Letter From America

Thyroid Sheilds and the Dr Oz saga continues

2011-04-19T15:39:00.000-04:00

In the US, there is currently a major scare triggered by a spot on the Dr Oz show where he (a well known and respected cardiothoracic surgeon) took on the imaging community with regards to dental x-rays and mammograms and the rising risk of thyroid cancer. Following his programme, women across the U.S. have been asking for the protection after an email went viral in March based on advice Dr. Mehmet Oz gave in his show that originally aired last year.

The background for this controversy is the rising incidence of thyroid cancer, which has increased fourfold since the 1970s. The original episode in 2010 said that some of the increase could be due to radiation exposure from dental x-rays and mammograms, and advised the use of thyroid shields to reduce risk.

In response to this erroneous message, the American College of Radiology (ACR) and the Society of Breast Imaging (SBI) released a joint statement urging patients to disregard trumped up risks of thyroid cancer due to mammography-induced radiation
ACR-SBI statement on the use of thyroid shields (PDF FILE)

The associations put the estimated x-ray scatter delivered to the thyroid at less than 0.005 mGy, equivalent to 30 minutes of natural background radiation and resulting in a cancer risk of less than one in 17 million. ACR and SBI further cautioned patients against using thyroid shields, which the organizations said could interfere with optimal breast positioning and create artifacts, thereby potentially compromising diagnosis

A follow up programme was aired on April 14, but appeared to be deliberately engineered as a lecture to professionals on listening to what women want. This week's episode was ostensibly intended to set the record straight, with Oz, inviting experts from dentistry and radiology to comment on the email controversy and the pros and cons of thyroid shielding.
Radiology experts included Dan Kopans, Phil Evans and Jocelyn Rapelyea who tried to objectively answer the criticism.
Dan Kopans talked about the radiation dose being tiny to the thyroid and about cumulative dose. Phil Evans explained about how thyroid shields obscure much breast tissue, and the mammograms may need repeating. Jocelyn Rapelyea also explained that certain body habitus can prevent women from successfully wearing thyroid shields which of course are a fixed size.

Either way, the programme just muddied the waters, and the fact that the basis of the claim about thyroid cancer risk and mammography screening is unsubstantiated, was never addressed, means that women are more concerned than ever.

We have thyroid shields available at Moffitt Cancer Center for women who wish to wear them, but we, as most other centers do not offer them routinely, as they degrade the quality of the subsequent mammograms in many women.

Is Mammographic Breast Density a Breast Cancer Risk Factor in Women With BRCA Mutations?

2010-08-07T08:48:00.000-04:00

In a paper from Sunnybrook in Toronto, Canada in this month's Journal of Clinical Oncology, researchers found that women with increased breast density who were also BRCA gene mutation carriers did not have an increased risk of breast cancer.

Is Mammographic Breast Density a Breast Cancer Risk Factor in Women With BRCA Mutations?
Kavitha Passaperuma, Ellen Warner, Kimberley A. Hill, Anoma Gunasekara, Martin J. Yaffe
Journal of Clinical Oncology, Vol 28, No 23 (August 10), 2010: pp. 3779-3783

Link to Journal -

Their purpose of the study was based on the knowledge that Increased mammographic breast density is a well recognized as a breast cancer risk factor in the general population. However, it is unclear whether it is a risk factor in women with BRCA mutations. They present the results of a nested case-control screening study investigating the relationship between breast density and breast cancer incidence in this population.

Between November 1997 and March 2008, 462 women (mean age, 44 years; 245 BRCA1 and 217 BRCA2) were screened and 50 breast cancers were diagnosed (38 invasive, 12 ductal carcinoma in situ [DCIS]). Density was not measured in 40 women of whom four developed cancer (three invasive, one DCIS). Mean PD (± standard deviation [SD]) for 376 women who did not develop breast cancer was 34% (23) compared with 31% (21) for 46 women with cancer (P = .51). Logistic regression model of breast cancer incidence and PD revealed an odds ratio of 0.99 (± 0.01 SD) for a one-unit increase in PD (P = .44). Results remained nonsignificant in multivariate analysis, as well as when women with pure DCIS were excluded.

Their conclusion was that ncreased mammographic breast density in "two-dimensional" breast imaging is not associated with higher breast cancer incidence in women with BRCA mutations.

On the basis of these findings, density should not be considered a factor for these women in decision making regarding prophylactic surgery or chemoprevention.

Some pointers they make are that what they call 3D breast imaging like Digital mammography and MRI may give a better reflection of true breast density (compared with conventional mammography (SFM) which tends to over-estimate breast density, may give different results, therefore the study should be repeated with current mammographic techniques using FFDM or using MRI.

Revised RECIST Guideline Version 1.1: What Oncologists Want to Know and What Radiologists Need to Know

2010-07-22T23:32:00.000-04:00

Mizuki Nishino, Jyothi P. Jagannathan, Nikhil H. Ramaiya, and Annick D. Van den Abbeele
AJR 2010;195:281-289

Link to Journal

The original RECIST guideline, version 1.0, provided definitions for "measurable lesion" and "nonmeasurable lesion". Measurable lesions must have a longest diameter of ≥ 10 mm on CT with a slice thickness of ≤ 5 mm (or a longest diameter of ≥ 20 mm on nonhelical CT with a slice thickness of > 10 mm) or a longest diameter of ≥ 20 mm on chest radiography

RECIST assigns four categories of response: complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD). Assessment of overall response is based on the evaluations of target and nontarget lesions at each follow-up time point. The measurements and response assessment are often recorded using tumor measurement tables.

Major changes in RECIST 1.1 related to imaging include the following: first, the number of target lesions; second, assessment of pathologic lymph nodes; third, clarification of disease progression; fourth, clarification of unequivocal progression of nontarget lesions; and, fifth, inclusion of 18F-FDG PET in the detection of new lesions. The number of target lesions to be assessed was reduced from five per organ to two per organ and from a maximum of 10 target lesions total to a maximum of five total.

In RECIST 1.0, there was no clear guideline for lymph node measurement. In RECIST 1.1, detailed instructions about how to measure and assess lymph nodes are provided. Lymph nodes with a short axis of ≥ 15 mm are considered measurable and assessable as target lesions, and the short-axis measurement should be included in the sum of target lesion measurements in the calculation of tumor response as opposed to the longest axis used for measurements of other target lesions

CONCLUSION:
Familiarity with the revised RECIST is essential in day-to-day oncologic imaging practice to provide up-to-date service to oncologists and their patients. Some of the changes in the revised RECIST affect how radiologists select, measure, and report target lesions

New guidelines published for scintimammography from the Socety of Nucelar Medicine

2010-06-29T11:22:00.000-04:00

For those of you who perform scintimammography in difficult cases, the Society of Nuclear Medicine has issued guidelines to assist breast imaging practitioners in patient selection, performance, interpretation and reporting for breast scintigraphy with 99mTc-sestamibi breast-specific gamma imaging.

The guidelines indicate the use of breast scintigraphy in:
•    Patients with recently detected breast malignancy;
•    Patients at high risk for breast malignancy;
•    Patients with indeterminate breast abnormalities and remaining diagnostic concerns;
•    Patients with technically difficult breast imaging;
•    Patients for whom breast MRI would be indicated; and
•    Monitoring neoadjuvant tumor response in patients undergoing preoperative chemotherapy.

Approximately 925 MBq [25 mCi] of the radiopharmaceutical should be administered using an indwelling venous catheter or butterfly needle followed by 10 ml of saline to flush the vein, according to the guidelines.

The guidelines suggest that the sensitivity, specificity and accuracy of the test depend upon several factors, including the size of the breast neoplasm being imaged. While the sensitivity of this test for subcentimeter tumors approaches 95 percent, sensitivity decreases with lesion size.

The report to the referring physician should indicate the most likely diagnosis and should recommend appropriate follow-up as with any breast imaging study, using Breast Imaging-Reporting and Data System (BIRADS) classification

Absolute numbers of lives saved and overdiagnosis in breast cancer screening, from a randomized trial and from the Breast Screening Programme in England

2010-04-01T10:29:00.000-04:00

Absolute numbers of lives saved and overdiagnosis in breast cancer screening, from a randomized trial and from the Breast Screening Programme in England
Duffy SW, Tabar L, Olsen AH, Vitak B et al
J Med Screen 2010;17:25-30

Link to Journal

Objectives: To estimate the absolute numbers of breast cancer deaths prevented and the absolute numbers of tumours over-diagnosed in mammographic screening for breast cancer at ages 50–69 years

Setting: The Swedish Two-County randomized trial of mammographic screening for breast cancer, and the UK Breast Screening Programme in England, ages 50–69 years

Methods: We estimated the absolute numbers of deaths avoided and additional cases diagnosed in the study group (active study population) of the Swedish Two-County Trial, by comparison with the control group (passive study population). We estimated the same quantities for the mortality and incidence rates in England (1974–2004 and 1974–2003, respectively). We used Poisson regression for statistical inference

Results: A substantial and significant reduction in breast cancer mortality was associated with screening in both the Two-County Trial (P < 0.001) and the screening programme in England (P < 0.001). The absolute benefits were estimated as 8.8 and 5.7 breast cancer deaths prevented per 1000 women screened for 20 years starting at age 50 from the Two-County Trial and screening programme in England, respectively. The corresponding estimated numbers of cases overdiagnosed per 1000 women screened for 20 years were, respectively, 4.3 and 2.3 per 1000.

