561.391.1728
Women's Imaging Update
by Kathy Schilling, M.D.

Medical Director of Imaging and Intervention Women's Center/ Center for Breast Care

December 2014 - Watch Dr Schilling @ RSNA and with a panel of experts from the GE booth discussing breast health options

October 2014 - Anxiety Over Mammograms Eased With Spa-Like Experience At Boca Raton Hospital

By Mary O'Connor / CBS12 News

Twenty-five percent of woman skip routine mammograms because they are scared or nervous. The Women's Institute at Boca Raton Regional Hospital has the perfect remedy - making your mammogram more like a day at the spa than a trip to the doctor.

"It's the best mammogram I've ever had," said patient Cynthia Justiniano.

The mammography exam room is called a Sensory Suite. You pick an "experience" you want to have during the 15 minute procedure – an afternoon in a garden or a waterfall – and the room takes you there. Sounds, sights and even smells.

"By engaging multiple senses at the same time, a woman cannot feel and anticipate pain and anxiety," said Women's Institute Director Shakira Sarqui-Kolber.

The room, from start to finish, cost $400,000 to furnish. It was done entirely through donations. There is no extra cost for a patient to use the Sensory Suite versus a typical exam room.

"It takes the fear and anxiety away," said Justiniano.

Once you're 40, the American Cancer Society recommends a mammogram once every year.

You should be advised that the USPSTF recommendations were not the result of new research. Nor are there any recent studies that demonstrate new risks of mammograms in women of any age. In fact, the Agency agreed that the data support that mammograms improve survival from breast cancer in all ages, including 40 to 50 year olds.

As the leading breast care center in the region, we are motivated by a singular goal; to do what is best for the patients we serve. Our motivations are clinical, not political. In the final analysis, we believe denying the medical advances made in breast cancer, including those in imaging, is to deny women the right to stand up against breast cancer through early detection and treatment of the disease.

We urge you to follow the guidelines that we, as well as a myriad other medical experts and organizations, recommend. Our physicians, nurses and support staff stand ready to serve you in that regard. For additional questions or concerns, please feel free to call us at 561.955.5000.

October 2009- Kathy Schilling, MD, earns recognition as "one of nation's best and brightest"

The Center for Breast Care at BRRH named one of the nation's "Top Five Women's Imaging Centers to Watch in 2009"

"Consensus Conference III – Image Detected Breast Cancer: State-of-the-Art Diagnosis and Treatment" featured in the October issue of the Journal of the American College of Surgeons (JACS) is destined to be a powerful document that will influence the management of breast patients and clinical debate for years to come.

July 2009- Digital Fight against Breast Cancer
Each year 300,000 new cases of breast cancer are detected in the European Union. While the cause of this fatal disease may not be clear, medical experts agree that if the disease is detected early the chances of survival are much higher.
The EU is funding the project HAMAM (Highly Accurate Breast Cancer Diagnosis through Integration of Biological Knowledge, Novel Imaging Modalities, and Modelling) to foster digital techniques in early detection of breast cancer. Digital techniques are at the forefront of early detection. The advantages are clear: digital technology allows different views and angles on one single desktop; doctors can share information from different tests more easily; and, patients will get quicker results. Modern detection methods, such as medical imaging "MRI" scans, also have many benefits as they detect small tumors much earlier than former methods. In addition, new scanners using ultrasound methods are being developed. These new scanners are a lot less harmful as there is no risk of unnecessary radiation.
The result: more cases of breast cancer can be detected at a very early stage. Digitization helps save lives.
Please find information & videos here on the HAMAM project funded by the European Union

June 2009- Dr. Schilling is a proud participant in the third Consensus Conference to be held on July 2009 in California as one of 20 physicians to develop the current consensus for early breast cancer dx and care. The results will be published and circulated to 60,000 in the Journal of the American College of Surgeons. This will represent the state of the art for the next four years.

May 2009- Mammography: An Extra Dose of Confidence. Efficacy of CAD with digital mammography. image article

April 2009- Technology Trends: Is your breast imaging center ready to perform same-day follow-up? Applied Radiology article


New Breast Cancer Risk Factor: What is Your Mammographic Density?

