Breast Cancer: Mammography and Breast MRI
Guest: Dr. Megan Baker – Surgical Oncology
Host: Linda Austin – Psychology
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Megan Baker who is a surgical oncologist and the medical director of the breast program here at Hollings Cancer Center, Medical University of South Carolina. Dr. Baker, one of the things that a lot of people are confused about now is the question of when do you get mammography, a mammogram, and when do you use MRI? First of all, what are the current guidelines for mammograms?
Dr. Megan Baker: Women at age 40 and older, according to the American Cancer Society, should be getting an annual mammogram as well as an annual breast exam by a healthcare provider. At the same time, they are encouraged to do their monthly self breast exams. There are certain groups of women who have been identified as being at higher risk for breast cancer, whether determined by things like family history of breast cancer or related malignancies, who may start their mammograms earlier than that. That is determined on a case by case basis.
In general, the choice of mammogram is really between film mammogram, which is the traditional one, or digital style mammogram. For the average woman, there is really no difference in terms of safety or quality. However, there is a select group of women where a digital mammogram should really be required or encouraged. That is for women who have denser breast tissue, so women who are premenopausal, women who are perimenopausal or women who have severe fibrocystic breast changes are often benefited by having a digital mammogram because it allows for a more accurate interpretation.
For certain groups of women, in particular for those women identified at higher risk, or who have difficult to interpret mammograms or who are very young, so much so that the mammogram is not very effective, we often will use breast MRI instead or in addition to mammograms. The American Cancer Society just recently updated their recommendations on when to use breast MRI.
A very important point that underpins all of those recommendations is that it is essential to identify the center at which you are having your breast MRI. It is not enough for that center to just offer an MRI. They need to be able to offer an MRI-guided biopsy. The importance of that is if they find an abnormality on an MRI that is only seen on that type of test, and no other, and they do not have the ability to do a biopsy, then that patient has to be sent to another center, have the MRI repeated and then have the biopsy performed in a third procedure. So, in an effort to minimize redundant procedures and putting patients through unnecessary ones, women should only have their breast MRIs done at centers that can do a biopsy, if needed.
Dr. Linda Austin: In other words, it is pretty standard, unless one has heard otherwise, to get the mammogram, usually the digital?
Dr. Megan Baker: Usually, now, in larger centers, the digital mammogram, yes.
Dr. Linda Austin: Then your doctor will let you know if you actually need an MRI?
Dr. Megan Baker: Your doctor will often let you know if you need an MRI but I always encourage patients to be their own best advocate. That really lends itself to not only asking physicians and healthcare providers to identify those patients at high risk, but I really educate patients to determine if they are at high risk. So, there are many tools available on the Web, in particular, where women can identify whether or not they are at higher risk. For example, www.muschealth.com has a tool called Gail Risk Model. Similarly, the National Institutes of Health and National Cancer Institute have a model that patients can get on and identify whether or not they are high risk and whether or not they should seek care at a high risk breast evaluation center. So, I really encourage patients to be very directed in their care and to sort out whether or not they should be evaluated at a special place.
Dr. Linda Austin: Now, you mentioned that women with denser breast tissue, such as those who are premenopausal or perimenopausal, are candidates for MRIs. Well, that is all women, sooner or later, assuming that they get to that stage. So, are you saying that any perimenopausal woman should have an MRI?
Dr. Megan Baker: No, MRI is not really to be used as a screening test. In fact, there have been plenty of studies that have shown that it is not an effective screening tool because it is a lengthy test. If it has one Achilles’ heel, it is that it overcalls things; it sees things that are not really there. So, as a screening, it would lead to many unnecessary procedures. However, for women who have breast tissue that is so dense that the mammogram is really limited in quality and the interpretation is compromised, an MRI can really be used to augment and enhance that mammogram.
MRI is rarely used in a vacuum. It is always used in addition to other forms of breast imaging, which may be mammography or may be breast ultrasound. But, it is particularly helpful for women who are at high risk for breast disease, if you are looking for occult or hidden breast cancers, for women who have already been diagnosed with breast cancer and you are trying to sort out the extent of disease, whether or not they would be a good candidate for breast conservation versus mastectomy, and whether or not they have a hidden breast cancer on the other side. What we do know, for women who are diagnosed with breast cancer on one side is three percent women will have a hidden or occult cancer on the other side at the same time. In these very specific situations, MRI lends itself to increasing detection but as a screening tool, it is not very good.
Dr. Linda Austin: Dr. Baker, thank you so much for talking with us.
Dr. Megan Baker: You are very welcome.
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