1. The most basic requirement is whether a facility is accredited under the MQSA (Mammography Quality Standards Act).  The accrediting body for most states is the ACR (American College of Radiology), which has a list of requirements and tests that facilities must comply with in order for the centers to achieve accreditation. They look at things such as equipment and film quality, radiation dose, credentials of the mammography technologists and of the radiology doctors who interpret the films, quality of reporting and follow-up, etc.  Inspectors visit centers at regular intervals for “site visits.”  If you are having a mammogram and the staff seems particularly stressed out, it’s likely that the inspector is lurking about.  Have pity, and try not to take it personally.The ACR has a convenient webpage for you to search for accredited facilities in your vicinity.
2. When you see the results of your search on the ACR site, look for this badge next to the names of the breast centers on your list:
   This symbol means that the center has jumped through many extra hoops to attain status as a “Breast Imaging Center of Excellence.”  My own practice in New Jersey has been designated as a Center of Excellence, after a lot of work by many people.  It’s worth your while to go to one of these centers if it’s practical for you, depending on where you live and how far you are willing to travel.  It can make your life easier down the line because if you ever need to have additional testing or a needle biopsy, these centers can handle it and won’t need to send you elsewhere.  At the very least, these facilities have demonstrated their commitment to their patients by dealing with the bureaucracy and mounds of documentation necessary to achieve this special status.  It’s not a guarantee of higher quality, but it’s a good sign.
3. It matters who reads your mammogram.  If your study is read by a radiology doctor (radiologist) who practices general radiology or another radiology subspecialty and only reads a few mammograms per week, you are probably not receiving the best care.  Yes, the guy is board certified and is licensed by law to read your mammogram.  But I am licensed to read all radiology studies as well, even though my specialty is breast imaging.  Doesn’t mean I should muddle through interpreting the next brain or shoulder MRI that comes my way.  Thinking about it now, I am “qualified” to read Peyton Manning’s next MRI of his neck.  Do you believe that anyone in their right mind would let me do this?  My point:  You and your life are just as important as the talented Mr. Manning’s career.  Don’t settle for less than the best. A well-done study published several years ago proves and quantifies this point.  The link to the journal article is here.  The researchers found that specialty-trained breast radiologists find significantly more cancers, and at earlier stages, than the general radiologists.

So how do you make sure the most qualified radiologist will read your mammogram?

• When you make your mammogram appointment, hopefully at a Breast Imaging Center of Excellence, ask if the center has radiologists who have completed fellowships in breast imaging, OR who read breast imaging studies at least 50% of their work hours.  If they say yes, take names, and ask to have your mammogram scheduled to be read by one of those doctors.  If they say no, or if they tell you that the center doesn’t allow you to request a particular radiologist, consider calling the next breast center on your list from your search.
• When you go for your appointment, confirm with the technologist (the person who runs the machine and takes the pictures) that the doctor you requested will be personally handed your examination to read.  Don’t worry about looking pushy–  unless you are in an emergency situation (or you have a really, really bad insurance plan), you have the right to decide who the doctor is that will treat you.
• When you receive the report that informs you of your results, confirm that the correct doctor performed the reading.  If there is an error, call the center and ask to speak to the Lead Mammography Technologist.  If this gets you nowhere, ask for the practice administrator.  An unhappy patient, especially one whose referring doctor sends other patients to the breast center, is an undesirable outcome for any practice administrator worth his or her salt.  The squeaky (but respectful) wheel usually gets the oil, in my experience at radiology practices over the years.

ALL MAMMOGRAMS ARE NOT CREATED EQUAL!  I urge you to do your homework and get the best medical care you can for yourself.  Where you have your mammogram, and who reads it, matter.

At her appointment for her breast imaging studies, she receives the awful news that her mammogram and sonogram show a new mass in her breast where she feels the thickening.  A needle biopsy is performed, and the diagnosis of breast cancer is made.  To make things even more terrifying, it is clear that her tumor has spread to the lymph nodes under her arm, worsening her prognosis.  She is now facing advanced breast cancer.

Though there is no certainty that her cancer would have been found at an earlier stage if she’d kept to her yearly mammogram schedule and had gone for her routine tests when they’d been due 8 months before, the patient is haunted by this question.  She feels guilty, sad and angry, and wonders if she’s made her situation worse for herself and her family because of her oversight.  No one can tell her whether or not things would have been any different, but that is of little comfort to her.  The best she can do is to put these thoughts out of her head, and concentrate her energies on facing the long treatment road that lies ahead.

So how do women remember when they are due for their mammograms?  Personally, I schedule it during my birthday month, which makes it easier for me to remember.  My practice sends out patient reminders each year; however, not all radiology centers do this.  I recently learned that there is a free reminder service offered by www.mammographysaveslives.org, sponsored by the American College of Radiology and the Society of Breast Imaging.  It takes less than a minute to sign up here.  Might be a minute well spent.

