Are your Breasts Dense? Maintaining Breast Health with Leading-Edge Tomosynthesis Mammography

Intro: MemorialCare Health System, excellence in healthcare, presents Weekly Dose of Wellness. Here's your host, Deborah Howell.

Deborah Howell (Host): And hello. Welcome to our show. This is your Weekly Dose of Wellness. I'm Deborah Howell. And today's guest is Dr. Richard Reitherman, medical director of breast imaging at the MemorialCare Breast Center at Orange Coast Memorial. Dr. Reitherman is here to explain the difference between low and high density breast tissue, how it's measured, how you can find out if you have dense breasts, actionable steps you can take, and how leading edge imaging technology such as tomosynthesis can help better detect cancer in women with dense breasts. Welcome, Dr. Reitherman.

Richard Reitherman, MD: Good morning. Thank you.

Deborah Howell (Host): How is breast density assessed?

Richard Reitherman, MD: Well, there are two components primarily in women's breasts. One is fat and the other is fibroglandular tissue. The fat shows up as black on the mammogram and the fibroglandular is white. So we measure breast density based on the proportion of white tissue in the breast.

Deborah Howell (Host): That's easy enough. How does breast density influence breast cancer screening then?

Richard Reitherman, MD: It influences it basically in three ways. Number one, cancers are white. So the larger the proportion of white in the woman's breast, the more difficult it is to see. It's like finding something white in the snow. On the contrary, in a woman who has primarily fat breasts, which are black, it becomes very easy to find a white spot. We call that masking, because the white's more difficult to see. The second factor is that at very high breast density, there's an increased risk in breast cancer. The third is the technological advances that we can use to mitigate the dense breast masking.

Deborah Howell (Host): Okay, got it. So three, three ways. All right. Now let's talk a little bit more about masking. What are some ways technology can mitigate the risk of missing a cancerous tumor in the breast?

Richard Reitherman, MD: So again, the challenge is we're trying to find something white in a sea of white. So there are multiple modalities. One that's a primary modality that's used is ultrasound. And ultrasound uses a different physics and technology. And it's not inhibited by the breast density. So whole breast ultrasound is one mechanism of looking for cancers in white breasts. Tomosynthesis is another. And that is a 3D slice method like a CT scan that takes multiple slices, maybe 40 or 50 slices of images through the breast. And because it does those individual slices, the breast density becomes less of a problem and we can see cancers. The third modality is basically breast MRI, which is a technique which totally eliminates breast density in the display and reading of tumors. Molecular breast imaging is a nuclear medicine technique that's not widely used but is becoming more popular. And that uses a radioactive chemical to detect breast cancer.

Deborah Howell (Host): And what is the procedure for molecular breast imaging?

Richard Reitherman, MD: The procedure is the person is injected with an isotope and then they're placed in a mammogram machine which instead of having the usual receptors will have a nuclear medicine receptor which looks at the photon emissions. And you get a picture of the breast where only the tumors light up and the breast density is again irrelevant.

Deborah Howell (Host): I see. So why would not every woman want that done?

Richard Reitherman, MD: Well, number one, it's not widely available. Number two, it's not an established standard of practice like MRI, ultrasound, and tomosynthesis. Number three, some women just don't like the idea of having an annual or bi-annual injection of radioactivity. So it has some, it has advantages and disadvantages in terms of reception in the public.

Deborah Howell (Host): Understood. And what about breast MRI? The same question, why doesn't every woman have that?

Richard Reitherman, MD: That's primarily because of cost. A breast MRI is used in high risk women because it's probably the most sensitive test for detecting breast cancer and it's independent of breast density. But it costs up to five or six times more than a mammogram. So you can't justify using it in everybody in the population basis of screening.

Deborah Howell (Host): Okay. Now, whole breast ultrasound. I have not heard much about this. Maybe you could shine a light on it.

Richard Reitherman, MD: Sure. Ultrasound is a technique that uses sound waves. It's used in all parts of the body. In the breast, it's very useful and we can scan the entire breast in an organized way. And the dense breast tissue shows up as white tissue in the breast, but the tumors are dark. So we have excellent contrast and so it works very well.

Deborah Howell (Host): And tomosynthesis, one more time. I know we touched on it.

Richard Reitherman, MD: Sure. Tomosynthesis is a mammographic technique. So it's, the patient doesn't really know the difference when they're having it done. It takes about the same amount of time. But instead of taking one exposure for the breast in one position and the other, it takes multiple exposures. And therefore it slices the density into slices so that the absolute whiteness is not as much of a problem. We can detect tumors in between the white areas.

Deborah Howell (Host): Fantastic. Ask any movie director, it's always best to have more coverage, more cameras.

