 --> 02:09A lot of us know a
02:09 --> 02:12little bit about breast imaging in
02:12 --> 02:15the sense that most people know about
02:15 --> 02:17the importance of getting a mammogram.
02:17 --> 02:20But what tends to be a little bit
02:20 --> 02:24confusing right now is what really are the
02:24 --> 02:27recommendations for screening imaging for,
02:27 --> 02:29let's start with people at average risk.
02:29 --> 02:31Let's suppose you don't have a
02:31 --> 02:33huge family history, or at least not
02:33 --> 02:34a family history that you know of.
02:34 --> 02:37You don't have a genetic predisposition.
02:37 --> 02:42You're just a regular individual in society.
02:42 --> 02:44The recommendations for breast imaging
02:44 --> 02:46in terms of screening for breast
02:46 --> 02:48cancer seem to be a moving target.
02:48 --> 02:50Where are we now and what do
02:50 --> 02:52you recommend for your patients?
02:53 --> 02:54What is breast imaging?
02:54 --> 02:55So in general,
02:55 --> 02:56we have different types of imaging
02:56 --> 02:58modalities that we do for breast imaging.
02:58 --> 03:01We do mammography, ultrasound,
03:01 --> 03:03MRI for screening evaluation.
03:03 --> 03:05Mammography is our gold standard
03:05 --> 03:07screening exam for breast cancer.
03:07 --> 03:08It's noninvasive, it's effective.
03:08 --> 03:10It allows us to have
03:10 --> 03:12early detection of cancer.
03:12 --> 03:14And so that's actually the
03:14 --> 03:15initial screening evaluation.
03:15 --> 03:17So now our Society of breast Imaging
03:17 --> 03:20and Academy and College of Radiology
03:20 --> 03:22recommends that women with average
03:22 --> 03:24lifetime risk of breast cancer
03:24 --> 03:26begin screening at the age of 40.
03:26 --> 03:27And like you said,
03:27 --> 03:29there is a lot of confusion
03:29 --> 03:31just because of the fact that
03:31 --> 03:32there are lots of different
03:32 --> 03:35imaging studies
03:35 --> 03:38out there that have been discussed
03:38 --> 03:40about what's the best timing to
03:40 --> 03:41start the screening.
03:41 --> 03:44And so different countries with different
03:44 --> 03:46risk profiles of their population
03:46 --> 03:49start screening at different times.
03:49 --> 03:50And so in essence,
03:50 --> 03:52you have some areas where they're
03:52 --> 03:55recommending from 40 to 45 that
03:55 --> 03:57they can just have the option
03:57 --> 03:59to start screening and then 45
03:59 --> 04:01to 54 you start annually.
04:01 --> 04:03And I would say the most important
04:03 --> 04:06thing that we always know is that
04:06 --> 04:08mammography is the most effective
04:08 --> 04:10exam for early detection of cancer.
04:10 --> 04:13And since the advent of mammography,
04:13 --> 04:17we've actually reduced mortality by 30%
04:17 --> 04:19and that's been documented since the 1990s.
04:19 --> 04:22So all this early detection of
04:22 --> 04:24breast cancer through mammography
04:24 --> 04:26screening is important to figure out.
04:26 --> 04:27I mean it's
04:27 --> 04:28the main reason why we
04:28 --> 04:29have the significant decrease
04:29 --> 04:30in breast cancer mortality.
04:30 --> 04:32So we have to kind of figure
04:32 --> 04:34out and parcel out what's
04:34 --> 04:35the most important thing.
04:43 --> 04:44Everyone recommends again starting
04:44 --> 04:48screening at the age of 40 and on
04:48 --> 04:50the option of an annual basis.
04:50 --> 04:52Once women get older and their
04:52 --> 04:55breast density starts to decrease,
04:55 --> 04:56that's actually the reason why.
04:56 --> 04:58Then in other countries they have the
04:58 --> 05:00option of doing it every other year.
05:00 --> 05:01And the reason is,
05:01 --> 05:02if the breast density decreasing
05:02 --> 05:04confers a slightly decreased
05:04 --> 05:06risk of breast cancer because
05:06 --> 05:07there's less vibrant glandular
05:07 --> 05:09tissue and so that's the reason
05:09 --> 05:11why that these recommendations
05:11 --> 05:13end up being where it could
05:13 --> 05:14be switching off to every other
05:14 --> 05:16year or less and less.
05:16 --> 05:18But we do recommend that women with
05:18 --> 05:20average risk still continue screening
05:20 --> 05:23as long as they have an expected
05:23 --> 05:25life expectancy of 10 more years.
