The Eighth Annual Breast Cancer Symposium from Wake Forest Baptist Health is planned for health care professionals who are involved in the medical care field and whose desire is to further their knowledge in breast cancer.
Objectives: • Incorporate current guidelines and recent data on therapies, including advances in medical, surgical and radiation therapy, into the treatment of patients with breast cancer. • Integrate genetic risk assessment in treatment decision-making for breast cancer when appropriate. • Summarize potential long term treatment effects of adjuvant therapies in breast cancer survivors. • Describe the effect of exercise and nutrition as part of a breast cancer treatment and survivorship regimen. • Describe the use of Tomosynthesis in breast cancer. • Discuss the conclusions from ATLAS research trial.
Submit a question to Dr. Rita I. Freimanis
RITA FREIMANIS: I was thinking last night. Actually, a friend was telling me that he saw a presentation somewhere where it was a nonmedical thing. But the person got up and said that cancer is going to be cured within a year. Now maybe you all have seen something in the literature that I haven't, and that sounds great. I know we're doing a lot of progress with genetic profiling of tumors and stuff. But we might be out of business here, you know, if they really do cure cancer. I hope it happens for women's sake. But all right, we'll see. All right. So tomosynthesis. What are we going to do here? This is my outline so you know kind of what to expect. I'm going to talk a little bit at first just about what it is and what the status of it is. It's a pretty new thing, but it's coming into the market rather quickly so you might as well learn about it. We'll talk about who may benefit from it. And to get to the bottom line quickly, I tell you once, I tell you twice, I tell you three times and you'll remember. It's basically women with dense breasts and how does this enhance mammography. Well, number one, it does not replace mammography. It is an enhancement of it. And I'll show you a lot more about that so hopefully you'll understand that. But the bottom line is that it does two things. It will help us find a few more cancers, we think. And it will decrease false positives as well by not quite as many women having to come back from screening for workup of things that are questionable on their screening mammogram. And then lastly, we'll go over some recommendations for breast screening by imaging, because it's gotten a little more complicated. And we'll see how tomo fits into that. So how did this all get started? This Time magazine cover is back from the early 1990s and reminds me to say that, back then when I was a junior faculty member, all we pretty much had was mammography. We had some sonography, but we really didn't have anything else for breast imaging. And mammography has always involved compression, and it's always involved radiation. And those are two things that we've always wished we could get rid of. Because radiation does have some risk and compression has some discomfort associated with it. But at this time, so they are talking about new thinking on breast cancer. But nothing has really come to take the place of mammography yet. It's still the best thing we have in terms of across-the-board screening. Nothing else has the resolution that mammography has, so it's still the workhorse. But there are some improvements that can be made on it, even if we can't get rid of it entirely. And like most good inventions, people all over the world are usually working on something before somebody finally figures out how to make it work, right? I mean, you can picture the cavemen all dropping apples and watching how they fall. And eventually, one of them comes up with a theory that happens to be true. But in our corner of the world, Dr. Weber, Richard Weber, was a dentist at Wake Forest he's now retired. And he had this problem where he would look at dental x-rays, and people that had fillings in parts of the teeth made it hard to see all of the tooth. So part of the tooth has the filling that you can see in the picture there, the big white blob. And right next to the filling, or right behind it, might be a cavity that doesn't show up very well. The cavities show up as these dark spots. Here's a tooth that's normal. And then this tooth has a cavity, this dark spot. And the one next to it has a filling in it. So if there was a dark spot behind this filling, you wouldn't see it. So you wouldn't see that there's a cavity there that needs to be fixed. So he thought, well, what if I develop some kind of x-ray technique where I can look around the corner and look behind these fillings? So we started working on this together. And because he knew that I was doing mammography and used the low-dose kind of x-rays. And ran into each other in the hallway, in short, the way these things usually start. And the dental problem is very similar to the problem we have in mammography because some cancers are really obvious, like this one here. This woman has what we call a fatty breast. It's basically black because the fat is black on x-ray. And her cancer shows up really well. It's this white mass in the middle of the fatty breast. But the other patient has very, very dense breasts. They're like dense white clouds. And she has a cancer of the same size in her breast, but you just don't see it at all. So that's our problem with mammography. Dense breasts hide cancers. Now we do have sonography. And on the sonogram we see this black hole in the middle of the breast tissue. But you need to know to go looking with sonography. So a woman has to have a palpable mass or something that will indicate that there might be something abnormal. So she did have a palpable mass. We did sonography, found the cancer, all is good. But when we do screening, which is for asymptomatic women who don't have palpable