Extensive research over decades has proven that mammograms save lives. Annual mammograms allow us to detect breast cancers at the earliest possible stage.
Cancer on mammogram: Small cancer – irregular white spot with spiky margins
Annual mammograms allow us to detect breast cancers at the earliest possible stage. Unfortunately, some aggressive cancers can exponentially enlarge in even a year which is why we need to do the test every year. In the old days, many breast cancers were only diagnosed when a patient presented with a large tumour which had already metastasized throughout her body. Most of these patients died within months to a year. These days, the majority of breast cancers are found when they are less than 2cm in size. (largely due to mammograms and ultrasound.) The prognosis for those patients is 90% survival at 5 years.
Interval Cancer ie grown within 10 months!
Cancer developed in 22 months
40. Although breast cancer incidence peaks in the 50s, breast cancer in younger patients is generally faster growing and potentially more devastating. Hence the need to begin at age 40. High risk patients often start earlier.
There is no cut-off age for mammograms. As people are living longer and are healthier at older ages, we are seeing many cancers in patients older than 70. The cancers can usually be successfully treated at any age.
Breast Cancer by Age
Every year. This means that cancers will be detected at an earlier stage than if mammogram is done only every 2nd or 3rd year. The smaller/less advanced the cancer the easier to treat and better chance of survival. Most breast cancers develop from microscopic individual cells into mammogram detectable lumps in 18 – 24 months. Mammogram intervals longer than a year are therefore not optimal.
The cash price for a mammogram, as linked to most medical aids, is usually between R1550 and R1770. Previously, almost all the medical aids paid the full cost on an annual basis, regardless of your particular plan. Unfortunately, many of the medical aids have cut back on account of financial considerations and are only paying for a mammogram every second year. In order to ensure patients have affordable access to a mammogram every year, many practices are offering cash discounts for the “intervening” year when the medical aid won’t pay. Discounts of up 10 - 30% can be expected. Some practices may also be amenable to cash discounts on other procedures such as ultrasound, biopsy and MRI
The decision taken to only pay every second year is a financial one, not a medical decision. There is substantial evidence from many years of breast cancer assessment and mammography application, showing unequivocally that yearly screening saves lives. As radiologists we see many cases of breast cancers growing in less than a year. ANNUAL SCREENING SAVES LIVES!
Yes. Although males can get breast cancer, it is very rare. Some males who carry the BRCA gene mutation, may need regular screening but this is only a small minority.
Density in the breasts is generally determined from a mammogram image. The mammogram shows two main types of tissue in every breast – fat and fibroglandular tissue. Fibroglandular tissue refers to the milk glands and the fibrous tissue that forms the surrounding supporting structure. Every women has different proportions of these tissues in her breast. Some women have predominantly fat containing breasts and some women have a high proportion of fibroglandular tissue relative to fat. The breasts with large amounts of fibroglandular tissue are called dense. On the mammogram, the denser the breast, the whiter it is. The opposite, fatty breasts, are mainly black.
X-rays from mammograms are not so good at penetrating dense tissue. As a result, a mammogram is less accurate in women with denser tissue and cancers can be obscured by the overlying fibroglandular tissue
Women with denser breasts are at a higher risk of developing breast cancer.
Dense breasts – more white tissue (fibroglandular) relative to black(fatty). Breast cancers are also white, which makes it sometimes difficult to diffrentiate the cancer from the normal breast tissue.
Sometimes, looking for a breast cancer in dense tissue is like finding Wally in a Where’s Waldo puzzle
A tomosynthesis mammogram or 3D mammogram is obtained with a special mammogram machine that takes multiple images while moving in an arc around the breast. The resulting compilation of images can be viewed in 3D allowing us to see right through the breast. It makes cancers easier to see and benign lesions more obvious.
Tomosynthesis – 3D Mammos
There is no additional cost for a 3D mammogram. At our practice all mammograms are now done on the tomosynthesis machine. The breast ultrasound which is routine is also no extra cost when having a mammogram.
