By Philip Croxford
As the patient demand for more personalized care increases and mammography is recognized as no longer the one-size-fits-all solution for breast imaging, many providers find themselves weighing the options regarding secondary breast imaging modalities.
To make an informed decision, there are four important questions a provider must consider: whether they’re thinking specifically about their patients with dense breast tissue; if they’ve done enough to screen for breast cancer; have they provided adequate assurance that cancer is diagnosed; and if they have chosen the most preferred modality for the patient.
Question 1: Are your patients with dense breast tissue treated at your facility receiving adequate care?
In the U.S., approximately 50 percent of women are reported to have dense breast tissue and are unaware of the implications dense breast tissue has on increasing their lifetime risk of breast cancer.
It’s important for providers to diagnose their patients’ breast density and recommend the appropriate primary and secondary screening requirements. Dense breast tissue and cancer both appear white on mammograms (both 2-D and 3-D/tomosynthesis), making it difficult to distinguish between the two. Trying to find a cancerous lesion in dense breast tissue on a mammogram is like trying to find a snowflake in a snowstorm. Not properly identifying the cancer can, in turn, lead to both false positives (overdiagnosis) and false negatives (missed diagnosis), ultimately resulting in delayed diagnoses. It’s no secret that early diagnosis is critical to improving the odds of successfully combating the disease. Providing a secondary screening protocol for women with dense breast tissue is essential to be certain that nothing has been missed.
Question 2: Pre-Cancer Screenings: Do your patients leave their breast cancer screening confident that nothing has been missed?
Facilities should offer patients with dense breast tissue secondary screenings to ensure cancerous lesions hidden by dense tissue are not going undiagnosed. While more than half of U.S. women have dense breast tissue, for some subgroups that percentage is higher. For example, 65 to 70 percent of women of Asian descent have dense breasts. Without accounting for breast density, mammography screenings can be largely ineffective for this patient group. In certain circumstances, more sensitive modalities can be used for secondary screening, such as in high-risk and dense breast tissue patients. One such modality is molecular breast imaging (MBI) that has been proven to deliver high sensitivity and even higher specificity than 3-D mammography (tomosynthesis), ultrasound and even MRI. The modality has a convenient user protocol, and it’s safe and efficient in terms of procedural and read time.
A breakthrough retrospective clinical study published in the American Journal of Roentgenology confirmed MBI’s high incremental cancer detection rate. MBI was able to detect 7.7 cancers per 1,000 women screened that were not found using mammography. Approximately 85 percent of these cancers were invasive and 82 percent of the invasive cancers were also node negative, meaning they were detected at an earlier stage and presented a better prognosis.
This complemented an earlier Mayo Clinic prospective study in the AJR in February 2015. While mammograms may fail to detect breast tumors due to tissue density, MBI highlights metabolic activity in these tumors despite breast density, leading to an earlier diagnosis.
Question 3: Pre- and Post-Surgical Screenings: Are you minimizing your patients’ odds of requiring multiple breast surgeries or experiencing a recurrence of the disease following a surgery?
MBI can be used for pre-surgical planning as well as post-surgical follow-ups and monitoring, particularly in women who have dense breast tissue. Anatomical diagnostic tools cannot highlight cancer or metabolic disease, yielding high false negatives. For a patient with a known cancer, the use of MBI ensures a more complete diagnosis of the disease scope. This includes cases where MBI identified more extensive disease, changing the surgical approach and potentially the clinical outcomes. MBI can be utilized to screen for cancer in women post-lumpectomy, monitoring for residual or recurrence of disease.
Using MBI on breast cancer patients before and after surgery can help ensure nothing was missed as well as make recurrence of the disease less likely.
Question 4: Overall Breast Care: Are you confident that the secondary screening methods you offer are the most accurate for all types of breast tissue?
Compared to MBI, using ultrasound for secondary screenings for patients with dense breasts or MRI for patients with high risk yield higher false positive rates. To avoid this significant risk, it’s important to ensure that your facility is doing everything in its power to be clinically accurate and combating the 40,000 deaths annually at the hands of breast cancer.
Dense breast notification laws – now in 32 states – are beginning to change this landscape by requiring that providers send women a letter following a mammogram informing them of their dense breast status. But even aside from extending these laws across the country, we have a long way to go. Many of these laws don’t require providers to explain the meaning of dense breast tissue or the risks involved or what to do as a next step, let alone that MBI is an important tool at their disposal.
Until we have adequate notification procedures and adequate patient education about breast density, it’s going to be especially critical for facilities to address all of the above questions to provide their patients with the personalized diagnostic care they need and to offer the opportunity to understand the risks and benefits of early detection through advanced contemporary technologies available.
About the author: Philip Croxford is the president and CEO of Gamma Medica.