The United States Preventive Services Task Force (USPSTF), a panel appointed during the George W. Bush Administration and supported by the federal Agency for Healthcare Research and Quality, a branch of the U.S. Department of Health and Human Services, issued recommendations regarding breast cancer screening in 2009.  This panel consisted of physicians in primary care (internists, pediatricians, Ob/Gyns), nurses, epidemiologists, biostatisticians, and public policy officials.  Not one single breast cancer expert (breast surgeon, oncologist, radiologist, radiation oncologist) was included at the table, and there was neither invitation nor opportunity for breast cancer experts to address the panel before the recommendations were handed down.  The panel recommended screening mammograms every other year, beginning at age 50; this was a significant departure from the 2002 USPSTF recommendations, which called for annual screening commencing at age 40.  Incredibly, the panel also recommended that women should not be taught or encouraged to do breast self-examination, and that physicians should not perform clinical breast exams on their patients to check for cancer. Instead of being applauded as one of the few interventions in the healthcare system that actually saves people, with a 30% reduction in breast cancer mortality in the U.S. since 1991, breast cancer screening was under attack.

To support its proclamations, the panel used a computer model to create new, non-peer-reviewed data extrapolated from previously published studies on mammography screening. (At least Colin Powell wasn’t tapped to bring in the poster boards this time.  The man is still my hero, despite all of that.)  Some of these papers were decades old.  The USPSTF used the lowest estimate of mortality reduction attributed to mammography (15%) among the various numbers that exist in the literature (as high as 54%).  Even with their selective use of a low mortality reduction figure to create their new numbers, the USPSTF’s own “data” confirmed that significantly more women would survive if mammography screening began at age 40.   But they ignored their own data, and they claimed that the supposed “harms” of screening (discomfort, anxiety, being called back for additional pictures, potentially having a needle biopsy that turns out to be benign, the risk of diagnosing cancers that wouldn’t necessarily kill the woman— though no one can tell us which cancers those are at the current time) outweigh the benefit of lives being saved.  This was clearly not an objective, impartial scientific judgment; this was a value judgment, made with the over-arching goal of creating cost-saving public-policy recommendations for a broken healthcare system.

In practice, we are beginning to see the fallout from that judgment.  The infamous “death panels” have already landed, folks.  But contrary to expectations, it’s not grandma’s plug that’s being pulled; it’s women in their 40’s who are being hung out to dry.

The yellow circle in the mammogram image below denotes a 0.7cm invasive ductal carcinoma in a woman in her 40’s who decided not to follow the USPSTF guidelines, and to continue annual screening.  This patient’s cancer was detected at stage I, with an estimated 5-year survival rate of 95%, an excellent prognosis.  Her treatment consisted of a lumpectomy (breast conserving surgery) and radiation therapy.  Chemotherapy was not required:

The mammogram image below is from a woman in her 40’s who had not yet had a baseline mammogram, and decided to put off screening until she turned 50 after she’d heard the USPSTF recommendations.  One day she felt a lump in her breast, and her doctor sent her for a diagnostic mammogram.  The yellow arrow in the image points to a 2.7cm invasive ductal carcinoma, at the site of her palpable lump.  Unfortunately, this patient’s cancer had metastasized by the time it was diagnosed; her cancer is stage IV, with an estimated 5-year survival of 20%.  Because her tumor is large compared to the size of her breast, a modified radical mastectomy (full breast removal) was recommended; the patient will also require many rounds of chemotherapy, and the best she can hope for is remission:

It has been estimated that if the USPSTF recommendations are followed as clinical guidelines, 20% of breast cancer deaths will occur in women who could have been saved.  We have excellent data on mortality reduction as a result of screening women in their 40’s from numerous sources, including Dr. Laszlo Tabar’s group, Dr. Hendrick and Helvie’s study, and research presented from the Elizabeth Wende Breast Center in November 2011, to support the assertion that the USPSTF guidelines should be revised. In addition, this month’s edition of the journal Radiology published important original research concluding that mammography screening for 40- to 49-year-old women significantly decreases mortality.