Breast augmentation does not increase or decrease your chances of getting a breast cancer. Your risk remains the same. You must have a mammogram prior to getting surgery (or an ultrasound in patients younger than 35) since it would be very unfortunate to be diagnosed immediately after having the surgery. Thereafter annual mammograms are advised like for everyone else.
Breast Implants – white oval shapes
The mammogram, although it does compress the breast a bit, will NOT burst or displace the implant. And the implant will not prevent us from seeing a cancer on mammogram or ultrasound.
Pregnancy is the only condition in which a woman over the age of 35, is advised not to have a mammogram
Parklane Radiology Women's Imaging Centre has been awarded accreditation in MAMMOGRAPHY by the American College of Radiology (ACR).
This follows on the ACR accreditation in BREAST MRI Parklane achieved in 2017.
The ACR gold seal of accreditation represents the highest level of image quality and patient safety. It is awarded only to facilities meeting ACR Practice Parameters and Technical Standards after a peer-review evaluation by board-certified physicians and medical physicists who are experts in the field. Image quality, personnel qualifications, adequacy of facility equipment, quality control procedures and quality assurance programs are assessed.
The most important sign of a breast cancer is feeling a lump. It will feel like a pea or marble under the skin.
Breast Cancer Symptoms. Most lumps are NOT cancer. Fibroadenomas and lumpy breast tissue are common benign causes of a palpable lump in the breast. Nonetheless, a lump must never be taken forgranted - the only reliable way to differentiate a malignant from benign lump is with imaging and biopsy if necessary.
A developing area of skin thickening, nipple retraction, bloody nipple discharge may also represent a cancer and must be checked out
Only around 50% of breast cancers are palpable. That is why a mammogram is so important – even if you don’t feel any lumps or other breast symptoms, you may still have a breast cancer. Mammograms can show most of these even if they’re very small.
Yes. There are two main groups, ductal and lobular cancer. The cancers are further divided into hormone responsive and non responsive types. Every breast cancer is slightly different based on the hormone receptors, grade and growth rate. Treatments are individualised based on the specific characteristics of a cancer.
DCIS stands for Ductal Carcinoma In Situ. This is a “sleeping cancer”. It is one of the earliest stages of breast cancer. Not all of these lesions develop into cancer but enough of them will which makes it a dangerous condition that must be treated.
DCIS is most often identified on mammogram as a group of tiny microcalcifications. Microcalcifications are specks of calcium “gravel” or powder that are often visible on mammogram pictures.
DCIS: Microcalcifications (tiny white spots) represent cancer cells within the ducts i.e. a “sleeping cancer” or pre-cancer. These microcalcifications are often the only sign of a developing cancer, and mammogram is the only modality that accurately shows them.
There are two known genes related to high risk of breast and ovarian cancer – BRCA 1 and BRCA 2. These genetic mutations occur in only 0.2 – 0.3% of all women. Only those women with strong family histories of breast and/or ovarian cancers need consider the test.
Breast examination is sometimes difficult to do on account of lumpy breast tissue or big breasts. Only around 50% of cancers are palpable. Often it is only the large or superficial cancers that can be felt. DCIS is hardly ever palpable. Therefore to catch cancers as early as possible, screening mammograms are strongly advised.
Physical examination: Either by yourself, preferably once a month, or by your doctor at your annual appointment
Ultrasound exams involve the doctor running a probe over each breast in a systematic way in order to survey the entire breast. The probe transmits ultrasound waves into the breast and receives returning waves from the breast tissues. As a result, a computer generates a picture on a monitor. Breast cancers which are composed of different tissue from normal breast tissue, are well demonstrated.
The radiologist runs a probe over the entire breast in a systematic manner to evaluate all areas thoroughly. Most specialist practices do an ultrasound as a routine to supplement the mammogram. This increases the sensitivity ie the ability to pick up cancer regardless of how subtle or well hidden they might be.
Ultrasound: The cancer is darker than surrounding tissue, has an irregular margin and casts a shadow
Ultrasound: note spiky margins and shadowing of cancer. Size is 8 x 11mm
Ultrasound is a painless and safe examination even in younger patients and pregnant women. In many practices ultrasound is used as a supplemental test to mammograms reducing the chances of missing a cancer on the mammogram. It is especially useful in women whose dense breast tissue reduce the sensitivity of a mammogram.
