Advances in Breast Screening Methods and Exploration of the Dense Breast Law

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

Deborah Howell (Host): Hello and welcome to the show. You’re listening to Weekly Dose of Wellness brought to you by MemorialCare Health System. I’m Deborah Howell and today’s guest is Dr. Richard Reitherman. Richard Reitherman is the Medical Director of the MemorialCare Breast Center at Saddleback Memorial and Orange Coast Memorial, and a board member of the American Society of Breast Disease. He is well known for his clinical role in the early adaptation, promotion, and refinement of breast MRI with more than 20 years of experience in breast imaging and intervention. His special clinical and research interests include improving screening for high-risk women less than 40 years of age, multi-modality imaging correlation with large section histopathology, and implementation of standardized workflow algorithms for breast centers. Welcome to you, Dr. Reitherman. You sound like a busy man.

Richard Reitherman, MD: Good morning. I’m here.

Deborah Howell (Host): Well, we have a lot to talk about today, so let’s jump right in. How frequently should women get mammograms?

Richard Reitherman, MD: I think the mantra would be for a normal risk woman, starting at 40, every year, 12-month intervals.

Deborah Howell (Host): Okay. And there’s been a little controversy about that, but you really can’t go wrong if you do that, correct?

Richard Reitherman, MD: Correct. There is controversy and probably not the place to get into it, but my recommendation is 40 and over, every year.

Deborah Howell (Host): Very good. So tell me about the screening methods at the MemorialCare Breast Center at Saddleback Memorial.

Richard Reitherman, MD: Well, there are three primary mechanisms or methodologies that we use for breast screening, and just to note the difference: screening is when a woman has no lumps or signs or symptoms of breast disease. That’s the definition of a screening test.

Deborah Howell (Host): Oh! I’ve already learnt something! Wow, okay.

Richard Reitherman, MD: If they have lumps, we use a different algorithm or paradigm, even though we use the same mechanism or instrumentations. So the most standard tool is the X-ray screening mammogram, which has been around for a while. It’s undergone multiple improvements with decreased dosage and increased resolution. And that is the primary mechanism where we screen normal risk women once a year starting at 40. The other modality we have for screening is ultrasound. And we have a whole breast ultrasound program which is automated and interrogates or screens with ultrasound both breast volumes, just like a mammogram would. The difference between the two is one uses X-ray and the other uses sound waves and the latter has no radiation. And the ultrasound is used primarily for women that have dense breasts, which we can come back to later. The third modality is breast MRI, magnetic resonance imaging. And that is used for high-risk women, that is those women with a significant family history in addition to mammography. So in general, the high-risk woman would have a mammogram and an MRI every year. The normal risk woman would have a mammogram, and the woman at an intermediate risk would have a mammogram, and if she has dense breasts, would have an ultrasound in addition. So that’s the complement of screening tests.

Deborah Howell (Host): So you really don't get out of having the mammogram if you get the ultrasound in many cases.

Richard Reitherman, MD: Good pickup. The mammogram is the constant feature for each group.

Deborah Howell (Host): Right. Okay, because, you know, as women, we sort of don’t look forward to our mammograms, but we know that we need them.

Richard Reitherman, MD: I think that's true. Again, we screen all women. Most women will not get breast cancer, so most women have to go through the screening procedures with no benefit other than knowing they don't have breast cancer. We have to screen everybody because other than those with a significant family history, we don't know who is going to develop breast cancer.

Deborah Howell (Host): Right. Well, I noticed that you did say that we’ve made progress in terms of the dosage of radiology. I think that’s what most women fear. So maybe you could address that.

Richard Reitherman, MD: Sure. Well, being that it’s a test that you have every year, it can be of a little more concern than say a test you have once every so often. So the radiation is a little more concerning. The current radiation that's used with the current digital equipment is very low dose, and it's equivalent to like taking a plane trip cross country at 35,000 feet, because we have radiation, X-radiation coming from the sun all the time. So it’s not considered a risk in terms of increasing the risk of breast cancer.

Deborah Howell (Host): That brings up another question. I’ve heard the plane analogy before. What about people who are on planes, women who are pilots and flight attendants, are they at an increased risk?

Richard Reitherman, MD: I’m not aware of any studies that have been done to test that.