The authors of this most recent study also found that cancers in women in their 40’s that were detected by mammograms required less invasive surgery (more lumpectomies rather than mastectomies; less lymph nodes removed), and these patients needed chemotherapy less frequently. These considerations were not even given a passing nod or mention by the USPSTF.  These important additional benefits for women in their 40’s, when many people’s lives are impacted if these women become sick, include:

• Higher likelihood of being a candidate for breast-conserving surgery, with a better cosmetic outcome.  Don’t let anyone shame you into thinking that you are shallow and vain if you believe this is an important consideration.
• Less likely need for chemotherapy—i.e. no hair loss, vomiting, fatigue, premature menopause, and a myriad of other side effects both temporary and permanent; less time missed from work and family obligations; less psychological trauma for yourself, your spouse and your children; less career disruption and the potential for discrimination due to your illness.
• Less expensive treatment.  In a world where even patients with “good insurance” end up spending a great deal of their own money out-of-pocket when they have cancer, sometimes putting themselves and their families into debt to cover the costs, this consideration matters a great deal.  Estimated cost to treat early stage breast cancer:  $14,000.  Estimated cost to treat advanced breast cancer:  $140,000. 
• Less likely need for complete removal of lymph nodes under the arm (axillary dissection), avoiding the potential lifelong misery of a chronically swollen and painful arm (lymphedema).

Any useful discussion regarding the value of screening for breast cancer must consider morbidity as well as mortality.  It is severely unfair to women if these factors are left out of the debate, as they invariably have been until now.

I am not suggesting that screening mammography, even when started annually at age 40, is a panacea.  If a woman has dense breast tissue, as half of women under 50 and 1/3 over 50 do, mammography is limited in sensitivity, many early cancers will not be seen on the mammogram, and a woman needs to discuss with her physician the possible need for an additional test in order to be effectively screened.  Even for women who do not have dense breasts, mammography can be imperfect, which is why self-examination and clinical breast exam by your doctor are so important.  In addition, women at high risk for breast cancer should develop an individualized, proactive screening plan with their doctor in order to protect themselves.

Breast cancer is the single most common cause of death in women age 35 to 50.  If there’s any time to screen for it, it’s then.  Don’t take one for the team on this.  Cost savings for the system should not be attained by sacrificing women in our 40’s.  An enlightened government should refrain from messing with what works, and should support efforts to make screening for breast cancer even more effective.

Physicians at Montclair Breast Center

At Montclair Breast Center we have always understood the importance of breast density, and we tailor our recommendations for our patients based on multiple factors, including breast density.  If this bill passes, a wider population of women in our state will benefit from this advance in promoting successful early detection.

Voice your support for Senate Bill No. 3174!

You can email Senator Nia Gill here. (Essex and Passaic)

You can email Senator Loretta Weinberg here. (Bergen)

Learn more about what breast density means to you here.

A patient feels a lump in her breast and calls her doctor.  The doctor examines her, agrees that a lump is present, and refers the patient to a breast imaging facility for a diagnostic mammogram and breast ultrasound (also known as a sonogram).  At her mammogram appointment, a little sticker is placed on the lump felt by the patient, and mammogram images are taken.  Something may or may not be seen on the mammogram at the site of the lump.  A breast sonogram is performed, and a suspicious mass is seen, clear as day.  And sometimes it’s not so tiny.  The yellow arrow in the sonogram image below demonstrates one such mass:

The radiologist assigned to read mammograms that day tells the patient that a mass has been found, and she needs to have a needle biopsy.  The biopsy is performed, cancer is diagnosed, and when the patient is given this news she exclaims, “But how can I possibly have cancer?  I just had a normal mammogram a few months ago!”  Everyone is upset.  The radiologist who read that “normal” mammogram a few months back (sometimes it’s only a few days or weeks before) frantically pulls up those films to see if he/she missed the cancer.  Very often there was nothing on the mammogram that would have raised suspicion, yet there must have been something there since the patient now comes in a short time later with a palpable lump.  How did this happen?

