Breakthroughs in Early Diagnosis and Prevention - 10/02/02 - Alice S. Rim, MD

Last Editorial Review: 10/23/2003

Find it early. If we can't wipe cancer off the face of the earth, at least we can find new ways to catch it. We discussed low-tech options like self exams, as well as what's on the leading edge of cancer detection and prevention when radiology expert Alice S. Rim, MD, was our guest.

WebMD Live Events Transcript

The opinions expressed in this transcript are those of the health professional and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD University. Our guest today is Alice Rim, MD, from The Cleveland Clinic. Let's start off by discussing the latest methods for early detection of breast cancer. What's the latest thinking about mammography?

Rim: I know that there has been a lot in the media on confusion about whether mammography truly saves lives and whether it's worth it to a woman to start screening every year and at what age. But I can tell you from experience in dealing with large numbers of women that mammography does save lives, in that it allows us to detect the cancers early. Women should start screening at age 40 and really should come every year after that point. In addition, monthly breast exams in conjunction with physical exams from your physician should accompany the mammogram. This is our first line of defense in early detection.

There are other ways to help detect early breast cancer, and that would include a directed ultrasound. Also, we do other tests, which include MRI of the breasts, and if the patient should have, specifically, nipple discharge, we could do a ductogram.

Member: How often should I get a mammogram? Mine was suspicious and they made me get an ultrasound. The doc decided that the problem was cysts. She wanted me to get one every six months. If it is just cysts, why every six months?

Rim: In my opinion, if the doctor found that the mammogram showed cysts, a cyst is completely benign, and in my practice I would have you come once per year. However, I did not evaluate you and maybe the physician was being overly cautious in following up at six-month intervals.

Moderator: Can you please explain what a "ductogram" is?

Rim: A ductogram is performed when a woman has nipple discharge from one orifice on the nipple. If you squeeze the nipple and milky white discharge comes out several openings in the nipple, that is a benign finding, and we don't do a ductogram for that. However, if one opening in the duct is secreting discharge, we do a ductogram to find out if we can illustrate what is causing the discharge in that particular duct. Sometimes, small masses within the ducts, which are tiny tubes in your breast, in your nipple, can irritate the duct and cause discharge. We identify the opening that causes the discharge and take a tiny hair-size tube and place it inside the opening. From that point, we inject contrast through that tube to better delineate that particular duct. Then we take two magnified views of the breast and look to see if we can identify the abnormality causing the discharge. If we are successful in identifying the abnormality, we can do the same procedure prior to a patient's outpatient surgery so that the surgeon can just remove that particular duct and not remove any other normal tissue in the breast.

Member: When should I get a mammogram? I am 34 and my mother died from breast cancer. I have clinical exams and perform breast self-exams.

Rim: Although there is nothing in the literature currently to support when a woman should get a baseline mammogram, here at The Cleveland Clinic if there is a family history, such as a mother with breast cancer, we like to start screening 10 years prior to the age at which the relative was diagnosed. For example, if your mother were diagnosed at age 40, we would recommend you start screening at age 30. Otherwise, we normally have women start screening at age 40.

Member: How important is family history when it comes to predicting potential for breast cancer?

Rim: Good question. Unfortunately, the two risk factors I see in my practice are being a woman and getting older. Having a family history puts you at a slight increased risk, but the majority of women I diagnose with breast cancer have no family history.

Moderator: So you still encourage women to do BSE?

Rim: Yes. Absolutely.

Moderator: What do you think about those aids that are sold to help you do a BSE?

Rim: I don't stress to women they need these aids, and I can't really comment on them too much. I usually encourage women to wait until after their menses [period], get in the shower, get soaped up, and do the BSE in the shower.

Moderator: What age do you recommend women start doing BSE?

Rim: Age 20 is what the American Cancer Society recommends, I believe.

Member: Is it true that the best time for women to get a mammogram is right after their menstrual cycle to experience less discomfort?

Rim: That's true and it also can change (sometimes) the density of breast tissue, allowing us to see more things.

Member: What happens with a young woman who performs BSE and finds lumps, but is told she is too young for a mammogram?

Rim: Good question. What we would do is a directed ultrasound of where she feels the lump. Usually we can delineate what is going on from that exam.

Member: I recently had a mammogram and my hospital has started offering CAD drawings of the breast. How much of an aid are these reports?

Rim: Here at The Cleveland Clinic we offer computer-assisted detection, which is simply a second look at your mammogram with a computer scan. The computer has been taught with software items to flag what may represent an abnormality. It's another way to have a second pair of eyes looking at the mammogram. However, it can't reason. It doesn't have your prior films to compare. And it can't make decisions. It's your radiologist's job to decide whether or not to pursue any of the CAD's findings.

Moderator: What are some effective methods of calming women's fears of getting mammograms? I know the message that it can save lives.

Rim: I realize that obtaining a mammogram is not a fun event. It can be very uncomfortable from the compression, and let's face it; you are coming for the detection of something very scary. But I tell women to assign a special date, and make that the date to get your mammogram every year. Take a friend with you. Make it a day where afterward you can go have lunch. It's a day of celebration. You are participating in your health, in preventing a horrible disease. I can speak from experience. I have to literally escort my mother every year, but we make a day of it, and I keep stressing that she's making a step in saving her life.