masses, we don't know that we need to do sonography or some other test that just has a local kind of exploration, then we may miss those cancers. So some cancers are completely hidden, and some are partially hidden. Here's an example. These are two views of the same breast. We always do two pictures of each breast in screening mammography, a cranial caudal view and a mediolateral oblique view. That's the side view. And this is the one picture where this kind of loose, cloudy stuff is normal breast tissue. I don't really see anything abnormal there. But the other view shows some of that loose, cloudy breast tissue and then the bright white spot right in the middle there, right? You can see that very clearly. And this turns out to be a cancer that just shows up on one view only. And this is why we do two pictures. We've learned over time that, if you do two, you might see something on one side that you don't on the other. Same thing if you break your ankle. They're going to take at least two pictures. They might take three because the fracture can be hidden on one picture. Turn it from the side and you can see it. So if two is better than one, why not, like, six pictures or 16 pictures or 30 pictures? Well, that's basically what they've done with tomography. And here we go with a little physics. Everybody knows that physics is just exactly what you want to do at 8:30 in the morning. But I will try to make it simple and palatable for you. So the way stereotactic breast biopsy works is that it's basically putting together multiple pictures. And then they're reconstructed into one kind of 3D set of information, which we don't really look at as a single 3D image, but we look at it in the individual slices that make it up. And this came to us originally from Sweden in the early 1990s. They've been doing it for several years, the stereotactic breast biopsy. And what it is is there is this table that the patient lies on face down. And there's a hole in the table, and the breast comes down through the hole. And then there is compression. These two things here come and compress the breast. And there's computerized x-ray that makes a picture of the breast. And then the computer guides the needle, the biopsy needle, to the spot in the breast that is of concern. And how does the computer know how deep to go? Well, that's where the stereotactic thing comes in. Here is a schematic. So this is the breast, the circle. And then there is a compression plate that is going to flatten it a little bit. And then the image detector is in the back. And then the x-ray tube is back here. And this is the x-ray tube on the table. So the x-ray tube is here, and the x-rays come out and shoot through the breast and land on the image detector here. So this x-ray tube swings from side to side. 15 degrees to one side, 15 degrees to the other side. And if you take those two different pictures and put them together, the computer can figure how deep a lesion is if you click on the picture and say, this is where I think the lesion is. If you hold your thumb in front of your face and hold it far away and close one eye and then close the other eye, it doesn't look like it moves a lot, right? But if you put your thumb right in front of your eye and close one eye and close the other eye, it goes from here to here. It moves a lot, right? So if I see my thumb moving a lot, it's close to my face. You started learning that when you were probably like 1 and 1/2 or something, right? So it's the same thing with this. If we have our two computer pictures and we click where our spot is and the computer says, well, that's moving a lot on each of those pictures, it must be close to the front of the breast. Or, it doesn't move a lot between the two pictures. It's at the back of the breast. So that's how the computer figures out where to guide the needle to. So that's the basic principle of stereotaxis. And so here we are doing this biopsy, patient lying on the table. But we don't do a lot of biopsies every day, like maybe one or two in our facility. Other, bigger facilities may do more. But compared to the number of mammograms we do, it's not very many. So you've got this room with this big table that only gets used for maybe one procedure a day. And the rest of the day it's unused because you can't do regular mammograms with it. Number one, because of the positioning, the patient can't get in there and kind of hug the machine the way she usually does to get a good mammogram to get all the way back to the chest wall. And secondly, the detector at this time was only about this big, like, 5 centimeters across, because the technology had not gotten to where they could make a big digital detector yet. That came years later. So some clever person said, well, let's try to figure out how to make this a stand-up or a sit-up machine. So they came up with this device. And this is a Siemens mammography unit, which looks like a regular mammography unit. And it is, except it's designed so that tube can swing in a similar way that it does for the stereotactic biopsy. So now we have this stereotactic possibility, where a patient can sit up, a unit that can be used more frequently. OK. So what other use can we put this to? Can we try to do regular mammography with it? So this is some of the work that Dr. Weber, our dentist, and I did. And again, here's a schematic of what we did. Here's the x-ray tube. And it shoots the x-rays through the breast. And we used a cadaver breast, and we inserted what's called a little phantom, this little plastic thing with fake tumors in it. It's got little masses and little specks of calcium. So the x-rays shoot through the cadaver breast, through this phantom, onto this little digital detector. And if you just do one straight picture going through there, you get a picture like this, where there is fuzzy breast tissue and fuzzy little specks of calcium, those