Dense breast tissue? Issues and comparative techniques

I’ve recently become involved - thanks to another cancer survivor friend back in New York state - with the Are You Dense campaign to inform women of the risks involved with relying too heavily on mammography alone if they have dense breast tissue as defined by the BIRADS Scale - a way that radiologists can classify the images seen on a mammogram.

Here’s is a basic bit on the physic and limitations of mammograms that you should be aware of, particularly if you pre or peri menopausal:

Basic Physics of Mammography:

X-ray images depend on differences in x-ray stopping power (attenuation) to separate tissues. In general, a clear separation between normal functioning tissue, and abnormal cancerous tissues is not possible since their attenuation if very similar. However both functional tissue and cancer can be separated from fatty storage tissues which normally surround active breast tissue, even in lean persons. This is due to a substantially lower attenuation caused by fat.

In older women, the functional glandular tissue diminishes, leaving only thin supporting tissues clearly outlined by fatty tissues. Mammography in these “mature” breasts is very effective, since even small cancers are well outlined by fat. In addition, many cancers develop calcium deposits which strongly stop X-rays and are easily seen on mammograms.

Basic Limitations of Mammography:

Since mammography cannot separate normal gland tissue from tumors, it is much more effective when gland tissue diminishes with age. Many women retain glandular tissue as they “mature”, and it camouflages tumors until they are large. As you might expect, the young women’s breast normally contains more active tissue, which again interferes with detection of small cancers.

Breast Composition Determination:

The ACR-BIRAD system recognizes this limitation by reporting the background composition of the breast in categories:

1.) Almost Entirely Fatty: Mammography very effective, sensitive to even small tumors.

2.) Scattered Fibroglandular tissue: Minor decrease in sensitivity.

3.) Heterogeneously Dense tissue present: moderate decrease in sensitivity.

4.) Extremely dense tissue present: marked decrease in sensitivity.

Mammography does retain some value even in dense breasts, by detecting calcium deposits (which are so dense, surrounding tissue does not interfere), but is not reliable in detecting small non-calcified cancers. In general, women with “dense” breasts remain so from year to year, and it is possible to let a women know when she cannot depend on mammography. In dense breasts, more emphasis on self-examination may be appropriate, particularly if there is a family history of breast cancer.

My breast cancer -  as determined by mammogram alone here in Reno - was supposedly ‘early stage’. Unfortunately, that wasn’t really the case. Had I allowed treatment, using this inaccurate staging, my chances of survival would have been very slim at best. Even pursuing a biopsy here would have set me on a course of disasterous results. Canceling my surgery without so much as discussion of a biopsy - that had been hastily scheduled by a local surgeon - I went OUT OF THE AREA to get a second opinion. By out of area, I don’t mean to the next town. That’s not out of area. I went to the University of Texas, MD Anderson Cancer Center in Houston, Texas which is a multi-disciplinary cancer center. There are many multi-disciplinary, comprehensive cancer centers located around the country and you probably have one near you.

I chose MD Anderson because, A- they were consistently ranked as either the number 1 or 2 leading cancer center in the entire country, B- what they told me was so educational/informational/rational and made such good sense in a way I could understand, that there was no question of going elsewhere. They made a strong, comprehensive case and backed it up, unlike the docs in Reno who seemed to be playing it by ear.

Bottom line: My cancer WAS NOT EARLY STAGE. It was late stage and large, requiring an entirely different treatment protocol. This was because I had extremely dense, fibrocystic breast tissue which had obscured the tumor. I knew about this from an ultrasound years before, but nobody ever explained how this mattered to me - how it would decrease my chances of getting an accurate mammogram, and find a cancer early when it was most treatable.

There are different types of breast imaging modalities now available. They each have their pluses and minuses. But when used appropriately - in concert with each other - they provide powerful tools to accurately depict and diagnose breast cancer at its earliest stage.

You can click on this image for more information

Here is a great comparative discussion of the different breast imaging modalities. The include breast ultrasound, Molecular Breast Imaging, Breast MRI, PEM and others.