The answer is simple.  Mammography is an imperfect test.  A “normal mammogram” report does not mean that a woman does not have breast cancer.  Overall, mammograms will pick up 80-90% of cancers.  That’s pretty good, but there are still 10-20% of cancers that will not be seen, and will present as an “interval cancer” with a palpable lump, as in the example above.

The cancer detection rate plummets in women with dense breasts to only 40-50% of cancers picked up on a mammogram.  That’s about the odds of a coin toss.  This is ineffective screening by anyone’s standards.

So what is a woman over 40 to do?  Find out your breast density.  If you have dense breasts, you need to be especially proactive to make sure that if you do have breast cancer, you increase the odds of it being found early.   Ask your doctor to send you for a screening breast ultrasound (sonogram) when you have your annual mammogram (and go to a facility that has digital mammograms).

The findings from a recent large multicenter study (ACRIN 6666) are clear:

• 7.6 cancers were found per 1000 women who had a mammogram only
• 11.8 cancers were found per 1000 women who had a mammogram and a screening sonogram

This equates to a 29% absolute increase in sensitivity by adding a screening sonogram, or an increase in the relative cancer detection rate of 50%!

Critics would argue that something might be found on the sonogram that requires a needle biopsy, and turns out not to be cancer (false positive).  In my experience, most women accept the low (5%) risk of possibly having a benign needle biopsy, and don’t subscribe to the “don’t ask, don’t tell” policy when it comes to their breasts.   Do yourself a favor and insist on that sonogram.  Don’t take no for an answer from either your doctor or from a radiology center that tells you they don’t do screening sonograms.  Seek a second opinion from another doctor.  Find a radiology practice that is proactive about breast cancer screening.  It’s worth your time and effort.

I’ve seen a few patients recently who have been turned away by other practices in New Jersey that won’t perform screening breast ultrasound, even though their doctor wrote them a prescription for one.  Truly unbelievable, but unfortunately true.  Perhaps these practices are unaware that a bill has been proposed in the NJ state legislature, which requires that women be informed of their breast density when they have a mammogram.  Connecticut and Texas have passed similar bills, and the radiology practices in these states have had to accommodate the increased demand for breast ultrasounds.  Bills are pending in 11 additional states, as well as at the federal level.  Practices need to plan for the increased volume as women and their doctors become more aware of this important issue.  (If you are at high risk for breast cancer, a breast MRI might be the better test for you; ask your doctor about this, and see “How Do I Know If I’m High Risk?”)

Be your own advocate!  Your life is too important, and you only get one.

I strongly disagree with this conclusion, and with the suggestion that screening for breast cancer does not save significant numbers of women each year.

• Computer models and statistical analysis can be bent to create almost any desired outcome; stating that this constitutes “proof” is misleading.  Common sense and our own experience, as well as numerous published studies using real patients, tell us that screening for breast cancer with mammography saves thousands of women each year.  The earlier the cancer is found, the smaller it is, which means that it is less likely to have spread, greatly improving the odds of survival.  Supplemental tests such as breast ultrasound and MRI, when used appropriately, can also help us find cancers at the earliest stage.

• Using the authors’ results, Parker-Pope estimates that in the U.S., somewhere between 4,000 and 18,000 women each year are saved by screening mammography.  Although these numbers are likely lower than what is true, this is still a significant number of women who avoid premature death because they had their mammogram.

• There are some breast cancers found through screening that might not progress to the point of being life-threatening in the woman’s lifetime.  The authors call this “overdiagnosis.”  Until science can reliably tell us which cancers will progress and which won’t, and which don’t need to be treated, we will continue to treat the cancers we diagnose.  How can they call this “overdiagnosis” and “overtreatment” when we don’t know which cancers will be the killers and which won’t?

