Mammograms can detect breast cancer years before they become palpable and large clinical studies have demonstrated their live saving value. There are two types of mammography: Screening and Diagnostic.
Screening mammograms are for asymptomatic women. Guidelines recommend that women start getting mammograms at age 40 and repeat them on a yearly basis. A woman who has a first degree relative (mother, sister or daughter) who has been diagnosed with breast cancer before the age of 50 years, should start screening when she is 10 years younger than her relative was at the age of diagnosis (i.e. if your mother was diagnosed at 45 years you should start at 35 years). Women with multiple family members who have been diagnosed with breast cancer and women with previous high risk biopsies should consult their physician for advice as to when to start screening mammography. See: High Risk Screening, Family History, Genetic Testing, and High Risk Biopsies.
Diagnostic mammograms are ordered for women with breast symptoms such as a suspected lump. Diagnostic mammograms include special additional images of the breast to get better information about the area of concern. A diagnostic mammogram should, in most cases, include a diagnostic ultrasound exam, especially if there is a suspected breast lump. Results of the diagnostic study should be explained in detail to the patient. If an abnormality is found appropriate action should be taken. If the examination is negative, appropriate follow-up must be outlined which should include a1-3 month follow-up medical examination based on the merits of the clinical situation. Recommending a one-routine follow-up for new focal breast symptoms is not recommended. Making the Diagnosis, Cyst Aspiration, Core Needle Biopsy, Open Biopsy.
When Does a Woman Under 40 Years Need a Mammogram?
• Women who have a first degree relative (mother, sister or daughter) who developed a breast cancer before the age of 50 years. Women with this Family History should start having yearly screening mammograms 10 years earlier than the age that their relative was diagnosed. For example, if a woman’s mother or sister was diagnosed at age 45, the women should start yearly screening at 35 years of age.
• Women under 40 who have a new breast problem: Making the Diagnosis
• Women with a previous High Risk Biopsies
• Any situation in which the patient and her doctor believe it would be in her best interest to do so.
Guidelines for Women Under 30 Years
Women under the age of 30 should avoid mammography when possible. Breast cancer is very rare in this age group, and breast tissue in the under 30 year age group is more sensitive to radiation damage. In general, the first diagnostic test we use for women under 30 is the Ultrasound. This test is safe and accurate, and in most cases is all we need for a diagnosis. In unusual circumstances, when cancer is suspected, a diagnostic mammogram is appropriate. The decision for a mammogram in the under 30 age group is best made by a physician who is knowledgeable about conditions of the breast.
High Risk Screening
Although all women are at risk for developing breast cancer, some women are considered to be at high risk. There are two major risk factors that influence life time risk of developing breast cancer and they are family history and history of a high risk biopsy. Women who have documented risk factors should be followed by a health care provider with a special interest in high risk patients when possible.
Every woman is at risk for breast cancer, and the risk increases as a women ages. Some women, however, are at an increased risk of breast cancer because of a strong family history, or a previous high-risk biopsy. Although women are generally aware of the increased risk of breast cancer associated with a positive family history, most are surprised when they learn that 75% of women who get breast cancer have no family history. This observation dispels the commonly held myth: “I don’t have to worry about breast cancer since it does not run in my family.” The bottom line is that all women are at risk for breast cancer, even those women with no family history of breast cancer. Women with a prevalent family history of breast or ovarian cancer are at a relatively higher risk of developing breast cancer as compared to women with no family history. There are multiple factors that influence this increase in risk, such as having one or more first degree relatives (mother, sister, or daughter) with breast cancer. The risk is further increased if the first degree relatives developed a pre-menopausal or a bilateral (both breasts) breast cancer. Other high risk factors include a family history of ovarian cancer, a male relative diagnosed with breast cancer, multiple generations of women diagnosed with breast cancer, or Ashkenazi Jewish and/or Eastern European heritage. Patients with strong family histories should consider the option of being followed at a medical center that has a special interest in high risk women. These centers (can be found on the web) usually provide expert counseling on risk evaluation, genetic evaluation, programs for following high risk patients and various risk reduction strategies. It is very common for women who believe that they are at high risk because of family history to find out that their personal risk is only slight elevated. In fact, most women with a family history of breast cancer tend to overestimate their risk of getting breast cancer.