To this end, however, it’s imperative that more women understand their own breast tissue density and what that implies regarding the ability of diagnostic radiologists in their area to get the best, most precise picture of their breast tissue and any abnormalities. Connecticutt has actually passed a law that women must be informed of this. Every state should have this mandate on their books, despite what the TeaParty and Libertarians think about mandates. In this case, at least, they save lives.

One caveat is important to remember. Ultrasound - which is an extremely accurate and useful way of viewing breast tissue - is highly dependant on the skill, experience and overall expertise of the technician/operator. At present, there is a shortage across the United States of ultrasound techs that can truly utilize this modality to its best. This is another reason to get the hell out of your local area and go to a cancer center - somewhere that does nothing but breast imaging - by the thousands.

These centers attract the best of the best in technical expertise - like MD Anderson and other comprehensive cancer centers. There is simply no substitute for this, since that initial diagnosis and staging is so critical to the ultimate outcome of breast cancer treatment and whether the cancer recurs.

At MD Anderson, the doctor that did all the ultrasounds on my breasts has been a leader in the field for many years. He was able to actually assess the involvement of the lymph nodes prior to any surgery or biopsy. Later, when a suspicious lesion was found, he was able to guide a Fine Needle Aspiration biopsy - with the Pathologist and her microscope right in the ultrasound room to read it immediately - by ultrasound. It was determined right then and there that it was a benign lesion. This put my anxieties to rest immediately - no waiting around for a report a week later.

Every woman should have some clue as to what the different ‘architectures’, tissues, masses and such look like and what the meanings are - this keeps you from being unnecessarily frightened by a report. Remember, knowledge is power. It can also help you sleep nights.

Read through the information on this Creighton University mammography website. Bookmark it. Refer to it before you get your mammogram, and even print it out and take it with you so that you can rationally discuss any initital findings right there with the radiologist.

For more information on breast tissue density, click on the following:

So, please … get the facts. Read all you can. Don’t become a victim of the local ‘we’ve always done it this way’ mentality. You get one first chance to beat breast cancer - any cancer - and you MUST get it right the first time.

You may not live to be a ‘wish I had only …’

-maven

Ask your cancer related diet and nutrition questions for answers from MD Anderson Cancer Center experts

NOTE: You must ask during this week to be included in this weeks forum.

Ask the Expert

A cancer diagnosis always comes with questions. How is it treated? What can I expect? Questions like these are best answered by physicians and other health care professionals who deal with cancer every day. Anderson Network’s Ask the Expert message board allows patients and caregivers to get accurate, credible answers from MD Anderson cancer experts for issues that may arise during or after treatment.

Ask the Expert will focus on different cancer-related topics. Questions submitted by you will be answered by MD Anderson faculty and staff members chosen to address topics in their fields of expertise.

Next Forum:

December 6-10, 2010

Diet Makes a Difference

Linda Pataki, L.D.

Supervisor

Clinical Nutrition

Please note that the message board will be active only during the posted dates for each topic. However, previous topics will be archived so that you may access the information. If you have questions regarding the board or topic, e-mail andersonnetwork@mdanderson.org. Please read the message board standards below, then click the “I Accept” button to submit your question.

How breast cancer biopsy is performed

I have had three different types of breast biopsies, as part of my treatment down at the University of Texas, M. D. Anderson Cancer Center in Houston, Texas. Fine Needle Aspiration, Core Needle Biopsy and Stereotactic Breast Biopsy.

Here’s the first thing to understand: none of them were so painful that I needed any more than a local anesthetic and some deep breathing/relaxation exercises during the procedure.

They were performed by a pathologist armed with a big microscope right there in the exam room. This was especially cool when a few months later, during a routine mammogram, they spotted something suspicious. I was taken from mammography, right across the hall to the ultrasound diagnostic suite where the top guy ( who I adore: Dr. Patrick Dempsey) came in with a pathologist.

He found the suspicious place with the ultrasound wand, took the FNA sample, the pathologist put it on a slide and read it. Right there. Right then. No waiting until Monday. No waiting for the freaking phone to ring. They didn’t want me to wonder and worry over the weekend.

Is that cool or what?

