Empowered to Choose: What Women Should Know about Screening Mammography

These days women are getting conflicting recommendations about when to start screening mammograms and how often to have them. I talked with breast surgeon Janie Grumley, MD, who says that a better understanding of mammograms as a screening tool and knowing how early detection impacts cancer treatment provides the best context for decision making.


Grumley, Janie Weng 11

Janie Grumley, MD

You say some providers are telling their average-risk patients that annual screening for breast cancer may be unnecessary. Why are some women hearing that going two or even three years between mammograms is OK?

Dr. Grumley:  Recent studies have been in the media that give conflicting information about screening mammograms. What’s important to understand is that all the experts agree there is a benefit to breast cancer screening. Where conflict lies is around the ideal interval for screening. Many of the studies focus purely on the rate of survival, but survival alone is not the only benefit. When cancers are found early the treatments needed to achieve survival may be drastically different compared to cancers found later.

The reason why some practitioners are recommending longer intervals between mammograms is an attempt to lessen anxiety for women undergoing screening. But that may come at a cost, if the result is later detection of cancer and possibly the need for more treatment. Instead, I think it is more important to educate women about the limits of screening mammograms so they better understand the process and are not alarmed when called back for additional tests.

Mammograms are not perfect tests and a percentage of women will get called back for more views, and may even require a biopsy. What would you tell women whose anxiety may be keeping them from getting a mammogram?

Dr. Grumley:  Here’s something women should keep in mind: A mammogram doesn’t see cancer cells. It simply helps us see differences in how the breast looks. So we take that first look, and sometimes pick areas that need a closer look. Even biopsies are done when something looks different, not because we know it’s cancer. Providers could do a better job of helping women understand that after a mammogram, there is always the chance they will be called back. And that just means we’re not sure of the nature of the change we’re seeing. A very small portion of the women that come back will need a biopsy, and a much smaller percentage will actually have cancer.

Doing a mammogram every year, beginning at age 40, is the ideal way to track subtle changes in breast tissue and identify problems early. It’s the series of mammograms that will give us the best information. It’s like weighing yourself one day, but not tracking your weight over time. It’s a very limited piece of information. Getting mammograms every year creates a more complete picture and helps us see what we need to see.

That said, breast cancer screening is not one-size-fits-all. If a woman has very dense breast tissue, for instance, the type of imaging is important. Somebody with very dense breasts should have 3D mammography, and possibly a screening breast ultrasound. Those with fatty breasts can have a good test with a 2D mammogram. So it’s also about selecting the right tool for the right patient.

You mentioned the difference in treatment when breast cancer is found early versus at a more advanced stage. What do treatment options look like today for early breast cancer? For more advanced breast cancer?

iStock_000020255467XSmallDr. Grumley: I have a perfect example of a patient I treated. Her annual mammogram revealed a small tumor. Because the tumor was just a few millimeters, the patient could have a partial mastectomy, with breast reshaping using oncoplastic surgery techniques, plus one dose of radiation administered during surgery. She was done with her main treatment in one day. Had we waited another year, the tumor would likely be larger and require more extensive treatment, such as weeks of chemotherapy and radiation therapy. One day of treatment compared to months, with more toxicity and side effects.

We have to help women understand the screening process, how it’s important not just for survival, but also because if we get it early, we don’t have to do as much to treat you. Women often think breast cancer means mastectomy and chemotherapy, but early detection means we are doing far fewer of both. There have been great advances, including drug therapies that treat by cancer type, breast preserving lumpectomies and the possibility of intraoperative radiation therapy for localized tumors. Today there is good reason to be less fearful of what can be a very treatable cancer.

Educating women about the benefits of regular breast cancer screening could greatly affect decisions they make about their own health. How do you help more women get this information?  

Dr. Grumley:  I meet with primary care physicians and say it’s not about telling your patients what they should do, it’s about providing education. Explain what mammograms really tell us, what a callback means, what a biopsy means, and the patient can decide for themselves. Talk about how treatment plans change depending on when cancer is found. It only takes one good conversation. And if the provider wants more support for that conversation, they can have their patient follow up with a breast specialist. Because when it comes to screening decisions for breast cancer, receiving complete information is the best anti-anxiety medicine there is.