05:25 --> 05:27So for some that may be in their
05:27 --> 05:2980s and others with very good
05:29 --> 05:31lifespan they might be later.
05:31 --> 05:33So it's a discussion that
05:33 --> 05:34women would have with their
05:34 --> 05:35primary care physicians.
05:36 --> 05:39What about for women who are at
05:39 --> 05:42higher risk? So let's suppose
05:42 --> 05:46you have a family history of breast cancer
05:46 --> 05:50or maybe you have a genetic mutation.
05:50 --> 05:53High risk women are women with
05:53 --> 05:55greater than 20% lifetime risk
05:55 --> 05:57of developing breast cancer.
05:57 --> 05:58And for those women,
05:58 --> 06:00that's a certain subset of women
06:00 --> 06:02and that could either be women that
06:02 --> 06:05may have a mutation like BRCA 1, BRCA 2.
06:05 --> 06:07They may have had a history
06:07 --> 06:09of chest radiation between
06:09 --> 06:12the ages of 10 and 30, strong
06:12 --> 06:14family history possibly like a pre
06:14 --> 06:16menopausal breast cancer diagnosis
06:16 --> 06:18in a first degree relative or they
06:18 --> 06:20have certain genetic disorders and
06:20 --> 06:22those are our high risk patients.
06:22 --> 06:24For those patients we do recommend
06:24 --> 06:26they actually start annual screening
06:26 --> 06:28mammography at the age of 30 and it
06:28 --> 06:31could actually even be as early as 25.
06:31 --> 06:35So if let's say I am a
06:37 --> 06:4025 year old female and my mother got
06:40 --> 06:42diagnosed with breast cancer at 35.
06:42 --> 06:45I can actually begin screening at 25,
06:45 --> 06:47but we don't recommend earlier
06:47 --> 06:50than 25 just because of the degree
06:50 --> 06:52of dense tissue and it limits
06:52 --> 06:54the sensitivity of mammography.
06:54 --> 06:56So we start mammography as early as 25,
06:56 --> 06:59but recommend at the age of 30 for high risk.
06:59 --> 07:01And then in conjunction with that
07:01 --> 07:04we do recommend also breast MRI.
07:04 --> 07:05So as we alluded to breast MRI is
07:05 --> 07:07actually a very effective type of
07:07 --> 07:09imaging modality and for screening
07:09 --> 07:12evaluation and we perform it in
07:12 --> 07:13conjunction with mammography
07:13 --> 07:15in these high risk women.
07:15 --> 07:18And breast MRI is in essence an
07:18 --> 07:20imaging exam where we give them
07:20 --> 07:23contrast and MRI images are obtained.
07:23 --> 07:25And what it allows us to do is
07:25 --> 07:27see very small lesions that may
07:27 --> 07:29be missed on mammography because
07:29 --> 07:31of that contrast enhancement.
07:31 --> 07:33So it's showing us tiny little
07:33 --> 07:35vascular lesions that are enhancing
07:35 --> 07:37and then they're seen
07:37 --> 07:39as discreet amongst the non
07:39 --> 07:41enhancing breast tissue,
07:41 --> 07:43so breast MRI is helpful in
07:43 --> 07:45these high risk patients.
07:45 --> 07:46One of the things that we notice
07:46 --> 07:48a lot of people get confused,
07:48 --> 07:50they say well if breast MRI is so
07:50 --> 07:52sensitive then why do I even have
07:52 --> 07:54to do mammography at the age of 30,
07:54 --> 07:57why wouldn't I just do breast MRI?
07:57 --> 07:59And the important thing to note is
07:59 --> 08:01that although it is the most sensitive
08:01 --> 08:04in what the highest cancer detection rate,
08:04 --> 08:06it can be sometimes so sensitive,
08:06 --> 08:07it could be difficult to distinguish
08:07 --> 08:09between normal and abnormal findings.
08:09 --> 08:11So it can potentially lead to
08:11 --> 08:12unnecessary biopsies.
08:12 --> 08:14So that's why we don't recommend breast
08:14 --> 08:17MRI routinely on average risk patients.
08:17 --> 08:19We specify for these high risk patients
08:19 --> 08:22and we always do it in conjunction
08:22 --> 08:24with mammography because it also
08:24 --> 08:25actually doesn't always detect stage
08:25 --> 08:28zero breast cancer or what we call DCIS.
08:28 --> 08:31And that sometimes may show up more
08:31 --> 08:33discreetly as calcifications on mammography.
08:33 --> 08:34So it's
08:34 --> 08:36really the combination of the two.