So the final comment I have about biopsies is this: be very careful about the small clinic excisional biopsy. This old style medicine and can leave you waking up with either a larger, unnecessary wound or, as I’ve seen happen - no breast. Gee, they got in there and it was worse than they thought - no breast. That’s garbage. No excuse for that. If it was that bad, then you probably should have sought another opinion and perhaps a completely different treatment modality, like neo-adjuvant chemotherapy.

Don’t be afraid of the biopsy. It’s a step toward a cure.

maven

A personal breast cancer journey

I never saw it coming.

Mammograms had been difficult to read, due to very fibrocystic breast tissue, but always ‘normal’. There were no ‘lumps’. But the technician came back in and said that they’d gone out to the waiting room to get my husband. That’s when my stomach lurched and I think all the blood drained out of the bottom of my feet, going down into the center of the earth. I didn’t feel dizzy, just completely numb.

This was the beginning salvo of a almost two year journey through advanced, Stage IIIa, lobular carcinoma - from chemo to surgery to radiation to more surgery and on toward survivorship.

June 27, 2008 marked my fifth anniversary out of treatment, and my sixth since diagnosis. I’m healthy and cancer-free.

If I’d stayed in Reno and done what I was told to do, I probably wouldn’t be sitting here writing this now. That’s why I am a cancer advocate for change in the way cancer, and breast cancer specifically is treated in hometowns across the country.

If you or somebody you love has breast cancer, I want to help arm you with information that you can use to fight your best battle.

If you don’t have breast cancer, I want to leave some thoughts with you that you can use to help others or yourself should the unthinkable happen.

Throughout the month of October, I will post bits and pieces here - of my own story, educational materials, differing opinions, stories about others who have made the journey and some of those who didn’t make it.

As an advocate and mentor, I’ve seen the look that must of been on my face on many other faces over the past several years. I’ve heard the fear in voices, and a lot of tears. I’ve raised money to get women to where they needed to be to get the best treatment, been a shoulder to cry on, a nurse, a fighter, a critic - but most of all I’ve been angry. Angry at a broken health care ‘system’ that through it’s very brokeness witholds not only treatment but the Standard of Care ‘right’ treatment in towns, cities and communities all across this country.  You can live in a medium size city and still not receive the current Standard of Care. You can live in a state, that unbelievably, has no accredited surgical oncologist in practice in the entire state.

I’ve seen the lousy care and I’ve seen the very best care. I know the difference. The best should be available to all, because you really don’t want to see what the lousy care looks like when it’s one of you or yours. I’m not talking about the results of the reconstructive ‘boob job’ - I’m talking about lives.

Since I was diagnosed, I have lost five woman that I cared about. I had to quit going to my breast cancer support group, because I could no longer deal with getting close to women only to see them die a few years later.

You’ll see a lot of informative material in here from the University of Texas, MD Anderson Cancer Center in Houston, Texas. That’s where I was fortunate enough to be able to go for my second opinion and all of my treatment. They literally saved my life, as you’ll hear. That’s where all of my cancer research dollars go, since they are the best of the best of the best.

I hope that you will join me, and become better informed about breast cancer, understanding that it is not a death sentence, especially if treated in a timely manner and with due diligence at a comprehensive cancer center.

-maven

Cancer patient pocket guides available from CURE

CURE introduces its new series of patient pocket guides. These guides are designed to help newly diagnosed patients navigate through everything from screening to treatment to side effects.

Breast cancer: The lingering fear of recurrence

This is something that I struggle with, as does every other breast cancer survivor I’ve met or talked to. During the last eight years since my diagnosis, treatment and recovery, I’ve lost dear friends who had breast cancers that didn’t seem as bad as mine, or were ‘identical’ in a very basic sense. Add to the sense of loss a sense of dreaded “why them and not me?”

What I can tell you, if you have just been diagnosed or are currently undergoing treatment, is this - I no longer dwell on this daily. It’s one of those middle of the night things that creep in when I can’t sleep usually. Having a busy, active and satisfying life is key. You really do have to live completely for today. Nobody knows about tomorrow.