In the 1970's when mammography was in its infancy, Dr. Thomas Wolfe, a pioneer in breast imaging, suspected patients with dense breasts were at a higher risk to develop breast cancer. In an article published in The New England Journal of Medicine in January, 2007, Boyd and coworkers confirmed these findings. Women with the densest breast on mammography were found to be at 4 to 6 times greater risk to develop the disease as women of similar age but with fatty breasts. The etiology of this finding is multifactorial.

We know that dense areas on mammography are seen as white elements on the black and white images. These areas are composed of glandular tissue and connective tissue. The glandular tissue is that which has the potential to develop cancer. Unfortunately, cancers also appear white on the mammogram and therefore differentiating the abnormal from the normal can cause difficulty for the mammographer. Women with fatty breast tissue on the other hand have mammograms which are predominantly dark so the identification of cancers which appear white is that much easier. We refer to this as the masking effect of breast density on cancer detection. This effect is found to be greatest in the 60-69 year old woman with the densest breasts.

However, not only is risk related to the masking effect of mammographic density, but also to a biologic link between breast density and cancer. As these patient have more tissue which potentially can develop cancer, this apparently does occur. More research in this regard is necessary. We do know however, that there are only two other factors which increase the risk of breast cancer more than mammographic density. These are age and genetic mutations such as BRCA 1 and BRCA2.

The American College of Radiology has developed the BIRADS classification of breast density which is reported in every mammography report. It includes:

  • Almost entirely fat: <25% breast density
  • Scattered fibroglandular densities: 25-50% breast density
  • Heterogeneously dense: 50-75% breast density
  • Extremely dense: >75% breast density

The reported breast density unfortunately is only moderately reproducible on subsequent exams by the same and different readers. Because of this fact, computer aided detection companies are in the process of developing an automated measure of the volume of breast density.

It is very important to understand that breast imagers do have tools available to improve cancer diagnosis in these women with dense mammograms. The Digital Mammography Imaging Screening Trial which compared film mammography with digital mammography found significantly more cancers in patients with dense breasts using digital mammographic imaging. Additionally, ultrasound in known to perform best in patients with dense breasts. Women should seek out centers using multiple modalities for early breast cancer detection.

In summary, increased mammographic density is strongly associated with increased breast cancer development and decreased detection of the disease. Women utilizing services at the Center for Breast Care at Boca Raton Regional Hospital should rest assured as we have available the most sophisticated complementary imaging tools as well as a High Risk Clinic supervised by Dr. Louise Morrell. Women seen in this clinic are given an estimate of the level of risk after reviewing family history, clinical history and breast density. Offered then, are individualized methods of surveillance for early detection as well as pharmacologic and non-pharmacologic means to achieve risk reduction.

For more information please call the Center at 561-362-5000.


Enhanced Breast MRI System Shows Great Promise in the Early Detection and Treatment of Breast Cancer

Researchers from FAU, Boca Raton Regional Hospital and MeVis Develop and Pilot Unique Software Platform that Supports Computer-aided Breast MRI

Researchers from Florida Atlantic University, the Center for Breast Care at the Women's Center at Boca Raton Community Hospital, and MeVis, The Center for Diagnostic Systems and Visualization at the University of Breman, Germany have developed new techniques to aid clinicians in the diagnosis and treatment of breast cancer. They have developed and piloted a unique software platform utilizing computational clinical imaging techniques for the analysis and display of serial-time MRI, which is showing great promise in the early detection and treatment of breast cancer.

These FDA-approved techniques were developed at MeVis, The Center for Diagnostics Systems and Visualization, under the direction of Dr. Heinz-Otto Peitgen, who is also a faculty member in the department of mathematical sciences at FAU's Charles E. Schmidt College of Science. Peitgen used the mathematical concept of fractals to begin developing this unique software.

"Fractals are large, irregular geometric patterns made up of infinitely smaller, but identical, irregular patterns," said Peitgen. "Fractal theory provided an appropriate platform upon which to build the software program because the ducts within human breast tissue have fractal properties."