08:36 --> 08:38Mammography is our gold standard,
08:38 --> 08:39which can allow us to see very,
08:39 --> 08:41very tiny, subtle,
08:41 --> 08:42faint calcifications and
08:42 --> 08:44then also breast MRI,
08:44 --> 08:46which allows us to see very,
08:46 --> 08:48very tiny vascular lesions.
08:48 --> 08:52And so in these patients where you're
08:52 --> 08:54recommending annual mammography and
08:54 --> 08:56you're also recommending annual MRI,
08:57 --> 08:58one question that often comes up is
08:58 --> 09:01should you do the two in conjunction?
09:01 --> 09:02So for example,
09:02 --> 09:04every year get a mammogram and an
09:04 --> 09:06MRI at about the same time
09:06 --> 09:07or should you stagger them?
09:07 --> 09:10So have your mammogram say in
09:10 --> 09:13January and your MRI say in July,
09:13 --> 09:18and that way you still have each test every year,
09:18 --> 09:23but have a six month interval between tests?
09:23 --> 09:24What do you recommend?
09:25 --> 09:27I think that's just as you labeled
09:27 --> 09:29it, it's very helpful to space
09:29 --> 09:31it out by six months and what that allows
09:31 --> 09:34you to do is that you're getting some
09:34 --> 09:36screening evaluation every six months
09:36 --> 09:39the breast MRI's at one point and then
09:39 --> 09:41six months later and do the mammography.
09:41 --> 09:43It's also helpful because of the fact that
09:43 --> 09:46you are giving contrast with the breast MRI.
09:46 --> 09:48If you did do mammography and
09:48 --> 09:50breast MRI on the same day,
09:50 --> 09:52you would have to make sure that you did the
09:52 --> 09:54mammogram first and then the breast MRI.
09:54 --> 09:56Otherwise the contrast enhancement
09:56 --> 09:59in the breast would affect the
09:59 --> 10:01results of the mammography.
10:01 --> 10:03So we will recommend every
10:03 --> 10:05six months so you do one.
10:05 --> 10:07Either a breast MRI and mammography and
10:07 --> 10:09then the other exam six months later,
10:09 --> 10:10and that allows us to see
10:10 --> 10:11you also every six months.
10:11 --> 10:14You're being evaluated every six months and
10:14 --> 10:15you're getting imaging every six months.
10:17 --> 10:18So, you know, this brings us to
10:18 --> 10:20another question, which is one of
10:20 --> 10:23the newer modalities that is coming
10:23 --> 10:26into the fore is something called
10:26 --> 10:28contrast enhanced mammography.
10:28 --> 10:30Can you tell us a little bit more
10:30 --> 10:32about that and how is that the same
10:32 --> 10:34or different from standard mammography
10:34 --> 10:36and how is that the same or different
10:36 --> 10:40from MRI and how does it fit into
10:40 --> 10:43standard practice now or does it? Yeah,
10:43 --> 10:44it's, it's very exciting.
10:44 --> 10:47I think, you know, in general our goal is.
10:47 --> 10:49Radiologists were always trying to
10:49 --> 10:51positively impact patient outcome.
10:51 --> 10:54We're always trying to try to diagnose
10:54 --> 10:56these diseases as early as possible and
10:56 --> 10:59with that trying to kind of keep on pushing
10:59 --> 11:01the envelope for our imaging modalities.
11:01 --> 11:04And what we notice is that if we can use
11:04 --> 11:07more of these functional based methods,
11:07 --> 11:09meaning this imaging with contrast,
11:09 --> 11:11so breast MRI or contrast
11:11 --> 11:12enhanced mammography,
11:12 --> 11:14then we'd be able to see these tiny
11:14 --> 11:16lesions and the great thing is,
11:16 --> 11:18the contrast enhancement mammography is
11:18 --> 11:20the combination of them both
11:20 --> 11:21where you do the mammography,
11:21 --> 11:24you can see these very tiny,
11:24 --> 11:26subtle fine pleomorphic calcifications
11:26 --> 11:29that could represent stage zero breast
11:29 --> 11:32cancer carcinoma and
11:32 --> 11:35then you can also have the breast MRI
11:35 --> 11:38which allows the contrast enhanced,
11:38 --> 11:40which again allows you evaluation
11:40 --> 11:43of these tiny enhancing lesions.
11:43 --> 11:45So the way we do contrast enhanced
11:45 --> 11:47mammography is that it's kind
11:47 --> 11:49of a dual energy exposure.