The most important thing I can tell you is that I know that I sought out the best treatment - not just the treatment I thought I could afford, or was most convenient or the least troublesome. If my cancer comes back, I’ll know without a doubt that I reached out for the latest, the newest and the most aggressive treatment available in the United States - although it was hard at times, both economically and physically.

I never wanted to have to second guess my treatment decisions later on. That alone helps me sleep at night.

You might find the following video enlightening. It’s by Lillie Schockney, R.N. of the Breast Center at Johns Hopkins, in Baltimore, Maryland.

Can Energy Balance Prevent Cancer?

The investigational literature has actually been trending in this direction for several years, but the evidence is becoming overwhelming - maintaining a healthy lifestyle of weight control and exercise, combined with lowered alcohol consumption can go a long way toward mitigating the risk of having certain cancers and avoiding a recurrence of cancer you’ve already beaten.

In these times of financial stress, it might seem easy to ask the question “can I afford the gym or healthier food options?” My question as an eight year survivor of Stage III breast cancer is “how can you not?” Had I known then what I know now, I certainly would have made a better effort to avoid cancer. But I have made huge changes since my cancer went into remission to avoid a recurrence, since I know a recurrence of my cancer (a ‘triple negative’ breast cancer) is essentially not survivable, there being no really effective treatments now or on the horizon.

Hey, that’s some kinda motivation? Right?

That said, I go to great lengths to maintain a healthy weight and BMI (Body Mass Index). I’m 5’3” and weigh between 136 and 138 pounds. BMI of 23.7. Actually, it’s lower than standard calculators, but I had mine done up at the UNR Center for Metabolic Research - where they do a couple very sophisticated body composition assessments. I’ve also gone up there and undergone nutritional and exercise analysis by their experts every couple years since my diagnosis.

I’m a nutritionists dream. At least that’s what they tell me. I think you can see from the Food page of this blog, that I’m not exactly living on celery and carrot sticks, but I’m still the food police. We’ve nixed the processed foods, fake food ingredients, saturated fats, refined white flours, sugars and - worst of all - sodium from out diets here. My husband - at 79 - has the clear arteries to prove it. We’re not vegetarian, but rather vegan trending ‘flexitarians’. We love our whole grains, veg and fruit.

And we exercise. A lot. During the warmer months I get in about 800 to 1,000 miles on my hybrid road bike depending on schedules. In the winter I ski, walk and run on the treadmill. We do Pilates and Yoga. I also meditate regularly. I hate gyms. I’m not a big joiner, and I don’t like being indoors to exercise unless forced to.

And we cut down the drinking. A lot.

The bottom line is that I’m now 8+ years out from diagnosis. Those who were diagnosed with same at the time I was are gone. Lifestyle choices are not the total answer. Chance, genes and medical choices also come into play big time. I just know that I’ve done all that I can. That’s all any of us can do.

-maven

The following feature article is from CURE magazine and is authored by Don Vaughn.

Click to read more ...

How health care reform will affect cancer patients

The main reason I was campaigning so hard for the passage of the Patient Protection and Affordable Health Care Act earlier this year is that I’m a cancer survivor. I know that my cancer -  Stage IIIa breast cancer - could return at any time, and times being what they are, the company my husband retired from could decide not to provide health insurance to retirees and their wives.

That means I could be left out in the cold. The plan that I had, previous to changes this year, also had a ‘cap’ that a return of cancer would have blown through in nothing flat. The insurance company could have also denied further benefits. Had I been tossed out by my current insurer, it would have been impossible, as in ‘too expensive’, to find other coverage - due to my pre-existing condition: Cancer.

We’re not poor. We have a good amount of savings. Our finances are sound and in order. We currently don’t owe a nickel.  But I know first hand just how a cancer diagnosis can go through it all in short order. If you think you are immune, think again. One in four Americans will be diagnosed with cancer in their lifetimes.

That nasty old ‘Obama-care’ that the Tea Nuts love to hate is the only thing standing between me - and a lot of other cancer patients - and financial ruin.