Breast MRI is a relatively new tool used by physicians to diagnose breast cancer as an adjunct to conventional mammography. Breast MRI displays the behavior of a cancerous lesion in three dimensions and approaches a nearly 100 percent accuracy rate in the detection of invasive cancer. In contrast, mammography provides a two-dimensional view of the breast and surrounding tissue and only detects 80 to 85 percent of tumors. One of the main strengths of MRI is its precise delineation of soft tissue and its ability to image the breast in fine sections dynamically by taking multiple MRI images over time. The percentage of medical centers doing breast MRI is small, but growing

A recent study spearheaded by Dr. Kathy Schilling, medical director of Imaging and Intervention at the Center for Breast Care at the Women's Center at Boca Raton Regional Hospital, was published in The American Journal of Radiology and entitled "Assessment of Suspected Breast Cancer by MRI – A Prospective Clinical Trial Using a Combined Kinetic and Morphologic Analysis." Findings of this study showed that in over 30 percent of patients there were additional tumors in the same breast, and in almost 10 percent of the patients there were tumors in the opposite breast.

"These tumors were not found using mammography or ultrasound," said Schilling. "We also found a resulting change in the course of treatment in nearly 25 percent of patients undergoing surgery for newly diagnosed breast cancer." In addition, findings from this study showed that MRI directed biopsies using computational clinical imaging led to definitive conclusions, demonstrating the clinical utility of this unique approach.

According to Dr. Roger Goldwyn, faculty member in FAU's department of mathematical sciences and director of the proposed Center for the Development of Computational Clinical Imaging at FAU, "Our approach is to use innovative image-processing tools to find additional tumors and to help determine patient management outcomes. These techniques have also led to biopsies directed by these image-processing tools, surgical planning modifications, and monitoring effectiveness of chemotherapy."

The Center for Breast Care at Boca Raton Regional Hospital is a high volume center, handling more than 45,000 cases per year and finding more than 320 new breast cancers annually. In conjunction with FAU, the Center for Breast Care is developing their expertise in the use of computer-aided clinical imaging to assist clinicians nationwide. The integration of this software into general imaging departments involved in breast cancer diagnosis will enable better care, a reduction in costs for unnecessary surgeries, and ultimately result in improved patient survival. The Center for Breast Care is also working with experts at FAU in the university's medical school program to further develop these specialized tools and continue to evaluate them in pilot studies to examine their ability to save lives.

"Our researchers at FAU will continue to conduct clinical evaluations and collaborate with the Center for Breast Care and MeVis to further develop these tools for use by clinicians in more routine settings in order to have a wider impact on patient care," said Dr. Larry F. Lemanski, vice president for research at FAU.

American women have a one in nine chance of developing breast cancer during their lifetime. Early detection is the single most effective tool in fighting breast cancer. The sooner the cancer is detected, the more options a woman has for treatment and the better her chance for survival. Methods for detection include mammography—a safe, low-dose x-ray of the breast—that can be a vital tool in helping to discover small lumps up to two years before they can be felt in a physical exam. With mammography, however, only 80 to 85 percent of tumors are detected, leaving 15-20 percent of tumors undetected. These undetected tumors will enlarge and become more lethal before they are identified in a later screening or when they become clinically apparent.

<click here to learn more about Breast MRI>


Exciting Breakthroughs in Breast Cancer

Women facing the possibility of a cancerous breast tumor have new options available to them in the detection and treatment of breast cancer. A new diagnostic tool in the diagnosis of breast cancer is computer aided detection (CAD). Using CAD, standard mammograms are converted into digital computer images, and the computer marks suspicious areas. Then, board-certified radiologists compare the CAD images to the original mammograms to determine the significance of the marked areas. The added technology helps detect subtle signs of breast cancer that may otherwise go undetected. Studies show that CAD can increase the detection rate of breast cancer by 20 percent.

Sentinel node biopsy, a surgical biopsy technique that can predict whether cancer has spread into the surrounding lymph nodes, has proven to be an accurate diagnostic tool for early stage breast cancer, according to a study by memorial Sloan-Kettering Cancer Center breast surgeons. A report of the first 500 cases performed at memorial Sloan-Kettering confirmed that breast cancer patients with small tumors between one and five centimeters could avoid unnecessary surgery to remove axillary lymph nodes if the sentinel node biopsy is negative. Since 80 % of patients with earliest stage breast cancer have no lymph node involvement, this technique spares an estimated 60,000 to 80,000 patients each year from undergoing unnecessary surgery and possibly developing painful lymphedema.