Conclusions: The benefit of mammographic screening in terms of lives saved is greater in absolute terms than the harm in terms of overdiagnosis. Between 2 and 2.5 lives are saved for every overdiagnosed case

New Gotzsche paper dismissing screening - this time in Denmark

2010-03-26T12:47:00.000-04:00

In a paper published in the Research section of the BMJ today, Peter Gotzsche once again lines up the guns against organized screening programs, targeting in this instance the Danish Screening Program.
http://www.bmj.com/cgi/content/full/340/mar23_1/c1241

His conclusions are -
"We were unable to find an effect of the Danish screening programme on breast cancer mortality. The reductions in breast cancer mortality we observed in screening regions were similar or less than those in non-screened areas and in age groups too young to benefit from screening, and are more likely explained by changes in risk factors and improved treatment than by screening mammography
We believe it is time to question whether screening has delivered the promised effect on breast cancer mortality."

As this may hit mainstream news media, I have gathered some responses so far -
Danish and Swedish experts have replied saying that -
They claim that mammography screening in Denmark had no impact on breast cancer mortality. This claim is unsubstantiated, firstly because the authors used very crude data, and secondly because the analysis was not geared to answer the question.

Firstly, breast cancer screening can only possibly have an effect on women not already diagnosed with breast cancer prior to screening. Therefore the so-called “refined mortality” should be used in evaluation of screening. Jørgensen et al did not used refined mortality. Furthermore, they merge data from three screening areas starting screening at different points in time, and used age groups instead of cohorts. Together this gave quite “polluted” data.

Secondly, they calculated “annual change in the relative risk of breast cancer death” by time period and areas excluding 1992-1996. The relevant outcome measure is, however, the change in breast cancer mortality in the screening area controlled for the change in breast cancer mortality in the non-screening area.

Even using these “polluted” data, the relative breast cancer mortality decreased for women aged 55-74 covered by screening, while the relative breast cancer mortality did not decrease for women aged 35-54 largely uncovered by screening, and the relative breast cancer mortality was slightly but statistically non-significantly decreased for women aged 75-84 where the majority, but not all, of the person years were uncovered by screening. Although this pattern in the data is actually visible in Figure 1 in the paper by Jørgensen et al, it was missed in their analysis among other things because they excluded data from the period 1992-1996.

As we have reported previously, the measured impact of mammography screening on breast cancer mortality is highly dependent on the data set used for the analysis. Use of “polluted” data leads to biased estimates (2). Using cohort based refined mortality, we found a 25% decrease in breast cancer mortality in the municipality of Copenhagen during the first 10 years following the introduction of mammography screening in April 1991 (3). We deliberately did not include data from Funen and Frederiksberg in that analysis, as cause of death data were not available at that time for the first 10 years of these two screening programmes.
Other commentators also note -

The analysis of population trends in breast cancer mortality in the presence of screening is complicated by the inability to measure exposure to screening, and the long period of follow-up required. Studies such as this one by Jørgensen et al obscure whatever benefit may be present with crude, insensitive methodology. While we expect to see a range of benefits from mammography, some small and some large, based on the design and quality of the screening program, its duration, and the participation rate of the target population, to argue that there is no benefit from modern mammography on the basis of such flawed methods means this paper contributes nothing of substance to the on-going debate

The US Preventive Services Task Force recommendations on Screening Mammography flawed

2010-03-16T15:18:00.000-04:00

Guidelines for mammography screening published by the U.S. Preventive Services Task Force (USPSTF) in November not only are based on flawed methodology, they also fail to address current breast imaging practice and data, making them obsolete, according to a critique published in this month's Journal of Diagnostic Medical Sonography

Author Kevin Evans, Ph.D., evaluated the USPSTF's report methodology and found that it did not meet established standards for systematic reviews (JDMS, January/February 2010, Vol. 26:1, pp. 19-23). Evans is chair of the radiologic sciences division in the School of Allied Medical Professions at Ohio State University in Columbus.

Evans used two resources to evaluate the USPSTF's report: the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a 27-point checklist, and the Assessment of Multiple Systematic Reviews (AMSTAR), an 11-point checklist.

The task force's report scored 7 out of 27 on the PRISMA checklist and 1 out of 11 on the AMSTAR list. These low methodological scores put in question the rigor used in developing the report, limiting it to a review of literature instead of a formal systematic review and reducing its overall scientific impact to a much lower level in the hierarchy of evidence, according to Evans.

"I picked two of the most well-known methods to evaluate systematic reviews and applied them to the report," he told AuntMinnie.com. "It's possible that USPSTF met these standards but failed to provide their methodology in the report. This becomes problematic in reading their guidelines."

The USPSTF's intention was to update its 2002 report by using other systematic reviews, meta-analyses, recently published literature, and data from the Breast Cancer Surveillance Consortium from 2000 to 2005. In its guidelines, it proposed the following, according to Evans:

Routine screening mammography in women ages 40 to 49 years should not be conducted; rather, this process should be biennial at ages 50 to 74 years.
A lack of published evidence currently exists to provide a guideline for screening mammography for women older than 75 years of age.
A lack of evidence exists for assessing the benefits and harms of using clinical breast examinations for women 40 years and older.
Self breast examination is not recommended to be taught to women by clinicians, as it is not a sensitive technique and raises a woman's level of anxiety.
A lack of published evidence currently exists to provide a guideline about benefits and harms associated with digital mammography or MRI instead of film-screen mammography.

USPSTF used data from film-screen mammography in its report, rather than taking into consideration that digital mammography was developed to address film-screen's limitations and is in widespread use, according to Evans. In fact, one of the puzzling things about the USPSTF report is its lack of any reference to the American College of Radiology Imaging Network (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST), conducted in 2005.

"USPSTF didn't make specific mention of DMIST," he said. "And yet they claim that more evidence is needed to provide a guideline about benefits and harms associated with digital mammography, instead of film-screen mammography."

"Other U.S. Preventive Services Task Force reports are routinely high quality," Evans said. "It's possible that the breast cancer screening task force did a good job but didn't spell out their methods. In any case, their report has created confusion for everyone, as well as our government officials."

If the U.S. Department of Health and Human Services had addressed the guidelines point by point, this confusion might have been put to rest earlier, Evans said.

"[After the guidelines were released], the Department of Health and Human Services responded by telling the public not to pay attention," he said. "They should have asked the USPSTF to provide an addendum with additional details on their review."

In the aftermath of the report's publication, USPSTF should take several steps to clear up the confusion, Evans wrote: It needs to provide an addendum that details its methodology, and if a systematic review as outlined by PRISMA or AMSTAR has not been conducted, it needs to be done.

"A revised set of guidelines is needed to assist patients in making the best decision about participating in screening breast examinations," he concluded.

Breast Cancer Screening Guidelines Changing again

2009-11-16T20:39:00.000-05:00

Furore in the colleges and societies, as the US preventive services task force releases it's new breast cancer screening guidelines, following the release of a paper in the Annals of Internal Medicine today

Their recommendations for starting screening at 50 (for women without a family history of breast cancer) with mammograms every 2 years, and ending at 74 years, more closely mimics the recommendations for screening in European countries, and broadly similar to the UK NHSBSP.

The task force is an independent panel of experts in prevention and primary care appointed by the federal Department of Health and Human Services.

The guidelines were published in today's (Nov 16, 2009) edition of the Annals of Internal Medicine

In order to formulate its guidelines, the task force used new data from mammography studies in England and Sweden and also commissioned six groups to make statistical models to analyze the aggregate data. The models were the only way to answer questions like how much extra benefit do women get if they are screened every year

Dr. Karla Kerlikowske, a professor in the department of medicine, epidemiology and biostatistics at the University of California, San Francisco said "The message for most women is to forgo routine mammograms if they are in their 40s.

Starting at age 50, Dr. Kerlikowske said, “the message is to get 10 mammograms in a lifetime, one every two years.” That way they get the most benefit and the least harm from the test. If women are healthy, she added, they might consider having mammograms every two years until age 74.

Nearly two-thirds of all women in their 40s had mammograms within the last two years, as did 72 percent of women age 50 to 65, according to an editorial by Dr. Kerlikowske that accompanies the report.

The Society of Breast Imaging and the American College of Radiology, the American Cancer Society, and many other respected professional organizations, have voiced strong opposition to the changes proposed in the articles.

It is the opinion of the SBI leadership that adopting these guidelines would result in a major step backward in women's healthcare and increased deaths from breast cancer.