Richard Reitherman, MD: Exactly. Yeah.

Deborah Howell (Host): All right. How is cancer risk calculated?

Richard Reitherman, MD: Cancer risk calculations are based on population studies where you look at the incidence of cancer in different populations as a function of age, family history, and other factors. There are multiple computer models that are available to the public and to physicians. And what you basically do is you put the patient's age in, their menarche, their first full-term pregnancy, any family history including mother, second generation, aunts, uncles, and so forth. And you push a button and it comes up with a risk. The risk is either a lifetime risk or more usefully, it's a 10 or 5-year risk. And the 5-year risk or 10-year risk will say, if I'm talking to woman A, I'll say your risk is two times the risk of a woman who does not have a family history. So it's a relative matter of risk in comparing two different women or a woman in front of you compared to the population.

Deborah Howell (Host): Got it. Got it. Who would be a good candidate for molecular breast imaging?

Richard Reitherman, MD: Anybody with dense breasts would be a good candidate for molecular imaging.

Deborah Howell (Host): Do you need a referral?

Richard Reitherman, MD: Yes, you do need a referral because it's a nuclear medicine study.

Deborah Howell (Host): Sure. And which of these tests are mostly covered by insurance?

Richard Reitherman, MD: The mammography one is the one that's ubiquitously covered by insurance. Tomosynthesis is covered by Medicare. They approved that at the beginning of this year in 2015. Other insurance companies are coming into line to approve that. It's a, it's an additional charge on top of the usual mammogram.

Deborah Howell (Host): Okay.

Richard Reitherman, MD: So it is being progressively covered. It's covered for all Medicare patients currently.

Deborah Howell (Host): Now this is a little bit of devil's advocate, but I've read a new article saying that these tests are not really helping with cancer incidence. Have you read the article that's saying that all this testing hasn't really reduced the number of cancer in women?

Richard Reitherman, MD: Well, there are two issues with that. One way to measure the effectiveness of any test is to look to see if it changes mortality, that is people dying of breast cancer.

Deborah Howell (Host): Right.

Richard Reitherman, MD: The only studies that have been done that look at mortality have to be done over 10, 15, 20 years. So you have to take a group of patients and follow them for that long. So those studies have been done like a decade or more before. And then you get the information of how much screening mammography helps.

Deborah Howell (Host): I see.

Richard Reitherman, MD: The newer modalities such as whole breast ultrasound and tomosynthesis are predicted to change the mortality because we're finding cancers earlier and more node-negative cancers. So we use those as surrogates for survival.

Deborah Howell (Host): So you would definitely disagree with that article.

Richard Reitherman, MD: I disagree with it because I think it's positioned in an incorrect way and doesn't give full information on both sides.

Deborah Howell (Host): I knew you were the right man to talk to about that article. I didn't believe it. And I just wanted to know why. I think, you know, the risk is so high for so many women to not get tested is just not a good way to go.

Richard Reitherman, MD: I certainly agree with that.

Deborah Howell (Host): Where can people go to get more information about mammographies and imaging technology and tomosynthesis?

Richard Reitherman, MD: They can go to a couple of different websites which would include American Cancer Society is a good website. The National Cancer Institute, NCI is a good website. The National Cancer Institute also has a risk calculator in it that's built for laypeople to use.

Deborah Howell (Host): Oh really? So you can just plug in your information and...

Richard Reitherman, MD: Correct.

Deborah Howell (Host): Oh, that's fantastic. Look, why don't we say one more time, the name of that organization?

Richard Reitherman, MD: If you type in your browser NCI.org, that's National Cancer Institute, you'll get a listing and then you can just go into the thing and look at the risk calculator and you can look at different modalities and so forth.

Deborah Howell (Host): That is fabulous. Do you have any final thoughts for our listeners today?

Richard Reitherman, MD: Well, I think one thing that we've talked about and one thing the article you referenced that kind of dissed the whole thing is the dense breast legislation, which now mandates that in multiple states that a woman be notified about her breast density because if you don't have that information, everything we're talking about is not actionable.

Deborah Howell (Host): Okay.

Richard Reitherman, MD: So that's a state law in numerous states, probably 18, and it now covers over 75% of the women in the United States.

Deborah Howell (Host): That is a wonderful new development. A very good thing. Well, thank you so much, Dr. Reitherman, for coming on the show today. We really appreciate it.

Richard Reitherman, MD: You're welcome.

Deborah Howell (Host): To learn more or to listen to a podcast of this show, please visit MemorialCare.org. I'm Deborah Howell. Join us again next time as we explore another Weekly Dose of Wellness. Have yourself a fantastic day.