little white dots. Which are these little white dots. But if you swing this tube from side to side and take lots of pictures and then have the computer sum those up together and make it into slices that you can look at individually, you get something that looks more like this. Or this picture down here, where the breast tissue is kind of fuzzed out and the calcifications come into crisp focus in that particular plane where they're actually located. So this kind of shows how the tomography, or the moving of the image from several different angles and summing them together, helps you see things more clearly. And then he pieced-- the mathematical genius, not me. But he then figured out how to de-blur it, take that fuzzy background out, and clarify the image a little bit. And then you can see these calcifications a little bit better here. OK? So that was back around the year 2000. And so that's, what, 13 years ago. Why is tomography just coming-- tomosynthesis coming across now? Well, basically it had to do with the detector size. You can see that small detector. That's a 5-centimeter detector that took many more years before the companies that build this sort of thing figured out how to make the detectors as big as the whole breast. We know that computer tomography-- you talk about body CT, head CT-- has been around for many years. Why couldn't we use that technology? Well, because you don't need the same resolution for liver scans and brain scans. But for mammography, since we're looking for microcalcifications as a sign of cancer, we need to have really, really, really high resolution. And that requires a different kind of detector technology. But eventually they figured out how to make one of those. So now we have it. And as of last year, the tomosynthesis units have been on the market. So it's still quite new, but they are really rapidly coming into the market. The initial data has been quite strong. And it's something that we've really been waiting for. And so it's been accepted readily. The next few slides are ones that Whologic gave me to show. This is a picture of their digital mammography unit. And you'll see it looks pretty much like any other mammography unit just to look at. And patients really won't notice much of a difference. If they didn't know they were having tomosynthesis, they probably wouldn't be able to tell unless they were particularly perceptive. If they noticed the tube swinging differently, they might notice that. But it just takes a second or two longer than a regular mammogram. And it has the same kind of compression, the same kind of positioning. So for the patient, it's not that different an experience. So this is how the new tomosynthesis works here. This is their little schematic, again, to show you. Here's the x-ray beam coming into the breast. And the little blue spots are normal little lobules of breast tissue. And the little red spiky thing is a cancer. And if you just take one picture going through the breast and if these little blue dots, the little normal breast lobules, all superimposed on top of each other, you might not see the cancer that's hiding in between it or beneath it. So this is going to be a little schematic that shows you how that tube swings. And it takes a series of a bunch of very low-dose images. If you do regular mammography and take two pictures of each breast, the dose is a good bit higher per exposure. But if you take a lot of these little pictures, you have to decrease the dose for each one because you can't give a lot of radiation. So here you have the tube swinging. And I'll just show you that again in case you missed it. It takes about that long or maybe just a little bit longer in real life. If a patient has a bigger breast, it's going to take just a little bit longer. So you can see it just isn't going to be that different for the patient. So what happens, then, is you get all these different slices. And you get this stack of images. And it's kind of like a deck of cards. On the computer you can pull one out and look at it. You can look at the whole series one after another. You can stop and look at one slice, page through it. So here's one card that's been pulled out with a normal little breast spot. Here's another image that shows you three little normal breast spots. But oop, on this one, now I can see the cancer because those other breast spots are on the other slices. I've sliced the bread so that I'm right at the part where the cancer is. And this is an example they have in their files, the Whologic company, of the regular 2D mammogram on the left. And the circle is around a little spiky white spot, which is a cancer-looking thing. All right? I went to school to learn how to recognize cancers on mammography, and that's what they look like. But on the right is the slice that goes right through the central area of the breast on the tomo, and you no longer see that spiky mass. So this is not a cancer. That's just a summation shadow, is what we call it. Lots of little normal breast density superimposed on each other. So here's the kind of opposite example, where the 2D shows nothing but the 3D does show the cancer. The circle is around an area that looks pretty much like normal breast tissue. But on the slice in the tomo, you see a little round mass there. So we've been doing this since February at Wake Forest. And so we now have some of our own experience. I've got some of my own examples to show. And it's not quite enough time to really show, with statistical significance, how much it has decreased our recall rate or increased our cancer detection rate. But I do have, at least, examples to show where tomo has helped us. Here's an example of a patient that has breast implants. And those are always a little bit harder mammographically. But this is what we call the push-back view, the implant-displaced view. And this looks pretty much like normal breast tissue