This post was contributed by a community member. The views expressed here are the author's own.

Health & Fitness

Saint John's Second Annual Pink Ribbon Lectures - Part Two

Finding breast cancer early – mammograms, ultrasound, MRI Dr. Daniel Kirsch, radiologist

On October 20th, 2011, Saint John’s Health Center, in collaboration with the American Cancer Society and a generous grant by the Harold McAlister Charitable Foundation, held its Second Annual Pink Ribbon Lectures at the Santa Monica Public Library.

A Woman’s Health – Breast Health and Cancer 
Finding breast cancer early – mammograms, ultrasound, MRI
Dr. Daniel Kirsch, radiologist

Dr. Daniel Kirsch – Up Close and Personal

Dr. Daniel Kirsch, Radiologist and Director of the Leslie and Susan Gonda Breast Imaging Center at Saint John’s Health Center and Director of Breast Imaging & Intervention at Tower Imaging Medical Group brought a smile to my face as he confessed to me, as so many people have, that he had never heard of the Pacific Palisades Patch. Regardless of the unknown, this courageous man had arrived early for our chat with his unbridled enthusiasm to share his passion and knowledge about diagnostic radiology: specifically, breast imaging.

Kirsch trained at UCLA and during his residency, he studied under radiologist, Dr. Larry Basset, a nationally and internationally known breast imager. Being able to learn at the leading edge and receive specialized training under him, motivated Kirsch. Furthermore, “in radiology, often you don’t have a lot of patient contact, but in breast imaging you did have that,” he said. Kirsch’s words were deeply rooted with authenticity and his deep eyes engendered a sense of his soulful medical purpose. “It was a field that had a significant influence on the course of the patient,” he continued. “Being able to diagnose something early and potentially save people from the disease was very attractive to me.” At the time Kirsch was training, there were a lot of new developments in breast imaging: digital mammography and breast MRI to site some examples. Another thing that attracted him to the field was the ability to diagnose every breast cancer with a needle without requiring a surgery.  "A surgery should be reserved for known cancers, of course, there are some exceptions. It used to be that a woman would have surgery for a biopsy. Those days are over.  With image guided needle biopsies whether it’s by mammography, ultrasound or MRI we can basically diagnose any finding on any type of study without having the patient have to go to surgery," Kirsch said.

Do you give radiation?
No. I’m a diagnostic radiologist. I do all the CAT scans, ultrasounds, MRI’s, with a specialty in breast imaging.

Breast imaging
Breast imaging is very scrutinized, as it should be. What gets talked about most is its screening test which is different than almost any other area in medicine. Women who get screened are healthy. They have no signs or symptoms. You don’t want to do any harm or as least harm as possible.

When do you recommend getting the first mammogram?
I would say start at age 40 for an average risk woman and then yearly from 40 onwards. The current recommendations are appropriate given the economics, the negatives and the benefits. There’s a reason not to start at an early age. You don’t want to expose the breast tissue to radiation at an early age because it is more metabolically active and hormonally responsive to things and it could be more vulnerable to radiation, ionizing radiation, a radiation that is strong enough that it could theoretically cause cell damage or cause a cancer.

Can women at 40 and older be vulnerable to a mammogram's radiation?
The effective dose you get from a mammogram is extremely low so realistically it’s not a significant risk factor. The potential benefits far outweigh the theoretical risks.

Find out what's happening in Pacific Palisadeswith free, real-time updates from Patch.

At what point do you get it earlier?
If there is a family history or the mother is diagnosed with premenopausal breast cancer – we recommend that the daughter be started at ten years before.

I’ve heard it’s painful.
Well… it involves compression. There are better times in the cycle to do it. You wouldn’t want to do it when your breasts are the most sensitive and densest.

Where should a woman get her mammogram?
I suggest going to a full service breast center that has dedicated mammographers reading the study. A general radiologist reading a mammogram is different than a breast radiologist.

What changes do you predict with technology?
At some point maybe imaging won’t be involved, maybe it’ll be a blood test; but until that time comes, the imaging is getting really, really sophisticated and really powerful. The biggest thing is breast MRI. We have a test that almost has 100% sensitivity, meaning that if breast cancer is in that breast, it will show it. It’s expensive, though. Certain women who have high risk are recommended to have it or women who are newly diagnosed with breast cancer because it will show the full extent of the disease.

Have you noticed a difference in the age of women being diagnosed?
Anecdotally, we’re seeing younger and younger women being diagnosed; that’s not scientific, but I think it’s generally accepted that there are more young women being diagnosed with breast cancer. No one knows why.