Although it is appealing to avoid the squashed breasts and theoretical radiation risks of a mammogram by having only an ultrasound instead, breast ultrasound cannot replace mammograms for cancer screening. Mammograms give us ultra-high resolution pictures of the entire breast. It shows up microcalcifications and subtle architectural distortion, that often are not visible on ultrasound. These features may be the only sign of an early cancer. Mammograms are always compared to previous year’s mammograms and slight changes can also be a sign of early cancer formation. It’s not practical to do the same comparisons with ultrasound. Almost all the studies that show that regular screening saves lives, have been done with mammograms.
In younger patients, we do prefer to do only ultrasounds, but patients over 35 should always have a mammogram.
Mammograms are the gold standard for breast imaging and the only test proven to save lives. However, in patients younger than 35 and in pregnant patients, an ultrasound is done without the mammogram.
In most practices, all mammogram patients will have an ultrasound immediately after the mammogram as we believe that combining the tests increases our accuracy.
Sometimes we do a six month follow up using only ultrasound especially if the area of concern was best seen on ultrasound in the first place.
MRI of the breasts is the most accurate method we have for diagnosing breast cancers. Women at high risk of developing breast cancer (more than 1 in 5 chance. Usually related to family history or BRCA gene mutation carriers) are advised to have an annual breast MRI.
The patient lies face down in the MRI machine and a small amount of dye is injected via a drip which will cause cancers to light up on the scans.Subtle cancers that are only visible on MRI can be biopsied under MRI guidance
Subtle cancers that are only visible on MRI can be biopsied under MRI guidance
A patient goes into the MRI tunnel lying flat on her stomach, her breasts hanging down. A drip is put up and a small amount of intravenous contrast injected during the scan
MRI is also used to help determine extent or multiplicity of a newly diagnosed breast cancer which is particularly helpful in patients scheduled for limited surgical excision.
Lastly, in patients with complex mammograms and ultrasounds where we cannot be certain that cancer is excluded, MRI is an excellent problem solver.
Cancer shown as white mass(lump) against black fatty background – 2D, 3D and with colour appliaction which shows likelihood of malignancy. Red most likely, blue least likely
A biopsy is a test whereby a small tissue sample is taken from an area of suspicion identified on mammogram or ultrasound. It is obtained using a hollow needle and under local anaesthetic. The sample is sent to a pathology lab for testing. The answer is usually definitive – cancer(malignant) or non cancer(benign).
Biopsies are preferably done in the mammography department under mammogram or ultrasound guidance. This ensures that the correct area is sampled.
Ultrasound Probe + Lignocaine (local anaesthetic) + Spring loaded biopsy gun
Breast Biopsy: Done under ultrasound or mammographic guidance and with local anaesthetic. A number of small samples are extracted with a biopsy needle and sent to the pathologist for microscopy and other special tests to determine whether the lump is a cancer and if so, what type. This will ultimately determine treatment
Real Cancer diagnosis - Pathology
- Breast cancers are all different on a cellular and molecular level
- Detailed pathology and biochemistry tests
- Individualised treatments targeted at particular type
- Cancers < 2cm have a 5 year survival of 90% 10 year survival of 80%
- Cancers > 2cm have a 5 year survival of 70%
- Modern cancer treatments have been proven to work
Thermograms are tests that measure heat patterns in the breasts on the assumption that breast cancers give off more heat than surrounding tissue. It is not reliable and should definitely not replace mammograms.
Blood tests for tumour markers are also not a reliable way to pick up breast cancers
Thermograms: Although cancers do theoretically generate more heat than surrounding tissue, this is not universally true. Thermograms are insufficiently accurate to be used as a screening or diagnostic test for breast cancer. Many of the promises made about thermography are misleading. Don’t trust your life to thermography or any other unproven test, no matter the hype and supposed safety.
