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3-D Mammography

The newest weapon in the battle against breast cancer is now available and doctors say it has the potential to save lives.

One-in-eight women will get breast cancer in her lifetime. Experts agree the key to successfully fighting the disease is early detection. New technology is available that can provide doctors a more detailed image.
Some call this machine a game-changer in breast cancer detection.

“I think it's a huge leap forward,” Ronald Prati, Jr., MD, Radiologist/Medical Director, Florida Hospital Tampa, told Ivanhoe.

Dr. Prati says tomosynthesis, or 3-D mammograms, doubles the cancer detection rate and decreases callbacks for additional testing. The machine images multiple layers of the breast.

“It's the difference between trying to look through a loaf of bread verses pulling out individual slices and looking at them,” Dr. Prati explained.

Dr. Prati showed an image of a conventional mammogram next to a 3-D image, which detected cancer.

Breast cancer patient, Shelby Coriaty, wishes this technology had been available years ago. It could have changed her life.

“I went for my very first mammogram and actually got a clean bill of health. So I went on my way thinking, alright, I’ve done all those things I’m supposed to do and about 3 months after that, I actually had an itch in my armpit and I felt a golf ball,” Coriaty told Ivanhoe.

Coriaty had breast cancer. Eighteen surgeries later she encourages other women, like Amy Janes, to get annual screenings. Janes was one of the first to try tomosynthesis.

“It really wasn't any different other than you notice the machine move slightly unlike the 2-D mammogram is stationary,” Janes said.

And with 3-D in the mix, the fight against breast cancer is magnified.

Doctors say the 3-D images can be beneficial for young women who have dense breast tissue, which is sometimes more difficult to screen. However, insurance companies do not cover tomosynthesis until January 2015. But, Florida Hospital Tampa offers it for free. Patients in other cities will want to check with their hospitals or insurance companies prior to undergoing the test.
 


BACKGROUND: About one-in-eight women in the United States will develop invasive breast cancer in their lifetime. In 2013 an estimated 232,340 new cases of invasive breast cancer were expected to be diagnosed in women in the United States. About 2,000 new cases were expected in men in 2013. Breast Cancer incidence rates in the U.S. started decreasing in the year 2000.There's a theory that the decrease was partly because of the reduced use of hormone replacement therapy. (Source: http://www.breastcancer.org/symptoms/understand_bc/statistics)


SIGNS/SYMPTOMS: The risk doubles in women if she has a first degree relative who has been diagnosed. About five to 10 percent of breast cancers can be linked to gene mutations inherited from a parent. BRCA1 and BRCA2 are the most common mutations. Women with the BRCA1 mutation have a 55 percent risk of breast cancer. The risk with a BRCA2 is lower at 45 percent. To understand this better...some genes control when cells grow, divide into new cells and die. Genes that speed up cell division are called oncognes. Tumor suppressor genes slow down cell division, or cause cells to die at the right time. But, when there is a mutation or changes in DNA that turn on and turn off tumor suppressor genes, normal breast cells can become cancerous. (Source: http://www.breastcancer.org/symptoms/understand_bc/statistics)


NEW TECHNOLOGY: The 3-D mammogram also known as tomosynthesis captures several slices of the breast, all at different angles. The images are brought together to create a crystal clear 3D reconstruction of the breast. Then the radiologist can review the reconstruction one slice at a time. It's kind of like turning pages in a book. This makes it easier for doctors to see if there's anything to be concerned about. There's also less chance for a cancer to hide behind overlapping tissue. A breast tomosynthesis exam can be used in conjunction with a traditional mammogram or it can be used by itself for a diagnostic mammogram. (Source: Florida Hospital Breast Care Center)


FOR MORE INFORMATION, PLEASE CONTACT:

Denise Smith, AS, RT(R)(M)
Clinical Manager – Breast Care Center
Florida Hospital Tampa
Office: 813-615-7200, ext. 50814
Denise.Smith3@AHSS.org



Ronald Prati, Jr., MD, Radiologist, Medical Director at Florida Hospital Tampa talks about a 3-D mammograms and how it can provide doctors a more detailed image.