Immediately, they provided a number of guidance documents and statements as follows (which is a model for speedy response to crises) -

STATEMENT FROM THE AMERICAN COLLEGE OF RADIOLOGY AND THE SOCIETY OF BREAST IMAGING:
USPSTF Mammography Recommendations Will Result in Unnecessary Breast Cancer Deaths Each Year

Talking Points in response to USPSTF Statement

Detailed ACR Statement on Ill Advised and Dangerous USPSTF Mammography Recommendations : Mammography Screening References

American Cancer Society Statement

Komen Screening Statement 11-16-09

NCI Statement

Rethinking strategies for breast and prostate cancer screening

2009-10-22T11:27:00.000-04:00

Twenty years of screening for breast and prostate cancer—the most diagnosed cancers for women and men—have not brought the anticipated decline in deaths from these diseases, argue experts in an opinion piece published Wednesday in the Journal of the American Medical Association

In an article published yesterday (Oct 21, 2009) in JAMA, Laura Esserman et al, one of our UCSF breast surgeons, and leader of the ATHENA project in the University of California, discuss whether we should be reconsidering looking at our screening tools for both breast and prostate cancer, and be more intelligent in their use.

"Screening does provide some benefit, but the problem is that the benefit is not nearly as much as we hoped and comes at the cost of over-diagnosis and over-treatment," said Laura Esserman, MD, professor of surgery and radiology, director of the University of California, San Francisco (UCSF) Carol Franc Buck Breast Care Center.

We acknowledge that screening is not perfect, as there are a proportion of women who are screened but would never die of the disease (lead time bias). Also there are the group of women who present as interval cancers due to their very different biology. These women still get their mammograms at the proscribed times, but tend to develop cancer between their screening tests.

"We need to focus on developing new tools to identify men and women at risk for the most aggressive cancers, to identify at the time of diagnosis those who have indolent or 'idle' tumors that are not life-threatening,"

Periodic screening may find some tumors early, but patients may not be screened often enough for lethal tumors to be detected in time to prevent death, leading the authors to conclude: "Without the ability to distinguish cancers that pose minimal risk from those posing substantial risk and with highly sensitive screening tests, there is an increased risk that the population will be over-treated."

The authors suggested that to improve screening, "a new focus is recommended for research and care to identify markers that discriminate minimal-risk from high-risk disease (and) identify less aggressive interventions for minimal-risk disease to reduce treatment burden for patients and society."

The authors made the following recommendations for early cancer detection and prevention:

Develop tests to distinguish between low-risk and lethal cancers.
Reduce treatment for low-risk disease. “Diagnosing cancers that don't kill the patient has led to treatment that may do more harm than good,” they wrote.
Develop tools for physicians and patients to help them make informed decisions about prevention, screening, biopsy and treatment.
Offer treatments individually tailored to a patient's tumor.
Work to identify the people at highest risk for cancer and use proven preventive interventions.

As part of the ATHENA project we are looking at these aspects across the whole of the University of California medical centers (UCSF, UCLA, UC Irvine, UC Davis and UC San Diego).
This is a mix of researcher and clinicians who are trying to put research to clinical use (bench to bedside medicine)

Targeting screening tests to the at risk population may give better outcomes with fewer so called "false positives" from screening, thereby benefiting the screened women the most. It will also save us from overtreating some of the lower risk/indolent cancers that occur.

NCI commentary is available in their bulletin

CAD and Screening Mammography: ready for prime time?

2009-09-29T14:52:00.000-04:00

In this months RADIOLOGY, Robyn Birdwell and Liane Philpotts share their different viewpoints on CAD and screening mammography. Both are well known mammographers in the North East, with Robyn being a guest of the RCR Breast Group at November's Annual Scientific Meeting

In the first of the two articles, Robyn Birdwell talks about the various CAD studies, and how the proponderance of data supports the use of CAD in screening mammography, and that "Having a system to aid the human eye that does nottake vacations, is not vulnerable to fatigue or environmental distractions, is without, emotion, and is designed specifically to assist the very human eye to "look over here" seems like a good idea"
The Preponderance of Evidence Supports Computer-aided Detection for Screening Mammography
Robyn L. Birdwell
Radiology 2009;253 9-16
http://radiology.rsna.org/cgi/content/full/253/1/9?etoc

In the second editorial article, Liane Philpotts points out that recalling patients from screening is sometimes more of an art than a science, and I am sure that many experienced radiologists would share her view.

One of the main issues with CAD is the necessary high false-positive rate of CAD prompts which subsequently means that the specificity is low, and we have the distracting factor of many false calls, while also knowing that not all cancers are picked up by CAD

Understanding of the limitations of computer-aided detection is important for those interpreting mammograms; this cautious approach to the use of computer-aided detection should help optimize this presently imperfect system and minimize the possible detrimental effects

Can Computer-aided Detection Be Detrimental to Mammographic Interpretation?
Liane E. Philpotts
Radiology 2009;253 17-22
http://radiology.rsna.org/cgi/content/full/253/1/17?etoc

Informing patients about breast cancer screening - risks of overdiagnosis

2009-09-14T12:18:00.001-04:00

A recent posting on the NHS National Prescribing Centre website blog addresses the issues of possible overdiagnosis of inconsequential cancers found as part of routine screening.

Blog link here

It is estimated that approximately 30% of breast cancers found at screening are of low grade and metastatic potential (low oncotype score) which may never kill the patient, and are therefore counted as being overdiagnosis.

Various tools are available to help primary care providers and others wishing to assist women to make informed decisions about whether to have screening or not.

Patient decision aids may help to guide women make the decision alongside the literature from the NHSBSP

Breast Cancer Risk in Female Survivors of Hodgkin's Lymphoma: Lower Risk After Smaller Radiation Volumes

2009-09-13T19:55:00.000-04:00

Breast Cancer Risk in Female Survivors of Hodgkin's Lymphoma: Lower Risk After Smaller Radiation Volumes
Marie L. De Bruin, Judith Sparidans, Mars B. van't Veer, Evert M. Noordijk, Marieke W.J. Louwman, Josée M. Zijlstra, Hendrik van den Berg, Nicola S. Russell, Annegien Broeks, Margreet H.A. Baaijens, Berthe M.P. Aleman, and Flora E. van Leeuwen
Journal of Clinical Oncology, Vol 27, No 26 (September 10), 2009: pp. 4239-4246

Link to Journal

Some good signs for the future in this article from the Netherlands on the breast cancer risk reduction following the reduction in radiation volumes for Hodgkin's disease sufferers.

Reduction of radiation volume appears to decrease the risk for Breast Cancer after Hodgkin's Lymphoma. In addition, shorter duration of intact ovarian function after irradiation is associated with a significant reduction of the risk for Breast Cancer

Image display contrast variation negates consistent mammo readings

2009-08-11T11:33:00.000-04:00

So it seems that much of the effects found by the DMIST Study were due to image contrast, inherent with digital imaging.................

A report in Radiology from the DMIST investigators in the August edition -
Radiology August 2009 252:348-357

Link to Journal

Readers most frequently attributed differences in DMIST cancer visibility to variations in image contrast—not differences in positioning or compression—between digital and screen-film mammography.

For women with both fatty and dense breasts, the most frequent reason given for the difference in visibility between film-screen and digital mammography was contrast differences between the two modalities. For women with dense breasts, contrast differences accounted for 70 of the 378 reasons given by the readers for better visibility. Positioning, compression, and technique differences accounted for only 37 of the reasons given for improved visibility

The odds of a cancer being more visible on a digital mammogram—rather than being equally visible on digital and screen-film mammograms—were significantly greater for women with dense breasts than for women with non-dense breasts, even with the data adjusted for patient age, lesion type, and mammography system (odds ratio, 2.28; P < .0001).

The odds of a cancer being more visible at digital mammography—rather than being equally visible at digital and screen-film mammography—were significantly greater for lesions imaged with the General Electric digital mammography system than for lesions imaged with the Fischer (P = .0070) and Fuji (P = .0070) devices. No comment was made about Hologic

The significantly better diagnostic accuracy of digital mammography, as compared with screen-film mammography, in women with dense breasts demonstrated in the DMIST was most likely attributable to differences in image contrast, which were most likely due to the inherent system performance improvements that are available with digital mammography. The authors conclude that the DMIST results were attributable primarily to differences in the display and acquisition characteristics of the mammography devices rather than to reader variability.

JNCI response to latest attack on screening by Grotzche et al

2009-06-26T18:16:00.000-04:00

JNCI response to latest attack on screening by Grotzche et al

In a very balanced editorial in today's JNCI, Liz Savage writes about the recent letter to The Times of London, and the claim that up to 50% of cancers are diagnosed unnecessarily by the NHS Breast Screening Programme (NHS BSP), but primarily the attack was again on the content of invitation leaflets sent to women at each invitation. These were changed or amended after their last attack in the media a few years ago.