Women with very strong family histories for breast cancer such as those with first degree relatives (mother, sister, and daughter) with early onset breast cancer (i.e. before the age of 50 years are advised to consider gene testing. Gene testing is usually performed after genetic councilor determines that the risk of having a mutation is sufficient to justify the cost of the test (approximately $2,500; usually paid by insurance if it meets their criteria). The decision to do genetic testing should not be made until the patient and her families have a clear understanding the benefits and limitations of the procedure. Fortunately, the majority of women who are tested for BRCA1/2 are negative for the mutation. These women are however, still considered to be at increased risk and should undergo continued careful follow-up. For those women who test positive, intensive counseling should be provided by experts in both the field of medical and surgical oncology. These women have an 80% lifetime risk of developing breast cancer, and a markedly increased risk of developing ovarian cancer. Multiple options are available to these gene positive patients. They can undergo careful follow-up with yearly imaging that includes diagnostic mammograms often including ultra-sound exam and yearly breast MRI’s. They can under go risk reduction therapy with estrogen blocking drugs or they can undergo prophylactic mastectomies with or without immediate reconstruction. Gene positive women should also have prophylactic removal of the ovaries which is usually delayed until completion of child bearing.
High Risk Biopsies
Most breast biopsies fall into the obvious categories of benign or malignant. There is, however, a sub-group of breast biopsies that contain cells that, when viewed under the microscope, appear abnormal but are not frankly malignant. If these cells meet certain criteria set forth by the pathologist, they are labeled as “atypical”. The diagnosis of atypia is associated with a significantly increased risk for the future development of breast cancer. There are two common forms of atypia: atypical ductal hyperplasia and atypical lobular hyperplasia. Both are associated with a similar increase in breast cancer risk, and some biopsies contain both types of atypia. This risk is amplified if there is a strong family history of breast cancer. There is also a long list of other pathologic conditions found in breast biopsies that are associated with an increased risk, such as radial scars, multiple papillomatosis, and lobular carcinoma in-situ (LCIS). It is important that a woman has a clear understanding of the exact nature of her breast biopsy. If there is any question of a high risk condition, it is essential that a patient be given a clear explanation of the risks as well as an appropriate plan of action. Women who have unresolved questions about the nature of their breast biopsy should consider having a second opinion.
Making the Diagnosis
There are two main goals when it comes to making an accurate tissue diagnosis of either breast lumps or abnormal spots on the mammogram. The first goal is to distinguish between benign tissue and malignant tissue. The second goal is to make certain that if a lump proves to be a cancer, the biopsy should have been done properly in order to facilitate future treatment planning. The important take home message is that for any lump or spot on the mammogram in which cancer is even a remote possibility, open surgical biopsy should be avoided. The diagnosis should first be made with a needle core biopsy. If the lump proves to be benign, open surgery can often be avoided. More importantly, if the lump proves to be cancer, a thorough evaluation can be performed to ensure that the appropriate cancer operation in the future. There are some cases in which the diagnosis is almost certainly benign and the patient is anxious to have the lump removed. An example could be a young woman with a clinically benign mass such as a fibroadenoma. In such a case, it would be reasonable to remove the mass with an open excisional biopsy, and this avoids the cost and inconvenience of a two-step procedure.
Breast cysts are benign (not cancer) fluid filled structures that are commonly found in the breast. For the most part they can be ignored. If however, they form a lump, or a distortion of the mammogram or cause focal pain, consideration should be given for needles aspiration. In this procedure, a needle is placed into the cysts (after local anesthetic is placed in the skin) and the fluid is drained. The fluid is usually discarded, but if it is bloody or if the physician as other reasons for concern, the fluid can be sent for cytology (microscopic evaluation of the cells). Surgical removal of cysts is rarely required. The common indications for surgical removal include recurrent cyst formation at a given location or characterizes of the cyst such that the treating physician judges to be at increased risk for malignancy. In most of these situations the cyst contents can be removed with large core needle biopsy.