• The analysis does not take into account the fact that finding breast cancer earlier through screening not only means a better chance of survival, but also means that treating the disease will be less time-consuming, less invasive, toxic, and painful, and less costly.  The woman can potentially choose breast-conserving surgery (lumpectomy instead of mastectomy), and is less likely to require chemotherapy, a miserable experience that affects the patient, her body, and her family for months if not years.   The woman’s job standing can be affected as well.  And for many women, taking a leave from work isn’t possible, as their job provides their health insurance coverage.  If you’ve ever been through chemo or witnessed someone going through it, you’d probably choose to avoid it if you possibly could.  In addition, if the cancer is found early, the woman won’t need to have all of the lymph nodes under her arm removed, and will avoid the potential complication of lymphedema (chronic arm swelling and pain).  She can also avoid radiation treatments to the chest wall and axilla (underarm).  Why are these issues not even mentioned in the Dartmouth analysis, or in Parker-Pope’s article?  These considerations are extremely important for all women, and need to have a place in any conversation about the value of screening.

I practice at Montclair Breast Center, where we believe in taking a proactive approach to screening for breast cancer, tailoring our recommendations to each woman and her individual history, risk status, breast density, and personal concerns.  As a result, our patients have significantly better outcomes than national averages.  Breast cancer is the leading cause of death for women age 35 to 50, and the second leading cause of cancer death among women all ages, claiming 40,000 lives per year in the U.S.  This is not a disease that we can be complacent about.  Early detection is still our best line of first defense.  Don’t let a “computer model” convince you otherwise.

Breast Cancer Awareness Month ends on Monday.  Of course awareness is important, but knowing what specific actions you can take to protect yourself against the disease is empowering.  Breast cancer can strike anyone, with or without risk factors.  However, there are several things you can do NOW to lessen the likelihood of advanced breast cancer happening to you.

1.  Lace up and take a walk!  According to the Women’s Health Initiative study, women who walked just 30 minutes per day at least 5 days a week (exercise pace, not a leisurely stroll) decreased their breast cancer risk by 20%.  I know how hard it is to fit exercise into a busy life, but then I think about what Rachel Ballard-Barbash from the National Cancer Institute says about that in this article by Liz Szabo:  “If you can’t make time for being physically active in your daily life, plan to make time for being sick.”  She’s got a point.

2.  Know your Body Mass Index, and make a weight loss plan to keep it under 25.  Calculate your BMI in less than a minute here.  According to the American Cancer Society, “Both increased body weight and weight gain during adulthood are linked with a higher risk of breast cancer after menopause.”  Some have placed this increased risk at 25%!  “If there was a medication that gave us the same improvement as weight loss, we would be all over it.” ~Dr. Oz.

3.  Learn how to do a breast self-exam, and set a date to do it every month.  The smaller a cancer is, the more likely you are to survive.  Go to Don’t Be Shy for
more info and links to instructional videos.

4.  Quit the smokes.  See everydayhealth:   “A recent review by a Canadian panel of experts showed that both active smoking and exposure to secondhand smoke increase breast cancer risk in premenopausal women. The panel cited evidence from studies suggesting that women who start smoking at a young age are 20 percent more likely to develop breast cancer, and smoking for many years increases risk by up to 30 percent.”

5.  Limit the cocktails.  One of my girlfriends said to me this week, “But I’m a mom, I need that glass of wine!”  Sip mindfully, ladies, and don’t shoot the messenger!  According to the American Cancer Society, the use of alcohol is clearly linked to an increased risk of developing breast cancer. The risk increases with the amount of alcohol consumed. Compared with non-drinkers, women who consume 1 alcoholic drink per day have a very small increase in risk. Those who have 2 to 5 drinks daily have about 1½ times the risk of women who drink no alcohol.