Although some of their criticism remains valid, their wild claims that 50% of cancers detected by screening would never kill women remains unsubstantiated.
While it is clear, that some women have an exceptionally good prognosis, and probably would never have had disease that would have killed them, the majority (or even if it was just the 50%) would definitely have been helped.

Newer genomic typing of tumors may assist at an early stage of diagnosis (perhaps at initial core biopsy) which group of risk she is in, then if low, she may not need any treatment, or just hormone therapy instead of the current more invasive procedures.

Typing, such as that used by mammaprint (nl), may be able to distinguish between three separate groups, with minimal overlap. Laura Vantveer, on sabatical with UCSF from Holland is developing this technique on all our cancers treated at UCSF. The middle group of women with less aggressive subtyping and the ones most likely to be helped by screening, the high risk women showed marked aggressivity at any size, and appear to need everything (including the kitched sink) thrown at them, to get a response (CPR - complete pathological response)

Women with the least aggressive subtype, may be represented by this group who never progress to a 'killer' cancer, and may be overtreated by being offered chemotherapy, radiotherapy or even surgery. If these cancers NEVER kill anyone, maybe a different term - other than carcinoma - may need to be used to indicate that these are a different disease compared with the real cancers.

These are interesting times, and allow us to start thinking more intelligently about screening, and the outcomes from screening. In the meanwhile.... let's get back to ensuring that women are adequately informed about the benefits and risks at their invitation.

Triple negative breast cancers are increased in black women regardless of age or body mass index

2009-03-25T11:17:00.000-04:00

More on Triple Negative Breast Cancer amongst Black Women - OF ANY AGE
Triple negative breast cancers are increased in black women regardless of age or body mass index
Lesley Stead, Timothy L Lash, Jerome Sobieraj, Dorcas Chi, Jennifer Westrup, Marjory Charlot, Rita Blanchard, John-cho Lee, Thomas King, Carol L Rosenberg

Breast Cancer Research 2009, 11:R18doi:10.1186/bcr2242

Reported online, on the breast cancer research website. black women are three times more likely than other women to develop an aggressive form of breast cancer characterised by "triple negative tumours. The findings held true even when other risk factors such as lifestyle, age and weight were taken into account. In the United States, where the study was conducted, the overall incidence of breast cancer is lower in black women than in white women. But when black women do get breast cancer, it tends to be more advanced when diagnosed, has a higher risk of recurring, and a less favourable outcome.

Black women of diverse background have 3-fold more Tneg tumours than non-black women, regardless of age and BMI.

Researchers led by Carol Rosenberg of Boston University analysed 415 breast cancer cases and noted the number of "triple negative" tumours, so called because three critical proteins -- estrogen and progesterone receptors, and the HER2 gene -- malfunction.

"The odds of having a triple-negative tumour were three times higher for black women than for non-black women," said Rosenberg

It had been known that pre-menopausal black women were disproportionately affected by this deadly form of cancer, but the new study showed that these tumours were just as common in black women diagnosed before or after age 50, obese or not.

The higher prevalence of triple negative breast tumours in black women in all age and weight categories likely contributes to black women's unfavourable breast cancer prognosis

Early detection of second breast cancers improves prognosis in breast cancer survivors

2009-03-25T11:08:00.000-04:00

Early detection of second breast cancers improves prognosis in breast cancer survivors
N. Houssami, S. Ciatto, F. Martinelli, R. Bonardi, and S. W. Duffy
Advanced access to the publication of this paper, published online March 19, 2009
The impact of early detection of second breast cancers in women who have survived a primary breast cancer is unknown.
The researchers looked at information on 1,044 women who were seen at a medical center in Florence, Italy, between 1980 and 2005 and who had developed a second breast cancer -- 455 with cancer in the same breast (ipsilateral) and 589 with cancer in the opposite breast (contralateral). Of the second breast cancers, 67 percent were asymptomatic, and 33 percent were symptomatic.

The study found that chances of survival improved between 27 percent and 47 percent if the second breast cancer was detected in the early, asymptomatic stage rather than at a later stage when women started to experience symptoms.

The researchers also found that mammography
was more sensitive than clinical examination for detecting second breast cancers -- 86 percent vs. 57 percent. However, 14 percent of the cancers were detected only by clinical examination.

Asymptomatic cancers were smaller than symptomatic cancers, and early-stage cancers were more common in asymptomatic women (58 percent) than in symptomatic women (23 percent). Fewer women with asymptomatic than symptomatic contralateral cancer had node metastases, an indication the cancer may have spread.

Take home message:
Early detection of second breast cancers can reduce the risk of death by as much as half

First Report of a Necrotising Fasciitis of the Breast Following a Core Needle Biopsy

2009-03-19T10:51:00.000-04:00

The first report of the aggressive infection, necrotising fasciitis following core biopsy of the breast has been reported by researchers in France.

In a paper published in The Breast Journal this month, the department of OB/GYN in Montpelier, France, describe the case of a 50 year old woman one week after a 14g stereotactic core biopsy for a BIRADS 4 - suspicious lesion.

This is an aggressive infection with a beta-hemolytic streptococcus, which requires aggressive surgery to clear (debride) the infected tissue. Previously only described following mastectomy or breast reduction, this has now occurred following a simple routine core biopsy.

When consenting a patient for a core biopsy, we routinely describe the complication of infection, along with bruising and non-removal of the target lesion. Based on this case, our management should not change, but it remains a salutary lesson, that the most aggressive type of infection can occur in patients attending for a routine biopsy.

Continued attention to hand hygiene, and an aseptic field during biopsy remain important. Interestingly, the staff performing the biopsy did not have their skin tested for whether they were carriers of the B-Hemolytic strep, so we wil never know whether this was a factor

Moderate Alcohol Intake and Cancer Incidence in Women

2009-02-25T18:05:00.000-05:00

Published this week in the Journal of the National Cancer Institute, and available to members on the RCRBG website, is the revelation from the Million Women Study, that any alcohol is 'bad' alcohol, as regards breast cancer risk.

Valerie Beral's team at Oxford demonstrated that increasing but moderate alcohol consumption in women was determined to be associated with an increased risk of cancers of the oral cavity and pharynx, esophagus, larynx, rectum, breast, and liver, and with a decreased risk for thyroid cancer, non–Hodgkin lymphoma, and renal cell carcinoma. No differences in cancer risks were observed between drinkers of wine only and other consumers of alcohol

As ever, this could be seen as a scare story, but has to be taken in context with some of the other proven beneficial effects - eg a glass of red wine and its protective effects against heart disease.
If you are a woman who is at increased risk already from family history or a prior biopsy of atypia, maybe you are the one who needs to be aware of this finding and consider modifying your lifestyle.

In the greater scheme of things, everything has risks and benefits - look at HRT use itself, which was the original target of this research

RECIST criteria for tumour volume measurement for trials

2009-01-27T17:37:00.000-05:00

The first, formal revision of specific guidelines, known as RECIST (Response Evaluation Criteria in Solid Tumours), used by clinicians to measure tumour size and response to treatment, has been published January 20 in a special issue of the European Journal of Cancer
European Journal of Cancer
Volume 45, Issue 2, January 2009

The only proven way of measuring tumour response is by measuring size on imaging. This of course is subject to measurement error, and so criteria have been published that allow measurement of response in even small tumours (5mm)

When it comes to clinical trials of therapeutic agents, tumour shrinkage (objective response) and time to the development of disease progression are both important endpoints in trials, and, increasingly in recent years, trials have been using time to progression (or progression-free survival) as their main endpoint on which to base conclusions about the efficacy of a drug.

The new RECIST (RECIST 1.1 to distinguish them from the original RECIST) answer some of the questions and issues that have arisen since 2000 as a result of changing methodologies and available treatments

Key changes in RECIST 1.1 that will simplify, optimise and standardise the assessment of tumour burden in clinical trials are as follows:

A reduction in the number of lesions to be assessed for response from a maximum of ten to five, and from five to a maximum of two per organ
New guidance on making robust measurements of lymph node involvement
Confirmation of response is required for trials with objective response as a primary endpoint, but is no longer required for randomised studies, since the control arm of these studies provides appropriate means for interpreting results of the experimental arm
The definition of disease progression has been refined so that it not only includes a 20% increase in the size of the lesion, but also a 5 mm absolute increase as well, so that changes of just a few mms in very small tumours, which may be within the range of measurement error, are not unnecessarily described as disease progression
Guidance on imaging, including its use in the detection of new lesions and the interpretation of FDG-PET scan assessment

Rising incidence of cancer in survivors

2009-01-07T10:46:00.000-05:00

Rising incidence of breast cancer among female cancer survivors: implications for surveillance
Paper in this months British Journal of Cancer, British Journal of Cancer (2009) 100, 77 – 81 from the Netherlands, showing a marked rise in breast cancer incidence among female cancer survivors.

There are certainly questions raised from this study, in contradistinction to recent papers suggesting that most patients who are not in trials or undergoing adjuvant therapy can be discharged after surgery.

