1. Dr. Julia Flukinger Breast Radiologist, Director Breast MRI, Advanced Radiology jflukrad@gmail.com May 21, 2106

2.  Breast density on mammography  Tomosynthesis (3D mammography)  What does cancer look like?  current recommendations for screening  Should I undergo supplemental screening tests?  Screening recall 11 cancer!

3.  Breasts are composed of glandular, fibrous supportive tissue, fat and ductal structures.

4.  Defined by mammogram  Glandular + fibrous supportive tissues = dense  Individuals have different proportions of fat and fibroglandular tissues, leading to different appearances on mammography.  We assign 1 of 4 density categories to each patient’s mammogram:  Almost entirely fat  Scattered fibroglandular elements  Heterogeneously dense  Extremely dense

6.  Masking  The density of cancer is similar to fibroglandular tissue  The cancer may not be visible because it blends in with the background  Higher risk of cancer in dense breasts?  Most data shows no significant difference  Maryland is one of 24 states which have enacted legislation requiring patients be informed of their breast density  Patients are told they are “dense” or “not dense”

7.  Accuracy of density categorization  Not a precise measurement  Gives an idea of what the picture looks like  Based on the radiologist’s judgement  Can change over time in an individual  Is this law a good idea?  My opinion: it causes more confusion for patients  There are no official recommendations about what to do with the information

11. 3D mammogram You can choose to have this for your regular screening exam instead of 2D. The radiologist may use this during your diagnostic exam.

15. Digital Tomosynthesis

16.  Strengths  Slightly increased sensitivity for subtle cancers  Slightly decreased callback rate  Same radiation amount as 2D digital mammography *  Most helpful in dense and extremely dense breasts  Weaknesses  Limited insurance coverage; may need to pay out of pocket  Limited number of machines; may need to wait  Bad for calcifications  Take longer to interpret  Learning curve for radiologists  Most cancers can be seen on 2D *as of January 2016, true in our practice but not for many private practices at this time.

17.  In the 1980’s, mammography was shown to detect breast cancer before it could be felt, leading to earlier treatment and reduced number of deaths.  One of the best studied tests  Proven to reduce death from breast cancer  All women 40 and over should have yearly screening mammograms.

19.  Data shows most lives saved when screening is done each year starting at age 40  6500 extra lives lost if the recommendations are followed  30% of cancers would be missed if screening is done every other year  “risks” listed are not true risks.  “anxiety” is not as important as finding a cancer  No breast cancer experts included in decision making  Experts consider these recommendations “disastrous”  USPSTF may cause loss of insurance coverage

20.  Theoretical risk based on experience from nuclear bombs and accidents  No cancer has ever been documented as caused by mammography, no scientific evidence suggests mammography causes breast cancer  Very little scatter from mammography compared to other diagnostic radiology tests  No thyroid shield needed  Gonads are shielded in younger patients but this is almost symbolic

21.  Mammography 0.4 mSV  Tiny dose with very little scatter to other body parts  Mammography does not cause cancer!!

22.  Images heat given off by breasts  In theory, cancer should give off more heat  The technology has been studied and does not detect breast cancer effectively  It was abandoned by the scientifically-driven medical community  Still offered by some “holistic doctors”  Plays on irrational fears of radiation

24.  Not a substitute for mammography; must do both  Shown to detect a few more cancers than mammography alone in dense, high risk patients  …but there were many false positives  Additional follow-ups of nodules  Biopsies which showed no cancer  Images inconsistency one year to next  In contrast to mammography which is more consistent  No picture record of whole breast  Very tedious  Often not covered by insurance

27.  Performed in addition to mammography each year  Most sensitive imaging test for breast cancer  Sometimes “opens a can of worms,” leading to more biopsies and followups  Very expensive, not covered for most patients  Uses intravenous contrast agent  Currently used to screen very high risk patients  BRCA 1 : 80% lifetime risk  BRCA 2 : 40% lifetime risk  Others  An abbreviated screening protocol is being studied which is faster and less expensive.

31. 2010 2014

32.  This is part of the normal process of looking for breast cancer  Most “callbacks” do NOT lead to a cancer diagnosis  When you come back you will have a “diagnostic” exam, tailored by the radiologist to your finding  The radiologist will be there to interpret the images, decide if any additional views or ultrasound is needed, and provide same-day results  The radiologist may or may not come speak with you, but you can ask to speak to him or her if you have more questions about your finding.

33. 2015 2014

36. 19 need a biopsy 13 benign 1000 Screening Mammograms 100 Callbacks (BIRADS 0) 56 Resolved (normal or benign) 25 need followup (probably benign) 6

37.  Get a yearly mammogram starting at age 40. The ACS and USPSTF recommendations are wrong.  Mammography saves lives—scientifically proven!  Recall from screening mammogram cancer diagnosis!  Radiation from mammography is insignificant and does not cause cancer.  If you are at very high risk of breast cancer, you should get a yearly mammogram + breast MRI.  If you might be at high risk, ask your doctor about risk assessment or genetic counseling, to determine if you should get MRI + mammo.

38.  Dense breasts are normal  Dense tissue can cause mammography to be a little less sensitive for breast cancer.  For many “dense” women, it does not significantly limit the exam  If your breasts are “dense” and you would like to do something additional to screen for breast cancer, then tomosynthesis (3D mammography) is the best choice over ultrasound and MRI.

39.  www.mammographysaveslives.org  www.breastdensity.info www.breastdensity.info  www.sbi-online.org www.sbi-online.org