Get Your Pink On!

It's October. That time of year when I once again remind ladies to 

As a registered x-ray technologist certified in mammography and a breast cancer survivor, I can't stress enough the importance of an annual screening mammogram. It's one of the few x-ray examinations that can save your life.

I know some women find them painful. Believe me. I hear it all the time. But a mammogram isn't nearly as painful as breast cancer. Trust me on this.

In June 2007, I had my screening mammogram. My friend and sister mammographer, Linda, "squeezed" me in after we'd finished our patients for the day. This was back when our hospital still had film screen, so the x-rays dropped from a processor. I pulled the curtain in the tech area and was standing in front of the view box in my pink floral cape when Linda began hanging the films. The Left CC (cranial-caudal--the film taken from the top of the breast) fell from the processor first. It looked fine. No different from the year before. Then the Right CC fell out. It looked--different from the mammogram I'd had 18 months earlier.

Yes, I was 6 months late getting my mammogram, but I had no pain, no lumps, no family history, and no reason to be concerned. Until I saw that Right CC. There, next to my chest wall on the inside of my right breast was a star-shaped lesion with a large calcification in the center. That same lesion was evident on the RMLO (right medial-lateral obligque image--the one taken from the side.) But it was the Friday before Father's Day and the radiologist had already gone home. So, I had all weekend to worry about that lesion. And suddenly, I had a BIG reason for concern. I'm not a doctor or radiologist, but I'd seen enough mammograms and enough cancers in my time to know that lesion didn't look good.

On Monday, the radiologist ordered additional images and an ultrasound. I had those procedures the following Friday. And the Friday after that, I had a biopsy. The results came back July 3, 2007. I had breast cancer. Stage 1, but on the cusp of being Stage 2 because the margins weren't clean and the cancer had a high proliferation rate...which meant is was aggressive and growing fast. I had DCIS (Ductal Carcinoma Insitu- an early cancer that is still contained in the ducts) and an invasive ductal carcinoma--a cancer in the duct that has spread to the surrounding tissue. And it was triple negative.


Triple-negative breast cancer doesn't express the genes for estrogen receptor (ER), progesterone receptor (PR) or Her2/neu. Prognosis for Triple Negative breast cancer is the same for other breast cancers at the same stage, but more aggressive treatment is require to achieve that prognosis.

Some types of triple negative breast cancer are known to be more aggressive with poor prognosis, while other types have a prognosis similar to or better than hormone receptor positive breast cancers. Studies of  triple negative breast cancers suggest that with optimal treatment, 20 year survival rates are close to those of hormone positive cancer.http://en.wikipedia.org/wiki/Triple-negative_breast_cancer

Although my cancer was Stage 1, I had a lumpectomy where more tissue was removed from the breast to ensure "clean" margins and I had to have a lymph node biopsy to prove the cancer hadn't spread beyond the breast. Four nodes were removed and all four were negative. But because of my triple negative status, I had to have chemo and radiation. I had the chemo first.--two chemo drugs, Adriamycin and Cytoxan once every other week for eight weeks. Then after an MRI to prove there were no more lesions or DCIS, I was given the choice of a mastectomy and radiation, or radiation treatments five days a week for 6 weeks.

I chose to keep my breast, which meant mammograms every six months for 3 years and yearly MRI's for three. To this day, there are times when I second guess my decision to keep my breast. But, had I chosen a mastectomy, I'm sure I would have second-guessed that decision as well.

Triple negative breast cancer has a different recurrence rate and pattern than hormone-positive breast cancers. The risk of recurrence is much higher for the first 3-5 years but drops sharply and substantially below that of hormone-positive breast cancers after that.

On December 12 of this year, it will be five years since my last radiation treatment. I will officially reach the five year mark and my personal risk of a recurrence will drop to that of someone with hormone positive breast cancer. Which isn't to say that I'm no longer at risk, but by God, I still think I have a reason to celebrate!

So the next time you hear a woman complaining about how much a mammogram hurts, remind her that a few seconds of discomfort could save her life.

If she claims she doesn't need a mammogram because she isn't having any problems, remind her that most breast cancers are silent and painless. By the time a woman feels a lump, she already has an active disease.

Remind her that if she has extremely dense breast, a mammogram can miss a lobular carcinoma hiding within the glandular tissue. So, if she feels a lump and the mammogram is normal, she needs an ultrasound and possibly a biopsy.

If she claims she doesn't have a family history of breast cancer, remind her that 70% of all NEW breast cancers are in women with no family history.

Hey, someone in the family has to be the first to screw up the gene pool. In my family, I was that person.

Although breast cancer is rare in women under 40 and the risk increases with age, no woman who has breasts is immune. That includes trans-gendered women.

Are you at risk? Check out the breast cancer assessment tool.
http://www.cancer.gov/bcrisktool/Default.aspx


And for more information on breast cancer, please visit http://www.cancer.org/Cancer/BreastCancer/index?ssSourceSiteId=null

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 http://www.thebreastcancersite.com/clickToGive/mammogramguidelines.faces?siteId=2#USPSTF 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?

Lori-

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.

Lilly-
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?

Lori-

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.

Lilly-
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?

Lori-

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. 

Lilly-

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