What implications will it have on your Cancer Centre's policy?

Do some screen-detected breast cancers spontaneously regress?

2008-11-25T11:31:00.000-05:00

An article in this weeks Archives of Internal Medicine from the Norwegian Screening Programme, discuss how there is an excess of cancers in the screened population, and how some of these regress spontaneously

Arch Intern Med. 2008;168(21):2311-2316

it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress

News from the Fall meeting of ACRIN at the Pentagon

2008-10-07T22:07:00.000-04:00

The Fall meeting of ACRIN was held last week at Pentagon City in DC.

Of note was the report from UCSF-led ACRIN study, on the use of breast MRI in the assessment of neoadjuvant chemotherapy -

"MRI is superior to mammography for evaluating the response to neoadjuvant chemotherapy for breast cancer, according to the early results of a trial from the University of California, San Francisco (UCSF) and nine other academic centers in the U.S. The results were presented at last week's American College of Radiology Imaging Network (ACRIN) fall meeting".

The study was developed under ACRIN's protocol 6657, representing the imaging side of the larger I-SPY (Investigation of Serial Studies to Predict Your Therapeutic Response With Imaging and Molecular Analysis) trial aimed at gauging breast cancer treatment response. Sponsored by the Cancer and Leukemia Group B Foundation (CALGB), the I-SPY trial is "testing imaging and tissue-based biomarkers in combination, predicting neoadjuvant response to standard chemotherapy," explained Nola Hylton, Ph.D., a principal investigator from UCSF who discussed the results.

Participants were scanned four times during chemotherapy, including once pretherapeutically, once after the first cycle of chemotherapy, and a third time between the anthracycline and Taxol agents. A fourth scan prior to surgery was intended to detect residual disease and evaluate the post-treatment sensitivity and specificity of MRI. Mammography scans were acquired to coincide with the first and last MRI scans

MRI measurements included morpholgic measurements of the tumors classified according to BI-RADS criteria for breast MRI, including tumor diameter measurements. "We're also measuring by computer the volume of the tumor and the microvascular parameters of the tumor, PE [percent enhancement] and SER [signal enhancement ratio]," used to distinguish malignant tissue, said Hylton.

he investigational software assesses tumor volume quantitatively based on functional rather than anatomic criteria, she explained. "We are measuring something that is based on how these tumors enhance, and assigning [volume] based on an algorithm calling it part of the tumor or not. So it's really a virtual volume [that defines] areas of the image based on function, in this case how the tumors enhance."

The investigators acquired one T1-weighted precontrast and two T2-weighted postcontrast scans, "and from that we looked at the early ratio of enhancement from the early time point to the late time point," she said. This calculation yields the signal enhancement ratio, which distinguishes tumor from nontumor. Another protocol ensures that the direction of diameter measurements remains constant over the course of multiple imaging exams

At the end of surgery, 43% of the patients were complete responders, 38% were partial responders, and 10% demonstrated stable disease. "There were a larger portion of complete responders among those who also received Taxol," she said. "And there were a total of 82 pathologic complete responders, meaning that there was no invasive disease left at pathology. Sixty percent of patients had a complete solid lesion, and 32% had two identifiable lesions in the breast.

Compliance with the study was surprisingly good, especially considering the complexity of the protocol, requiring both biopsy and multiple imaging exams in addition to treatment, she said. In addition, lesion morphology was very similar to a pilot study. There were 36 single masses; 65 multilobulated masses with well-defined margins; 66 lesions with area enhancement, irregular margins, and nodularity; 30 of the same without nodularity; and 19 patients with septal spread.

Once the analysis has been completed, more precise data will be presented at the 2008 RSNA meeting in Chicago.

Researchers Are Investigating Two New Potential Tools for Diagnosing Breast Cancer

2008-08-29T12:20:00.000-04:00

Researchers at Jefferson Medical College of Thomas Jefferson University in Philadelphia are investigating contrast-enhanced subharmonic ultrasound as a noninvasive exam that could help physicians make a diagnosis. In subharmonic imaging, pulses are transmitted at one frequency, but only echoes at half that frequency are received

In a study reported in the September 2007 issue of Radiology, researchers tested their technique on 14 women ranging in age from 37 to 66 who had 16 biopsy-proven lesions. The researchers used a GE Logiq 9 ultrasound machine that was modified to perform grayscale subharmonic imaging, transmitting at 4.4 megahertz and receiving at 2.2 megahertz. The women underwent precontrast imaging and imaging using contrast

The researchers’ results using subharmonic imaging were better than conventional ultrasound and mammography. Of the 16 lesions, four were malignant. Mammography had 100% sensitivity and 20% specificity for these lesions. Subharmonic imaging had 75% sensitivity and 83% specificity for the same lesions.

The other tool -
Researchers at Duke University in North Carolina have developed a new scanner that they believe is better at finding early cancers in women than conventional mammography, and it can also be used for diagnosis and monitoring of therapeutic response(s). It is a hybrid between a SPECT and a CT scanner they are collectively calling mammotomography

The researchers have done imaging observer studies using phantoms to compare x-ray digital mammography with CT. “We have been able to show a significant statistical improvement using CT compared to mammography,” Tornai says. “In mammography, you lose a lot of information because you have only a 2D image. With the 3D image that the SPECT/CT scanner produces, lesions become more conspicuous because overlapping tissues are removed. In contrast to x-ray tomosynthesis, a pseudo-3D x-ray imaging modality, the SPECT/CT system produces a uniform 3D image and does not require any breast compression.”

The hybrid scanner that the researchers have built from novel configurations of conventional equipment circles the breast as the patient lies on a specially built table.

The scanner is also able to see areas, including the chest wall, that traditional mammograms may not. They have tested the hybrid scanner extensively with phantoms and has begun successfully scanning subjects with known cancer.

Because SPECT requires IV injection of imaging agents, the SPECT portion of the scanner would not likely be broadly used for routine screening mammography. However, if it proves to be more effective, the hybrid SPECT/CT system might be especially helpful for women who are at high risk for developing breast cancer because of familial history or a genetic predisposition.

Breast SPECT/CT also could be used for women with dense breasts or implants because mammography is known to miss up to 25% of cancers in these women, Tornai says. The scanner and associated imaging procedure also should be less costly to employ than MRI

Potential mechanisms of breast cancer risk associated with mammographic density: hypotheses based on epidemiological evidence

2008-08-26T22:28:00.000-04:00

Lisa J Martin; Norman F Boyd
An interesting paper published online in Breast Cancer Res. 2008;10(1) by the above authors
This is reported in a Medline article this week

There is now extensive evidence that mammographic density is a risk factor for breast cancer, independent of other risk factors, and is associated with large relative and attributable risks for the disease. The hypotheses that we have developed from the observations described above are summarized here

Cumulative Exposure to Mammographic Density and Breast Cancer Risk

Mammographic density reflects variations in the tissue composition of the breast, and is associated positively with collagen and epithelial and nonepithelial cells, and negatively with fat. Increasing age, parity, and menopause are all associated with reductions in the epithelial and stromal tissues in the breast, and with an increase in fat. These histological changes are reflected in the radiological appearance of the breast, and are consistent with mammographic density being a marker of susceptibility to breast cancer, in a manner similar to the concept of 'breast tissue age' described in the Pike model. Like breast tissue age, variations in mammographic density may reflect the mitotic activity of breast cells and differences in susceptibility to genetic damage, and cumulative exposure to density may have an important influence on breast cancer incidence.

Mitogens, Mutagens and Mammographic Density

Mammographic density is influenced by some hormones and growth factors, as well as by several hormonal interventions, and is associated with urinary levels of a mutagen. We postulate that the combined effects of cell proliferation (mitogenesis) and genetic damage to proliferating cells by mutagens (mutagenesis) may underlie the increased risk for breast cancer associated with extensive mammographic density. As described above under 'Relationship of mitogenesis and mutagenesis', mitogenesis and mutagenesis are not independent processes. Increased cell proliferation can increase lipid peroxidation, and the products of lipid peroxidation can increase cell proliferation

Potential areas for genetic influence include variation in the regulation of the hormones and growth factors that act on the breast, the response and modelling of breast tissue to these stimuli, and the processes that are involved in oxidative stress and the generation of mutagens.

Use of Lidocaine gel pre-mammo may help to reduce discomfort

2008-08-18T11:55:00.000-04:00

Compression and the occasional discomfort and pain it brings in the breasts lead many women to avoid mammograms altogether.

However, results from a recent study from Boise, to be published in September 08 edition of Radiology, showed that application of lidocaine gel prior to a mammogram significantly reduced the degree of discomfort experienced.

Lambertz and colleagues recruited 418 women ages 32 to 89 who expected significant discomfort with screening mammography. Fifty-four of the women reported that they had probably or definitely delayed their mammograms due to concern over possible discomfort.