6.  Find out if you are at high risk.  Have a discussion about your breast cancer risk status with your doctor, as you might need to take action.  But keep in mind that 75-90% of women diagnosed with breast cancer are not high risk.  Learn more here.

7.  Schedule an appointment for a mammogram.  If you are over 40, you should definitely be having yearly mammograms.

Your doctor might want to send you for  a baseline mammo at 35, and I wouldn’t argue with that.  See why the USPSTF (government task force) recommendation to start having biannual mammograms at 50 is irresponsible here.

8.  Know your breast density.  If your breasts are dense, your mammogram won’t find up to half of cancers, and you should have a test in addition to a mammogram every year (breast ultrasound or MRI).  See www.AreYouDense.org.  Your density information should be in the official report from your mammogram, so ask your doctor.  If it’s not in the report, call the radiologist who read your films and ask them.  It might take some legwork, but you have a right to know this, and the information could save your life.

A movement is afoot to make disclosure of breast density information mandatory when a woman has a mammogram.  More about this in a future post!

Since they were given “normal” mammogram reports, they did not pursue second-level screening with breast ultrasound or MRI. However, adding one of these tests to their screening regimen would have increased sensitivity, and it’s very likely that their cancers would have been found at earlier stages. When both women were diagnosed, they were shocked that crucial information had been withheld from them for all of those years of “normal” mammograms.

Nancy and JoAnn have made a mission of making sure all women who undergo mammograms receive information about their breast density, so that if second-level screening could help them, they could choose to pursue it. Women with dense breasts are not being effectively screened when they have a mammogram alone, and they should be informed of this. Check out this video, and visit www.areyoudense.org for more information about their advocacy work.

In addition to education, the foundation offers financial assistance for women 45 years old and younger, with a family history of breast cancer or with a positive BRCA gene test, to gain access to Breast MRI, regardless of insurance status. Insurance companies often deny coverage for Breast MRI exams for high risk women, even when the test is clearly indicated and the woman’s doctor orders it. Many women cannot afford to pay for the cost of a breast MRI out -of-pocket, and must forgo the test. Ms. Applegate’s foundation is trying to bridge that gap.

Christina Applegate has been very open and honest with the public about her diagnosis of breast cancer at such a young age, and about her decision to undergo bilateral mastectomy with reconstruction. Due to her family history of breast cancer in her mother, she started having yearly mammograms at the age of 30. Because her breast tissue was dense, the mammogram was limited in terms of its ability to see a potential cancer. Fortunately, her doctor was on top of this, and recommended that she have a breast MRI (magnetic resonance imaging) for more effective and complete screening, given her high-risk status.

On her first MRI, a suspicious area was seen in her left breast. (The mammogram was negative.) The area was biopsied, and breast cancer was found. Because it was found early and it was small, the first recommendation was that she have a lumpectomy (small lump of tissue removed) and six weeks of radiation treatment. No chemotherapy would be needed. However, because she was only 36 years old when she was diagnosed, and because of her family history, her doctor suspected that she might have a BRCA gene mutation (the “breast cancer gene”). The special blood test was sent off, and it came back as positive for the BRCA-1 gene. This meant that Christina faced a 60% risk of developing additional breast cancer in her lifetime (compare this to the average lifetime risk of 12%).

Taking these sobering facts into account, Christina Applegate decided to undergo a bilateral mastectomy (removal of both breasts) with cosmetic reconstructive surgery in 2008. She’s met this obviously difficult decision with irony, and a positive outlook, while admitting sadness. In several media accounts, she notes that on the bright side, she’ll never have to wear a bra again.

She has stated on many occasions that she’s convinced her doctor saved her life by sending her for that MRI. Her mission is now to make access to this potentially life-saving test available to all of the women who need it.

If you or someone you know could benefit from financial assistance for a necessary breast MRI, call Patient Services Incorporated at 1-800-366-7741 to apply.