There is no definite prevention for breast cancer. There are some known risk factors that increase a person’s likelihood of developing a cancer. Most of these are out of your control – family history, breast density, having children, previously biopsied high risk growths. Some lifestyle factors however can be modified eg obesity, excessive alcohol, smoking, Hormone Replacement Therapy. Nonetheless, it is important to realize that ±75% of breast cancer patients had no risk factors at all. That is why, even if you have no family history, no known risk factors and consider yourself healthy, you are still at risk of breast cancer and should have annual screening.
There is suspicion that some diets predispose people to cancers especially those high in animal fat and processed food. However, there are no direct dietary links to breast cancer and a healthy diet does not exclude you from getting it. Being healthy though, certainly makes the various cancer treatments easier to tolerate and may provide better outcomes.
Mammograms, like all x-rays do transmit radiation and theoretically, this radiation in large enough doses could cause cancer. However, there has never been any proof that patients receiving x-rays or mammograms have developed cancers from the radiation. The radiation dose from a mammogram is miniscule(less than the radiation you are exposed to living in Johannesburg for one year).
The theoretical likelihood of getting a breast cancer from mammograms is 1 in 70,000. Your chance of getting a breast cancer during your lifetime (with or without mammograms) is 1 in 8. Clearly the benefits of early detection of such a common and treatable cancer outweigh the remote theoretical risks!
There is also a bizarre theory that the compression of the breasts during a mammogram will create a cancer or cause a cancer to disseminate. This concept is without any scientific reasoning
One of the biggest criticisms of screening mammograms , both from the lay and medical press, is that of overdiagnosis. In other words, the allegation is that mammograms pick up too many cancers and since many of those cancers will either regress or remain static, many patients undergo unnecessary treatment some of which is harmful.
None knows the exact figure for overdiagnosis. It is generally based on assumption, not fact. Despite some claims of 30 – 40% of breast cancers being called “harmless” and therefore diagnosed unnecessarily, the real figure is probably closer to 2 – 3%. There has never been a documented case of spontaneous breast cancer regression. And although some cancers are very slow growing, we cannot know which without at least doing a biopsy and pathology tests.
Treatment these days is dependent on the type of cancer as diagnosed with biopsy. Cancers which are high grade, hormone receptor negative and rapidly growing are treated more aggressively, while low grade hormone responsive, slow growing cancers are treated less aggressively.
Mammograms are not compulsory. They are elective. If as an informed adult, you choose to have mammogram screening, you are electing to find out if you have a cancer, slow growing or fast. The diagnosis isn’t the point. It’s a question of overtreatment or not. The treatment decided on must be appropriate for your type of cancer. And that is largely dependent on detailed pathology and astute breast surgeons and oncologists.
Lastly, we know that mammogram screening has reduced death from breast cancer by ±30%. That’s a well proven fact. The supposed harm from overdiagnosis is largely hypothetical. Not to say treatments such as mastectomy, chemotherapy and radiation aren’t without risks or complications. However, death and severe disability for modern breast cancer treatments are negligible. The benefit : risk ratio is pretty clear.
Although you are at a higher risk of getting breast cancer if there is a family history, most breast cancers occur in women with no family history! 80% of breast cancers are spontaneous i.e. no known risk factors evident.(risk factors are family history, abnormal cancer genes – BRCA, obesity, not having had children, hormone replacement, dense breast tissue and alcohol abuse.)
Maybe there are other factors involved such as environment, hormones in food or exposure to unknown toxins. But at this time, we have no evidence of this, so you can’t avoid what you don’t know!
- Family history is the most important
- Previous biopsy that should abnormal cells even though not a cancer. These are called high risk lesions and have a higher chance of developing into cancer than ordinary tissue (ADH, LCIS) – make sure you always receive and understand results from your biopsy!
- Not having children or having a first child over 40
- Long term hormone replacement therapy (HRT)
- Ashkenazi Jewish or Afrikaans heritage
- Previous breast cancer
- Dense breast tissue. This is a description of the density of glandular tissue in your breasts, compared to background fat. It is usually determined from your mammogram.
- Keep in mind: for 80% of breast cancers, there are NO known risk factors!!
No. Mammograms do NOT cause thyroid cancer. The radiation from a mammogram is extremely low and insignificant dosages reach the thyroid gland. We certainly do not see increased rates of thyroid cancer in women who have had many mammograms. Although there is an increase in thyroid cancer numbers this is for men too (who are not receiving mammograms!)