The women were randomized to receive placebos or premedication with acetaminophen, ibuprofen, and/or a local anesthetic gel followed by mammography screening. The gel was applied to the skin of the breasts and chest wall and then removed 30 to 65 minutes before mammography. The gel had no effect on subsequent image quality.

Results showed that oral medication produced no significant differences in breast discomfort, nor did other factors such as breast density. Women who received a topical application of 4% lidocaine gel, however, reported significantly less breast discomfort during mammography.

Eighty-eight percent of study participants indicated they would definitely get a mammogram the following year, and 10% said they would probably get a mammogram the following year.

"Women can now take charge of the situation," Lambertz said. "They can schedule a mammography appointment for a time in their cycle when their breasts are least tender, apply the gel at home, and travel to the appointment knowing they have taken steps toward a positive experience with this potentially life-saving procedure

Hot topics from Arizona - well you would expect that wouldn"t you!

2008-07-30T18:44:00.000-04:00

Last week was the 9th International Workshop on Digital Mammography in Tuscon, Arizona.

Most of the papers given are already online - at SpringerLink

Hot topics were Tomosynthesis, Dual Energy mammography - some using subtraction techniques, and others using contrast enhancement.

John Boone, a physicist from UC Davis in Sacramento also was describing his experience with Breast CT using a cone beam - good for resolution, equivalent radiation dose, but not so good for calcifications.

Mammography screening of the elderly - controversies

2008-07-08T10:01:00.000-04:00

Last month a paper was published in the Journal of Clinical Oncology entitled - Mammography Before Diagnosis Among Women Age 80 Years and Older With Breast Cancer from MD Anderson Cancer Center in Texas.

The study found that among those who had a mammogram every year or two before their diagnosis, 68 percent found the cancer at an early stage, compared with 33 percent of those who skipped mammograms altogether.

Their conclusion was that regular mammography among women > or = to 80 years of age was associated with earlier disease stage, although improved survival remains difficult to demonstrate. Health care providers should consider discussing the potential benefits of screening mammography with their older patients, particularly for those without significant comorbidity.

This sparked coverage by the New York Times, which did a good job of presenting the pros and cons of screening the elderly. Considering that the end point for measuring a screening program is mortality reduction, then it should be looked at in a proper light rather than just concentrating on reducing morbidity from the disease.

We have the occasional patient in San Francisco having screening mammograms in their eighties, similar to the NHS BSP in the UK, where patients can self refer. With the rising elderly population, and better breast-awareness, it may well be that we do more mammography in the elderly and reduce morbidity than we do for now.

FDA relaxes rules on FFDM regulation - could enable new technologies to get to the market quicker

2008-06-10T14:49:00.000-04:00

The FDA have made an announcement that would reclassify FFDM systems from the current class III category, which requires premarket approval (PMA) applications, to class II, which requires the less rigorous 510(k) process. The reclassification would eliminate or reduce the requirement for vendors to conduct large-scale multireader, multicase (MRMC) clinical trials prior to submitting applications for equipment approval.

If the proposal is adopted, the FDA will rely upon well-designed bench studies and limited clinical testing in lieu of large-scale MRMC clinical studies. Products using new technology, with dissimilar designs from approved systems, or having indications for use that are dissimilar from legally marketed devices of the same type, may be required to collect additional clinical data.

An MRMC study may be required to compare sensitivity, specificity, and receiver operating characteristic curves if the results of physical laboratory testing and mammographic feature analysis raise concerns by the FDA.

Vendors have been quick to respond, even with comments that the CR mammography market, particularly in Europe will not be affected due to the initial fast and extensive uptake of CR, but that newer technologies will get to market sooner. This is reflected in the announcement by Hologic, that they plan to have a device for tomosynthesis released at RSNA in 2009.

However, tomosynthesis may need to be subject to a large trial like the DMIST study, as it's eventual aim is to become the main screening tool for breast cancer detection.

MRI increases mastectomy rate

2008-05-17T21:30:00.001-04:00

Two interesting stories hit the headlines this week. The first concerned breast density, and the fact that passing through the menopause can greatly affect the rate at which a woman's mammographic (breast) density changes over time.
This was a report from the American Journal of Epidemiology
Am. J. Epidemiol. 2008 167: 1027-1036

The researchers retrieved and digitized 5698 mammograms from 1689 women who were imaged in 1990-2003 to evaluate PD in the Minnesota Breast Cancer Family cohort. The women completed two questionnaires, the first in 1990-1996 and the second in 2001, which provided extensive risk factor data. Postmenopausal women showed a decline in PD of 1.0% over a mean of 6.2 years, while premenopausal women showed a decline in PD of 1.8% over a mean of 4.0 years.

Further analysis showed that, before the age of 50 years, postmenopausal women who never used hormones had a higher PD compared with former and current users. After the age of 50 years, women who never used hormones had larger declines in PD than current or former users.

Higher BMI was associated with lower PD among postmenopausal women at any age after adjusting for covariates. And women in the 95th (highest) percentile for baseline PD showed greater declines in PD over time than women in the 5th (lowest) percentile.

You can get a FREE PDF of the paper from - here

The other story was widely reported in the NEW YORK TIMES this Friday. Thanks to press releases, details about the study which will be presented in Chicago at the annual meeting of the American Society of Clinical Oncology, which begins May 30 has got into the media.

The study revealed that "the percentage of women opting for mastectomy rather than lumpectomy began rising sharply after 2003." A possible explanation for the increase is that MRI "detects more possibly cancerous growths than mammography," which "could be causing patients and doctors to conclude that a lumpectomy, which removes just the part of the breast containing the primary tumor, may not be sufficient."

We certainly are doing far more MRIs, but in our case at UCSF, many of these patients are in trials. Wait until we start following the American Cancer Society Guidelines for women at high risk of breast cancer, with the increase in false positives we get, plus the increased anxiety because of family history...........

Ultrasound screening in HIGH RISK WOMEN - article in JAMA May 2008

2008-05-14T15:55:00.000-04:00

Wendy Berg and her ACRIN group published the results of Combined Screening With Ultrasound and Mammography vs Mammography Alone in high risk women in JAMA.

The ACRIN study in full is listed here

The JAMA abstract is here

Conclusions Adding a single screening ultrasound to mammographywill yield an additional 1.1 to 7.2 cancers per 1000 high-riskwomen, but it will also substantially increase the number offalse positives.

Breast cancer risk and aspirin use - report from the National Cancer Institute

2008-05-01T18:32:00.000-04:00

Nonsteroidal anti-inflammatory drugs and breast cancer risk in the National Institutes of Health-AARP Diet and Health Study

Gretchen L Gierach, James V Lacey Jr, Arthur Schatzkin, Michael F Leitzmann, Douglas Richesson, Albert R Hollenbeck, Louise A Brinton
Breast Cancer Research 2008, 10:R38 (30 April 2008)
Available online through breast cancer research

Conclusions
Breast cancer risk was not significantly associated with NSAID use, but daily aspirin use was associated with a modest reduction in ER-positive breast cancer. Our results provide support for further evaluating relationships by NSAID type and breast cancer subtype.

This story hit the headlines in the USA last night, with several analyses on NBC news. Overall the reaction and advice was sensible, but yet again we will have more questions to answer when we see our patients this week

NEW BIRADS FAQs released by the ACR

2008-04-30T12:48:00.000-04:00

While we discuss the pros and cons of some of our 1-5 grading systems, the American College of Radiologists has released an updated FAQ about the BIRADS classification system for breast imaging, widely used in Europe as well as North America.

Here is the link to the PDF file

Accreditation for Digital Mammography

2008-03-31T22:51:00.000-04:00

I have just posted a PDF document on the website advertising a course to see and experience a fully digital breast unit on the website - see the news at the top of the page. You could of course come and visit us at UCSF to experience this

In the USA, mammography is highly regulated under the MQSA (Mammography Standards Quality Act). Congress enacted MQSA in 1997, to ensure that all women have access to quality mammography for the detection of breast cancer in its earliest, most treatable stage.

This ensures mandatory minimum standards and accreditation of both equipment and staff

Equipment has to be accredited each year
Typical examinations for each breast type have to be submitted by the hospital
Reporting mammographers have to meet a minimum number of examinations per year

As part of accreditation of mammography units (we were just commissioning a new Hologic Selenia in our screening pavillion), all 'attendings' reporting digital mammograms require 8 hours of training/background knowledge, to legally report digital mammograms. This is checked by the FDA inspectors whose job is to insure compliance with the 'Act'.

Part of the training can be with an applications specialist, enabling you to get the most from your workstation, and how to use (and not abuse) your digital workstations. We were running a breast imaging update course in San Francisco last weekend, and covered Digital Mammography with 4.5 hours of AMA accredited CME, covering all aspects of Digital, including medico-legal aspects, pitfalls in reporting, IHE applied to FFDM, review of the trials and recent reviews, the use of CAD etc.