How big is this for the patients?
Ronald Prati: Well, I can tell you my wife, this is what she’s getting, my mother this is what she needs to get. I mean, if you’re going to get mammograms from here on out you really want to try to get tomosynthesis if you can find it and it's available. I think any technology that increases your cancer detection rate and decreases your callback rate, is what you want to do.
Can you walk us through how it works?
Ronald Prati: Yes. With a regular mammogram the breast is compressed. The reason why you have to compress it is because you want to have less tissue for the radiation to go through. So by compressing the breast you make it thinner and then you can do a lower dose of radiation. With tomosynthesis we do the same thing. We compress the breast so we can have less radiation going through. With a regular mammogram the x-ray fires once goes through the breast and into a detector so you get one view of the breast and it’s the summation of all that tissue that’s compressed together. With the tomosynthesis image, the machine actually moves. The radiation is only about one and a half times that of a regular mammogram, so the radiation is really a non-issue. You get a bunch of tomographic slices and the number of slices you get depends on how thick the breast is and this is similar to a CAT scan with a CT. So instead of looking at a summation of all the breast tissue stuck together where dense tissue might overlap and you can’t tell if it's dense tissue or a mass, the tomograms can separate slices out and you can see whether it’s normal breast tissue or a mass. So it’s stuff that hides on a regular mammogram that doesn’t hide with the tomo. It doesn’t take any longer than a regular mammogram. The breast is compressed, the machine moves very quickly and you create a bunch of tomographic images from that or a bunch of slices. It’s like slicing bread, it’s the difference between trying to look through a loaf of bread versus pulling out individual slices and looking at them.
It kind of makes it seem like a regular mammogram is a waste of time.
Dr. Prati: It’s not a waste of time and I think there’s plenty of good evidence especially out of Sweden. There is one study where they looked at a large population of women and there is a benefit from screening with regular mammography. This is a bigger benefit. And so, again, if you’re going to go through mammography and do it and you have a choice you would prefer to do  tomosynthesis.
Who has the choice to do that?
Dr. Prati: Well you need to have the technology rolled out, this is fairly new technology that’s only been recently FDA approved. I believe it was last year that it got approved. This technology is going to take a while for breast centers to purchase it and then actually put it into operation.
Is there a certain candidate who could get this kind of mammogram or is it anybody?
Dr. Prati: Every patient that comes to our center for a screening mammogram, we’ve chosen to use it on screening patients. If they want tomosynthesis, we do this exam on them for their screening study.
So insurance obviously covers something like this.
Dr. Prati: I believe the cost will be essentially the same as it is for regular mammogram, with a new code available in January, 2015. For us to read it takes a little bit longer, it may take me another couple of minutes to look at this, but for the technologist to shoot it, it does not take much more time. It’s very similar to regular mammogram.
So what are the benefits compared to the conventional mammogram?
Dr. Prati: The benefits of this compared to a regular mammogram is the increased detection of cancer. It happens even with women with less dense breasts but the biggest gain appears to be in women that have denser breasts that are harder to see through on regular mammograms. The other big benefit: any time a woman has a mammogram, if you see something suspicious and you’re forced to call her back to do additional views or an ultrasound to try to decide if it’s real. It’s very anxiety provoking for the patient, it makes people very nervous and everybody is uncomfortable. We don’t like to do it. We constantly wrestle with 'do I bring this poor woman back or do I call her normal?' Nobody wants to miss a breast cancer but you don’t want to call people back unnecessarily. So this technology lets you call less people back because things that before you thought might be a mass when you look at these tomographic images you can say 'no it’s not a mass it’s just a bunch of tissue that’s adding up or summation artifact that makes it look like it’s a mass.'  And rather than have to bring her back and do additional views you can clear it already.
And less biopsy?
Dr. Prati:  I don’t know if it’s going to decrease the number of biopsies because if you find suspicious things you’re still going to have to go to biopsy to make the diagnosis. The big advantage of the technology is you find more cancers and you find people don’t need to come back for extra views and then get told you’re normal. You get called normal at the time of the screening as opposed to having to go through the screen, maybe there’s something there you come back and get your diagnostic workup and then you find out you’re all right.
So how has this changed the way you detect breast cancer?
Dr. Prati: This is the same kind of technology you’d use with digital mammography to look through the breast and find abnormal calcifications, distortions, abnormal masses but it’s better, so you can see better. The difference would be before you’re trying to look with a low powered telescope or low powered microscope and now I have high power that I can really zoom in and see. So things that you weren’t sure about before that you were having to guess or again bring patients back and do all this extra work a lot of times, you can sort it out ahead of time now by using this new technology.
So you’ve been using this now for about a year?
Dr. Prati: Yes, we’ve been using this for almost a year now.
What’s your experience then?
Dr. Prati: We’ve looked at some of the data and we’re finding a few more cancers and the callback rate is lower, It’s not quite as good as what’s reported in the literature but we’re headed in that direction. As with any new technology we’re very cautious, we don’t want to just accept what’s published we want to verify it and you want to verify it for your own radiologist and your own patients. Our main goal is to not miss breast cancer and not make mistakes and so my expectation is as time goes by and we get more experience that the numbers will improve and continue to improve.