One thing that shouldn’t be overlooked is that we’re better at diagnosing now, so women who might not have been diagnosed for several years are being diagnosed now so it can make it look like there is an increase in younger women when we really are just finding it sooner. But, even given that, everyone seems to feel that there is a trend; there is a higher incidence in younger women.

Find out what's happening in Pacific Palisadeswith free, real-time updates from Patch.

Finding breast cancer early: Mammograms, Ultrasounds and MRI’s.
When we talk about early detection, there are three imaging modalities we’re talking about. Mammography is the most used, but there is also the breast MRI, and the breast ultrasound. When we’re talking about early detection, we’re basically talking about a screening, detecting cancer before it has become clinically evident or clinically apparent in any way; the rationale being that the earlier we can diagnose the abnormality, the greatest our chance of successful treatment.

Mammography Limitations

  1. Anxiety. Because it’s a screening study, it adds to the anxiety. In screening mammography, people are healthy – there is only bad news that could come out of this.

  2. False positives – being asked to have additional views, ultrasound or even a biopsy that turns out to be nothing. That is a definite limitation of the study. Optimally about 5%, but more realistically about 10% of women who have a mammogram are going to be asked to come back for additional views purely because we can’t always tell from the initial four views. It might help to know that the majority of the time it turns out to be nothing.

  3. Overly diagnosed. Some cancers that we are diagnosing might not do anything to the patient. They might sit there forever and never harm the patient. The patient may have been better off without ever knowing about it. But, some of them do. Some of those early calcification DCIS cancers become truly invasive cancers and we don’t know which ones will become cancer and which ones won’t.

  4. Some women who are higher than average risk of breast cancer particularly those who are at risk for heredity breast cancer - a mammography may have the lowest sensitivity: the lowest ability to detect an abnormality.


Benefits of mammograms

  1. Reduce mortality from breast cancer and save lives.


A recent study showed a 39% overall decrease in mortality due to screening mammography.

Breast MRI
Technology that’s becoming more and more important. It increases detection of breast cancer of women with high risk. It has the highest sensitivity of any test we do. If there is cancer in the breast, it is very likely to show. Breast MRI should not replace mammograms because some calcification may or may not be evident on the breast MRI. It is a complimentary test to the mammogram.

But who should get it?
It’s an expensive test and slightly minimally invasive. It requires an IV injection of contrast material. It’s not a candidate for replacing mammography, even if it could. It is recommended for women who are deemed to have a greater than 20% lifetime risk of breast cancer. The main categories in this risk level include the gene mutation BRCA 1 and 2, a woman who has two or more first degree relatives, a mother or sister, or two sisters for example, a first degree relative with premenopausal breast cancer, a family history of breast and ovarian cancer and a history of a male family relative with breast cancer.

There is a gray area in the 15-20% lifetime risk zone. The two main categories in this are: personal history of breast cancer – if you’ve been diagnosed or had breast cancer. The surgeons and oncologists we work with are recommending screening MRI to a large extent. Also women who’ve had previous biopsies that show what we call, risk lesions. This would be something to speak to your physician about.

Less than 15% lifetime risk, screening breast MRI in general is not recommended at this time.
 
Breast ultrasound
We use breast ultrasound all the time. It’s a very powerful and useful tool if a woman has a palpable finding on the mammogram and we want to characterize it in a different way – it’s very helpful. Classically, the ultrasound will tell you if it’s a solid mass or a cyst, which is very useful, but it has other utilities as well, however it has problems as a screening exam.

Studies have shown that use of the breast ultrasound in women that have dense breasts and correctly read negative mammograms, the cancer detection rate is increased. It will show cancers that the mammogram will not.

Ultrasound limitations

  1. Has unacceptably high false positives. There would be too many biopsies.

  2. It’s a very labor intensive exam and requires a skilled radiologist or skilled technologist.

  3. It’s operator dependent – the quality of the exam depends on who does it.

  4. In the end, it doesn’t show anything the MRI doesn’t show.


Ultrasound role
It may have a role for women with dense breast or contraindications to MRI, whether it’s a pacemaker or contraindication to the IV dye.

On a closing note, Kirsch said, “we have good evidence that screening mammography, even with its limitations, which should be recognized and should be addressed and should be attempted to be minimized going forward, still is a worthwhile thing to do.”

We’ve removed the ability to reply as we work to make improvements. Learn more here

The views expressed in this post are the author's own. Want to post on Patch?