Some of the issues of working in a mixed environment (due to economic constraints) we are encountering every day, as we work with a mix of analogue, FUJI CR and Hologic FFDM. Our workstations are Selenia's but do not display the FUJI images as intended, which is where IHE is supposed to come in and ensure that images can be displayed, independent of vendor.

ARRS MRI Course

2008-03-09T22:31:00.000-04:00

The course was excellent, and covered the range of MRI based information with case studies, as well as Jeffrey Weinreb giving an excellent coverage over the debate about NSF and gadolinium based contrast agents

There was one registrant from Cheshire, but never got to see them there.

If this is repeated next year, I would recommend folks considering applying and attending for CME.

Viva Las Vegas!

2008-01-31T21:28:00.000-05:00

Well today I was supposed to be travelling to Las Vegas, where the American Roentgen Ray Society (ARRS) are hosting a Practical Breast MRI session at the Westin, similar to that held by the Radiology Academy in Norwich last April.

Weather has conspired against this so far. In California the rain is teeming down and 2 runways have been closed at San Francisco International Airport, with the associated delays, I am now experiencing what most Americans have to put up with on a regular basis. Hopefully will get off before midnight as we have a 7am start tomorrow.

The mid-West are having serious arctic weather right now, just like the UK appear to be having a similar arctic blast for the end of the week.

Does this remind you of the film - 'the day after tomorrow'?

Latest analysis of the DMIST trial - subset of women under 50 years

2008-01-29T15:08:00.000-05:00

In the February edition of Radiology, Eta Pisano reports on some of the sub-group analysis of the DMIST study data.
Radiology, February 2008, Vol. 246:2, pp. 376-383
The subgroup of pre- or perimenopausal women younger than 50 years old with dense breasts was the only one for which FFDM performed significantly better than FSM.
The AUC for digital mammography was 0.79 versus 0.54 for film-screen mammography. Sixteen cancers in this group were found with digital and missed with film-screen mammography, while only two were found with film-screen and missed with digital.

The results also showed a trend toward improved accuracy of FSM over FFDM in women age 65 or over with fatty breasts, but it was not significant, according to the researchers. In this group, 15 cancers were found with film-screen mammography and missed with digital, and four were found with digital and missed with film-screen mammography

Motile in-situ cancer cells (DCIS)

2008-01-04T16:43:00.000-05:00

Reported in this month's edition of The Journal of Cell Biology, there is evidence that malignant epithelial cells become motile within their own environment, similar to that occurring in the development of organs during embyrogenesis.

Although the cancer cells are not yet invasive (they do not have the ability to pass through basement membranes), motile cells may indicate the development of a higher grade, or aggressive form of cancer that is developing.
These type of motile cell may require fewer mutations to become fully invasive. Further work needs to be done to see if we can identify what cell lines are developing this way, and devise a test that will differentiate the more aggressive form of DCIS which needs a more aggressive surgical treatment from the outset.

Cost-Effectiveness of Digital Mammography Breast Cancer Screening

2008-01-01T23:13:00.000-05:00

A paper in the Annals of Internal Medicine published today 1 January 2008, Volume 148 Issue 1, Pages 1-10, was part of the economic analysis of implementing the move to digital mammography as part of the ACRIN 6652 DMIST study, which reported in October 2006.

The authors Dr. Anna Tosteson et al, from Dartmouth Medical School, performed a discrete event-simulation model to evaluate the cost effectiveness of Digital Mammography (FFDM) compared with analogue (film-screen) mammography. The headline result shows that there are NO cost savings by moving to digital unless breast screening is targeted to a higher risk population where digital mammography has been proven to have a better track record for detecting cancer like younger women with dense breasts.

While this study is useful as it relates to QALYs and cost per life year saved, there are other real world events that also have to be taken into consideration when deciding whether to upgrade your mammography machine to digital.

One of these factors is the decreasing production of medical x-ray film and chemicals, which will eventually be phased out. There are other benefits of moving to digital, which include the eventual elimination of film libraries, physical film hanging, along with the elimination of having to deal with dangerous chemicals and the environmental aspects of disposal of the used developer and fixer. Photographic emulsions are steadily being phased out, so in the medium to long term, there is no real question that digital mammography has to be the final solution.

Perhaps we were originally aiming too high in the original trials, as scientifically it is correct that there has to be a benefit compared with the gold standard examination. An economic evaluation was correctly performed but maybe the most important finding is that digital mammography in its 2003-4 iteration was as good as, and occasionally more accurate than conventional mammography.

Pragmatically, when replacing a mammography unit, a digital one should be purchased. Newer versions of FFDM are better quality, and can only improve our ability to diagnose breast cancer. Workstations and comparison with prior mammograms are now the current challenges facing us as we move forward in attempting to advance the diagnosis of breast cancer.

Microbreweries and celebrating the holidays

2007-12-22T22:30:00.000-05:00

Holiday Season is well upon us again, and the hospital has closed down for the holiday break. We return to work on Wednesday (Boxing Day).

Celebrating "Christmas cheer" in a micrbrewery here, means drinking the seasonal beers, and last night we went to the Gordon Biersch microbrewery on the Embarcadero. As part of the welcome you are offered a taster of small glasses of several beers, including the seasonal beer, which had both a subtle taste of fruit, along with quite a kick at the end (8% wbv alcohol)

The beers are placed on the informative sheet of paper, shown above, which allows you to choose the beer of choice for the evening.

Happy Holidays everyone

RSNA Breast Imaging - Ultrasound

2007-12-10T17:39:00.000-05:00

US screening of women with personal history of breast cancer: Cancer detection in the contralateral breast (Korea) - US can detect mammographically occult cancers - increased from 4 to 9 cancers in 1314 women
Breast Ca staging using cortical thickness of axillary lymph nodes at ultrasound (Boston, MA) - Maximum cortical thickness of >3mm (compared with Nottingham Criteria of 2mm) is a simple and accurate sonographic criterion (US + FNAC/core gave sensitivity of 91%, specificity of 100%, PPV 100%, NPV 72%)
3D US for the identification and diagnosis of breast cancer (Peoria, IL) - SomoVu 3D reconstruction enabled visualization of mammo occult and MR occult lesions
US screening of mastectomy site for detection of non-palpable recurrent cancer (Korea) - some recurrences visible when non-palpable
Reproducibility of tool for breast ultrasound assessment and reporting (San Diego, CA)
Adjunct diagnostic value of US in patients with suspected ductal breast disease (Rome, Italy) - Important role in the diagnosis of benign focal masses and duct ectasia. Can replace galactography
Elasticity imaging of the breast: results of a multi-center trial (Korea) - high sensitivity in characterizing malignant breast lesions. Variability in specificity between centers requires standardization of the technique
US Elastography of breast lesions associated with suspicious microcalcifications detected at mammography (Korea) - Malignant calcifications have less strain (HARDER) than benign calcifications
Inter and Intra-observer agreement in interpretation of US elastography (Korea) - Interobserver agreement was moderate to substantial and intraobserver agreement was substantial to perfect for the visual assessment of strain images

RSNA Breast Imaging - Computer Aided Detection

2007-12-10T11:04:00.000-05:00

CAD of malignant and benign clustered microcalcifications in temporal pairs of mammograms and it's effect on Radiologists characterization performance (Ann Arbor, MI) - increased diagnostic accuracy when using interval change analysis
CAD review of false -ve FFDM exams on priors (Korea) - CAD correctly identified 34 0f 46 (73%) of retrospectively visible lesions and 14 of 14 (100%) of actionable lesions
Critical analysis of studies measuring the effectiveness of CAD in screening (Chicago, IL) - while each individual study is small, the aggregate of studies indicate that performance is comparable to double reading by radiologists
An inductive CAD system using genetic algorithms for detection of calcification on mammograms (Orinda, CA) - CAD teaching itself and learning from it's mistakes
US CAD into clinical practice: and observational study (Chicago, IL) - cautious optimism using CADx
Independent US CAD BI RADS assessment of breast lesions (Philadelphia, PA) - Initial study showed significant improvement in the hands of trained users
MRI detected suspicious findings: comparison of kinetic feature measurement using CAD in benign and malignant lesions (Seattle, WA) - ONLY delayed kinetics categorized by the most suspicious type of enhancement were significantly different between B/M. In keeping with MRI BI RADS recommendation of reporting the most suspicious kinetic curve. Any washout enhancement was assoc with malignancy in nearly 50%, entirely persistent with 13.3%
Application of CAD in MRM: do we really need whole lesion time curve distribution analysis? (Jena, Germany) - Higher diagnostic accuracy for curve distribution data after application of a statistical regression model compared to semi-automatic detected 'most suspect curve' type