A new, recently FDA-approved follow-up treatment option, MammoSite breast brachytherapy is now available for the first time in South Florida. MammoSite breast brachytherapy more effectively targets radiation to the tumor site, sparing healthy surrounding tissue. It shortens the course of radiation therapy to five days, rather than the five weeks that is typical of standard external radiation. It also significantly reduces patient discomfort.

Brachytherapy delivers high dose radiation directly to a tumor site using radioactive seeds, or sources. A relatively new generation of cancer treatment, it has been widely used for prostate and other cancers. FDA approval of the MammoSite Radiation Therapy System makes brachytherapy practical for treating select, early stage breast cancer as well.

The MammoSite device is designed to irradiate the lumpectomy site and treat the surrounding tissue most likely to contain any residual cancer cells. The device consists of a hollow catheter to which an inflatable balloon is attached. It is temporarily implanted into the breast at the lumpectomy site. During treatment, typically two 15-minute sessions per day for five days, beads of radioactive iridium are inserted into the catheter and centered within the treatment site by the balloon. The catheter remains in place over the course of treatment and is then removed.

The device is intended primarily to treat early stage breast cancer tumors of less than four centimeters, when there is no need to remove the whole breast. It does not replace whole breast irradiation for women who need that treatment. According to the American Cancer Society, there are 203,500 women diagnosed annually with breast cancer and about 70 percent are potentially candidates for lumpectomies.

The MammoSite device can be implanted at the time of the lumpectomy or within ten weeks. Additionally, breast brachytherapy can be completed prior to any chemotherapy, if needed, rather than waiting six months or longer from the time of surgery.

Although a cure has not been developed for breast cancer, there are many new developments in the detection and treatment of breast cancer.


BLURRED VISION: THE FLIP SIDE

An article entitled, "Spotting Breast Cancer: Doctors are Weak Link" appeared on the front page of the New York Times on June 27, 2002. This lengthy article commented on the perceived lack of skills of mammographers such that the anticipated benefits of screening mammography were compromised. Despite the fact that mammography centers, specifically their personnel, equipment and film quality have been strictly monitored for more than a decade by the federal government, the article pointed out that failure to detect breast cancer was not uncommon and that more regulation may be necessary to combat this deficiency. The author appeared to have had little input from radiologists and made little effort to understand the limitations and frustrations they face daily.

The author and the American public may have a misperception about the art of interpreting mammography. The article noted several times the difficulty in interpreting these exams but never explained why. Typically in medicine, once learning and seeing a disease and its presentation, a physician will feel comfortable recognizing it again in the future. Mammographic interpretation is different. No two mammograms look exactly alike which is different than most imaged body parts. They vary in appearance by the amount and distribution of fat and fibroglandular tissue. Fat on film appears gray/black. Fibroglandular tissue appears white. To complicate matters, cancers also appear white. The difficulty comes when the cancer originates in an area of fibroglandular tissue. The cancer (white) may then be obscured by the adjacent fibroglandular tissue (white). Detecting breast cancer may then be likened to detecting a specific snowball during a snow storm. Mammographers have to therefore rely on other subtle signs of the tumors presence

Another important fact to understand is that breast cancer is a heterogeneous disease and may present in a variety ways mammographically including as calcifications, masses or distortions. These findings may also however, represent benign lesions. Oftentimes biopsy is required to distinguish between the two.

Breast cancer pathologically is known to evolve with time from benign normal cells to those which are atypical and then cancerous. This process occurs on a continuum. There is no absolute point in time when the pathology turns from benign to frankly malignant. Similarly, there is no specific point in time when a mammographic finding can no longer be considered normal or benign. Each radiologist must reach a balance when reading films. The goal is to find cancer. To find cancer the screened patient must be called back for additional evaluation. It is important not to call back too many women for false alarms resulting in unnecessary anguish to the patient and her family. If too few patients are called back, some cancers will be missed. Every mammographer must have their own level of comfort when reading films but it is recommended that fewer than 10% of screening patients be called to return for questionable finding.