Innovative Radiation Therapy Attacks Early-Stage Breast Cancer in One Treatment

Virginia Mason was the first medical center in Washington state to offer intraoperative radiation therapy (IORT) to treat women with early-stage breast cancer. Since 2012, 350 patients have participated in the IORT clinical trial, receiving a one-time dose of internal radiation therapy directly to the tumor site during surgery.

Potential candidates for breast IORT are women aged 45 or older, with a new diagnosis of early-stage breast cancer who are planning to undergo lumpectomy. Watch the video to learn more and hear from IORT patients.

For more information or to discuss if you may be a candidate for IORT, please contact a Breast Cancer Nurse Coordinator at (206) 223-8862.

Surviving Breast Cancer: Linda’s Story

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Linda

I’m Linda and I’m 68 years old. Three years ago, I was diagnosed with breast cancer. When I had my regular mammogram, something didn’t look right. They wanted me to come back for another mammogram and ultrasound. That showed a possible tumor and a biopsy revealed I had cancer. I also had an MRI that gave them a better picture of what was there.

Luckily, it was Stage 1A HER2 positive and I wasn’t in immediate danger. But I felt like everyone at Virginia Mason took it just as seriously as if it had been Stage 4. A meeting was quickly set up for me to talk to an oncologist, radiologist and surgeon. I felt that each one focused on me as a person, on my particular cancer and how it might be treated. They answered all my questions.

I decided to have a lumpectomy and that went well. I had a one-time intraoperative radiation treatment and was only in the hospital overnight. I did have some problems with the follow-up treatment because my wound was proving difficult to heal. It was a couple of months before I was able to receive chemotherapy once a week and had some difficulties with that, but a nurse was always available for me to talk to.

One of the oddest things was that I didn’t like the taste of silverware during my treatment. So I had to eat every meal with plastic utensils. But the good thing was that I didn’t eat as much and lost 55 pounds. I love to cook and bake and I knew I was too heavy.

Today, I am eating much better and I feel better because of it. I have rheumatoid arthritis and I need to stay active, so I exercise by doing water aerobics. My family has been terrific through all of this. When I was in treatment, my sister-in-law would visit every Tuesday. She knew I wouldn’t be feeling well that day because of the chemotherapy and she would bring me things I could eat.

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Linda’s daughter Traci

Just recently, my daughter, Traci, was diagnosed with breast cancer. When she found out about it, she knew immediately she wanted to be treated by the same doctors at Virginia Mason who treated me. It was also recommended that she visit Virginia Mason’s genetic counselor — and we went together.

I learned a lot from that visit. When you look at the big picture, you can see how cancer has affected my family through generations. I suppose that’s true for a lot of families, but it was surprising to realize how many of my relatives have had cancer.

I’m so glad that Virginia Mason was there for me and Traci. And in 2005, it was there for my husband, Otis, as well. He had prostate cancer and is doing well today — and so am I. Otis, Traci and I have all had the best care possible. I can’t say enough good things about the people at Virginia Mason who took such good care of us.


 

This story originally appeared on VirginiaMason.org. Meet other patients who bravely shared their stories of fighting cancer, and get the latest information on cancer treatment outcomes and wellness and support at Virginia Mason.

Getting a Mammogram: Why the Conflicting Recommendations?

Dr Peter R Eby_2014

Dr. Peter Eby

**By Peter R. Eby, MD, FSBI**

The controversy over when to start screening mammograms and how often to get them in average risk women has been around since the early 1990s. The American College of Radiology (ACR), United States Preventive Services Task Force (USPSTF) and American Cancer Society (ACS) all agree that screening every year starting at 40 will save the most lives. And yet, all three organizations have different recommendations for patients about mammograms.

The ACR, along with the National Comprehensive Cancer Network (NCCN), American Congress of Obstetricians and Gynecologists, and American College of Surgeons recommend screening every year starting at age 40. The ACS recommends considering a mammogram between ages 40 to 44 then definitely getting one every year between ages 45 to 54, followed by continued screening every one to two years. The USPSTF draft for 2015 recommends starting at age 50 and getting a mammogram every other year. How can all these prestigious organizations, which are full of smart people, look at the same data and come to different conclusions?