Deborah Howell (Host): Okay. Well, that’s all we can answer then, until there are some tests. How do these three screening modalities work together to produce the best result for women?

Richard Reitherman, MD: Well, the screening mammogram, the X-ray mammogram, is excellent for women who have what we would call non-dense breast tissue. Some women on the mammogram have essentially - it’s all black, it’s like a negative that you see of a photograph. Some women on the other hand have a totally white breast that has nothing to do with the texture, the size or anything. You’re just born with that texture. In general, the breast density decreases with age, so the lower breast density produces a higher sensitivity of mammogram, meaning that we can detect cancer more easily in the woman with a not dense breast than we can with a dense breast. So in women with a dense breast, we want to add other modalities, which mitigate the dense breast issue. For example, ultrasound would be the next one. No radiation, no risks really, in terms of radiation or compression, there is no compression. And that test is not dependent on breast density. The sound waves are well suited to interrogate dense breast tissue. The MRI is the most expensive test, and so it's reserved for people that have a very high risk of having breast cancer.

Deborah Howell (Host): Okay. Maybe you can describe the breast MRI a little bit more.

Richard Reitherman, MD: Sure. Breast MRI is essentially an angiogram where contrast substance is injected and during the course of the examination and the accumulation of the images by the machine, tumors uptake blood flow, and that's how we detect them. The images are subtracted from each other so whatever the woman's breast density or if she has augmentation or previous surgery, it's all essentially subtracted out, and so we get as perfect a picture as we can of any tumors that are in the breast.

Deborah Howell (Host): Okay. Which leads me to my next question: what is the California Dense Breast Law all about?

Richard Reitherman, MD: As we just had discussed, breast density decreases the sensitivity of a mammogram. So the denser the woman's breast, the less sensitive a mammogram is and therefore, maybe her physician would suggest other procedures such as ultrasound or MRI. The Dense Breast Law simply states that all women having a mammogram in California must receive written notice of whether their breasts are dense or not, and if they are dense, that it may decrease the sensitivity of mammography, and that they should consult their physician for other imaging modalities. So it's basically an informed consent so that the patient having the study actually has the information they need to make an informed decision.

Deborah Howell (Host): Information is power. This is the government working for you, actually, right?

Richard Reitherman, MD: Surprise!

Deborah Howell (Host): Exactly. Okay, when is genetic counseling recommended, Doctor?

Richard Reitherman, MD: There are specific guidelines for genetic counseling. And if a patient has a certain history in their family above a certain threshold, then genetic counseling is recommended. And genetic counseling is not genetic testing, so it's a filter. If you meet certain criteria, you're referred to the genetic counselor. The genetic counselor takes a more exacting history of family history of tumors, and then recommends blood testing if it needs to be performed. For example, a woman who is 40 years old and she goes in for her first mammogram and her mother was 40 and she was diagnosed with breast cancer, would be referred to genetic counseling to see if she met criteria for genetic blood testing, specifically we're talking about the infamous BRCA1 gene, BRCA2 gene.

Deborah Howell (Host): Okay. So know your family history. Very important. Do you have any other advice for women?

Richard Reitherman, MD: Well, I think knowing your family history is very important because it sets your risk. And we base all our imaging and complementary imaging in addition to mammography on risk. For example, if a woman has enough family history we will start screening her with mammograms earlier than 40 years of age. And everybody that comes to our facility, be they screening or diagnostic patients, receives an assessment of family history. Then the radiologist translates that into whether the woman should have additional testing or genetic counseling. So we assess every woman who comes in.

Deborah Howell (Host): That is great. Well, you know, it’s been really a pleasure to have you on the show. I really enjoyed hearing about the three different screening methods. I wasn't aware about the screening having no lumps, is why you're there in the first place, and that’s why you get what you get in terms of your mammogram, which we may dread, but we really do need, because it can lead us to some very, very important healthy information about our own bodies. Thank you so much, Dr. Reitherman, for taking the time to talk to us today about advances in breast screening methods and so much more. It's been a real pleasure to have you on the show.

Richard Reitherman, MD: You're welcome. Thank you.

Deborah Howell (Host): I’m Deborah Howell, join us again next time as we explore another Weekly Dose of Wellness brought to you by MemorialCare Health System. We hope you have a wonderful, safe and healthy week. Thanks so much for tuning in and have a fantastic day.