A thyroid shield is unnecessary and may effect the quality of the mammogram
Surgery: mastectomy (whole breast removed) or lumpectomy (the cancer lump with surrounding tissue removed but most of breast left behind)
Radiation Therapy: A special powerful x-ray beam is used to eliminate any residual cancer cells in the remaining breast tissue/chest wall/underarm.
Chemotherapy: Cancer killing medication of different types. Administered in multiple doses over ±6 months
Ant-Hormone/Endocrine Treatments: Tamoxifen or other similar drugs that block oestrogen and progesterone from stimulating cancers. These drugs are sometimes taken for many years after the cancer is initially treated.
It is extremely important for women over the age of 40 to have regular mammograms. If the mobile mammogram service is your only opportunity, then by all means, have your mammogram with them.
Mobile mammograms. An excellent initiative but not as comprehensive or accurate as mammograms and sonars performed in a specialist department with doctors on-site
There are, however, many reasons that having your mammogram in a dedicated specialist department is better than in a mobile unit;
Most mobile units use the older 2D mammogram machines. This is significantly inferior to the new 3D Tomo machines in terms of cancer detection.
Having your mammogram in the same department every year allows the radiologist to compare old and new images. This is very important when it comes to detecting early cancer changes.
Breast Ultrasound – in most specialist departments an ultrasound is done with every mammogram. Mammograms cannot pick up every cancer. In fact they pick up only ±70% of cancers at best. In women who have dense breast tissue - ±50% of the population – mammograms are even less effective, picking up only 30 – 40% of cancers. To compensate for this, we do ultrasound exams of the breasts on every patient. The combined tests can pick up 80 – 90% of cancers! The ultrasounds are performed immediately after the doctor has assessed your mammogram.
Mammogram: No cancer visible due to dense breast tissue
Ultrasound clearly shows a large cancer (2,6cm)
Personal interaction with a specialist breast radiologist. Your questions and concerns are addressed face-to-face by a medical specialist with many years of experience in breast cancer detection. Any abnormalities on your mammogram or ultrasound are discussed straight away. No delay getting results!
Procedures that need to be done eg biopsies (sampling of breast lumps to tell if they are cancerous) and cyst aspirations are done in the same department by the same doctor who has done your mammogram and ultrasound.
If further tests such as a breast MRI is needed (certain difficult cases), they are referred within the unit and again, interpreted by the very same breast radiologists.
If cancers are found, you are already in the system. The radiologists are part of a highly experienced multidisciplinary breast cancer team – breast surgeons, oncologists, pathologist and plastic surgeons. Your case goes immediately through to this team who ensure that you receive the very best level of care available.
No extra cost!! The addition of a 3D mammogram, sonar and specialist doctor consultation are all included in the same tariff.(medical aid rates apply). It costs the same as a mobile mammogram that lacks all of the above ..
Ideally, breast cancer should be managed by a team of specialist doctors ie a Multi-Disciplinary Team (MDT). This is usually comprised of breast surgeons, radiation and medical oncologists, radiologists, pathologists and plastic surgeons.
Usually, a person is diagnosed by radiologist and pathologist (radiologist may find the lump on mammogram/ultrasound, followed by a biopsy which is interpreted by the pathologist, following which they are referred to the breast surgeon. The surgeon will put together the reports and results as well as interview and examine the patient. The case will then be presented to the rest of the multi-disciplinary team for discussion and consensus on best treatment approach.
Some patients receive chemotherapy first, in order to shrink a cancer prior to surgery.
Some have surgery first
Reconstruction is a part of the treatement discussion from early on.
All treatment decisions are taken in consultation between the various doctors and the patient/their family. It is imperative that patients and families are well informed at all times. They must, based on a good understanding of diagnosis, treatment and long term outcomes, decide on the path they wish to follow.
Diagnosing and treating breast cancer .. A team approach
After cancer diagnosis .. Treatment options vary from patient to patient and treatment plans are individualised to best treat a particular cancer depending on type of cancer and stage (size and spread)