Breast cancer is the most common cancer in women and the second leading cause of death in women. With 12% of the female population in the United States encountering breast cancer during her lifetime, it couldn’t be stressed enough that the next best thing to an “all clear” is early detection. And overall, mammography remains the most effective screening tool to detect breast cancer in women.
Radiologists understand the importance of mammograms and early intervention. In honor of Breast Cancer Awareness month, Dr. Michael Mishra of Texas Radiology Associates, which is a founding member of radiologist-owned alliance Collaborative Imaging, is sharing his insight on what led him to the field of radiology and how to best educate female patients on the benefits of regular screenings.
What led you to pursue a career in radiology and what’s your experience with mammography?
Ever since first being introduced to radiology while in medical school, I was fascinated with it as a specialty. I liked the ability to non-invasively see what was normal and abnormal inside a patient. Searching the images for findings was like being a detective searching for subtle clues that would be passed over by the untrained eye but would inevitably point to the answer or diagnosis. I was thrilled by finding and assembling these clues, the various imaging findings and imaging studies, like pieces of a puzzle to come up with the diagnosis. Ultimately in doing so, I help someone get the correct diagnosis and therefore correct treatment.
I also enjoyed that radiology is the perfect marriage between technology and medicine. It is a fast and ever changing field of medicine that is as rapidly changing as technology is around us. Most of our modalities and our ways of displaying or interacting with images are based on the current available technology. This could make the field of radiology seem daunting and challenging to some, but I saw it as a constant impetus for learning, growth, and motivation to improve myself. I love that it requires me to remain at the cutting edge in my knowledge, abilities, and practice.
I have been working in the subspecialty of breast imaging since finishing residency in 2011. I was always drawn to the subspecialty due to it allowing a continuity of care with patients. In breast imaging, I am taking care of the same patient from the moment of detection of a screening abnormality through the diagnostic mammogram and ultrasound appointment. And then I am with them through any biopsies and procedures for surgery and for the years of follow-up after their treatment. This involvement allows me to help them at many points throughout their journey and see them do well into the future because of the help that I have given.
When should someone start thinking about making an appointment for a mammogram?
A woman should start getting her screening mammogram annually starting at age 40 unless she has other reasons in her history to start at an earlier age. Reasons to start mammography at an earlier age include a family history of breast or ovarian cancer, personal history of breast cancer or high risk lesion, a genetic susceptibility to breast cancer, a history of chest radiation between the ages of 10-30, etc. If she has any of these risk factors, she should consult with her physician about when the best time to start mammography for her is and whether any additional testing, such as a breast MRI, is indicated in addition to the screening mammogram.
Certainly if she has any breast symptoms such as a lump, pain, skin changes, nipple changes or nipple discharge, she should get her mammogram at the time of the symptoms, which can be earlier than age 40. This exam should be performed as a diagnostic mammogram and may include additional images and ultrasound to help evaluate the symptom. This also applies to any symptomatic male patient who should get a diagnostic mammogram with ultrasound to evaluate his breast symptom as breast cancer can occur in men as well.
How would you describe mammography to a new patient?
During a screening exam, a mammography technologist will position your breast in the mammography unit and then compress the breast to improve image quality, decrease motion on the image and allow less radiation to be used for the images. Then, the unit will take the image and immediately release compression when it is done. A standard screening mammogram typically consists of two views per side and takes only several seconds per image. The whole screening appointment is usually less than 30 minutes.
The mammogram is reviewed at a later time by the radiologist and a result is sent to the patient’s physician stating whether or not there is an abnormality that needs further evaluation. Not all areas needing further evaluation on screening mammography are breast cancers. Further investigation is necessary to determine whether the abnormality is something normal, benign or requires follow up or biopsy. This further evaluation typically includes a diagnostic mammogram with additional images of the area and/or breast ultrasound. During the diagnostic mammogram appointment, the images are reviewed by the radiologist, an ultrasound may be performed and the result and recommendations are relayed directly to the patient before they leave.
How do you educate your female patients on the benefits of regular screening?
Each patient visit, whether it is with the technologists or myself, is an opportunity for us to educate our patients and explain the benefits of mammography. Typically the information I give includes the following: Breast cancer is the most common cancer in women and the second leading cause of death in women. One in eight women will be diagnosed with breast cancer at some point in her life. Starting annual screening mammograms at age 40 saves the most lives from breast cancer and most years of life by detecting breast cancers early at a smaller size before they are symptomatic and when they are more easily treated. Annual screening mammography can reduce the risk of dying from breast cancer and the severity of treatment needed. It has led to the largest reduction in breast cancer deaths and has reduced breast cancer mortality by 40%.
I also participate in annual programs to help educate the public and other health care providers in lecture or in Q/A format. We have various pamphlets and handouts on the benefits of screening mammography at our breast centers, and there are a variety of well-known web-based resources through the ACR, SBI, ACS and others detailing the benefits of mammography that we can share with our patients and referring physicians.
Have there been any technology advancements at your practice as it relates to mammography?
I would say the biggest recent advancement in mammography would be tomosynthesis or 3D mammography. In tomosynthesis, the x-ray tube moves in an arc over the compressed breast, acquiring images at multiple angles – compared to 2D mammography where an image is obtained at a single angle. These multiple images are then reconstructed by a computer into a set of three-dimensional images, which the radiologist can review in 1 mm thin slices. This process helps minimize tissue overlap (which can hide/mask cancers or make normal areas of breast tissue appear concerning on 2D mammography) – in effect increasing breast cancer detection and lowering the recall rate when compared to traditional 2D mammography.
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