Another factor weighing on the radiologist is the presence of prior films. Prior films are extremely important when interpreting films in that stability of a finding suggests benignity. However, when a cancer is found prior films can be reviewed, typically by lawyers and their expert witnesses, to say that it could have been picked up earlier but wasn't, resulting in delay of diagnosis. Interpretation is always easier when looking backwards.

As mammographers, we know cancers can be missed. Reasons include technical or interpretive factors. Technical factors account for a small percentage of problems. These may be caused by poor patient positioning, poor film technique or processing. In most centers these issues are addressed when abiding by the guidelines set forth by the federal government. Of concern in the N Y Times article are interpretive errors made by the radiologist. These errors may be due to misinterpretation of perceived findings and failure to perceive abnormalities. Misinterpretation of an identified abnormality can occur when a finding is seen in only one view and subsequently dismissed as not significant. If an abnormality appears stable when review is made of prior exams it may also be discounted although a significant finding. (Breast cancers typically grow with time.) Occasionally, certain types of breast cancer demonstrate benign characteristics and therefore may not be immediately evaluated until a change is demonstrated.

Failure to perceive can easily occur in a busy practice when many films are being read. Reading requires intense prolonged concentration when looking for the infrequent subtle sign of an early breast cancer. Adjustments can be made in a radiology practice to address this problem. Mammography should be performed only by those truly committed to the process. When the volume of exams permits, dedicated mammographers can commit all their time to breast disease and its diagnosis. Volume of interpretation and close followup is instrumental in becoming expert in interpretation.

Secondly, films can be read by two radiologists. This has been shown to increase the cancer detection rate by up to 15%. Many practices do not have the resources available to commit to double reading. Recently developed is a new technology called computer aided detection. This technology utilizes computers to analyze mammograms in search of early signs of breast cancer which may include calcifications, masses or densities. The computer marks films when abnormalities are resent. The radiologist initially reviews films and then refers to the computer analysis. The mammogram is then reviewed again with knowledge of the computer findings. The computer has been shown to increase cancer detection by up to 23%. The public needs to realize the benefits of screening mammography. Negativism as portrayed in the NY Times article can result in scaring women from obtaining the exam, forcing closure of some centers which may limit access particularly in poor and rural areas. We must remember that the vast majority of exams are interpreted correctly and have been for years. Reduction in patient mortality has been demonstrated many times in numerous studies as a result of accurate interpretation by radiologists. With a negative report, the high likelihood is that the interpretation is correct. The odds are in favor of the value of screening.

To assure a correct diagnosis, women when scheduling a screening mammogram should ask the following questions:

  • Is the center and the radiologist dedicated or specializing in breast imaging and diagnosis?
  • Are films read by two radiologists?
  • Is computer aided detection utilized?

At the Center For Breast Care we are committed to the women of our community and have been for the last twelve years. We have three dedicated mammographers spending nearly 100% of their time reading mammography. We spent more then ten years having every film read by two radiologists. Since May of 2002, computer aided detection has been utilized to review patients films. The center is high volume imaging more than 35,000 cases per year and finding more than 400 new breast cancers. This volume is the second largest in the state of Florida. With volume comes expertise.

Correct interpretation and demands for quality cannot be mandated through government regulation. The desire to achieve quality comes from within the institution and its peopleThe federal government has improved the quality of mammography practices. It must be remembewred that it is an imperfect tool but the best we currently have available to detect early breast cancer. We are fortunate aas a community to have such local expertise and commitment make by both Boca Radiology Group and Boca Raton Regional Hospital.


The State of the Art of Percutaneous Breast Biopsy in 2000: Comfort, Accuracy, Confidence

Breast cancer is the number one cause of cancer in American women. We expect to diagnose over 200,000 new cases this year in the USA. For the last several years we have witnessed for the first time a decrease in mortality from the disease. We believe that this is due to improvements in diagnosis and treatment of the disease in the last decade.