The issue boils down to one important question: Should patients decide or should organizations decide for them?

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While all agree that starting at age 40 and getting a mammogram every year saves the most lives, the reason why they disagree about when to start has to do with the relative value that each group places on the potential risks and costs associated with screening mammography. These include the money and time spent on the exam, the anxiety it may cause and the possible additional tests that the mammogram may generate when cancer is not present. Different patients often value each of the risks and benefits from a mammogram differently. Some are more anxious than others. Some have greater concerns about the expense of the exams. And some have a more pressing need to know the results.

The UPSTF and the ACS have tried to weigh the life-saving benefit of mammograms against the risks and choose what is best for all patients. Unfortunately, the USPSTF recommendations are tied to insurance coverage through the Affordable Care Act. For women between the ages of 40 to 49 years old the Task Force has assigned mammography a grade C. A grade C does not require insurance coverage. While the words of the USPTSF suggest the freedom of choice, their actions may require patients to pay the full cost of a mammogram from their own pocket. Those with limited incomes may have no choice at all.

The ACR, NCCN and others recognize that women at average risk for breast cancer have different values and support continued insurance coverage for patients to get a mammogram and exercise their right to choose for themselves. The opportunity should be offered every year beginning at age 40 because – as the ACR, ACS and USPSTF agree – that is the schedule that saves the most lives.

Peter R. Eby, MD, FSBI, is section head of Breast Imaging in the Department of Radiology at Virginia Mason. He practices at Virginia Mason Hospital & Seattle Medical Center, Virginia Mason Kirkland Medical Center, Virginia Mason Issaquah Medical Center and Virginia Mason Federal Way Medical Center.

More Information: Two organizations in their own words

The ACS says

“Screening mammography in women aged 40 to 69 years is associated with a reduction in breast cancer deaths across a range of study designs, and inferential evidence supports breast cancer screening for women 70 years and older who are in good health.”
[Oeffinger KC et al. Breast Cancer Screening for Women at Average Risk 2015 Guideline Update From the American Cancer Society JAMA. 2015;314(15):1599-1614]

The USPSTF says

“The USPSTF found adequate evidence that mammography screening reduces breast cancer mortality in women ages 40 to 74 years.”
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/breast-cancer-screening1

 

 

Can How You Eat Reduce Your Risk of Breast Cancer? Mediterranean Diet Study Suggests Link

In September study results published in JAMA Internal Medicine got a lot of attention: the almost five year study showed women who followed a version of the Mediterranean diet significantly lowered their risk of developing breast cancer.

Dietitian Cindy Snyder

Dietitian Cindy Snyder

The clinical trial, known as PREDIMED, randomly assigned about 4,200 women to one of three groups: the Mediterranean diet supplemented with extra-virgin olive oil, the diet supplemented with mixed nuts, or a control group following a regular low-fat diet. Compared to the control group, those on the olive oil diet showed a 68 percent reduction in breast cancer risk, after controlling for variables including age, BMI, smoking, family history of cancer, and physical activity.

But before you grab a bottle of olive oil and a straw, consider the study’s limitations: just 35 women were diagnosed with invasive breast cancer – a small number for analysis – and the women recruited were all postmenopausal and at high risk for heart disease. That’s because PREDIMED’s first purpose was to assess cardiovascular benefits of the Mediterranean diet.

So what could be so special about this diet, and olive oil in particular? Most of us have heard of the Mediterranean diet – full of vegetables, fruits, whole grains and olive oil, and low in dairy products and red meat – known from over a decade of study to improve heart health. PREDIMED and earlier studies show the Mediterranean diet has a favorable effect on blood pressure, lipids, artery plaque, insulin sensitivity and inflammation, lowering the risk of heart attack and stroke.

“What extra-virgin olive oil has are polyphenols, a type of phytonutrient known for strong antioxidant activity,” says Cindy Snyder, MPH, RD, CD. “It also has a unique blend of fatty acids which may reduce the inflammation that leads to atherosclerosis, or hardening of the arteries, and cardiovascular disease.”

