Treatment Guide: Diagnosing Breast Cancer

The best local options for detection

Every three minutes somewhere in the United States a woman is diagnosed with breast cancer, and every year 40,000 will die from the disease. Thanks to advances in diagnostic technology, more and more breast cancers are being discovered sooner and sooner. While studies verify that earlier diagnosis leads to more successful outcomes, the question kicked around by specialists is “How early is too early?” “By finding and treating very tiny cancers,” says Dr. Brian Englander, Director of Pennsylvania Hospital’s Women’s Imaging Center, “we don’t always know if we’re going to prevent the growth of a threatening cancer or treat something unnecessarily.”

[sidebar]Until more refined screenings can definitively resolve that issue, local doctors will continue to aggressively hunt for tumors using these tools:

Mammography: This remains the gold standard of diagnosis and the only modality whose routine use is credited with the lowering the death rate from breast cancer. Most hospitals are gradually converting from analog x-ray mammography to digital technology, which converts the image to a computer and gives radiologists the ability to enhance the pictures for more accurate viewing. Digital mammograms emit a smaller dose of radiation and put less compression on the breast so they’re more comfortable for patients. A study in JAMA showed that digital mammography picks up more cancers than the analog version in pre- and- peri-menopausal women under 50 who have denser breast tissue. For women over 50 it doesn’t make much difference.

Digital tomosynthesis: According to the National Cancer Institute, mammograms miss up to 20 percent of cancers, and it’s hoped that this new tool will identify more of those missed. Unlike the traditional flat picture taken from two views, this instrument produces a three-dimensional computer model made from images taken at multiple angles. As Dr. Emily Conant, chief of breast imaging at Penn explains, “Think of how you can’t see the sun on a cloudy day. This technology peels away the clouds so we can see the cancer hiding underneath.” The University of Pennsylvania expects to have a machine in 2009 as soon as it’s FDA approved.

Ultrasound: If you have a family history of breast cancer and are too young for annual mammograms or your screening shows a suspicious mass, doctors may order an ultrasound for additional evaluation. It’s very popular in Europe; less so here.

Ductal lavage: Pennsy’s Dr. Englander is a big fan of this approach for a small population of younger women with dense breasts who have no symptoms of breast cancer but indications for more careful watching. It gently pumps cells from the nipple, which are then sent to a lab to be screened for abnormalities. “It’s controversial,” he says, “because nobody knows quite what to do with atypical findings.”

This is based on the principle that cancer tissue in the breast is hotter and will show up in different color patterns when screened with a special infra-red camera. Some studies say this indicates where cancer is likely to develop. Others say it picks up too many false positives. It’s controversial because there are no large scale studies with outcome data, but it’s another arrow in the breast imager’s quiver.

Breast MRI:
Traditionally this was reserved for women who’d already been diagnosed with breast cancer, but the trend is to use it for high-risk patients with a family history, a genetic marker like the BRACCA gene, an unusual lesion or a murky mammogram. It’s a keenly sensitive technology that highlights up to 30 percent of previously unseen cancers. “The caveat with MRI,” says Dr. Richard Bleicher, assistant professor of surgical oncology at Fox Chase, “is that it leads to three times as many unnecessary biopsies and many unnecessary mastectomies because of the false positives.” Your best protection is to have the results read by the kind of experienced MRI breast imager that you’ll find at Penn, Jefferson, Fox Chase or South Jersey Radiology under Dr. Cathy Piccoli.