Screening mammography has made possible the diagnosis of breast cancer often years before it is palpable, providing a more favorable prognosis. With the increased use of screeening mammography more non-palpable abnormalities are found. We anticipate 1.2 million breast biopsies to be performed in the year 2000 as a result, but expect that 80% of these will be benign . This means that nearly 1 million women will have to undergo a biopsy to find out that there is no cancer

Traditionally, non-palpable breast lesions were evaluated with surgical biopsy after needle localization. This procedure has been considered the "gold standard" to which all others have been compared since the late 1970's. It is a two-stage procedure. Initially, the patient is sent to mammography where a hook wire is placed adjacent to an abnormality. The patient is then sent to the OR where the surgeon performs excisional biopsy as guided by the localizing wire. Specimen radiograph is often taken to prove the excision of the lesion. The skin is then closed. General anesthesia is often required. A two percent failure rate is quoted in the literature. This is not unexpected as the lesions, which may be calcifications, masses or architectural distortions may not be palpable and the procedure is therefore considered semi-blind.

The diagnosis and treatment of non-palpable breast cancer can require 2 surgical procedures if pre-operative diagnosis is not made. The first is needle localized excision. The second, after diagnosis of cancer is made and options are discussed with the patient, is definitive surgery. The goals of the surgeon in all cases are tumor removal, obtaining free margins and node sampling for those with invasive cancers.

Patients are reluctant to consent to the possibility of extensive surgery before a tissue diagnosis is made. We also know that frozen section of breast lesions has its limitations and should not be performed on non-palpable lesions as diagnosis may change on permanent section. It is for these reasons that percutaneous breast biopsy was introduced as an alternative to surgical biopsy of non-palpable breast lesions. Stereotactic biopsy was first introduced in 1990, followed by ultrasound biopsy in 1993.

Stereotactic breast biopsy is most often and reliably performed on a dedicated prone table. The precise location of a lesion in three dimensions can be determined on the basis of its apparent change in position on two angled or stereotactic images. Varying devices, which we will discuss later can be used for tissue sampling. Typically, microcalcifications, masses not seen with ultrasound and densities are evaluated stereotactically.

Ultrasound biopsy technique is usually freehand which allows great flexibility in the approach to the lesion. The ultrasound transducer is held in the physician's non-dominant hand with the needle in the dominant hand. This provides for unlimited angles of approach to lesions situated in any location in the breast. The needle pierces the skin adjacent to the short end of the transducer after local anesthesia is administered. The needle is advanced real time towards the lesion along the plane of the ultrasound beam. Multiple specimens can be obtained quickly, accurately, comfortably and without the use of ionizing radiation.

Varying biopsy tools have been utilized over the years. Initially and currently with palpable lesion, fine needle aspiration has been performed. This technique utilizes a small, 22-25 gauge needle to sample cells from a lesion. Results have typically been disappointing with this technique. Not infrequently results are non-diagnostic or inconclusive and as tissue is not obtained, tumor type or the presence of invasion can not be determined.

The 14 gauge spring loaded core needle biopsy device has been utilized extensively when diagnosing breast lesions. With this device, each sample requires removing and replacing the needle in the breast. It results in discontinuous sampling of a lesion and oftentimes scanty amounts of tissue/blood is obtained. This technique is known to be very difficult when sampling microcalcifications. However, large core permits better characterization of both benign and malignant breast lesions as a histologic diagnosis is given. There is a much lower incidence of insufficient sampling with this technique.

Since 1995, the Mammotome, a directional, vacuum assisted device has been available for stereotactic and now ultrasound guided breast biopsies. It is an 11 gauge hollow needle which is guided towards the abnormality. Vacuum is used to draw tissue into the sample chamber which is then removed by a high speed rotating cutter. The probe can obtain more than one sample contiguously with a single insertion in the breast. By rotating the aperture toward a different position the next sample is obtained. In my practice, the Mammotome is used for all stereotactic breast biopsies as well as all ultrasound guided procedures for masses less than 1.5 cm. Due to the large size of the specimen, lesion removal is possible and placement of a 2 mm tissue marker can be performed at the end of the procedure for future lesion localization and documentation of the biopsy site.

