Talk with Dr. Lisa Weinstock

The articles appearing now about over diagnosis from mammography are missing some significant points.  Yes, some small cancers will not harm you, but others will metastasize and turn deadly.  We still can’t determine which cancers are harmless without removing them. The price of Watching and Waiting can be catastrophic – .wait too long and the deadly cancer will spread.  Until we know how to recognize harmless cancer, all malignant tumors should be treated as potentially deadly.  More harm is done by leaving a possibly dangerous cancer alone than removing one that may not cause trouble.

Now we are back to the best way to find these cancers before they spread.  A three year study by the American College of Radiology Imaging Network (ACRIN)  found
that adding Ultrasound to mammography detected 34% more invasive breast cancers
than mammography alone.  There were additional false positives and negative biopsies.
But I think it’s worth the additional effort and, yes, anxiety to be sure of getting the invasive cancer.  Also, an invasive cancer removed as early as possible means less treatment.   The patient can be saved from additional surgery and chemotherapy.

What do you think?  Wouldn’t you rather have a negative biopsy than take the chance of
having a cancer metastasize when it could have been removed?

I recently wrote a blog about mortality and morbidity in breast cancer
diagnosis.  The main point was that mammograms find breast cancer earlier and as a result, patients had treatment that was less invasive with fewer complications.  A new study, reported in the March issue of Radiology, confirms this finding.  The author of the study, Judith A. Malmgren, PhD, found in a study of 2,000 women diagnosed with breast cancer in their 40s that “women with mammogram-detected breast cancer require less treatment.  They get more breast-conserving surgery and less chemotherapy.”  The women in the group whose cancer was detected by mammogram also had fewer recurring cancers.  Dr. Malmgren has found that as the rate of early stage mammogram detected cancers went up, the incidence of later-stage cancers has gone down,   “All the US
Preventive Services Task Force (USPSTF) looks at is mortality,” Dr. Malmgren
said.  “But should we not also consider as benefits the reduced need for treatment and less relapse?”  I couldn’t have said it better myself.

What happened to your New Year’s resolution to get in shape?

If it’s still on your ‘to do’ list, start with a DEXA Total Body Fat Composition Analysis.  DEXA is “the gold standard” for analyzing fat percentage and distribution in your body.  It gives the most accurate picture of your body and tells you exactly where the trouble spots are.  If you have a clear idea of where you are and where you have to go, you’ll be more motivated to start.

A DEXA Total Body Fat Comoposistion Analysis is quick and painless.  We have a dedicated software program for Total Body Fat Composition that works with the imaging equipment we use to look for osteoporosis.  You simply lie down on our table and the DEXA camera captures images of your bones and body.  You’ll get a colorful graphic to take home that gives you the results of  your exam.

If you’re a personal trainer, you’ll do your clients a big favor by recommending DEXA Total Body Fat Composition Analysis.  You’ll be able to structure exercise programs that zero in on what your clients want to accomplish and tell them what they have to do to get the body they should have.

Make an appointment for a DEXA Total Body Fat Composition Analysis exam by calling Women’s Digital Imaging of Ridgewood at 201/444-4484.

If you are a resident of New Jersey, you can help pass important health-care legislation.  Bill S792, introduced by Senators Loretta Weinberg and Nia Gill, would require mammogram providers to let patients know when they have dense breast tissue and require insurers to cover additional Ultrasound screening.  Please contact
your Senator and ask him or her to vote for this bill.  Our legislators listen.  If they see there is a groundswell of support for this legislation they will consider it more favorably.  If the silence is deafening, they may be less interested in giving the bill their support.

Why should you care?  Dense breast tissue has been identified as an important cancer risk.  Women with dense tissue are 4 to 6X more likely to get breast cancer.  Mammograms are not as sensitive in women with dense tissue.   With mammography images, tissue is white and tumors are white.  It can be impossible to differentiate.   So if you have dense tissue and you are told that your mammogram is normal, you may be getting a false sense of security.

On Ultrasound screening, tissue is white but tumors are gray so they can be seen more clearly.  I have several patients whose cancer was not visible on their mammograms but was identified with Ultrasound.  In some cases, the patients came to me from other practices and they were not diagnosed as early as they could have been.

Currently, most mammogram providers send out one report to referring physicians and a diffferent one to patients.  While they report breast density to physicians, breast density is not reported to patients.  In too many cases, the referring physician does not tell patients that they have dense breast tissue.  I give my patients complete results after their mammograms, including information about breast density and recommendations for additional screening if necessary, but this has not been standard practice.

I requested a meeting with Senator Weinberg’s office last fall after reading about legislation in other states.   I explained to Senator Weinberg’s knowledgeable and receptive legislative director, Mr. Scott Devlin, why breast density was a serious health care issue and gave him the reasons New Jersey needed to join other states in passing breast density inform legislation.

Senator Weinberg listened.  And she acted.  Now it’s time for you to do your part.  Tell your Senator to vote YES on Bill S792 for patients to be informed directly about their breast density at the time of the mammogram and for 3rd party insurers to cover breast ultrasound screenings.