Here’s a run down of just how ‘Obama-care’ or the Patient Protection and Affordable Health Care Act stacks up for cancer patients:

Click to read more ...

Nutritional supplements. Do you really need them?

This is a soapbox that I’ve stood firmly on for a couple decades now, as study after study has failed to show conclusive evidence that supplements do anything more than drain your wallet of money. In these hard economic times, it’s important to overcome wishful thinking about supplements. This is hard in the face of the hundreds of millions of dollars spent marketing them to us, and the little that is done to control the claims they make.

You can also thank the anti-government types for this. Leaving it up to the supplement industry to police themselves hasn’t been a success under any measure.

Click to read more ...

Cancer self-assessment is easy to do

Could you be at risk of developing cancer? Find out by taking our online cancer risk assessment.

MD Anderson developed Cancer Risk Check to help community members like you.

Cancer Risk Check calculates your chances for cancer based on your gender, race, health history and lifestyle habits. After completing a short questionnaire, you’ll receive customized suggestions for lifestyle changes and cancer screening exams that may help you prevent cancer.

Excellent explanation of breast cancer mechanisms

From Sloan-Kettering Cancer Center.

Click here.

There was no embed code, or I would’ve put it on the blog for you.

Controlling Your Cancer Care Costs

The very last thing my husband and I were worried about when I was diagnosed with Stage IIIa breast cancer was how we would deal with the costs. When you’ve suddenly had your own mortality crammed into your face, the bills aren’t at the top of the list.

As the year+ of treatment wore on, however, and we travelled again and again from Reno to Houston for the best care possible, the bills did add up. We finally ended up taking out an equity line of credit against the house to help ease the cash crunch.

Click to read more ...

Are you getting all the health insurance benefits you deserve?

If you have a serious illness - such as cancer - you should start searching around your providers website like I did. Nobody at UnitedHealthcare ever told me that I was eligible for extended coverage at a National Center for Excellence ( like the University of Texas, M. D. Anderson Cancer Center in my case).

I found this benefit completely by accident, called and got enrolled. It pays for travel and lodging at UT, MDACC.

Here’s what the UHC website - separate from their regular site - says:

Specialized Networks

Enhancing care for patients with serious illness.

Click to read more ...

Breast Cancer: Treatments for early, confined cancer

The following article is from The University of Texas, M. D. Anderson Cancer Center publication, OncoLog, January 2009, Vol. 55, No. 1 :

Choosing Treatment for a Common Group of Early, Confined Breast Cancers

Overview

By definition, ductal carcinoma in situ (DCIS) is a cancer arising from and pathologically confirmed to be confined to the terminal duct lobular units of the breast. It is therefore considered a noninvasive breast cancer. Each year in the United States, about 64,000 women are diagnosed with DCIS, representing 30% of women diagnosed with breast cancer.

Three decades ago, DCIS was found in patients relatively rarely, typically co-existing with invasive cancers in mastectomy specimens. In the even rarer instance in which a patient presented with clinically evident DCIS—a palpable mass or nipple discharge—she was treated with mastectomy.

Today, it is still unusual for DCIS to present symptomatically;

Click to read more ...

Cleaning for a reason gives help to cancer patients

Wow, I wish I’d known about this when I was undergoing treatment! What an outstanding idea: housecleaning services around the country donating time to help cancer patients.

Cleaning for A Reason should be commended - and supported. Here’s what their website says:

Fighting cancer is difficult enough, but living with it is even tougher - and that’s where the Cleaning for A Reason Foundation steps in. This newly formed nonprofit offers free professional housecleaning, and maid services to improve the lives of women undergoing treatment for cancer - any type of cancer.

Hey, if you know a woman with cancer - any type of cancer - do something really big for her. Give her the gift of a clean house.

Click to read more ...

Multidisciplinary approach helps cancer patients

Being a nearly eight year survivor of Stage IIIa Breast Cancer, and having had all treatment at The University of Texas, M. D. Anderson Cancer Center, I’m a huge believer in the multidisciplinary model of treating cancer. I believe it was a crucial part of my survival and recovery.

