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Beyond the Mammogram: Supplemental and Alternative Screening Methods for Breast Cancer

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MRI can be used to screen for breast cancer

When breast cancers are diagnosed early, prognosis is usually quite good for most women. The tricky part is actually detecting the disease early, and this is where breast cancer screening enters the picture. Without some kind of screening, it is almost impossible to catch invasive breast cancers before they can grow and spread, after which they become much more dangerous and difficult to treat. For this reason, medical professionals have placed great emphasis on the importance of early detection for the successful treatment of breast cancer. The American Cancer Society recommends that all women over the age of 40 have a yearly screening mammogram to protect themselves against this disease, while those under 40 who have been classified as high risk for breast cancer are also encouraged to have regular mammograms as a precautionary measure.

Campaigns to raise awareness about the threat of breast cancer have been highly successful, as tens of millions of women in the United States alone have been going for regular mammograms over the past few decades. However, while much attention has been focused on the mammogram, it is not the only tool available for medical professionals that can help them detect breast cancer in its nascent stages.

Traditional Detection: The Mammogram
Virtually every important cancer organization and recognized medical expert in the world recommends the mammogram as the first line of defense against breast cancer. A mammogram is an X-ray picture of the breast that can show lumps or other malformations in breast tissue that could be cancerous. Because this screening method has proven its effectiveness over the course of decades, it is considered to be the gold standard in this area - so much so that other officially approved screening methods are only recommended for use in conjunction with mammograms and never as replacements for them.

This consensus of opinion has perhaps given many women a false idea about the actual effectiveness of the mammogram, however. Mammograms can find abnormalities and lumps, but they cannot distinguish cancerous lumps from non-cancerous ones. Consequently, there are many false positives - it is estimated that if a women is screened annually by mammogram for ten years, there is a 50% chance that a lump will be found that will later turn out to be benign. There are also many false negatives, which reduce the overall utility of the procedure and give women a false sense of security, since women have been led to trust in the mammogram so much. Younger women have denser breast tissues that are more difficult to penetrate by X-ray, and it is for this reason that most false negatives occur in this group.

Based on these and other problems, the U.S. Services Preventive Task Force, a government committee of medical experts chosen to examine issues related to breast cancer prevention, has urged the abandonment of the old standard that recommended women receive a screening mammogram every year after the age of 40, stating that a mammogram every other year after the age of 50 for women with average risk is more than sufficient.

The new recommendations are controversial but the overall statistics do seem to indicate that the chances of a mammogram actually saving a woman's life if she is in the 40-49 age group in particular is statistically very small. It does need to be noted, however, that the new standards are not meant to apply to women who are judged to be in a high-risk category for developing the disease. In this case, frequent mammograms are still highly recommended. And it also must be noted that most cancer organizations are continuing to urge women to get annual mammograms after the age of 40.

The Triple Test Approach
In reality, the mammogram is only one part of a three-pronged approach to detecting breast cancer tumors. The first diagnostic tool used by medical professionals is the clinical breast exam. This involves the visual observation and physical probing of the breast by a doctor, nurse, or medical assistant, who will be searching for lumps, malformations, or changes in skin texture that might indicate something clinically significant is happening.

There is no way that a doctor or nurse can tell if a breast lesion is cancerous based strictly on a physical examination. However, if a lump or other unusual formation is found, the doctor may order further testing without even waiting to see what a mammogram might show. Mammogram X-rays can and do miss some malformations, and clinical breast exams can occasionally find things that the mammogram will miss.

Regardless of whether or not the clinical breast exam and/or the mammogram find something abnormal, a biopsy will be needed to determine conclusively whether or not a breast lesion is malignant. This procedure, which is commonly performed when any kind of cancer is suspected, involves a process called fine needle aspiration. Under the use of local anesthesia, a long thin needle is inserted into the breast in the area where the abnormality is located, and a tissue or fluid sample is removed for further testing.

Actually, if the sample turns out to be fluid, this generally means that the breast lesion is a benign cyst - although bloody fluid can sometimes raise suspicions. If the lesion turns out to be solid, and the sample removed is tissue mass, it must be subjected to laboratory examination to firmly establish its identity as cancerous or non-cancerous.

Clinical breast exam and mammogram followed by biopsy are the standard version of the triple test for breast cancer. However, there are alternative diagnostic exams that are frequently used in addition to, and sometimes even instead of, the screening mammogram to find lumps and malformations in the breast.