It is found that there is less lesion histologic underestimation with 11 g. Mammotome as compared to 14 g. core. 20-56% of patients found to have atypical ductal carcinoma on 14 g. biopsy are found to have cancer at surgical excision. 0-38% of Mammotome patients diagnosed with atypical ductal hyperplasia are found to cancer at surgical excision. It is for this reason that when the diagnosis of ADH is made at percutaneous breast biopsy, the patient must be sent for excisional biopsy. Other lesions such as Radial scar, atypical lobular hyperplasia, lobular carcinoma in situ and some papillary lesions are somewhat more controversial in their management.

Certainly, it is the biopsy physician's responsibility to determine if the pathologic diagnosis is concordant with the imaging findings when recommending follow up for the patient.

Currently, as percutaneous biopsy is a sampling technique, we recommend a six month follow up for all patients found to have benign, concordant pathology. The accuracy of percutaneous breast biopsy has been found to be similar to that of needle localized excision with a 2% miss rate. Certainly, performing large numbers of cases improves accuracy.

It has been found that a single surgical procedure was performed significantly more often in patients whose non-palpable breast cancer was diagnosed at core biopsy rather than at excision. Core biopsy provides the information necessary to plan surgical therapy and can decrease the number of surgical procedures required in patients with non-palpable breast cancer. A surgeon's approach is different when performing a diagnostic biopsy than a therapeutic operation after core diagnosis of cancer.

At our center, surgical consultation is obtained prior to all percutaneous biopsies. This is of benefit to the patient who will obtain a thorough physical exam to ensure that no suspicious palpable abnormalities are present and to establish a relationship with the patient should further follow up be necessary.

Percutaneous breast biopsy has become the standard of care for nearly all non-palpable breast abnormalities in our community. The majority of lesions are BIRADS Category 4 of which 20-40% are found to be cancer. Due to the high rate of finding a benign lesion in this population, surgical excision should be avoided. The BIRADS Category 5 patients are found to have a cancer 75-90% of the time. A preoperative diagnosis improves the care of these patients. Occasionally, we are asked to biopsy w patient with BIRADS Category 3 abnormality. 0.5-2% of these patients are found to have a cancer. These patients are only done if follow-up is considered unlikely, prior to breast augmentation or pregnancy or in the high risk patient or one with extreme anxiety.

We have found percutaneous breast biopsy to change the way we approach patients with non-palpable breast lesions. It offers a less invasive, less costly alternative to surgical excision with high accuracy, lack of cosmetic and mammographic deformity and few complications. Patients also benefit from fewer surgeries if cancer is found . We look forward to continued evolution of the diagnostic and therapeutic techniques for breast cancer with the hopes for improved outcomes for our patients.


Digital Mammography

In late January 2000, the Food and Drug Administration approved for immediate use the General Electric Full Field Digital Mammography system in facilities that are MQSA certified. Up to this time, all mammography was performed using specialized screen film combinations, collecting images using an analog technique and radiographic film. Digital imaging appears to be the greatest breakthrough in breast imaging in the last 25 years.

Digital mammography improves the radiologist's ability to read mammograms, as there is improved contrast between normal and abnormal tissues making diagnosis easier. Images are obtained using digital technique and are displayed on a computer monitor for review. The physician then has the opportunity for image manipulation using enhancement methods not available with standard imaging technique. Contrast can be changed. Magnification can be utilized and overall there appears to be better visualization of the breast especially at the skin line, chest wall and in areas of dense breast tissue. Using computer technique there appears to be better differentiation of abnormal from normal tissue.

Like digital cameras, this technique does not use film. Images are created on a computer screen and are available for review within 10 seconds after the patient exposure. These images are available for physician review within minutes. It has been found that the exam can be performed in half the time of a standard mammogram (yes, compression of the breast is still required!) and in certain patients at a reduced x-ray exposure.

The equipment appears as a standard mammography unit except for the presence of a computer and monitor where images are displayed. It has been found that there is improved physician confidence in interpreting digital screening mammograms resulting in fewer patient callbacks. Additionally, with the advancement of Tele-medicine, these computerized images can be sent anywhere in the world electronically for review. The images are stored electronically making it more efficient for hospitals to archive and retrieve records.