in a patient with an implant. Just slight kind of streaky pulling in here, but we often see that in patients with implants because the tissue is kind of stretched around the implant. It does require surgery to put the implant in, so there's a little surgical scarring. But on the tomo picture where the circle is, we see more prominent architecture distortion. And this is a place where there is tumor pulling in on the fibrous bands in the breast. And this is what invasive lobular cancer does. This is a pretty typical appearance of an invasive lobular cancer, which is what this patient had. So this was an example of a case where the tomo found her cancer for us. This is a cyst, not a cancer. But even so, it just kind of shows how masses will sometimes show up better on the tomo. The mass is here. You can see it kind of in retrospect, but it shows up a little bit better on the tomo. It's a very flat, compressible cyst so it's not very dense. But the tomo does show us the margins better. That's how we detect it. This is an example of how tomo prevented a lady from having to be called back from her screening. In her 2D mammogram, looks like a pretty obvious white spot there, right, on the left side there. Looks like a little cancer, a little spiky thing. But the tomo, you page through it, and it pretty much disappears. So it's what we call a summation shadow. Several normal breast spots adding together to look like a cancer. It can be helpful for calcifications, showing us if they're in the skin. We don't use tomo so much for calcifications. But if calcifications are in the skin, they're not caused by breast cancer. And calcifications in the skin are very common. So it can help me in this way. Here's the 2D mammogram. And there's a circle around five or six little white specks. And they look like they're in the middle of the breast tissue, right? But when I do the tomo and I go to the-- this is highly magnified here-- I go to the slice that's all the way at the back of the breast where the skin is, and I can see that because those vague dark spots throughout are the little skin pores, so I know I'm at the skin slice. I can also see it's the last slice in the study. And I see that the calcifications are right in that slice, so I know they're in the skin. I don't have to worry about it. Another example of a mass that you can see a little bit better on the tomo. 2D mammogram you don't see very much. And on the 3D, small mass in the middle of the circle there. And I look at these all the time. So I know they're more obvious to me. I know they may be hard for you all to see, especially with the lights in the room. And this isn't necessarily all that important. But it just does show the increased clarity. This is a patient where we can see the ducts going into the nipple. On the 2D, you don't see them very well. And I've got it zoomed up here so you can see. But on the tomo, you can see the little black tubes going actually into the nipple. So what are your take-home points for tomosynthesis? Well, it is rapidly penetrating the market. Most big facilities now have either gotten one or are in the process of getting one. It's kind of an example of one of those things penetrating the market before it's completely, definitively proven. It's also sort of a marketing thing. Once one facility has it, then all the others want it too. But it really does look like it's helpful, mainly in patients with dense breasts. And I think you understand why now. Most people are starting to use it in their screening population rather than the diagnostic mammography population because of exactly what you're seeing here, that it decreases the recalls and helps you find some cancers that otherwise would be undetected. It does have a little more radiation. I showed you those additional pictures. If you add up all the extra slices, it ends up equaling about what one straight picture would be worth. So if you do the tomosynthesis together with the regular mammography, it just about doubles the dose of a regular mammogram. And people will say, well, how much radiation is that? Is that really risky for me? Well, it comes to about the same amount of increased radiation as if I moved from here to Colorado, lived in Colorado for a year as opposed to living here. So yes, it's more radiation, but the amount of radiation that's being doubled isn't that much to begin with. So that kind of brings us to screening guidelines. Let's summarize what our screening guidelines are and how tomo fits into that. The latest American Cancer Society breast screening guidelines still say that yearly mammography from age 40 is recommended. They don't give an upper limit. We don't really have a defined age at which one should stop doing that. There is data that shows that, if you think a woman is going to live seven more years, then it's probably worth doing a mammogram. But that's not actually in their guidelines. Yearly MRI is being recommended by them and by other organizations for women that are of high risk. And you go into one of these computer models and they have 20% to 25% risk of having breast cancer in their lifetime. They can qualify for MRI screening. And doctor's breast exam, looking for lumps. They no longer stress breast self-exam. I think the wording is something like, you should never ignore a lump. Or if a woman feels a lump, she should bring it to the attention of her doctor. But they used to say, do monthly breast self-exam. But they've dropped that. So additional recommendations. Well, just in July of this year and to become effective in January 2014, there's a new North Carolina law called the Breast Density Law. And it's pretty amazing. There are 12 other states that have had this done. And what it says is that every mammography facility is required to tell patients if they have dense breasts. And this is based on the fact that there's ongoing many studies over