To screen or not to screen. That isn’t the question. The heart of the matter is when to screen for breast cancer and how often – and the answer varies according to the individual. Family history? Dense breast tissue? The list goes on. That’s why Women’s Digital Imaging creates individual risk profiles and determines a screening plan for each patient. But this presents a conundrum for legislators who must determine how to allocate health care dollars. They look at how many lives are saved by a procedure. Studies may result in a number that policymakers decide is not high enough to warrant the investment. And studies often have conflicting conclusions.

There is more at stake in studies of early detection and breast cancer than the raw numbers. One study currently in the news says only 13 percent of those diagnosed are saved by mammograms. Only? What if that life was yours? Another study just out shows that women who had at least three screening mammograms had a 49 percent lower risk for breast cancer mortality. No one is going to argue with those figures!

There’s another issue getting lost in all the talk about how many lives are saved by early detection – treatment and the quality of life. When cancer is found at an early stage, the treatment is less aggressive, less invasive and generally less traumatic.

In medical terms this is framed as a discussion of mortality vs. morbidity. Mortality is death from disease. Morbidity is the presence of disease, and resulting complications. When we find disease at the beginning stages, treatment options, as well as prognosis for survival, are much better. Early detection may not save every life. But it certainly saves the quality of life for anyone with breast cancer.

On Friday, November 4, the National Mammography Quality Assurance Advisory Committee (NMQAC) held an open hearing to discuss legislation requiring women to be informed about their breast density.  As reported in The Record (11/5) of Bergen County, New Jersey, I told the committee why I am in favor of this legislation.  Now I’d like to go further.

Physicians are required by law to give patients the results of their mammograms.
Radiologists issue a complete report to referring physicians and send patients a layman’s report.  This version does not include information about breast density.  So a patient with dense breast tissue who has a normal mammogram may not be getting the full story.  The problem is that breast tissue and tumors are both white on mammograms so cancer may not be visible.  However, the lesions are often seen on other modalities including Ultrasound, MRI and Breast Specific Gamma Imaging (BSGI), a form of Molecular Imaging.  I don’t let patients out the door of my practice without fully disclosing the results of their exams, including breast density.  The new requirement would “close the loop” between referring physician, radiologist and patient by making the radiologist who performed the exam responsible for informing a patient about her breast density.

I think of myself as a “Primary Breast Care Specialist.”  I work in tandem with referring physicians but give my patients complete information about their mammography exams.  I obtain a family history including risk factors, analyze the images, perform image-guided biopsies (Ultrasound and Stereotactic) as needed and give patients their biopsy reports within a few days.  I make recommendations directly to patients when I think additional imaging is necessary.

One panelist at the hearing asked me, “If referring physicians (primarily gynecologists and internists) don’t take density seriously, what should we do?”  I told the panel it all comes down to education – for both doctors and patients.  Some doctors may not know that dense breast tissue heightens cancer risk and mammography alone is not adequate for these patients.  If women understood this, they could initiate a conversation with their doctors about whether to obtain additional imaging.

More direct reporting from breast radiologists to patients would also help women obtain the correct diagnostic workup.  I know several women who had abnormal mammograms and were told by their physicians to see a breast surgeon.  That’s a big jump.  I would advise additional imaging first, with an image guided-biopsy if necessary.  One of my patients was told by her physician to get a second opinion on her mammogram.  Second opinions are often useful.  However, he advised her to go to a general radiology center that I know does not specialize in mammography.  Who is reading the films?

Breast Imaging Specialists know what to look for and how to walk the line between too much imaging and not enough.  We should be at the forefront of communicating results to patients.

Do we really need the government to tell doctors how to communicate with patients? I am a doctor, and I think the answer is YES.

I am going to Washington tomorrow to tell Congress why I support legislation to require physicians to inform women patients when they have dense breast tissue. Dense tissue has been cited for being a significant risk factor for developing breast cancer. I think women should know this as it affects decisions about how and how often to be screened.

This legislation will not affect me or my patients at Women’s Digital Imaging of Ridgewood. I have always been a proponent of developing individual risk profiles for my patients and I let them know if they have dense tissue. With that knowledge, I frequently advise testing in addition to mammography. With dense tissue, tiny cancers are sometimes not visible on mammograms but are visible on other modalities including ultrasound, MRI, and molecular imaging.
So why don’t all physicians tell their patients about dense tissue? There are two main reasons: 1) more testing means more possibility of false positives and more anxiety for patients 2) higher costs for doctors and patients.

False positives are annoying but not life threatening. Studies have shown women would much rather undergo additional tests to confirm that they do not have cancer rather than take the chance of a cancer being missed. Cost is another factor. Physicians who are reimbursed at a low rate are not motivated to offer this service.
Ultrasound, a safe, non-invasive test, often finds cancers in dense tissue that mammograms miss. But very few practices are willing to perform screening ultrasound. I am bringing a patient with me to this meeting who had a cancer found with ultrasound that was hidden on her mammogram. There are unfortunately, many women with the same diagnosis.

We know that there are tiny cancers that would cause no harm if left alone. But we don’t know which ones are harmless and which are potential killers until they are removed. And if they are the kind that can cause harm, the earlier they are removed, the better the prognosis for the patient.