These new digitized images are also suitable for review by a computer with the hopes of detecting missed lesions. The computer in the case acts as a "second reader". One study found that the computer flagged more than 75% of previously missed lesions. Therefore, since even the best dedicated mammographers miss up to 15% of cancers which are detected by a second human double reader, there is tremendous potential for computer assistance in reading mammography.

Several studies have been conducted using digital mammography both in the screening and diagnostic setting. Results indicate the two, film screen and digital technology, are equivalent in their ability to detect breast cancer. The equipment costs about four times that of standard mammography, in the range of 4 to 500,000 dollars.

Thirty-two and one half million mammograms are performed annually. Over 200,000 new breast cancers will be diagnosed in the USA this year. We know that the earlier we find these cancers, the better chances are for patient survival. We hope through the use of this new and exciting technology that more women will be screened and smaller, curable breast cancers can be found.


Patients to be notified of their mammogram resultsy

For the last several months, many people at the Center For Breast Care have been busy working on a project which is aimed to inform all mammography patients of the results of their exam. This is a huge undertaking for a center that sees 150 patients per day! Using a computerized program, we were successful in generating standardized letters which can be efficiently produced and sent by mail to our patients.

The Mammography Quality Standards Act (MQSA) which was passed by Congress initially in 1992, instituted a new regulation this year which became effective on April 28, 1999. This act initially established minimum standards for mammography equipment, image quality and training of the interpreting physician as well as the support staff. More recently, each of the 10,000 accredited facilities must notify in writing all women undergoing mammography in language easily understandable by the lay public. This report must be made available within 30 days for those with normal results and within 5 days for those with questionable or indeterminant findings. The purpose of this policy is to assure that both the physician as well as the patient are notified of mammography results. This will hopefully prevent any woman from being lost to follow up and empowers each woman to participate in her follow up care.

So! Be Prepared! After your next mammogram , you will be receiving your results personally by your caring staff at the Center For Breast Care. We hope you appreciate this added effort and would encourage you to call with any questions or suggestions.


Screening Mammography <40 yrs age

Oftentimes there are questions in the community about the routine screening for breast cancer in asymptomatic women who are less than 40 years old or for those patients considered at increased risk for the development of breast cancer. I would like to communicate my thoughts on these matters and how we address these issues at the Center for Breast Care in 1999.

The current recommendations for routine mammography for screening of the general asymptomatic population includes the initiation of screening mammography at age forty. These guidelines are endorsed by the American College of Radiology and the American Cancer Society.

Some women are considered at increased risk for breast cancer because of an early onset of menstruation (before age 12) , no live births before age 30, Jewish heritage or the routine consumption of alcohol. These people are considered at only a slightly increased risk for developing breast cancer as compared to the general population. No particular guidelines for the screening of these patients is recommended. As for the general population, annual screening mammography should begin at age forty.

Similarly, women who are often considered at a higher risk for the development of breast cancer will not require more frequent screening. Those with a history of Hodgkin's disease post radiation treatment, a history of strong family history of breast cancer or BRCA-1 positivity or a prior biopsy diagnosis of lobular carcinoma in situ will be considered at slightly higher risk for the development of cancer but the guidelines do not deviate from those of the asymptotic, low risk patient.

For those women with a strong family history of breast cancer to include a mother or sister with the disease, particularly if the disease was bilateral and prior to the onset of menopause, the screening process should begin at an earlier age. Screening recommendations suggest the woman begin annual mammography at ten years earlier than the age of diagnosis of the affected family member.

Other specific routine screening modalities to include ultrasound and magnetic resonance imaging are not currently recommended. Further information concerning screening of women for breast cancer can be obtained at the Center for Breast Care at (561) 955-5000.

Kathy Schilling, M.D., is the Medical Director of Imaging and Intervention at Boca Raton Regional Hospital's Center for Breast Care. Boca Raton Regional Hospital's Lynn Regional Cancer Center, accredited by the American College of Surgeons, is the largest community cancer program in South Florida. For more information call (561) 955–7050 or visit www.brrh.com.



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