11:49 --> 11:51Where you take the images prior
11:51 --> 11:53to giving the contrast,
11:53 --> 11:55then you give the contrast
11:56 --> 11:58through the
11:58 --> 12:00IV as if you were giving it
12:00 --> 12:02for any exam on contrast enhanced
12:02 --> 12:04CT exam or MRI exam.
12:04 --> 12:06And then you do a subtraction of the
12:06 --> 12:08two of the contrast image and then
12:08 --> 12:10the non contrast image and allows
12:10 --> 12:12those areas that are enhancing and
12:12 --> 12:14then you can visualize
12:14 --> 12:16those enhancing over
12:16 --> 12:18the non enhancing tissue and you
12:18 --> 12:20have the combination of the two.
12:20 --> 12:23If we do see any abnormality with
12:23 --> 12:25the contrast enhanced mammography,
12:25 --> 12:27we often can actually target just
12:27 --> 12:29based on that and we are still
12:29 --> 12:31in the development of this, but it's
12:32 --> 12:34really great that we're
12:34 --> 12:36able to now actually target
12:36 --> 12:37unconscious enhanced mammography.
12:37 --> 12:39And if for some reason we think that
12:39 --> 12:41there's a solid mass there that we
12:41 --> 12:42can see on ultrasound we will recommend
12:42 --> 12:44a targeted ultrasound to evaluate it.
12:44 --> 12:46And potentially if there's a lot
12:46 --> 12:48of findings on contrast enhanced
12:48 --> 12:50mammography where we feel as though
12:50 --> 12:51further dedicated evaluation with
12:51 --> 12:54the breast can be performed
12:54 --> 12:56then we can also recommend that too.
12:56 --> 12:58So it's a great initial exam.
12:58 --> 13:00Now where are we within the span of
13:00 --> 13:03it being in screening versus diagnostic?
13:03 --> 13:06I would say in academic centers
13:06 --> 13:08everyone is pretty much doing it now
13:08 --> 13:10definitely for research reasons trying
13:10 --> 13:13to see what is the increased cancer
13:13 --> 13:15detection rate and prove
13:15 --> 13:17that it's something that would be
13:17 --> 13:18helpful for the screening population.
13:18 --> 13:21So in general if you just think about
13:21 --> 13:22screening population, every 1000
13:22 --> 13:25women has
13:25 --> 13:27just a routine 2D mammogram.
13:27 --> 13:29You can detect about anywhere from about
13:29 --> 13:333 to 7 breast cancers.
13:33 --> 13:35And then what it does is the contrast
13:35 --> 13:36enhanced mammogram actually allows you
13:36 --> 13:38to even actually get an additional 10
13:38 --> 13:39for the 1000.
13:39 --> 13:41So it's very helpful.
13:41 --> 13:43What we need to do is just look
13:43 --> 13:46at the the risk of the procedures
13:46 --> 13:48anytime you're giving any contrast you have
13:51 --> 13:53make sure that you have staff
13:53 --> 13:55that are able to put in an IV,
13:55 --> 13:56that the patient can tolerate the
13:56 --> 13:58IV contrast and then also if there's
13:58 --> 14:00any kind of contrast reactions.
14:00 --> 14:02But these things are handled by the
14:02 --> 14:03radiologists on a routine basis
14:03 --> 14:05with all contrast imaging studies.
14:05 --> 14:08So that's something that's easy to do.
14:08 --> 14:09It's just really making sure
14:09 --> 14:11about the cost and just seeing the
14:11 --> 14:13effect on the patient experience
14:13 --> 14:15that they're able to tolerate it.
14:15 --> 14:18And then once that's really been proven,
14:18 --> 14:20then I really do think that it's
14:20 --> 14:22going to become our main mainstream
14:22 --> 14:24way of screening all patients.
14:24 --> 14:26Great, we're going to learn
14:26 --> 14:28a lot more right after we take a
14:28 --> 14:30short break for a medical minute.
14:30 --> 14:31Please stay tuned to learn more
14:31 --> 14:33about improvements in breast imaging
14:33 --> 14:35with my guest, doctor Kiran Sheikh.
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15:45 --> 15:48You're listening to Connecticut public radio.
15:50 --> 15:52Welcome back to Yale Cancer Answers.
15:52 --> 15:54This is doctor Anees Chagpar and
15:54 --> 15:55I'm joined tonight by my guest,
15:55 --> 15:57doctor Kiran Sheikh.
15:57 --> 15:58We're discussing recent
15:58 --> 16:00advances in breast imaging.
