Imagine finding a lump in your chest – it's big, and you can feel it with your fingers. So you…
Imagine finding a lump in your chest – it’s big, and you can feel it with your fingers. So you go to a breast examination clinic, and the doctor will send you to a mammogram image center.
You expect a quick diagnosis – it is a big lump after all – but the radiologist finds nothing on the scan.
Radiologist orders an ultrasound, the next step in breast cancer imaging, but still can not see it.
The tumor is obviously invisible, hidden in a lining of connective tissue and glands.
That’s what happened to Lisa Van Liefde 2003, when she was diagnosed with breast cancer at 46 years.
“It was almost as scary as the diagnosis ̵
1; knowing it was there but it did not get up,” she said. “Then the question was” Who knows if there had been there on my previous mammogram? “It must have been a smaller size and it was missing.”
Van Liefde had something called “dense breast tissue”, a normal physiological condition that increases the woman’s risk of developing breast cancer. It’s common – about half of all women over 40 have dense breast tissue, according to the National Institute of Health. Younger women tend to have higher breast tightness, which decreases with age.
Extremely dense breast tissue can make screening for breast cancer almost impossible.
“The person with dense breasts has an increased number of driving elements, which means that their breasts can produce more milk – and that’s good – but when it comes to breast cancer, it’s bad,” says Jonathan Sims, radiologist at Oregon Imaging Centers in Springfield
It is equally important a risk factor that has direct family history of cancer, he said.
Inconsistent cancers in dense breasts can be undiscovered until they grow large enough to have a breast examination. But with the implementation of new screening technology risk assessments, increased awareness of breast fatigue risk and regular self and clinical breast tests, also difficult to find breast cancer, are found early, said Sims.
A game of Genetic Russian Roulette
Van Liefde followed the American College of Radiology and the Society of Breast Imagings guidelines: annual mammogram for all women 40 or older.
The biggest benefit of regular mammographic screening is that higher rates increase the risk of catching breast cancer at their very beginning, when they are less and easier to treat, Sims said.
However, as Van Liefd’s case nothing is easy about breast or cancer detection, he said.
“It’s not just a disease. There are about 15 different types of breast cancer, and they look all different,” says Sims.
Breasts vary and vary more than other parts of the body that get cancer – every woman’s breasts are physiologically unique and they change through a woman’s monthly menstrual cycle and during her lifetime, Sims said.
“So you try to find something that looks variable in a process that is completely variable from individual to individual and variable within every single woman based on her life cycle. It’s extremely, very complicated, “he said.
In dense breasts, tissues of fibrous and glandular tissues block the x-rays of a mammogram, which sometimes conceals cheating cancer.
When a cell divides it must copy one billion DNA instructions to another cell, according to Dr. Benjamin Cho, oncologist at the Willamette Valley Cancer Institute in Eugene.
“When you do, mistakes can be made. And when these mistakes are made, each time a mistake can cause a cancer, Cho said. Mutations in cells occur all the time, but most are eliminated by the immune system.
When a woman’s breasts are dense there is “more and more elements participating in the genetic Russian roulette,” said Sims, meaning she has a higher chance of developing breast cancer.
At Cedar Clinic, another training center in Eugene, uses director and radiologist Dr. Michael Milstein a computerized risk assessment program to estimate the woman’s lifetime risk for developing breast cancer. It is a system that they implemented three or four years ago as most imaging services use, he says, and consists of a number of questions and answers. Milstein is looking for patients who fall in the “high risk” category – 20 percent or higher.
For high-risk patients with dense breast tissue, he can recommend ultrasound or magnetic resonance formation. MRI is not a good screening tool for women with low to moderate risk because they can show too much detail, and harmless breast changes can look suspicious. But MRI is useful for high risk patients and evaluates the extent of already diagnosed cancer, said Sims.
Breast Cancer Survival Linda DeHart was a breast cancer nurse navigator at the Willamette Valley Cancer Institute and retired in 2012. She remembers many women who found lumps in their breasts that were not found with mammograms during their time there.
There was a connection between radiologists and primary physicians – many family practitioners reported mammography results to patients and were not aware of the problems with dense breast tissue, DeHart said.
“It took me a while to get it,” she said. “They have not come into contact with dense breast tissue yet.”
In the time since Van Liefde’s initial diagnosis 15 years ago, 35 states have adopted laws in the last seven years that require radiologists to inform patients about their chest tightness or high chest risk, including Oregon 2014.
It’s a new one contact point in the risk of breast cancer and discovery, as radiologists are looking for ways to effectively manage it.
New Technology and a Triangular Strategy  In an attempt to improve diagnostics, many imaging centers switch from 2-D mammograms to 3-D mammograms, something called digital tomosynthesis.
Some radiologists hope this new type of mammogram helps to get cancer in thick breast tissue, and a 2014 study in the Journal of the American Medical Association shows that it increases the number of cancer rates.
“It has made us able to find more cancers in smaller size,” said Sims.
The study also showed a reduced patient recurrence rate, which means fewer patients were recalled for further screenings, which happens when something suspiciously but unclear is noted on a mammogram. The 3-D mammogram gives radiologists a more complete and detailed image of the breast tissue and helps them to distinguish suspected deviations from benign changes.
Oregon Imaging Centers began using 3-D in 2015. Their cancer detection rate has increased from 4 cancers of every 1,000 screenings to 5 cancers out of 1,000. And their recall rate dropped by 2.5 percent – from 7.5 percent to 5 percent, says Jennifer Cantu, head of the women’s image processing and looking at the Oregon Imaging Centers.
3-D is more expensive than a 2-D mammogram when paying a pocket, and depending on where the patient goes it can cost $ 85 to $ 100, Cantu said.
But most insurance companies now cover it, “said Sims.
Both the Oregon Imaging Center and Cedar Clinic provide 3-D mammograms to all their patients. But it’s not idiotic.
“Even 3-D could lack a cancer that grows in very dense tissue,” says Milstein.
Some types of breast cancer are only present as a lump or thickening and do not occur on mammograms or ultrasound, according to Sims.
“Therefore, self-examination and clinical breast examinations are crucial,” he said.
Sims recommends a triangular approach to breast cancer screening: annual mammography starting at 40 annual suicide tests and annual clinical examinations.
“The three-dimensional method has diagnosed breast cancer from having a 40 percent mortality rate down to 4 percent – a 10-fold decrease,” said Sims.
When Van Liefde found her lump she had a recent mammogram.
“When they finally got MRI and got the pictures, it was like a hot dog – it was already so big and it was almost touching my chest wall,” said Van Liefde. “But the bottom is, it was a good tumor and they could not even see it.”