Seafood, another staple in the Mediterranean diet, may also contribute to the health benefits of this dietary pattern. Fatty acids known as Omega-3’s – like in salmon, tuna and other fish – areiStock_000016218804Small[1] essential for healthy cell function, and the body is inefficient at making them. Phytosterols, a type of natural plant fat that slows the absorption of cholesterol in the body, are found in avocados, nuts, seeds, whole grains and legumes – all of which have a number of other important nutrients.

When considering the known health benefits of the Mediterranean diet alongside very preliminary findings on reducing breast cancer risk, what is the takeaway for women? For starters Cindy advises against focusing on one thing, like olive oil, as a magic bullet.

“For years, researchers have investigated individual food components,” says Cindy. “But, what PREDIMED demonstrates is that a pattern of eating, in which dietary components work together, could improve people’s health.” She points out that the PREDIMED study included specific lifestyle factors associated with the Mediterranean region, requiring participants have at least two meals seated at a table each day, spending a minimum of 20 minutes eating each meal.

In fact, a 2014 multi-study review has linked a “Mediterranean dietary pattern” with a decreased risk of breast cancer. But while the suggestion that a certain diet or oil may help prevent breast cancer is encouraging, more long-term studies specifically targeting breast cancer are needed. Meanwhile, with all the upsides for choosing a Mediterranean diet and virtually no downside, it may just be the diet you’ve been looking for.

A Labor of Love: Creating Hats for Hope

Kailey and John Ryan, MD, a retired Virginia Mason surgeon and longtime family friend.

Kailey and John Ryan, MD, a retired Virginia Mason surgeon and longtime family friend.

Kailey Druffel has visited Virginia Mason a number of times, but not as a patient. Her mother, Shelly, was a surgical technician at Virginia Mason when Kailey was young, before a long battle with breast cancer took Shelly’s life. Now her mom’s former colleagues are like extended family for Kailey, staying in touch with the high school graduate as she plans her own career in medicine.

Last summer, Kailey spent a week learning about orthopedic surgery at Virginia Mason, rounding with a surgeon who had worked with her mom, looking at X-rays and scrubbing in to observe procedures. The experience cemented her desire to become an orthopedic surgeon.

“I’d never been surrounded by so many people who absolutely love what they do,” says Kailey, who plans to study biochemistry at Washington State University this year. “The team at Virginia Mason loves teaching and sharing their passion for what they’re doing. It makes me excited about becoming a doctor.”

Kailey has always looked ahead with optimism despite also losing her father, who died in a boating accident just months before her mother died. Raised by her grandparents in Clarkston, Wash., Kailey grew into a community volunteer, working through her church to serve homeless families and administer other programs, and in her local Salvation Army soup kitchen.

In her junior year of high school, Kailey started the volunteer project that felt closest to her heart: Hats for Hope.

“As a kid I watched my mom go through cancer treatment and her head was always cold,” remembers Kailey. “I wanted to do something in her memory, something she would be proud of.”

So Kailey recruited an eager group of high school students – interestingly all boys – to learn how to crochet beautiful, toasty warm hats intended to comfort cancer patients undergoing treatment. Working during their free “flex time” earned by students doing well in their classes, Kailey and the Hats for Hope team created an impressive collection.

When it was time to find people who needed the hats, Kailey knew where she would go. She recently met with some of her mom’s friends and former colleagues at the Floyd & Delores Jones Cancer Institute at Virginia Mason, bringing along the donations from Hats for Hope.

“I want people to know they don’t have to be cold during treatment,” says Kailey. “There are people thinking about them, like secret angels, who want to help.”

Ice Sculpture Resonates with People Touched by Cancer

On April 27, Virginia Mason made cancer disappear. Five-foot tall letters made of ice spelled the disease, then slowly broke apart into icy rubble under blue sky at Seattle’s Westlake Center. Part of the “See What’s Happening to Cancer” campaign, Virginia Mason physicians and health care experts were near the sculpture to provide information on cancer prevention and screening.

Lauren Lindeman

Lauren Lindeman

We asked Virginia Mason team member and breast cancer survivor Lauren Lindeman to talk about how she experienced the event.

How was this event personal to you?

