Transcript of a chat about breast cancer screening

March 28, 2007

Tina: Hi Dr. Birdwell, Thanks for chatting. What defines someone as having a "high risk" of breast cancer? Is family history the only factor?

Dr. Robyn Birdwell Thanks for your question, Tina. The following paragraph comes directly from the American Cancer Society. Screening MRI is recommended for women with an approximately 20 to 25 percent or greater lifetime risk of breast cancer, including women with a strong family history of breast or ovarian cancer and women who were treated with radiation for Hodgkin disease. There are several risk subgroups for which the available data are insufficient to recommend for or against screening, including women with a personal history of breast cancer, carcinoma in situ, atypical hyperplasia, and extremely dense breasts on mammography.

Nikki: After a study like this is released, do you think there will be a large group of women rushing to get MRIs?

Dr. Robyn Birdwell Thanks for asking this important question, Nikki. Unfortunately, information in the media is both helpful and a bit harmful. Any women reading some of today's information could feel unnecessary panic. MRI is a great tool and appropriate for some women, but for women without breast complaints 40 and over, MAMMOGRAPHY is the best known screening imaging test.

Grace: Can women at high risk of breast cancer who do not have health insurance expect to be able to have an MRI for screening?

Dr. Robyn Birdwell Thanks very much for asking this question, Grace. I am sorry that I do not have very much information at this time, but have printed below the response of the American Cancer Society to one of the "frequently asked questions".

Dr. Robyn Birdwell Will the National Breast and Cervical Cancer Early Detection Project (NBCCEDP) cover these exams for high risk women?

Dr. Robyn Birdwell While the program has not decided on that issue, it is unlikely MRI will be covered by the program in the near future. Since the program is designed to focus primarily on uninsured women with an average risk of breast cancer, particularly those ages 50 to 64, it's unlikely that there will be an increased demand for these services right away. At current funding levels, and if the program were to focus on the needs of high risk women, considerably fewer women of average risk could be screened and receive the benefits of early detection.

Todd: The chart on A1 of the Globe showed that mammograms only detected 33% of tumors. Don't most women and medical officials rely on mammograms to detect breast cancer? 33% seems to be like a really, really low number for our most reliable method...

Dr. Robyn Birdwell Todd, this is a very important issue that you raise. This lower range of breast cancer detection has to do with breasts that are very dense. The sensitivity for breast cancer detection in the fatty breasts is > 95%.

Mimi: How would you determine who would be high risK? My mother had bi-lateral breast cancer

Dr. Robyn Birdwell Individual risk for the development of breast cancer, Mimi, can be calculated using several different programs. As you might look further into this question it is important to know that the risk assessment models use different combination of risk factors and and may generate different risk estimates for a given woman. From information from the American Cancer Society comes contact information for three of these programs that I have included below. Please note that these are geared to health professionals.

Dr. Robyn Birdwell BRCAPRO Version 4.3, http://www4.utsouthwestern.edu/breasthealth/cagene/default.asp

li: Every year at my mammogram, there is a new calcification cluster that shows up. My father was very cystic and his sister developed breast cancer at the age of 80. Would you consider this history to put me at risk? thanks.

Dr. Robyn Birdwell Li, calcifications in and of themselves are not cancer. The cells around calcium may usually not cancer, but the shapes and patterns of the calcifications sometime result in recommendation for further mammographic images or less commonly biopsy. Most of the calcifications we see in breasts are not assoicated with breast cancer. The family history you include in your question does NOT put you at a high risk for developing breast cancer.

Cindy: I am BRCA1 positive and do get MRIs. I do not get mammograms because of the radiation. Does this new study mean that just getting breast MRI is okay? My doctors want me to get both, but I don't think it's a good idea. This study seems to confirm that MRI is best for high risk women. Does getting a mammogram also just duplicate information?

Dr. Robyn Birdwell Cindy, thank you for sharing some your personal challenges. The guidelines and good practice dictate that MRI should be IN ADDITION to regular mammography because putting the two together (and don't forget about the importance of a good phyiscal examination of the breasts by your health care professional) finds more cancer than MRI alone.

KRH: Hi Dr. Birdwell, Thank you for taking your time today. Can you please tell us if MRI is currently standardized like mammography? Does each hospital follow the same technique?

Dr. Robyn Birdwell KPH, this is a very good and important point to highlight. Breast MRI is much more technically complex (and expensive) than is mammography and there are differences in how the images are created as well as in what fashion they are interpreted. I think a critical piece to the increasing use of breast MRI is that of the need to have available a means to biopsy some worrisome cases with MR-guidance. It is important for women to be aware that even though some facilities might offer breast MRI, it should not be assumed that MRI-guided biopsy is available at that same facility.