Christina Applegate gave birth to her first child, Sadie Grace, in January 2011, and her new series, Up All Night, premiered on NBC last month. Best of luck, Christina! You deserve good things, and I’m rooting for you.

General Guidelines

For most women, age 40 should be when you start having yearly mammograms in order to minimize your likelihood of developing advanced breast cancer (“Government Mammography Task Force vs. You”).  Some doctors send their patients for a baseline mammogram at age 35, and I wouldn’t argue with that.

Family History

If you have a strong family history of breast cancer (mother or sister), start having your mammogram 10 years younger than the age that relative was diagnosed, OR at age 40, whichever is younger.  For example, if your sister had breast cancer when she was 44, you should start having your mammogram at age 34.  If your mother had breast cancer at 60, you would start having your annual mammogram at age 40.  If you have a strong family history or other factors that put you at high risk for breast cancer, you should also be having a breast MRI every year once you start having mammograms.  Talk to your doctor about this.  If your breasts are dense, you should also be having a breast ultrasound or MRI starting at age 40 (“What Breast Density Means to You”).

Breast Cancer Gene & Hodgkins Lymphoma

If you or your mother or sister have been diagnosed with the breast cancer gene (BRCA1 or BRCA2) you should begin having annual mammograms at age 25, and annual breast MRI sometimes even younger than 25.  Your breast doctor should advise you on this.

If you have had Hodgkins disease (lymphoma) in the past, and were treated with radiation to your chest, you should start having annual mammograms 8 years after your treatment was completed.  You should also be sent for yearly breast MRI.

Finding a Breast Lump

At any age, if you feel a breast lump or detect thickening, see your doctor immediately.  They will decide if you need to have a mammogram, ultrasound, etc.  If your doctor doesn’t send you for any tests, and you still feel the lump, get a second opinion.

If the 2009 USPSTF (U.S. Preventive Services Task Force) recommendations are followed, as many as 20% of breast cancer deaths will be in women who could have been saved. The USPSTF knew this when they issued their report.

1. The Task Force’s own data shows that the most lives are saved by starting mammography screening at age 40, but they chose to ignore that data. They made a value judgment as to how much a woman’s life is worth. The science clearly shows that starting annual screening at age 40 saves more lives, and the Task Force does not dispute that fact.

2. The panel was charged with the task of finding a way to cut healthcare costs, NOT with saving the most lives. You are a statistic in this form of public health decision-making, not a person. The Task Force is asking young, productive women to “take one for the team.”

3. There was not a single expert in breast cancer on the panel. Experts’ input was not even sought out.

4. The suggestion that screening between 40 and 50 should be reserved for women at high risk is absurd. Perhaps the Task Force is not aware that the vast majority of women diagnosed with breast cancer each year (75-90%!) are NOT at high risk.

5. The Task Force was more concerned with women’s supposed “anxiety” over possibly being called back for additional pictures or having a benign needle biopsy than with death by breast cancer. Yet the supposed “harms of screening” pale in comparison to the harms of not being screened.

6. The harms to an individual woman and her family as well as the harm to society, by losing women in their 40’s, important years when many women have children who need them and they are often working productively in our economy to support their families, are completely overlooked by the Task Force. This is a HUGE COST. If you know of a family where the mother has died young, you know what suffering this brings.

7. The only value of mammography, according to the Task Force, is avoiding death from breast cancer. They completely ignore the value of finding a cancer early enough so that a woman can have a better cosmetic outcome after her surgery, and she might be able to avoid having chemotherapy, resulting in much less suffering. An early cancer is also treated much less expensively than a late stage cancer, yet this was also ignored by the panel.

8. The Task Force argues that there are some cancers that will not become life-threatening, and thus finding them and treating them is worthless. But WE DON’T KNOW at this point which cancers will progress and which won’t – we’d just be guessing, and gambling with women’s lives. Until science can reliably tell us this crucial information, I’d rather err on the side of “over-treatment” than take the big risk of “under-treating.”

