Friday, October 29, 2010

To Screen or not to Screen

Should women under fifty get a screening mammogram? As a mammographer and breast cancer survivor diagnosed by a screening mammogram at age 47, I say YES!

But according to the U.S. Preventive Services Task Force (USPSTF,) a government-appointed, independent panel of medical professionals whose recommendations inform decisions by health professionals and insurers claims:

The benefits of detection and early intervention  by screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for women aged 40 to 49 years. The strongest evidence for the greatest benefit is among women aged 60 to 69 years. They also say that  for biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small and they do not recommend it.
But the truth is, every year 1-8 women will develop breast cancer. The statistics I learned while studying for my mammography boards were that 70% of all breast cancers are in women over age 50. One percent of all breast cancers are found in men. So, that leaves 29% of women younger than 50 who will develop breast cancer.

And that brings me to today's guest, Dr. Lori Gillespie, a Radiation Oncologist and my friend.When I was first diagnosed with breast cancer, Lori was one of the first people I contacted for advice. And words alone can never express just how helpful and encouraging she was.

Lori, as a medical doctor and radiation oncologist, what is your opinion of the new USPSTF guidelines for mammography?

Most organizations are ignoring the USPSTF guidelines and absolutely urge women to have a screening mammogram before age 50.   The American Cancer Society (ACS), the American College of Radiology (ACR) and the American College of Surgeons recommends annual screening mammograms starting at age 40.  Also high risk patients should have a breast MRI.  High risk means BRCA1 or BRCA2 mutation, or a first degree relative with these mutations.  Prior chest irradiation between ages 10 to 30 such as with a mantle field for Hodgkin’s lymphoma is considered high risk.  Also certain genetic diseases such as Li Fraumeni, Cowden or Bannayan-Riley Ruvalcaba syndromes are high risk.

Okay, now a tough question and one you helped me answer. Mastectomy and chemo vs. lumpectomy and radiation or lumpectomy, radiation, and chemo. I had a lumpectomy, radiation, and chemo because I had DCIS and an invasive carcinoma. I know there are as many different types of beast cancer as their are types of breasts. I know you're not a breast surgeon, but you do help women make informed choices. So, what are some of the criteria you use when giving woman choices between lumpectomy and radiation or mastectomy. And do you ever recommend a mastectomy and radiation?

The original NSABP B-06 data compared mastectomy VS lumpectomy alone VS lumpectomy plus radiation therapy (XRT).  The lumpectomy alone patients had an in breast failure rate three times higher than the lumpectomy plus XRT patients.
(41% VS 12%)    This is why adding XRT to lumpectomy is standard of care today.
The National Cancer Care Network (NCCN) recommends post mastectomy radiation when the tumor is > 5 cm in size, > 4 lymph nodes are involved and when surgical margins are < 1 mm.   More recent data advises strong consideration for post op XRT when any lymph nodes are involved.

What are your feelings on breast reconstruction? Is there an age you believe is too old? Too young? Too soon after diagnosis? And what types of reconstruction are best? TRAM flap? Implants?

There is no age limit regarding lumpectomy VS mastectomy.   Some young women want a mastectomy.  Some older ladies want to save their breast at all costs.  It is really patient preference.  As far as the timing of reconstruction, some patients want to go to sleep with a breast and wake up with a breast after their mastectomy.  As a Radiation Oncologist, I like to have the final pathology report back before breast reconstruction.  Whether the patient has a permanent implant OR tissue expander VS TRAM flap OR latissimus dorsi reconstruction, the decision is completely between the patient and their plastic surgeon. Negative margins are always preferable.  It’s more difficult to adequately irradiate a reconstructed breast sitting on top of a positive margin.  I also warn women that irradiation of a permanent implant has about a 30% contracture rate over time, meaning the implant can become rock-hard and ultimately need to be changed.  When patients come for chest wall irradiation after mastectomy alone, I ask them to wait at least 6 months after completion of XRT before having a reconstruction.  As far as follow-up is concerned, it is much easier to clinically detect a local recurrence on the chest wall as opposed to in a reconstructed breast

Thanks so much for taking the time away from your busy schedule to guest on my blog.


  1. Extremely informative. My mother detected a large lump in her breast and ask for biopsy. Since it was malignant and big, she had an immediate mastectomy, but refused radiation and chemo, saying she was too old at eighty for that suffering. She never had cancer again. But she felt disformed and wore special bra with filling in the right part.

    For five years, I was told that my mammogram done every year, showed suspicious fibrous tissue. I was regularly asked to do another mammogram and ultra sound after six months. This lasted five years. Then suddenly I was told the insurance will not paid for more than one mammogram every TWO years. Two of my aunts also died of cancer. Should I insist to have the mammogram every year again? How?

  2. Mona,
    I'd insist on a mammogram. And your doctor should order it as a diagnostic study. Tell your doctor you feel a lump. Insurance has to pay for it then because it is no longer considered a screening study. And you have a strong family history and prior suspicious mammograms. It would be justified. And in the USA, insurance can no longer charge a co-pay or deductible for screening studies. However, I do not believe there's a mandate that says they have to pay every year rather than every other. But, if it's diagnostic, then it's no longer screening so your insurance should still pay.
    PS- glad your mom survived without the chemo and radiation. And for the record, chemo wasn't nearly as bad as I thought it would be. And the worst thing about radiation was having to go everyday! And there was that one really bad burn...but Silvadene cream is a miracle drug!

  3. Your blog is a fantastic source of GOOD, HELPFUL information. I'm a believer that one of the best ways we can battle the menace of cancer is by educating ourselves and actively participating in the treatment and exams required. I had my mammogram today. I'm 49yrs. old and have been having them every two years since I was 30. The reason? I've got such fibrous breast tissue that self-exams are very "iffy" even when performed by my Gynocologist. Some years I also require follow-up ultra-sounds just to make certain everything's clear. I'm blessed with the fact that I've never had cancer and still don't but both my doctor and I feel the regular mammo's are a must. Even tho' I'm ONLY 49.

  4. Maeve, glad you got that mammogram today. And I hope you keep getting them until you're too old to care what kills you. lol!