16:00 --> 16:03And right before the break we were
16:03 --> 16:05talking about screening modalities and
16:05 --> 16:07some of the interesting work that's
16:07 --> 16:09going on right now in terms of research,
16:09 --> 16:12looking at contrast enhanced mammography,
16:12 --> 16:14which might actually blend
16:14 --> 16:17together the best of both worlds
16:17 --> 16:20in terms of mammography and MRI.
16:20 --> 16:23Another question that comes up I think is
16:23 --> 16:26with regards to the role of ultrasound.
16:26 --> 16:29So many people will say,
16:29 --> 16:31I know the data on mammography,
16:31 --> 16:34my doctor always sends me for a mammogram.
16:34 --> 16:38Why can't I just have an ultrasound
16:38 --> 16:40for screening instead of a mammogram?
16:41 --> 16:42Can you speak to that?
16:42 --> 16:44And so in a sense what the different
16:44 --> 16:46modalities that we have in imaging,
16:46 --> 16:48each modality kind of gives different
16:48 --> 16:49information to the radiologist.
16:49 --> 16:51Mammography is
16:51 --> 16:53In essence a 2 D mammography
16:53 --> 16:55takes 2 pictures of the breast and
16:55 --> 16:57then 3D mammography which we have
16:57 --> 16:59is also called digital breast
16:59 --> 17:00tomosynthesis, and takes multiple images
17:00 --> 17:02of the breast at different angles
17:02 --> 17:04and then that allows us
17:04 --> 17:07to visualize the breast in different layers.
17:07 --> 17:09And so we have optimized
17:09 --> 17:11mammography with our 3D mammography
17:11 --> 17:14and it now allows us to see abnormalities
17:14 --> 17:15that previously were obscured
17:15 --> 17:17by just overlapping tissue.
17:17 --> 17:19And that actually has given us
17:19 --> 17:21a higher cancer detection rate
17:21 --> 17:23than just routine 2D mammography.
17:23 --> 17:25And it's giving us an
17:25 --> 17:27additional 2 cancerous breast per 1000
17:27 --> 17:29now screening breast ultrasound was
17:29 --> 17:32in essence recommended for women with
17:32 --> 17:34dense breast tissue and to be performed
17:34 --> 17:35in conjunction with mammography.
17:35 --> 17:37And you may ask then,
17:37 --> 17:38well, why are we
17:38 --> 17:40doing breast ultrasound
17:40 --> 17:42in patients with dense breast
17:42 --> 17:45tissue and not in patients with
17:46 --> 17:47routine breast tissue such as
17:47 --> 17:49scattered or fatty tissue?
17:49 --> 17:50And in essence it's
17:50 --> 17:53a numbers game.
17:53 --> 17:55Anyone who has heterogeneously dense
17:55 --> 17:57or extremely dense breast tissue
17:57 --> 17:59just has more fibroglandular tissue.
17:59 --> 18:01So having more of the fibroglandular
18:01 --> 18:03tissue just naturally increases
18:03 --> 18:05your risk of developing disease.
18:05 --> 18:07And then also there's the fact
18:07 --> 18:09of that obscuring tissue.
18:09 --> 18:11So what we did is we've been recommending
18:11 --> 18:13breast ultrasound in these patients
18:13 --> 18:15with dense breast tissue to see
18:15 --> 18:17the tissue in a different way.
18:17 --> 18:19So besides X-ray with ultrasound waves,
18:19 --> 18:22it penetrates the tissue and it allows us
18:22 --> 18:24to see that same abnormality that maybe
18:24 --> 18:26that mass that we saw in mammography.
18:26 --> 18:29But then it gives us additional information,
18:29 --> 18:30is it a solid lesion or is
18:30 --> 18:31it a cystic lesion.
18:31 --> 18:32When those sound waves
18:32 --> 18:34penetrate through a cyst,
18:34 --> 18:35which is very pliable and
18:35 --> 18:36kind of soft,
18:36 --> 18:39it shows up as
18:39 --> 18:40marked fluid containing structure,
18:40 --> 18:42while something that's solid
18:42 --> 18:44and has a lot of strain,
18:44 --> 18:46it displaces those sonographic waves and
18:46 --> 18:49it shows up as something more solid and
18:49 --> 18:52a different appearance on ultrasound.
18:52 --> 18:54And so that gives us a lot of information.
18:54 --> 18:58Now for evaluating masses,
18:58 --> 19:00it's fantastic.