Are there any studies that we should include in this report that might back up this or might have interesting opinions?
Dr. Prati: If you Google on the web “breast tomosynthesis” there are plenty of recent studies that are out within 2013 that will show a big advantage of using tomo over regular mammography.
And that Canadian study that pooh-poohs mammograms? What do you think about that?
Dr. Prati: There are a lot of problems with the Canadian study that pooh-poohs the mammograms. The facilities were not accredited and were not of the same quality with the same imaging equipment and the same training and quality of the technologists that is done here. Also the radiologists or the people interpreting those studies did not have the same level of training and expertise of the people that read here. In the US to be able to read mammography, you have to do a certain amount of continuing medical education. It’s 15 hours in breast every three years and you also have to read every two years a certain number of studies just to be privileged to read this. So again there’s a much higher standard. Those were some of the problems with those studies. And then they also looked at mammography with the old 2-D technique as opposed to the 3-D techniques that we have now.
In the bigger picture are you seeing more breast cancer, are you seeing less?
Dr. Prati: Again you’ve got to collect enough data to be able to say that with confidence. What I can say is the people that have used this technology for a longer time are able to collect enough data to show our cancer detection rate is higher per number of mammograms we’re doing and then our callback rates are lower. And so anybody that gets this technology within a year or two that’s going to obviously be their goal, is to achieve that same result.
How long have you been doing this for?
Dr. Prati: I’ve been doing breast disease and mammography since the mid-1990s.
Do you see any changes?
Dr. Prati: I think we're better able to detect breast cancer. I think we find it earlier now, I think tools like tomosynthesis, tools like breast MR are huge advantages in the field. I think the ability to do core biopsies so that you can make a benign diagnosis and save a woman from going to surgery by just putting a needle in the breast is an advantage. You do it as an outpatient procedure, it might take an hour. That’s another huge advantage that back in the late 80s and early 90s, to diagnose breast cancer, even benign disease, you went to surgery to be sure. Now you can put a needle in it and find out what it is and save the woman from surgery. There are big advantages with avoiding surgery for benign disease and when the woman goes for surgery now you have other technologies to find other lesions in the same breast or a lesion in the opposite breast. Now you can make those diagnoses and instead of having a woman have recurrent cancer you’re finding more up front so that when she goes she gets more definitive treatment. So I think there have been huge advantages and advances in imaging and what we can do for people.
For those that do have cancer do they have similar characteristics?
Dr. Prati:  People used to think of it as one disease and now people have found out it’s actually a very complex disease. Some breast cancers are less aggressive and need to be treated less aggressively. Other breast cancers are more aggressive and need to be treated much more aggressively. And people are doing genetic testing now. When we get a sample with a needle biopsy they can do genetic testing a lot of times on those core samples and decide different ways and different approaches to treat and even different medications.
Did the women come from similar backgrounds, did they eat certain kinds of foods?
Dr. Prati: Your biggest risk of breast cancer is just being a woman. And once you get to the age where breast cancer becomes more frequent which is around 40, the ACR and the American Cancer Society recommend yearly screening. A lot of times it’s the younger women that get the more aggressive breast cancers, they’re the ones that have the denser breasts. It’s harder to pick up and if you don’t get your yearly screening those are the people that you might catch later if you’re screening every two or every three years. And those are the people that it’s catastrophic because now it’s bigger, it’s more aggressive, maybe its spread. So those are the people that really need yearly screening. The older patients that are in the 70s and 80s and again these are generalizations, but they tend to get less aggressive breast cancer and they tend to have a good prognosis because you’re catching a disease that is not as intense, not as severe and tends not to be as quick.
Why is it that when you’re 40?
Dr. Prati: I wish we could explain those things. Some of it is genetic, some of breast cancer is inherited and people that meet certain risk criteria, there are models out there to look at a woman’s risk for breast cancer which her family physician can look at and say how high a risk she is. Some women need more than just a tomosynthesis or a mammogram. They actually need a screening breast MR. Or they may need some genetic testing, a BRCA test. It depends on your family history and how high your risk is. Breast cancer can occur in younger patients but it’s just much less common. So if you’re doing a screening exam you don’t want to screen people that don’t have a high chance of disease. You want to screen the people that have a higher chance so you can catch it and that’s where the cutoff of 40 years old has come from.
Anything else you want add?
Dr. Prati: I’m just excited about this technology. People were talking about it in 2004 at the National Breast Cancer meeting and they showed some pictures of dense breasts and they showed the whole audience which was full of you know 150– 200 radiologists. Nobody can see the cancer and then they showed the tomo and boom there is this two centimeter cancer and if you biopsied it and it wasn’t cancer you want to take it out and look at it under the microscope  because that’s what it is, it’s a cancer. And when you saw that people were like 'oh my gosh this is got to be fantastic' and you kept waiting and waiting for it to come out and now it’s finally here and the worst thing is it took so long to get there. But it’s a great technology. I’m very excited about it and I am glad to have seen it developed while I was still practicing. Because I really think it’s a huge leap forward.


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