Why would there be so many surgical biopsies instead of the less invasive needle biopsy?  According to the authors of the above paper, in some areas of the country there are no radiologists available who have the training and experience necessary to perform the procedures safely, reliably, and accurately (lack of access).  In addition, the authors postulate that there are some surgeons who are not educated regarding the value of needle biopsies as opposed to surgery, and who might be motivated by financial incentive to do the biopsy themselves with surgery.  I would argue that the overwhelming majority of doctors do not fall into that description, but it would be naïve to think that they don’t exist.  I was once forbidden to speak to the patients of a now-retired surgeon who didn’t want his patients to even consider the option of a needle biopsy because he didn’t want to potentially lose the surgical case.  Since I’d read the mammograms on these women, they were technically my patients as well as his, and I ignored his edict.  He didn’t like me very much.

Here are a few reasons why a needle biopsy makes more sense than an open surgical biopsy for most women:

1. Needle biopsies have proved to be just as accurate as surgical biopsies.  Considering the fact that 8 out of 10 breast biopsies will be benign (NOT cancer), many surgeries for benign conditions can be avoided.
2. If the mass biopsied with a needle does turn out to be a cancer, the breast surgeon can plan the surgical treatment and biopsy of the lymph nodes under the arm to be performed in one trip to the operating room.  If the surgeon knows something is cancer before he/she performs the operation, he/she is more likely to get clean surgical margins, and the patient doesn’t have to return to the operating room again to get those clear margins.
3. Patients are sometimes concerned that a needle biopsy can potentially cause a breast cancer to spread.  A few studies have addressed this issue, and have shown no increase in recurrence rates or decrease in survival in women who have had needle biopsies as opposed to surgical excisional biopsies.
4. Surgical biopsies require IV sedation or sometimes general anesthesia, adding potential complications.  Needle biopsies are performed with local anesthesia (i.e. Lidocaine).
5. A needle biopsy is much less invasive, with fewer complications.  It can be performed in an outpatient examination room in less than 20 minutes, without a trip to the Operating Room.  The patient can return to work the next day, unless the work requires lifting or heavy activity.
6. No stitches, less scarring, and less potential for a surgery to deform the breast.  Cosmetic concerns are entirely valid!  Don’t let anyone shame you into thinking they aren’t.
7. Future mammograms will not look much different after a needle biopsy.  However, after a surgical biopsy, the patient’s mammogram often looks quite different from those obtained before the surgery; this can sometimes make the mammogram more difficult to interpret accurately.
8. A needle biopsy costs much less than a surgical biopsy.  In Florida, it is estimated that $37 million could be saved annually if the surgical biopsy rate is brought down to 10%.

The February 2012 edition of the Journal of the American College of Radiology published a rebuttal to the 2011 study from the American Journal of Surgery.  These investigators from Thomas Jefferson University Hospital argue that the numbers stated in the study of Florida biopsies are erroneous, and do not accurately reflect national figures from Medicare data.  They calculate that the surgical biopsy rate is more in the vicinity of 11% nationally, and they conclude that surgical breast biopsy is not being overused.

Be that as it may, it is best to know about this issue for yourself, so that if you are ever in the situation where you need to have a breast biopsy, you are informed enough to ask the right questions.  Keep in mind that there are occasional cases where a needle biopsy is not technically possible, and a surgical biopsy is truly indicated.  If your doctor recommends a surgical biopsy over a needle biopsy for your situation, you can always seek a second opinion to determine if surgery is truly the better choice in your case.

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.

I wear my seatbelt, get my flu shot, wash and sanitize my hands, wear sunscreen, scrub the fruits and veggies clean, look both ways when I cross the street, and never take candy from strangers. But what can I do to protect myself (and my family) from the single most common cause of death among women in my own age group, 35 to 50 years old? Here are a few evidence-based strategies to increase your odds of avoiding advanced breast cancer.

Me at Union Station

In November I traveled to DC to issue a statement to the FDA advisory committee regarding breast density.  Several radiologists, breast cancer patients and advocates, representatives from the American College of Radiology, as well as Karen Handel from the Susan G. Komen foundation were on hand to render opinions regarding a new rule being considered by the FDA, which would mandate the inclusion of breast density information in the official mammogram report that goes to the referring doctor, and that the radiology facility providing a mammogram would directly inform the woman of her breast density when she receives her mammogram results in the letter known as the “lay summary.”

Here is an excerpt from my statement to the FDA:

Testimony at the 2011 FDA National Mammogram Quality Assurance Advisory Committee Meeting

“When I give a woman with dense breasts a normal mammogram report, I am only 50 percent certain that there’s no cancer in her breast. This is ineffective screening by any definition. And by not routinely informing women with dense breasts that their mammogram is limited and that they have a choice to pursue second-level screening with breast ultrasound, MRI, or another test, we are poorly serving many of our patients.