19:00 --> 19:03But the caveat is again is those
19:03 --> 19:05tiny little calcifications,
19:05 --> 19:06so fundamentally mammography,
19:06 --> 19:10whether you have dense breast tissue
19:10 --> 19:14or you have a fatty tissue if
19:14 --> 19:17your average risk or your high risk,
19:17 --> 19:19it's still fundamentally the gold
19:19 --> 19:20standard screening evaluation
19:20 --> 19:23because of the fact that it is
19:23 --> 19:25the best way to evaluate those
19:25 --> 19:27tiny ducts to see if any kind of
19:27 --> 19:28subtle calcifications are existing.
19:28 --> 19:30And that's always our goal of
19:30 --> 19:32screening evaluation, early detection.
19:32 --> 19:35This brings up another question.
19:35 --> 19:37Sometimes different populations of women
19:37 --> 19:40may have questions about how to screen,
19:40 --> 19:43particularly women who may have
19:43 --> 19:45breast implants for augmentation,
19:45 --> 19:48so they still have breast tissue
19:48 --> 19:50and perhaps even have a family
19:50 --> 19:53history of cancer, or perhaps not.
19:53 --> 19:56But when they have implants in place,
19:56 --> 19:58can they still get a mammogram?
19:58 --> 20:00Talk a little bit about how they
20:00 --> 20:02should screen for breast cancer.
20:02 --> 20:05So when a patient has implants,
20:05 --> 20:07oftentimes the implants now I
20:07 --> 20:09would say routinely are placed
20:09 --> 20:11behind the pectoralis muscle.
20:11 --> 20:13So we call those retro pectoral
20:13 --> 20:15implants and that does actually
20:15 --> 20:17allow us to move the implant away
20:17 --> 20:19from the glandular tissue that's
20:19 --> 20:22in front of the pectoralis muscle.
20:22 --> 20:23And so by doing that,
20:23 --> 20:25we actually take two different
20:25 --> 20:27types of pictures with mammography.
20:27 --> 20:29We'll take a picture with the implant
20:29 --> 20:31in view and then we'll actually
20:31 --> 20:33displace the implant to the side.
20:33 --> 20:34And so then we take that picture
20:34 --> 20:36and then we can evaluate the
20:36 --> 20:37tissue just as we would evaluate
20:37 --> 20:39the tissue in any routine patient.
20:39 --> 20:40And so again,
20:40 --> 20:41we evaluate the tissue and evaluate
20:41 --> 20:43if we see any calcifications,
20:43 --> 20:44masses,
20:44 --> 20:46asymmetries or architectural
20:46 --> 20:48distortion in these patients.
20:48 --> 20:49Now if they do again, the
20:49 --> 20:51same thing, if they have dense breast
20:51 --> 20:53tissue where they have a higher
20:53 --> 20:54percent of fibroglandular tissue,
20:54 --> 20:56we would recommend them to get
20:56 --> 20:58a screening breast ultrasound.
20:58 --> 20:59Some patients with implants if they've
20:59 --> 21:02had a lot of surgical history
21:03 --> 21:05we have cases of patients that
21:05 --> 21:07either have had silicone injections
21:07 --> 21:09and when they've gone to other
21:09 --> 21:11countries and they've actually
21:11 --> 21:13injected silicone within the tissue,
21:13 --> 21:14that can actually then
21:14 --> 21:16make the breasts a little bit
21:16 --> 21:18more difficult to interpret.
21:18 --> 21:20So for those patients we would
21:20 --> 21:21recommend a breast MRI to evaluate
21:21 --> 21:24it just because they have a lot more
21:24 --> 21:26post surgical changes and foreign
21:26 --> 21:28body granulomas and so on within
21:28 --> 21:29the tissue that it would
21:29 --> 21:31be helpful to have that contrast
21:31 --> 21:33enhanced evaluation with breast MRI.
21:33 --> 21:35So it is a per case basis,
21:35 --> 21:37but a routine patient with implants
21:37 --> 21:39can definitely get screening evaluation
21:39 --> 21:41just as a patient without implants
21:41 --> 21:43and they would be mammography
21:43 --> 21:451st as the gold standard and we would
21:45 --> 21:46do the implant displays views and
21:46 --> 21:48then if they have the dense tissue,
21:48 --> 21:49we would do the breast ultrasound
21:49 --> 21:51and then MRI on a per case basis.
21:52 --> 21:54What about patients who have
21:54 --> 21:56had bilateral mastectomies,
21:56 --> 21:57maybe they've had cancer in the
21:57 --> 22:00past or maybe they've had bilateral
22:00 --> 22:01mastectomies prophylactically and
22:01 --> 22:03they've gotten reconstructed,
22:03 --> 22:05whether that reconstruction has
22:05 --> 22:07been with implants or whether it's
22:07 --> 22:09been with using their own tissue,
22:09 --> 22:11moving tissue around from their belly,
22:11 --> 22:14etcetera to create new breasts.
