Mammograms

Mammograms are preventative care

• Diagnostic mammograms consists of 6 images
• Screening mammograms consists of 4 images take in 2 positions
  • Craniocaudal & Medial Lateral (slightly oblique)

• Mammograms decrease mortality 30% in individuals under the age of 40, and even more so for those above the age of 40!
• Bilateral mammograms are often ordered when something is felt in only one breast. This is to look for synchronous lesions.

• A normal mammogram will show a radial pattern extending out from the nipple
• Cysts will appear as a radiodense object with regular borders, but a cyst cannot be diagnosed using mammography, instead you must do an ultrasound & biopsy.
  • Tumors usually appear speculated.
• Microcalcifications may be seen in old lesions, like fibroadenomas. We don’t really worry about microcalcification unlesss:
  • There is a change in them over time
  • Clusters of 5 or more are found in one area

It seems like there is nothing but good things to say about mammograms…so why are so many women hesitant to get one? Glad you asked – here’s a list of some common concerns.  Through education and counseling, you can convince many of your patients to get a mammogram.
 

• Most women experience no pain, but some women do. Usually women who experience pain w/ menses will also have pain during mammographies.
  • Its important to tell your patients this up front!
• The pain is caused by the breast being compressed. Why is compression necessary?
  •  Compression will immobilize the breasts allowing for a better image to be taken.
  • Also, the thicker the breast the more dense it will appear and this will result in a poor image.
  • The thinner the breast, the LOWER the dose of radiation!
  • Its hard to get medial and lateral areas in the film, unless compression occurs.

• What can be done to minimize discomfort?
  • Tell the patients that the breast will only be compressed for 15 seconds  per film taken.
    • You can call local radiology suites in the area to determine which  allow women to compress their own breasts to the extent they are comfortable with. Studies show that women actually compress as much as the tech would.
  • If a patient normally has tender breasts advise her to go one week after her cycle begins because there is less pain at that time.
  • NSAIDS
  • Evening Primerose Oil: a patient has to take this for 2 weeks, and while it does decrease discomfort, it increases bleeding. This can be an issue if something is detected and a biopsy wants to be done on the same day.

• Fear of BAD NEWS
  • Reassure the patient that 9/10 abnormal mammograms are actually benign. So only 1 in 10 is actually cancer.
    • “Heart disease is the #1 killer of women, and no one is afraid to go to Outback and eat a steak (or a bloomin onion)”
  • Mammographies will decrease the risk of death by 30%
    • Detection of smaller lesions occur during routine mammograms.

    
     

    • A person w/ routine mammograms will have a lesion 1cm in size detected. This is a T1 tumor, stage 1. They have an 88% survival.
    • A first mammogram can detect a lump that is slightly greater than 1 mammogram but at the same stage and grade. This is the size the initial lesion would grow in 1 yr.
    • Regular monthly checkups will find the initial lesion after 2 yrs of growth.
    • If the initial lesion was never detected, in 3 yrs it would grow to 3-4 cm (T2 tumor). This is the size of tumors found on one’s own. The risk of death at this point is 75%.....all because preventative measures were not taken.
• The test ISN’T ACCURATE
  • 10% of tumors are not picked up on mammograms for a variety of reasons. They may be located in a hard to image area, or the architecture of the tumor may not show findings. This is why mammographies are NOT recommended as the sole mean of prevention!
  • Mammographies are used in conjunction w/ clinical exam (by a doctor, or nurse practioner)
  • If a cystic lesion is found on exam, a biopsy is ordered not a mammogram bc it may not show up.
  • 10-13% is the frequency of False Negatives
    • Birad category 1: normal mammogram
      • 1 negative mammogram and you have a 5 in 10,000 risk of developing/ being diagnosed w/ cancer.
      • w/o a mammogram the risk of being diagnosed at 40 is 1 in 250.
    • Birad category 2:benign findings: radial scarring, fat necrosis
      •  same
    • Birad category 3: look benign w/ some abnormal findings
      • <2% of all women have underlying cancer. Most are not biopsied, but are followed with a mammogram 6 months later. The individual patient needs to make a decision on their own whether they want to wait 6 months or a year for their next mammogram. The growth in a year may not be that significant.
  • False positives: 5-7% (something is found, but nothing is there)
    • Over 10 yrs these patients have a 46% chance of developing a true positive, 5% will need a biopsy and of that 5%, 17% will have cancer.
• Mammographies CAUSE cancer
  • There is some radiation exposure, but there are age related effects. Older individuals are less effected by the radiation, and since most of the women getting mammograms are older – its ok.
  • The dose of radiation has decreased over the past 20 yrs to <0.2 rads
  • Is there a risk? 1 per 1 million women screened will develop extra cancer – but this is still a lot lower than your risk of developing breast cancer.
  • Also, remind your patients of the risk of everyday exposure. If you breathe the air in NYC or take a transatlantic flight you are exposed to the same dose of radiation as in a mammogram.
• COST
  • As a physician we need to know what the normal cost is in our area. Normally its about $100, but in the D.O.C for example its $170.
  • Medicaid/Medicare/ HMOs will cover all women over 50 to get mammograms, and most over 40, though the regulations differ so check it out.
  • Some programs are available that offer low cost mammograms, or even free mobile ones. In October (Breast Cancer Awareness Month) Susan G. Komen offers a mammogram program. You can also check out the American Cancer Society (www.cancer.org) or the C.D.C (www.cdc.gov/cancer/nbccedp).
  • In Newark, mammograms and pap tests are free.
• Breast isn’t right – either too large or too small
  • Size does not matter -  but density does.
  • An older women with large breasts will have a better image than a young women with dense breasts. With larger breasts & implants inform your patients that you may have to do more films (6 instead of 4)
    • For implants, displace implants backwards. Worries of rupturing are unwarranted.

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