RSNA Breast Imaging - Mammography

2007-12-06T14:32:00.000-05:00

Assessment of microcalcifications with large core biopsy (VAB) in a screening population (Weisbaden, Germany) - biopsy of all clusters of microcalcification lead to an improvement in their benign/malignant ratio through increased detection of DCIS
Coronary Artery Calcification on mammograms ? correlates with coronary artery disease? (Staten Island, NY) - No correlate with C.A.Disease, but with age only
Mammo features post Mammosite therapy (Norfolk, VA) - 7x more likely to get seromas and 3.3x to get fat necrosis compared with whole breast irradiation
Single dilated duct at Mammography - outcomes (San Francisco, CA) - Rare finding with a greater than 2% chance of malignancy. Should be called a BIRADS 4A rather than a 3 assessment
Breast density evaluations from mammograms and central tomosynthesis projections (Philadelphia, PA) - Correlation better with tomosynthesis
LCD vs CRT displays for digital mammography calcs and masses (Korea) - Comparable performance, but LCDs better than CRT for microcalcifications - non significant

RSNA Breast Interventional Papers 2

2007-11-30T15:03:00.000-05:00

More interventional papers given on Wednesday morning -

Is surgical excision of core biopsy proven benign papillomas necessary? (Durham, NC) - close imaging FU is all they do in their practice.
Underestimation of papillary lesions by core: correlation with surgical excision ( Scottsville, NY) - 6% underestimate by core. 91% of lesions were identified as atypical
Follow-up rather than excision for papillary lesions with VAB (Philadelphia, PA) - 11g VAB can be safely followed rather than having surgical excision
How many calcs for diagnosis in VAB for non-mass calcifications? (Korea) - 6 or more cores should be obtained
Impact of 10g Vacora and 9G Suros ATEC biopsy for MRI guided biopsy (Bonn, Germany) - Lesions sampled at VAB reduced the chances of localisation biopsy
8G vs 11G needle diagnostic accuracy for stereo cores (Boston, MA) - improvement of over 90% by using 8G for calcs
False -ve rate for 14G core biopsy (Korea) - accurate method for diagnosing cancer
Clip displacement following VAB, comparison of conventional and gel markers(Vienna, Austria) - SenoRX clips cw Micromark clips. Displacement of up to 20mm with conventional clips. Conventional clips should no longer be used.
Diagnostic accuracy of 14G core biopsy for Phyllodes tumours (Korea) - tendency to UNDERSAMPLE.

RSNA Mixed Papers

2007-11-30T14:50:00.000-05:00

Comparison of Mammo, US and MRI in evaluation of DCIS extent (Korea) - MRI better correlate with pathology
Correlation between Mammo and US findings of node -ve IDC (Korea) - HER2 +ve correlated with segmental microcalcs with a mass on US
Performance of electrical impedance device to detect cancer in women (Charleston) - HEDA breast scan has a better diagnostic accuracy for breast cancer detection than mammography in women under 50 yrs and small breasts, but no difference with normal sized breasts.

RSNA DIGITAL MAMMOGRAPHY Papers

2007-11-29T18:03:00.000-05:00

Adding tomosynthesis to FFDM reduces callbacks by 43%, regardless of breast density (Boston)
Comparison of Tomosynthesis and FFDM in an OP symptomatic setting (Amsterdam) - No differences found between the 2 techniques in their population
Tomosynthesis vs conventional: comparison of breast mass detection and characterisation (Ann Arbor) - More masses detected by tomosynthesis. Better margin assessment but same malignancy rating
Comparison of FDDM and SFM within a population based UK screening programme (Barts, London) - Similar recall rates, cancer detection and PPV. FFDM detects larger invasive tumours in the 50-60 age group
Digital monitor zooming vs magnificaton FFDM ( Korea) - Better quality of image and increased confidence of diagnosis of radiologists when using magnification rather than simple magnification
Improved diagnostic accuracy with contrast enhanced FFDM (Berlin)
Technical recall rates FFDM vs SFM (Houston) - digital significantly LOWER TR rate regardless of whether there were prior mammograms available

RSNA Breast Interventional Papers

2007-11-29T17:49:00.000-05:00

Axillary US in SLNB (Korea) - including US localisation to prevent technical failure of SLNB or false -ve when tumour filed with malignancy
Radiofrequency ablation of breast cancer and assessment of ablation zone (Glasgow) - Safe and effective in achieving cell death with CE US to assess immediate response
Cryoablation vs radiofrequency ablation of small breast cancer: measurement with 3T MRI imaging ( Rome) - US guided ablation feasible and reliable. CE MRI ideal method to quantify procedure efficacy
US mammotome excision of low risk benign lesions (Korea) - can replace surgical excision for low risk benign lesions
US mammotome excision of benign intraduct mass for treatment of nipple discharge (Korea)
US mammotome excision of benign papillary masses (Korea) - to preclude surgical biopsy

RSNA HIGH RISK SCREENING SESSION

2007-11-28T12:39:00.000-05:00

Wendy Berg presented 2 papers with the early results of the ACRIN 6666 trial
When added to mammography in the high risk setting, the diagnostic sensitivity of screening increases. The second paper showed the serious downside with a large proportion of false positive screens with additional unnecessary biopsies.

Increased workload/demand for breast MRI as a result of the 2007 American Cancer Society guidelines on screening high risk women, similar to the October 2006 UK NICE guidelines
It was shown that in the USA, current units could theoretically cope with the increased numbers of screening examinations 2-3 per week, without additional investment.

Nick Perry hits the news

2007-11-27T14:16:00.001-05:00

Nick managed to cause a few headlines yesterday with the presentation of data from the Princess Grace Hospital, showing that women in the city have denser breasts than outside of London.

Thanks to the RSNA press releases, it hit the BBC

So NOT relevant that this was a selected population with a higher use of hormones then??
Would be interesting to do the same thing with the Bart's population

Breast MRI Papers

2007-11-25T23:06:00.000-05:00

Today in the Arie Crown Theater, there were some interesting papers on -

Review of false negative cases (small size and masking with enhancing parenchyma - Chicago)
Despite the use of pre-op MRI, no increase in Mastectomy conversion rate (San Diego)
MR CAD - great for IDC but only 50% for DCIS (Toronto)
Small cancers (<5mm)>
Kinetics good for mass enhancement BUT NOT non-mass like enhancement (Chicago)
Value of MRI in work up of lobular Ca (Nice)
MR in occult metastatic malignancy - neg exam means treat axilla only (Milan)
MR Galactography - initial experience (Erlangen)

RSNA STARTS TODAY

2007-11-25T08:08:00.000-05:00

First day at RSNA today. Some breast MRI papers and the film interpretation session.
Hot topics to follow in later posts

Sentinelle MR Breast Biopsy Table

2007-11-21T15:23:00.000-05:00

Interesting day looking at the Sentinelle breast biopsy for MR.
Their Vanguard table is installed in the UCSF breast center MRI facility at Mount Zion.
The software they use to analyze and target lesions to biopsy is called Aegis, and is a very simple system to use.

The table is able to support the patient in a comfortable position with arms down by her side for the scan and biopsy. The table can also be moved out of the MR room to a separate biopsy room, so that the MR can continue being used, compared with other types of biopsy which require the patient to remain in close proximity to the magnet. Looking forward to using and developing biopsy with this table

BACK TO FRONT FILMS AND BIRADS

2007-11-19T21:58:00.000-05:00

One of the hardest aspects of reporting in the USA is reading mammograms the opposite way to having the patient facing you. Of the centers I have visited in the USA, some view films the 'right' way around, and some (including UCSF) read back to front!

When reporting in UCSF however, a score is given for breast density followed by a score for each breast in turn, starting with the right, then the left, followed by an overall BIRADS score. The films have been read by the residents, before the 'attending' does a readout - essentially dictating the result. In San Francisco, there is a database started by Ed Sickles, which is what the residents use to enter the data, and a patient report is generated.

I wonder how long it will take to adjust to reporting films in mirror image configuration

My new office

2007-11-18T10:55:00.001-05:00

Well, after attending a research meeting and getting my UCSF ID badge from the Police Department, I was awaiting my office to be allocated, but there is a shortage of space. As a result, a quick trip to Sausalito was called for, and a lovely lunch was taken overlooking the bay.

The IT guys are meeting with me Monday to explain the choice of computer for my office - I think I need a quad core Mac Pro with 30 inch display, as I use OSIRIX as a DICOM workstation for mammography.

It's tea Jim, but not as we know it

2007-11-17T12:49:00.000-05:00

My first week in San Francisco has been different to what I expected. The flight from Heathrow was delayed arriving due to strong headwinds, but the process through immigration was far easier than previously. The border guard was very pleasant, and took us through the paperwork for the I-94 that we had to complete when entering the country with an H1B visa.

Once we arrived at our rented apartment, and we had settled in, sleep took over. The great thing is that there is a Safeway across the road, so it was easy in the morning to get the essentials needed for breakfast, especially as the store opens at 5AM!!!. (see photo above - shot from the apartment)

I bought some Twinings Tea Bags, expecting them to be similar to home, but the whole taste thing was just so insipid!!! I have had that problem with Lipton's tea before, but never with 'British' teas. Oh well. Now I know why I used to take PG tips from Sainburys or Tescos to our vacation home in Florida. Obviously a job for the next trip home.