Fine Needle Aspiration
A fine needle aspiration is simple office procedure that takes only a few minutes. A small gauge needle is placed in a breast lump/problem area, and cells from are extracted and placed on slide. The slide is sent directly to the pathologist, and a reading is often available in less than 2 hours. This simple and well-tolerated procedure can be quite effective in clarifying a clinical situation, and can thus expedite the treatment process. The problem with this procedure is that it takes expert cytologists to interpret the results, and these experts are not available in many hospitals. Also, in about 30% of the cases, a definitive diagnosis cannot be made, and thus a core biopsy is required (see next section). We use the FNA in select cases in which we anticipate it will accelerate the diagnostic process.
Core Needle Biopsy
Rather than just extracting cells (as with the fine needle aspiration), the core biopsy takes a sample of tissue. This small sample of tissue is usually sufficient to provide a specific tissue diagnosis. In other words, this procedure not only distinguishes between benign and malignant findings (as does the fine needle aspiration), it also usually defines a specific pathologic condition. For example, in the case of a benign condition, it might diagnose a fibroadenoma, in which case nothing more needs to be done. If the core biopsy states that the lesion of concern is malignant, it will typically differentiate between invasive or non-invasive cancer. It will also give information on the type of cancer present (i.e. ductal vs. lobular and high grade vs. low grade; see links to understanding your path report). In most cases, it will also allow for measurement of hormone receptors and other protein markers. Core needle biopsies can be used to diagnose large tumors without any form of guidance (i.e. free-hand, in which the surgeon does inserts the needle by feeling where the tumor is). However in most cases, it is done with either ultrasound or x-ray guidance.
Ultra-Sound Guided Core Needle Biopsies
If a lesion can be seen on ultrasound examination, we prefer to do an ultrasound guided core biopsy. This procedure is well-tolerated and is done with the patient lying comfortably on her back. A small titanium tissue marker is placed in the area of biopsy to show us where the biopsy was taken. The procedure usually takes only 10-15 minutes and can be done under local anesthetic in the doctor’s office. Some post-biopsy bruising and tenderness can occur.
Stereo-Tactic Core Needle Biopsies
If a spot in question (usually calcifications) can only be seen on the mammogram, a stereotactic core biopsy is the procedure of choice (see diagram). In this procedure, the patient lies on her stomach and her breast protrudes though an opening on the table. The biopsy device is below the table. A core needle is directed to within a millimeter of the area. An aperture in the needle opens up and the tissue in question is sucked into the needle and removed. A small titanium tissue marker is placed in the area of biopsy, just in case all of the tissue and/or calcifications are removed and the lesion later proves to be malignant. The location of the tissue marker guides the treatment team to the area of the previously core biopsy, so that the entire malignancy can be removed. Bleeding is the most common complication of this procedure. It is important that patients stop any medicines that can increase bleeding time (such as aspirin or other NSAIDs, coumadin, Plavix, etc.) at least 10 days in advance of the procedure. After the procedure, the patient is wrapped in a pressure dressing, which minimizes bruising. The procedure usually takes less than an hour.
An open surgical biopsy is a procedure done by a surgeon in which the entire lump or spot on the mammogram is removed. If the lump is palpable (i.e. the surgeon can feel it) and is though mostly likely to be benign, the surgeon will usually make the most cosmetic incision possible (usually at the edge of the areola or in the armpit). The entire lump is removed. I there is concern about malignancy, it is important that the surgeon orient the lump before sending it to pathology (marker are placed on the specimen so that the pathologist can determine where the cancer comes closest to the margin if it turns out to be cancer). In a situation where there is only a spot on the mammogram and there is not palpable lump, the radiologist places a small wire into the spot on the mammogram. The surgeon can use the wire as a guide to finding the spot. It is essential that the surgeon send the removed tissue back to the radiologists to be re:X-rayed (i.e. specimen radiographed). The specimen should also be orientated so if there is cancer close to the edge, the surgeon can be instructed as to what area must be removed at a future surgery to ensure complete removal of the cancer.