In January I was diagnosed with very early stage breast cancer.  The early detection made possible by 3D mammography meant I could undergo a lumpectomy, have radiation just once during the surgery, and not need chemotherapy at all! Even though we’ve all heard the words “early detection” like a mantra, it’s finally real for me. It may take some time and persistence, but cancer can be defeated!  I loved how the ice sculpture symbolized that in such a tangible and visual way.

What did it mean to you as a Virginia Mason team member?

Many members of our leadership team made a special trip down to see and support this amazing concept that cancer can and will be overcome. Throughout the day, team members from all areas and job descriptions used their breaks to come see the sculpture.  It gave me a true sense of pride in our Virginia Mason family and reflected the commitment we all feel in our role as ambassadors for the patients.

How did it feel to be at the sculpture site?

Joy and excitement within myself and also from the crowd!  Who knew it could be so exciting to watch the letter E disintegrate or see a chunk of a C crash loudly to the ground, or better yet, watch a survivor pose for a picture where she was “kicking cancer?”

What did you see and hear from others?

Throughout the day, people shared incredible stories of their own battles with cancer.  Either they had been touched by cancer personally or experienced it with loved ones.  Those who had lost loved ones to cancer were especially supportive of our efforts.  Everyone wants to rally together in this fight, and that was truly amazing to see.

resizeAny particular moments that stood out for you?

After hearing my story, several women admitted that they were way overdue for a mammogram, and committed to get in right away!

There was a beautiful little girl who was trying to melt a fallen chunk of the letter C with her tiny hands. An 80-year-old man shared his story of beating prostate cancer and being able to visit his children in Seattle.

Then there was the roar of the crowd every time another letter bit the dust!

See CANCER have a meltdown in just 25 seconds.

 

Think Pink This October

admin-ajaxOctober means pumpkins and Halloween costumes – and everything in the stores is a festive orange and black. But for those of us who know someone who has or has been through breast cancer, the only color that matters this month is pink for breast cancer awareness.

Breast cancer is the second most common kind of cancer in women, and many women can survive breast cancer if it’s found and treated early. Which is why during October, we want you to talk to your doctor about your risk for breast cancer and how often you should be getting mammograms.

Virginia Mason is celebrating this special month with two very special events – the opening of our new Breast Clinic and the Making Strides walk.

New Breast Clinic
We’re very excited to open the new Breast Clinic at the University Village Regional Medical Center during Breast Cancer Awareness Month. Starting Tuesday, Oct. 7, we will offer screening mammography at this site for scheduled and walk-in appointments. In mid-October, the clinic will also begin offering appointments with a breast health nurse practitioner to evaluate any concerns for women and men.

For more information on the University Village Breast Clinic, please visit VirginiaMason.org/breastclinic. For an appointment for a screening mammogram or with a Breast Clinic provider, call 1 (877) 433-9813.

Making Strides
Join the Virginia Mason team on Saturday, Oct. 18, for the American Cancer Society Making Strides Against Breast Cancer walk, as we help make breast cancer a disease of the past.

Since 1993, 9 million walkers in Making Strides events across the country have raised more than $528 million to support not only cancer research, but access to mammograms, information and services for women in need. Funds help pay for everything from transportation and lodging to support programs and financial assistance. Every Making Strides walker helps push research forward, maintain essential services and build awareness in their own communities.

When: Saturday, Oct. 18; walk starts at 9 a.m.
Where: Seattle Center
What: 5K (3.1 mile) non-competitive walk
Team Virginia Mason: Click here to register with the Virginia Mason team.

Want to learn more about breast health? Visit these past blog articles:

Should I Get a Mammogram?

I'm told that life begins at 40. Apparently, so do mammograms.

I’m told that life begins at 40. Apparently, so do mammograms.

I turned 40 in February and was reminded a few weeks later at my annual exam that it was time to start thinking about getting a mammogram. Great – as if turning into a woman of a certain age wasn’t hard enough, I now had to gather the motivation to make an appointment that would not only make me feel 40, but rather squished and awkward. It was easy to put off making the call.