It makes so much sense. Get all the practictioners in there to consult and confer as a team right from the start. About every other appointment for Chemotherapy, I would first be seen by my Clinical Oncologist, then a team of doctors ( radiation oncologisty, oncological surgeon, plastic surgeon, pathologist, nutritionist and others ) would come round to evaluate me, and then step into another room where my primary Oncologist would, essentially, defend her case.

By the time I was ready to proceed to each subsequent step in the process of arresting my cancer, the doctor that I was ‘handed off’ to was already very familiar with me and my case. The close working relationships were standard operating procedure all the way through my treatment and recovery phases.

Unfortunately, this type of treatment isn’t usually available outside of a teaching hospital. When you are a patient of the average local practictioner, he may confer with other collegues or not. Your case may reach the local ‘tumor board’ for evaluation or not.

Multidisciplinary teams should be the Standard of Care. This goes for breast cancer or prostate cancer as you can read below.

maven

When Specialists Confer, Patients Benefit

Network - Winter 2010

By Mary Brolley

It all started with feedback.

For several years, Deborah Kuban, M.D., asked men who’d been treated for prostate cancer at M. D. Anderson how they felt about it.

Click to read more ...

33rd Annual San Antonio Breast Cancer Symposium

Now underway, the symposium presents a ton of great, cutting edge information about breast cancer’s breaking news, frontiers, new breakthroughs and much more.

The 2009 San Antonio Breast Cancer Symposium (SABCS) is presented by the CTRC, AACR, and the Baylor College of Medicine. The driving force behind this collaboration is the shared mission of the organizations to advance progress against breast cancer. By combining their respective strengths, the San Antonio Breast Cancer Symposium encompasses the full spectrum of breast cancer research and facilitates the rapid transition of new knowledge into improved care for breast cancer patients.

Patients are both encouraged to attend, and mine the symposium site for a multitude of resources that are constantly available. You can also view streaming video.

What is pancreatic cancer anyway?

From the University of Texas, M. D. Anderson ‘Oncolog’, October 2009 issue:

You might not know much about pancreatic cancer, but chances are you’ve heard of it. Public awareness of the disease has increased in recent years as well-known people including Steve Jobs, Luciano Pavoratti, Patrick Swayze, and Gene Upshaw were diagnosed with various forms of pancreatic cancer. According to the American Cancer Society, more than 35,000 Americans are expected to die from pancreatic cancer during 2009.

Risk factors

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Six ways to take a mental vacation for good health

I used to ‘pooh-pooh’ meditation. That was until I was diagnosed with advanced breast cancer. You’re willing to listen to a lot of new ideas then.

On one of my first trips down to the University of Texas, M. D. Anderson Cancer Center, I was seated on the airplane next to a Ph.d candidate from Tulane University. We got talking about mental attitudes and disease (I’d told him where I was going and why). He gave me a very persuasive ‘chapter and verse’ about my attitude being everything … and the importance of meditation and visualization as a part of my successful treatment for cancer.

Fortunately, I listened and put meditation and visualization as part of my daily routine through my treatment and continue to do it now.

Here are some ideas that might help you, even if you don’t have cancer:

Stress Relief: Six Quick Mental Trips

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Myth #4: When breast cancer shows up, it may have been in your body for 6-10 years

Oh, how true. I can attest to this.

My well meaning, but wildly off the mark surgeon in Reno, when he first saw my mammogram, told me that all was just ducky, since it had been caught really early. The real news came during my workup at The University of Texas, M.D. Anderson Cancer Center. They told me that the cancer had been in my body “at least two to three years”. And at Stage IIIa, it had most certainly not be caught early.

Here’s my takeaway message on this: Yes, at your date of diagnosis, you’ve been living with cancer much longer than you may want to think. But this very fact should help you understand why you don’t need to be rushed into a ‘tomorrow’ or ‘next week’ or even ‘next month’ decision on a course of treatment. Don’t let your emotions run the show.

For crying out loud, you’ve had it this long. Take the time to understand all the ramifications, get an accurate diagnosis and the right course of treatment. You get one chance to get it right. There are no ‘do-overs’ in cancer.

Click to read more ...