22:14 --> 22:16And now it looks like they have breasts,
22:16 --> 22:19although they've had a mastectomy.
22:19 --> 22:22So should they have imaging for
22:22 --> 22:25further surveillance or not?
22:25 --> 22:28And how do we monitor them
22:28 --> 22:30for breast cancer risk?
22:30 --> 22:31That's a great question.
22:31 --> 22:33And so I think the most important thing
22:33 --> 22:35is that when anyone has had any kind
22:36 --> 22:37of prior history of breast cancer,
22:37 --> 22:39the relationship with their breast
22:39 --> 22:41surgeons and plastic surgeons that
22:41 --> 22:43they've had is a very crucial one.
22:43 --> 22:44And so a lot of times
22:44 --> 22:45when a patient has had mastectomy,
22:45 --> 22:47they still actually have their
22:47 --> 22:49routine visits with their breast
22:49 --> 22:50surgeons and breast care team.
22:50 --> 22:52And on these routine visits they
22:52 --> 22:54will evaluate them and see
22:54 --> 22:56if they've noticed any kind of
22:56 --> 22:57differences in their breasts,
22:57 --> 23:00have they noticed any pain or
23:00 --> 23:03lump or any kind of new things, and if they had
23:03 --> 23:04nipple sparing mastectomy,
23:04 --> 23:06if they have any kind of discharge, or
23:09 --> 23:10any new symptoms, and then that's
23:10 --> 23:12evaluated by that breast surgeon.
23:12 --> 23:14If there are symptoms then
23:14 --> 23:15we will do imaging.
23:15 --> 23:18And so if the patients had mastectomy,
23:18 --> 23:21there's actually no more actual
23:21 --> 23:23glandular tissue to really be
23:23 --> 23:25able to image on mammography.
23:25 --> 23:27So if they have a little small palpable lump,
23:27 --> 23:29we would do then a targeted
23:29 --> 23:31ultrasound in that area to evaluate
23:31 --> 23:33it and see if it's something that's
23:33 --> 23:34associated with the skin,
23:34 --> 23:36superficial skin lesion or if it's
23:36 --> 23:38something just underneath the
23:38 --> 23:39dermis and possibly a recurrence.
23:39 --> 23:42And we can easily see that with
23:42 --> 23:43ultrasound if there is actually any
23:43 --> 23:45other questions where we feel as
23:45 --> 23:47though there could be additional
23:47 --> 23:48abnormalities or anything subtle,
23:48 --> 23:50then we would recommend
23:50 --> 23:53to breast MRI and get that contrast
23:53 --> 23:54enhanced evaluation for evaluating
23:54 --> 23:56something more subtle.
23:56 --> 23:58But that would be the mainstay with
23:58 --> 24:00patients that do have mastectomy
24:00 --> 24:02and then end up actually having
24:02 --> 24:04a tram flap those of patients.
24:04 --> 24:06Then again like you describe having
24:06 --> 24:08tissue kind of placed and put in that area,
24:08 --> 24:10there is actually then tissue
24:10 --> 24:11to do an X-ray of.
24:11 --> 24:15So if they do have a palpable area in a
24:15 --> 24:18tram flap then it can be done using mammography.
24:21 --> 24:23And I would say that sometimes
24:23 --> 24:25on occasion the mammography is
24:25 --> 24:27helpful because a lot of times these
24:27 --> 24:29patients have post surgical changes
24:29 --> 24:31like fat necrosis and they develop
24:31 --> 24:34calcifications and so they have a very
24:34 --> 24:36distinct appearance on mammography.
24:36 --> 24:37And so then mammography can be
24:37 --> 24:39helpful for us to delineate something
24:39 --> 24:41that's normal like fat necrosis
24:41 --> 24:43in a tram flap versus something
24:43 --> 24:45that's abnormal like a recurrence
24:45 --> 24:47at the edge of the flap.
24:47 --> 24:49What about men who get breast cancer?
24:50 --> 24:53If a man has developed
24:53 --> 24:56breast cancer and we know that about
24:56 --> 24:581% of all breast cancers do occur in
24:58 --> 25:02men and let's say maybe he's got a
25:02 --> 25:05genetic mutation in BRCA 2
25:05 --> 25:08and he has a unilateral mastectomy.
25:08 --> 25:11So we know that he is still is at
25:11 --> 25:13increased risk in the other breast.
25:13 --> 25:16Does he need to get mammograms on a yearly
25:16 --> 25:18basis just like his female counterparts?