Mal: From Mal: I am 55 years old and have two maternal aunts that have had breast cancer, my mom being the only sister left at age 80 who hasn't gotten cancer. Also, I have a paternal aunt who has had both breasts removed because of breast cancer. All three are survivors. I have very dense breasts and get annual mammograms and have been called back twice on numerous occassions to redo but it has always been negative. Am I considered in that high risk group? My PCP and the facility at where I have the mammograms done don't seem too bothered by this history.

Dr. Robyn Birdwell Mal, your family history does not sound like the pattern associated with high risk.

Neel: Is digital mammography any more accurate than traditional mammography with screening dense breasts (i.e., especially in younger women)?

Dr. Robyn Birdwell Neel, the study reporting a large number of women who had both digital and non-digital mammograms reported a 15% increase in cancer detection in women who had dense breasts. This is positive and important information, however should not result in neglecting to get a mammogram if the facility you use does not have digital mammograms. The non-digital mammograms do a good job in cancer detection in many many women.

Meghan: Hi, Dr. Birdwell, and thanks for answering questions! I have what I think is a strong family history of breast cancer. My mother was diagnosed with breast cancer at age 47, had a recurrence which metasticized 7 years later and passed away at age 58. I also have 2 maternal great aunts who died from breast cancer. I have not had genetic testing done, and am wondering whether it would be recommended. Also, at what age would you recommend I start getting mammograms (I am 30) and would I qualify as a high risk woman who should look into MRI screening as well?

Dr. Robyn Birdwell Meghan, you pose a number of important questions. I am copying information below directly from the American Cancer Society.

Dr. Robyn Birdwell Although a high proportion of women in the general population have at least one relative with breast cancer, for the majority of these women, this “family history” either does not increase risk at all (that is, the cancer was sporadic and not related to a genetic risk) or is associated with, at most, a doubling of lifetime risk. Only one to two percent of women have a family history suggestive of the inheritance of a gene defect conferring up to an 80 percent lifetime risk of breast cancer.

Dr. Robyn Birdwell The benefits and risks of genetic testing are beyond the scope of the guideline but are reviewed in the American Society of Clinical Oncology (ASCO) policy statement update on genetic testing for cancer susceptibility. The American Cancer Society, ASCO, and other organizations can provide guidance about which women might benefit from genetic testing. Women who are considering genetic testing should talk to a genetic counselor or a health provider trained in medical genetics. It is not necessary to undergo genetic testing in order to be considered at increased risk for breast cancer and a candidate for MRI screening.

Dr. Robyn Birdwell Genetic testing for a BRCA1 or BRCA2 mutation is generally offered to adult members of families with a known BRCA mutation, or to women with at least a 10 percent likelihood of carrying such a mutation, based on either validated family history criteria or a standard risk assessment model. If a woman from a family in which a BRCA mutation has been previously identified does not have that mutation, one can generally safely conclude that her breast cancer risk is no higher than it would have been if she did not have a family history of breast cancer.

rugbymom: I don't understand this. I have a personal history (twice), and the first one was not picked up by mammography because of "dense breasts". So my daughter would be in the group recommended to get MRIs, but I wouldn't? I'm also wondering if that means that insurances and government programs (Medicare/Medicaid) won't pay for MRIs for those of us worried about a 2d or 3d recurrence.

Dr. Robyn Birdwell Interesting issues. The field of breast MRi is evolving and efforts such as those of the American Cancer Society to help define some populations of women who might be particularly benefited by its use are important. However, in my practice there are many cases of women with histories such as yours and so I would suggest that you share your concerns with your physician.

Shadow: I was diagnosed with lobular carcinoma (invasive) 18 years ago. The cancer did not show on three mammograms taken within the previous 14 months of my diagnosis. Would it be prudent for me to get an MRI on my remaining breast in addition to, or instead of, my annual mammogram? (I just logged on, sorry if this has been covered.)

Dr. Robyn Birdwell Shadow, we know that lobular carcinoma can be difficult to feel on physical examination, hard to see on mammography and has been reported as even difficult to detect on breast MRI. I think you should speak with your physician about the possiblity of a breast MRI.

Dr. Robyn Birdwell My apologies. This will have to be my last response. Thank you all for participating. I found this very educational. I hope you found it informative. Remember please get annual mammograms if you are over 40 and don't hesitate to pose any pressing questions you have concerning your breast health to your personal physician. Thank you and have a wonderful day.

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