9. Recommending against women being taught to do self-examinations, and recommending that a woman’s doctor not perform annual breast examination on her, is completely irresponsible and ludicrous. Would the Task Force prefer that a breast cancer be discovered when the tumor has broken through the skin and is fungating and ulcerating from the breast? Here’s what that looks like on a breast MRI. This is a 79-year-old woman who never had a mammogram, and who ignored large lumps in her breasts for several years. She didn’t go to the doctor until the cancer in the right breast started to break through the skin, and the smell was unavoidable:

DON’T TAKE ONE FOR THE TEAM! Breast cancer is the number one cause of death for women age 35-50. Don’t let a government panel determine your fate.

Remember:

• Annual mammograms starting at age 40.
• Physical breast exam performed by your doctor every year
• Monthly breast self-examination Don’t Be Shy – Know Your Breasts!
• Find out your breast density, and have an additional test (ultrasound or MRI) each year if you are dense What Breast Density Means to You.
• Know if you are at high risk for developing breast cancer in your lifetime How Do I Know If I’m High Risk?

References:

1. Kopans DB. The 2009 U.S. Preventive Services Task Force Guidelines Ignore Important Scientific Evidence and Should be Revised or Withdrawn. Radiology 2010;256:15-20.

2. Hendrick RE, Helvie MA. United States Preventive Services Task Force Screening Mammography Recommendations: Science Ignored. AJR Am J Roentgenol. 2011

Feb;196(2):W112-6.

The insurance clerk she spoke with after she was notified of the denial told her she didn’t need to have the MRI because she didn’t have a strong family history of breast cancer. But, she explained to the clerk, she’d had breast cancer herself– didn’t that count? The clerk told her that “a history of having had breast cancer yourself isn’t on our list of approved reasons for breast MRI. “ The patient was amazed. She then asked if her own mother and daughter would be approved for breast MRI since they both now had a family history of breast cancer (her!), and the clerk said yes, that would be on the list of approved reasons.

Our patient was furious. Who is at higher risk for breast cancer than someone whose body already had made one? There’s a lot of talk about “evidence-based medicine,” but how about using common sense as well? She decided to appeal the denial, and after many hours in phone-tree hell, and after emailing and writing to the insurance company over many weeks, with the assistance of her own doctor’s staff (they were paid for none of this time), she was ready to give up. She’d found a radiology practice within driving distance that performed breast MRI, read by fellowship-trained breast imaging doctors, and they would accept payment directly from her rather than from her insurer. It was expensive, but at this point she didn’t care. She was willing to forgo a few luxuries that year if it meant possibly finding an early cancer, and easing her fears of a recurrence.

As it turns out, her doctor had kindly persisted, and finally got through by phone to the doctor employed by the insurance company. Authorization was granted, and the insurance company would cover the cost of the test. Keep in mind that health insurance companies CANNOT be sued by patients for denying coverage of services (they are protected by law); but a doctor who orders a test for a patient, and the test doesn’t happen because the insurance company denies it, CAN be sued for delayed diagnosis. Insurance companies can effectively practice medicine without a license, and I’ve seen no indication that this will change with “healthcare reform.”

So, the patient had her MRI. In the MRI image below, there is a suspicious 2.5cm mass in the right breast, circled in yellow. Remember that the patient had cancer in the LEFT breast a few years back, treated with lumpectomy and radiation. Because of the radiation, her left breast does not “light up” much on the MRI. However, the right breast, which had not been radiated, has a great deal of tissue that “lights up.” This is the dense tissue that makes her mammogram so difficult to read, and which hides up to half of breast cancers, including this one. Even so, the MRI clearly demonstrates the tumor.

It was biopsied with a needle under ultrasound guidance, and the diagnosis was Ductal Carcinoma in Situ (stage 0 breast cancer, i.e. early detection). Take home lesson: pick your battles, and don’t give up.