25:18 --> 25:21How do we screen for the other breast
25:21 --> 25:23in men who are at increased risk
25:23 --> 25:25of developing breast cancer?
25:25 --> 25:27And that's actually a
25:27 --> 25:29great question and I think it's something
25:29 --> 25:31that we're always trying to pursue at
25:31 --> 25:32least even within our research trying to
25:32 --> 25:34figure out what is their risk profile
25:34 --> 25:36and how often they should be screened.
25:36 --> 25:38We will still actually do lifetime risks.
25:38 --> 25:41And so if they do have a mutation or if
25:41 --> 25:44they have also again lifetime
25:44 --> 25:46risk of you know greater than 25%,
25:46 --> 25:49we do have a subset of males that we
25:49 --> 25:51do routine screening evaluation if
25:51 --> 25:53they have that very strong evaluation
25:53 --> 25:55and they would get
25:55 --> 25:56mammogram on the other side,
25:56 --> 25:58but I would say more often than
25:58 --> 26:00not they end up not being greater
26:00 --> 26:03than that lifetime risk and so then
26:03 --> 26:05it ends up being symptomatic.
26:05 --> 26:07If they have any abnormality that's
26:07 --> 26:09felt on their routine
26:09 --> 26:11follow up visits by their doctors,
26:11 --> 26:14then we will do further evaluation with
26:14 --> 26:16diagnostic exam with again mammogram,
26:16 --> 26:17ultrasound,
26:17 --> 26:20possible MRI to evaluate the abnormality.
26:20 --> 26:22Perfect. Well, you know the
26:22 --> 26:23other question that often comes
26:23 --> 26:26up is that there's always new
26:26 --> 26:27technology that's being developed.
26:27 --> 26:29And oftentimes being marketed
26:29 --> 26:31as straight to consumers,
26:31 --> 26:36so things like Thermography or elastography.
26:36 --> 26:39Can you talk a little bit about some
26:39 --> 26:40of these technologies and whether
26:40 --> 26:43you think that they play any role in
26:43 --> 26:46terms of screening for breast cancer?
26:47 --> 26:49Sure. I think it's always a good thing
26:49 --> 26:51to always be thinking out-of-the-box
26:51 --> 26:53what are different ways for us to
26:53 --> 26:55evaluate these abnormalities and see
26:55 --> 26:57and look at the characteristics of it.
26:57 --> 26:59So these other imaging modalities
26:59 --> 27:01such as Thermography and so on,
27:01 --> 27:03what they're looking at is different
27:03 --> 27:04characteristics of a cancer.
27:04 --> 27:05So in essence,
27:05 --> 27:07if the cancer has angiogenesis,
27:07 --> 27:08that means some vascularity
27:08 --> 27:10to it has blood flow to it.
27:10 --> 27:13So we use contrast enhanced
27:13 --> 27:16mammography and MRI to evaluate that.
27:16 --> 27:18But then there's also a functional
27:18 --> 27:19art to the cancer.
27:19 --> 27:21And so the thermography is
27:21 --> 27:24pretty much based off of that.
27:24 --> 27:27The only issues with these types of functional
27:27 --> 27:30methods that we just haven't gotten to
27:30 --> 27:33the point where
27:33 --> 27:34we can delineate them very well
27:37 --> 27:39since they're sensitive but they're not specific.
27:39 --> 27:42So in a sense they can show
27:42 --> 27:45a degree of high,
27:45 --> 27:47high signal in the sense where
27:47 --> 27:49you're seeing a lot of uptake,
27:49 --> 27:50but then you don't know what it is.
27:51 --> 27:53There's an area of inflammation,
27:53 --> 27:55is it actually a small cancer,
27:55 --> 27:56is it an inflamed sebaceous cyst.
28:00 --> 28:02And so that's the thing about these
28:02 --> 28:03other functional based methods.
28:03 --> 28:04And we still have to optimize it.
28:04 --> 28:06So it's not mainstream and I
28:06 --> 28:08think the the issue is
28:08 --> 28:10that patients often then
28:10 --> 28:12depend on these more functional
28:12 --> 28:15based methods that don't have that
28:15 --> 28:17specificity and then they're not
28:17 --> 28:19doing the screening exams that have
28:19 --> 28:22been proven to and that are still
28:22 --> 28:25also non invasive and are more
28:25 --> 28:28effective in detecting that cancer.
28:31 --> 28:34Doctor Kiran Sheikh is an assistant professor
28:34 --> 28:36of clinical radiology and biomedical
28:36 --> 28:38imaging at the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu
28:42 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

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