By Bonnie Rush, RT(R)(M)(QM)
A colleague recently sent me an online response to an OregonLive article, “Let scientists bicker over breast cancer, but don’t keep putting your health last” by Susan Nielsen. Commenter Cynthia K stated: “I certainly hope we do move away from the one size fits all recommendations. I was always in a very high-risk category due to family history, breast density, no children, etc, but no provider suggested anything other than mammograms even when I asked several times. After I found a lump a few months ago that turned out to be breast cancer definitely needing surgery and treatment, I’ve lost track of the doctors who’ve told me that my mammograms look something like a blizzard. Maybe some women don’t need mammograms, maybe some do, and maybe some need something more or different. I’ve been very confused over the past few months about why it appears so difficult for patients to be evaluated as individuals.”1
How ironic that Cynthia should point out our need to revamp our current screening to an individualized future – a debate that’s currently going on within the medical community. We should have found her cancer earlier given her dense tissue along with her other personal risk factors. We should have moved her into an individualized screening algorithm, perhaps adding breast MRI due to her family history. Now her future is impacted adversely.
Columnist Susan Nielsen iterated a scary fact: “it’s all too easy to perceive a lack of scientific consensus as a lack of credible information, and then regard all medical advice with unhealthy suspicion.” She stated that “women might decide to do nothing, and skip cancer screening altogether, in the face of dissonant medical advice.” 1
It’s time to concede that mammography has an inherent weakness when it comes to dense tissue – even tomography cannot overcome the attenuation factor that will not allow visualization of a cancer hidden in dense tissue. It is the major cause of false negatives, and false negatives kill. If we do not get consensus on this, Susan’s words may ring true.
At the 2012 RSNA Annual Meeting, Rachel Brem, MD, from George Washington University stated, “In our study, automated whole breast ultrasound found clinically significant cancers that would undoubtedly present as interval cancers, or at the next screening as larger or node-positive disease.”2 At the 2013 RSNA Annual Meeting, Wendie Berg, MD, principal investigator of the ACRIN 6666, the definitive study that proved the early detection value of whole breast ultrasound, observed, “It’s time to level the playing field for women with dense breasts.”3
We need to stem the confusion and restructure our screening protocols to be technologically appropriate, using our screening resources where they give us the biggest bang for the medical buck. Mammography every two years will still provide adequate protection against advanced cancers for those at low risk. But for those with dense breasts, adding a screening ultrasound yearly will reduce the dose absorption by the dense tissue, letting screening ultrasound find the hidden killers. Those at highest risk should have an MRI added to their yearly mammogram and/or a whole breast ultrasound if they do not want an MRI.
But unfortunately, we may be losing the opportunity to direct screening algorithms. Insurance carriers are taking advantage of the controversy over the value of mammography, and rumor has it they may revamp screening to once every other year. Already fewer carriers are covering MRI for high-risk women. What other decisions will they make before we come to a consensus?
It’s time for us to establish a new paradigm in breast screening – and level the playing field – before it is too late.
1. Neilsen S. Let scientists bicker over breast cancer, but don’t keep putting your health last. OregonLive. February 21, 2014. Available at: http://www.oregonlive.com/news/oregonian/susan_nielsen/index.ssf/2014/02/susan_nielsen_let_scientists_b.html. Accessed March 27, 2014.
2. Madden Yee K. Breast US could be option for primary cancer screening. AuntMinnie.com. November 25, 2012. Available at: https://www.auntminnie.com/index.aspx?sec=rca&sub=rsna_2012&pag=dis&itemId=101626. Accessed March 27, 2014.
3. Berg W PhD. Special Interest Session: Breast Density: Risk Assessment, Communication, and Approaches to Supplemental Imaging. Presented at: 2013 RSNA Annual Meeting; December 2013; Chicago, IL.