I want to add another thing: When the technologist compresses your breast, please remember the more she compresses, the better the mammogram, and the better the chance that the radiologist will be able to detect a small cancer.

Member: How could a mammogram test in December 2000 not reveal cancer, when in fact I was diagnosed just seven months later with stage 2A breast cancer?

Rim: It's hard for me to comment on your particular case without looking at your mammogram. It should be noted that 10-20% of breast cancers are not seen on the mammogram. At least the stage at which the cancer was detected is a very treatable one.

Member: Is a Miraluma test an experimental procedure? My breast cancer was not diagnosed with a mammogram because of my dense breast tissue. Now in my post-treatment (surgery, radiation), I had a Miraluma screening but it was denied by my insurance due to being experimental. I want to appeal this denial. Please give me your opinion.

Rim: To my knowledge a Miraluma scan is not experimental. If the test was performed after your lumpectomy and radiation therapy to exclude a recurrence of cancer, I feel this was a reasonable indication. The Miraluma scan is a nuclear medicine study that allows for detection of recurrence vs. the normal scar tissue you would expect from your prior treatment. At The Cleveland Clinic we do not perform Miraluma scans for this indication. Instead, we perform MRIs.

Member: I have a small (approx. 6 mm), palpable lump that did not show up on my mammogram or ultrasound. My doctor at Emory Clinic in Atlanta said not to be concerned about it unless there are changes and to follow up with my regular bilateral annual screening. Should I insist on further tests?

Rim: Since the mass you feel cannot be seen on either the mammogram or the ultrasound and I am assuming your doctor has felt this lump and feels that it has a benign feel to it, it's not uncommon for us to have someone return in a year for her annual screen. However, if this area continues to really bother you, it's not unreasonable for you to have your physician do a needle biopsy of the lump to ease your fears.

Moderator: What factors indicate the need for an MRI of the breast?

Rim: Here at The Cleveland Clinic, if the woman's mammogram and ultrasound are negative or difficult to interpret, we can offer a woman an MRI of the breast for the following reasons:

1. For implant rupture

2. Recurrence in a woman who has had a lumpectomy and radiation therapy

3. A woman who presents with a cancer of unknown primary and we're trying to rule out the breast as the source of the cancer

4. Staging of a woman who is newly diagnosed with breast cancer

Member: How accurate is an MRI?

Rim: An MRI can be very accurate in the detection of invasive ductal carcinoma of the breast. At this time, the sensitivity for other types of cancers is not known. In addition, its false-positive rate, meaning giving positive results for lesions that are not cancer, is high. We can't use it currently as a screening tool because it's expensive and the high false-positive rate at this time is not acceptable. That would lead to an increase in unnecessary biopsies. A screening test should be affordable and accessible to the majority of the public. We would never have enough magnets to adequately screen the population of women in a timely and costly fashion.

Moderator: How accurate is an ultrasound?

Rim: An ultrasound currently is an excellent tool to help better delineate a finding on a mammogram or a clinical finding (like a lump you may feel). If anyone has ever looked at an ultrasound screen, it looks like a snowstorm. Its sensitivity is low due to its resolution.

It's better with masses, cysts, and larger findings than it is with tiny findings such as microcalcifications that are only seen on mammography.

Member: I saw a headline today but didn't get a chance to read the article, about doubt being cast on self-exams. Do you know what that is all about?

Rim: I want to stress that both monthly self-exams and yearly mammograms together with your doctor's yearly exam is what's needed for early detection. One alone is not adequate. In my practice, women who do breast self-exams many times will find a lump that no one else could have detected, either through mammography or her physician. Vice versa, sometimes the physician picks up the lump and it may not show up on the mammogram. It's important to note that the study did not disprove if a woman does a dedicated monthly breast self-exam, it does not do some good.

Moderator: You can read a great article about this study on WebMD in the Breast Cancer Condition Center.

Member: Now we hear that BSE doesn't work and mammograms are in question, how do we sift through all the "news?"

Rim: I realize that sifting through all the news stories about the inadequacies of mammography and BSE can be confusing and irritating to a woman of screening age. However, I can tell you that it's very difficult, even for me, as a physician, to digest the findings of all of these studies based on whether or not they are valid. I can only tell you now from experience that the best first line of defense we have is your BSE, annual mammogram, and annual physical exam with your physician.

Member: I'm a medical reporter at a local TV affiliate in Rhode Island and am covering this new study on breast self-exams. What is the best way to communicate this information to our viewers? I think women will start thinking that nothing is working to detect early breast cancer.

Rim: You are right. I have the same worries that a lot of these news stories about the flaws with BSEs and mammography will stop women from coming in for their annual checkup. Unfortunately, I can't quote you a study that proves that mammography and BSE will decrease your chances of dying of breast cancer beyond a shadow of a doubt. That study won't ever be performed because the only way to do it would be to make a large number of women not do BSEs or mammograms. How can these services be withheld ethically from women? So we really will never know. Again, all I can do is talk from experience that early detection saves lives and annual mammography and BSEs and annual physical exams are all integral in early detection.

Moderator: We are almost out of time. Do you have any final comments for us today?

Rim: Remember to get your mammogram, do your BSEs, and see your doctor every year for a physical exam. And thanks for chatting with me today.

Moderator: Thanks to Alice Rim, MD, for joining us today. To learn more about breast cancer, be sure to explore all the breast cancer info here at WebMD, including our message boards and live chats.

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