many years about, does breast density, high breast density, increase cancer risk? And it probably does, at least a little bit. Perhaps not as much as some of the data suggested, but there probably is some increased risk there. And we know that mammography is less sensitive in dense breasts. But it's a little bit problematic because this is what the law says. And they give you these words and they say, you have to put these words in your letter to the patient. I'll just read it to you phrase by phrase. "Your mammogram indicates that you may have dense breast tissue." So right there, what does that mean? Do you or don't you? Am I supposed to give this to everybody, or people that are, like, sort of dense or what? "Dense breast tissue is relatively common and is found in more than 40%, 40% of women." Relatively common, like almost half the people have it and you're saying it's relatively common? That's like almost every other person in the room. "The presence of dense tissue may make it more difficult to detect abnormalities in the breast and may be associated with an increased risk of breast cancer. We are providing this information to raise awareness of this important factor and to encourage you to talk with your physician about this"-- and there's also a little typo in it-- "about this and other breast cancer risk factors." So all these women, half the population that have mammography, are going to be calling their doctor, saying, talk to me about my dense breasts. It says I might have cancer that might be missed. You all are going to love that, right? You're going to be having all these phone calls, and you're not going to know what to tell them. And then it says, "Together, you can decide which screening options are right for you." I can't figure out which screenings are right. How is a patient and her doctor, who's not a specialist in this, going to know? Anyway, so "a report of your results was sent to your physician." So I anticipate that there's going to be a lot of hoopla about this when January comes around. So I thought I would just talk a little bit about some things you can think about if people do ask you about, what are your screening options for dense breasts? Well, number one, they can do the souped-up mammography. Definitely they should get digital mammography. And I think all patients should be getting digital mammography now, as opposed to film screen mammography. Film screen is the old-fashioned kind where there actually is a piece of film. You don't read it on a computer. It's really, really getting harder for facilities to keep the quality of film screen mammography up because almost nobody does it anymore. And so I think the companies are having trouble keeping the film fresh and the processing chemicals fresh. I just see a decreasing quality of film screen mammography wherever it's still being done. So you all as health care providers can, I think, help by encouraging. If you see a facility, if your facility is still doing film screen mammography, do whatever you can to either help them get their digital mammography in there or, I say it, but have the patients go to a facility where there is digital mammography. And tomo. If a patient has dense breasts, it's tomography, tomosynthesis, can really be helpful. Not all facilities have it. For example, at Wake, we now have two of our mammography sites that offer it, but not all of them. MRI. MRI is a screening option. It's expensive. It's not available everywhere and really should be restricted to women that are of high risk. Because there are a lot of false positives with screening breast MRI. So if we screen a lot of young women that are of normal risk, we're going to be doing a lot of callbacks and a lot of biopsies of normal breast tissue. But for a little bit older women or women that are of high risk, it's very helpful. Now the big question is whole breast ultrasound. There are some people that believe very strongly in this. There is some data, some papers out there that say it's very helpful. But it's not a universally held opinion. There are many people that don't think screening whole breast ultrasound is useful. It's a very operator-dependent kind of process. It's not like a mammogram where you take a picture of the whole thing. But you have a little probe and you drag the probe across the breast and you go, oh, oh, there's something, there's something. And then you kind of investigate that. Now there are machines now that are called automated whole breast scanners, where the machine kind of drags the probe across. But it's still basically that same concept that you don't get the whole picture of the whole breast at once. And again, like MRI, there are a lot of false positives because normal breast tissue looks like little dark spots on the ultrasound, just like cancer does. And young women, especially, have a lot of those little normal dark spots. It's also quite physician intensive, which makes it expensive. A physician has to go back and scan and study these areas, or do the scan themselves if the facility doesn't have an automated scanner. So at our facility, we don't recommend whole breast ultrasound scanning. We don't do it at Wake Forest. So to summarize everything I've told you today. Screening mammography, still the best thing, yearly from age 40. Digital mammography is great for everybody, but especially for women with dense breasts. And for women with dense breasts, consider getting tomosynthesis if it's available to you. The benefits of the tomosynthesis. We do have increased sensitivity. We're going to find more cancers and, at the same time, lower recall rates or better specificity. So it really is a good test. And then remember about screening MRI for patients that are of high risk, like 20% to 25% or greater. And if people ask you about ultrasound, it is an option. It's not necessarily something that we recommend at Wake Forest.