Women who are diligent and come to me yearly for their mammograms expect to be effectively screened for cancer. They trust me to do that for them. We do not provide effective screening if breast density is ignored.

The FDA does not accept blurred films or images with dust or small artifacts on them. Why do we accept the huge limitations of breast density?”  - Dr. Stacey Vitiello

The entire transcript from the meeting can be viewed here:  http://tinyurl.com/7kuc3zm

End result:  The consensus of the NMQAAC was that all mammography reports and lay summaries should include a woman’s breast density.  Yippee!  However, considering how slowly the wheels turn at the FDA, these changes may not be seen in real practice for many years.  In the meantime, we’ll continue to support legislative efforts in statehouses across the country, as well as at the federal level, to make breast density notification a reality for all women in the near future.

Learn more about breast density and what it means to you here.

I wrote this essay in 1999 when I was applying for a fellowship position at Yale. It holds as much truth for me today as it did then.

The Allure of the Breast

Breast cancer has run a rampant course through my extended family, claiming the lives of four great-aunts, shocking my cousin with a diagnosis at age 29, and necessitating a mastectomy for my paternal grandmother. Through familial experience, I have witnessed the changes in our culture’s attitude toward this disease over the past thirty years.

As a child, I recall female family members clustered over coffee, discussing in hushed tones the plight of my great-aunt, who was to have a mastectomy. The men, shielded from this discussion, watched football in the next room. When I approached the table of women to ask what was wrong, I was told that my aunt had “female troubles,” and to be a good girl and go play with my cousins. My older cousins, the source of all knowledge, told me that our aunt’s breast was “sick and had to get cut off.” I had the distinct impression that this was viewed as a shameful secret, a topic not to be broached again. At later family gatherings until she died, my aunt was withdrawn and somewhat embarrassed, bearing not only the burden of a terrible illness, but suffering the shame and humiliation brought by a society that did not know how to deal with her.

In the mid-1970’s, when Betty Ford revealed that she had lost her breast to cancer, this was viewed by many as a courageous, though shocking, admission. It seems inconceivable that a country could remain so prudish while in the midst of a sexual revolution. Slowly, things began to change at our family holidays. The word “breast” was uttered in mixed company. The next aunt to be diagnosed talked about her chemotherapy openly, and planned a group outing to find a decent wig. By the mid-eighties, another aunt was telling a hilarious tale to the entire gathering about shopping for a swimsuit with a prosthesis. When she lay dying, the men of the family visited her without the old discomfort and embarrassment, and were able to let her know how much her life had meant to them.

Soon, my cousins and I were reminding our mothers to get their annual mammograms. Olivia Newton-John appeared on television and in print, talking openly about her illness. Breast self-examination was taught in a seminar at my college dormitory. New York magazine ran a cover in 1992 with “MY BREAST” boldly emblazoned across it. The previously pitied, humiliated victims of breast cancer evolved into proud “survivors.”

Today, the expression “one in nine” is part of the vernacular. Pink ribbons are ubiquitous. Public service commercials on mammograms and self-exams abound. Celebrities with breast cancer appear on Oprah as heroines. Dr. Susan Love has become a guru to a certain subset of women. It is recognized that the middle-aged woman at the supermarket with the not-so-perfect breasts is just as attached to them as the Victoria’s Secret model is to her own breasts. Radical mastectomy for all is no longer appropriate, and breast conservation is often an option.

However, it would appear to some that the pendulum has swung too far. Physicians complain that women come to their offices brandishing the latest articles on breast cancer from magazines and newspapers. They expect the doctor to have the time and patience to answer seemingly endless questions. Procedures must be scheduled immediately, and results available yesterday. Evening and weekend hours are required to accommodate women’s busy lives. Getting a mammogram has become an emotional “event”; one mammographer recently told me that she spends half her day “peeling women off the ceiling” at her practice. Second opinions are sought routinely. And the price for a mistake is extremely high.

In my view, however, women need and deserve well-trained physicians who are intellectually, technically, and emotionally competent to discuss their options, listen to their fears, answer their questions. Radiologists are now an integral part of the team diagnosing and treating women with breast disease. We have the opportunity to positively affect a woman’s view of the often ominous and faceless “health care system,” and provide medical advice and services with caring and compassion. The rewards that a physician can potentially reap from a partnership with a patient in need are great, and tend to remind us why we chose medicine rather than Wall Street.

Breast imaging is the field for me. I want the opportunity to train as a fellow at a high quality, cutting edge program with research activity that also manages to keep the needs of patients in mind. I aspire to learn the technical aspects necessary to become an excellent breast radiologist, as well as to glean as much knowledge as possible about the terrorist known as breast cancer. In the end, if it will be necessary for me to “peel women off ceilings” during the course of my day, well, hand me the scraper. I’ll get them down safely.

In Memory of my Aunts Mary, Ann, Gloria and Rosie.

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.