Ultrasound
Ultrasounds imaging, strictly speaking, is not currently classified as a screening technology for breast cancer. The US Food and Drug Administration has not approved ultrasound for this usage because it believes the technology has certain resolution problems that limit its overall effectiveness. While ultrasound advocates will argue this conclusion, at present it is probably safest to identify ultrasound as a supplemental method that can effectively assist doctors in the overall process of diagnosing breast cancer.

Ultrasound tests use sound waves that are bounced off the interior tissues of the breast and then captured as echoes and displayed on computer screens in pictorial form. Ultrasound is excellent at providing contrast, which allows medical professionals to examine malformations in more detail. Unlike the mammogram, ultrasound can differentiate very nicely between fluid-filled cysts and solid mass, and can to some extent differentiate between normal or abnormal lumps. One of the biggest difficulties with mammograms is that its X-ray technology has problems finding abnormalities in breasts with a lot of dense tissue, which is a normal characteristic of breasts in younger women.

In 2008, a study published in the Journal of the American Medical Association reported that breast cancer tumors were found 28% more frequently when ultrasound was used in combination with a mammogram. However, this approach also led to four times as many false positives, with all the extra tests, expenses, and anxiety that goes along with these cases.

While the ultrasound is not going to replace the mammogram any time soon, as the technology continues to improve it is likely to be used more commonly by medical professionals looking to be as thorough in their diagnostic techniques as is possible.

Magnetic Resonance Imaging (MRI)
This technology uses magnets, radio waves, and computer technology to generate a detailed picture of what things look like in the body. Used more frequently than ultrasound, MRIs are recommended for use in combination with mammograms in women who have a greater than 20% lifetime risk of developing breast cancer. MRIs can penetrate the denser tissue that is common in the breasts of younger women much more effectively than mammograms, which makes it a preferred diagnostic tool in high-risk women who must start getting mammograms earlier than 40. Some of the women who are referred for MRIs are women with strong family histories of breast cancer; those with mutations in the BRCA 1 or 2 genes or women who were treated with chest radiation therapy between the ages of 10 and 30.

MRIs are actually considered to be somewhat more sensitive than mammograms. However, they also tend to give more false positives, which means they frequently find suspicious lumps that turn out to be harmless upon further testing. When abnormalities are discovered on an MRI, it is possible to have an immediate biopsy that can be guided using MRI technology. Any woman planning on having an MRI performed should try to find a facility that has the technology available to perform this on-the-spot procedure.

Tissue sampling
This procedure looks for abnormal cells in healthy breasts, on the assumption (backed by some research studies) that the presence of these cells can be a predictor of future breast cancer. Needles, suction devices, or catheters are used to take tissue and fluid samples from the breast, and these samples are then examined under a microscope in search of anomalous cell activity. This method for possible future breast cancer detection or prediction is very much in its infancy, and more work will need to be done to find out how much promise this method really holds.

Breast Thermography
This controversial screening method is based on the idea that breast cancer activity, even in its early stages, has a noticeable heat signature. Breast thermography uses sensitive infrared energy detectors and advanced computer technology to generate images of any unusual hot spots inside of a woman's breast. Unlike the other screening technologies listed, breast thermography has not received a seal of approval from most medical authorities, perhaps because some of its less responsible practitioners have tried to claim it can be used as a stand alone replacement for the mammogram. As an adjunct to the mammogram, however, breast thermography has actually proven its worth - one meta-analysis of all the data showed that when thermography was combined with a clinical examination and a mammogram, breast cancers could be detected 95% of the time.

Breast Cancer Screening Means Early Detection
Ultimately, the biopsy will be used to determine in a lump found during breast screening is malignant. Only by actually taking a sample from an abnormality and examining it in a laboratory setting is it possible to determine whether or not cancer is present. Breast cancer screening is not designed to diagnose cancer, but simply to let women know that something is present that needs their attention. Fortunately, even if the abnormality is proven on biopsy to be cancerous, when cancers are caught early the chances of full recovery are excellent, which is the real rationale for breast cancer screening mammograms and other forms of supplemental screening.

The More Diagnostic Tools Available, the Better
Mammograms are still by far the most commonly used form of screening procedure for the detection of breast cancer. Now that the first 3D mammogram technology has been approved by the FDA, this trend should continue well into the future. Nevertheless, medical science is doing its best to use every tool at its disposal to help diagnose and treat breast cancer. For some women in some situations, when technologies like ultrasound and MRI are used in the testing protocol they can help more than a mammogram. And as these methods of breast cancer detection continue to improve, who is to say they won't someday rival the mammogram in popularity among women concerned with the threat posed by this deadly disease.

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