My angst and procrastination continued when articles published in the British Medical Journal, JAMA and New England Journal of Medicine regarding mammography screening prompted more news media discussion about the value of mammograms in reducing deaths from breast cancer among women. The American Congress of Obstetricians and Gynecologists, American Cancer Society, American College of Radiology, National Accreditation Program for Breast Centers and Society of Breast Imaging recommend that women start getting annual mammograms at age 40, while the U.S. Preventive Services Task Force recommends beginning at age 50. All the experts agree mammograms between age 50 and 74 will decrease the risk of dying of breast cancer.

“Virginia Mason continues to recommend screening mammography every year, beginning at age 40, for as long you are in good health,” says Carly Searles, ARNP, at the Virginia Mason Breast Clinic. “Given the recent discussions, you might want to discuss what screening schedule is best for you.”

The two main risk factors for breast cancer are being female and getting older. However, family history can also play a role. Having two first-degree relatives (a mother, sister or daughter) with breast cancer increases risk five-fold. To my knowledge, no one in my family has ever had breast cancer – cardiovascular disease and accidents are the usual ways we’re taken out. However, my aunt died of ovarian cancer, so I have since been keenly aware that our bodies can angrily turn on us without so much as a whisper that something is wrong.

“This is why screening is so important,” explains Carly. “It can detect early stage tumors before you can feel them, while they are small and there are more options for treatment.”

Despite the different opinions of experts and organizations regarding when to begin mammography screening and at what frequency, the main message is this: Talk to your health care provider about what screening recommendations are most appropriate for you. Virginia Mason has specialized Breast Clinics in Seattle and Federal Way, where you can also receive guidance to help you decide what works for you.

All women should do the following to detect breast cancer:

  • Consult your health care provider about your individual risk factors and how to modify or manage them to reduce your risk. This includes what age is right for beginning screening mammography.
  • Know your family history and share it with your provider. Early onset breast cancer (premenopausal) in a close relative or three close relatives on the same side of the family with breast cancer, ovarian cancer or both may indicate elevated risk. In some cases genetic testing may be suggested.
  • Practice breast awareness by checking your breasts periodically. Don’t get too stressed out about your technique. It’s most important to be familiar with what is normal for you.
  • Always report to your provider any changes to your breasts, including lumps, thickening or discharge. It may be nothing, but early detection is best.
  • Talk to your mother, daughters, sisters and girlfriends about breast cancer screening. Keeping the conversation alive will help ensure survivability rates stay strong.

Once you decide to start mammography screening, Carly suggests scheduling your mammogram around your birthday or another special occasion each year. “Getting appropriate screening will ensure you’ll have many more birthdays to celebrate with family and friends,” she says.

Admittedly, I have yet to schedule my happy birthday mammogram. But, I do have it on my list of things to speak with my primary care provider about the next time I visit her.

Breast Clinic Now Offers 3D Digital Screening for Cancer

Virginia Mason is now offering a new technology for screening women for breast cancer called Digital Breast Tomosynthesis, also known as DBT, which provides 3D mammography to help care providers make more accurate diagnoses.

Scan from DBT

“The Virginia Mason Breast Clinic, along with the American Cancer Society, recommends yearly 2D or 3D screening mammograms for women 40 and older,” says radiologist Peter Eby, MD, who specializes in breast imaging. “3D mammograms may be especially beneficial for women that are pre-menopausal or have dense breast tissue.”

DBT looks and feels just like a standard two-dimensional digital mammogram to the patient, but the images appear differently to the radiologist. While standard 2D mammography provides a single image of the entire breast, DBT provides multiple image “slices” of each breast that can be examined individually like cards in a deck.

Compared to 2D mammography, research shows DBT examinations are more sensitive and specific because of increased cancer-detection capability and decreased false positives. The improvement in test performance is achieved through the combination of advanced technology and an increased radiation dose (although the total dose for the exam remains low and is still within the federal limit for screening mammography).

The primary role of DBT is screening, especially for patients with dense breast tissue who may have the greatest benefit. DBT is currently available in the Breast Clinic in Lindeman Pavilion in Seattle. The examination can be ordered as a screening mammogram with request for DBT, and it is billed as a standard screening examination.

Please call  (206) 625-7250 for more information or to schedule an appointment.