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In 2002, Victor Vogel, M.D., the nation’s preeminent authority on breast cancer risk assessment invited Alan Hollingsworth, M.D. to serve on a national working group that was being formed to standardize levels of risk and to design management strategies. Fifteen national experts formed the working group in response to Dr. Vogel’s survey discovery that even “breast cancer specialists” were not well-informed on the information explosion regarding risk assessment and risk reduction strategies. Nine of the 15 were asked to be authors of the landmark consensus paper, and Dr. Vogel asked Dr. Hollingsworth to serve as lead author/editor of the group. After a one-year effort to assimilate and organize the nationwide input, the article was published in the March 2004 issue of the American Journal of Surgery. For a reprint of the article, call 405-936-5455 or e-mail: alan.hollingsworth@mercy.net. PUBLICATIONS BY DR. HOLLINGSWORTH (and, since 2000, the Mercy Women's Center team):
A Surgeon’s View of Breast MRIby Alan B. Hollingsworth, M.D. In 1990, I saw my first ‘spinning hologram’ of RODEO MRI in a presentation by Dr. Steven Harms at a breast conference in Dallas. On the “inside” of this 3-D breast image was a cancer NOT SEEN on mammography. This led me to ask the question: “Why don’t all cancers show up on mammography?” Today, we know the answer, but at the time, this information was not generally appreciated, and a literature review revealed only three papers on the subject, implicating one special type of cancer that was particularly elusive (invasive lobular cancer). With my strong interest in breast pathology, I reviewed the experience at my institution that resulted in a paper entitled, "The Histologic Basis of False Negative Mammograms" that was published in the American Journal of Surgery. In that paper, where I served as the quasi-pathologist doing all the photography myself, I described tumor growth patterns, even with the more common invasive ductal carcinoma, that would be very unlikely to be picked up by mammography (depending on the density of the normal breast tissue touching the tumor). The conclusion of that paper states that mammography is a strictly “anatomic” picture of breast tissue, and…given the growth patterns of certain tumors, an anatomic approach alone (mammography) will NEVER be perfected…that a physiologic parameter MUST be added to the anatomic picture to make cancer stand out.” When the Golden Anniversary Issue of the American Journal of Surgery was published years later, they selected this article as one of the most outstanding contributions among their Oncology publications for the past 50 years. Mammography has the distinct advantage of revealing tiny flecks of calcium that can lead to the earliest forms of breast cancer (calcium doesn’t show up well on MRI). These calcium flecks can show up nicely even in dense breast tissue. But there’s one problem here – most breast cancers become invasive WITHOUT developing mammographic calcium. And if there’s no calcium, and if the growth pattern of the tumor blends in with the breast tissue, then a good portion of the breast can be involved by cancer, yet the patient can still have a normal mammogram and normal exam. And this is the paradox of mammography – it is the modality that finds the earliest form of breast cancer, while at the same time can miss large cancers! When “failure to diagnose breast cancer” moved into the Number One Slot under reasons for malpractice litigation, it was found that in 80% of cases, the MAMMOGRAMS ARE NEGATIVE. And typically, this occurs in younger women where the breast tissue is denser, and more capable of hiding cancer. I believe there has been a delay in recognizing the magnitude of this problem because the “breast community” for many years became infatuated with their own strides in discovering the earliest form of breast cancer – DCIS. Prior to mammography, this was a rare find, less than 5% of cases. Now, if your cancer is diagnosed by mammography, then odds are 25-40% that it will be DCIS. That’s great, but what about the remainder? Many of the women whose cancers do not appear on X-ray show up in the surgeon’s office with a palpable lump, NOT at the mammography centers where their mammograms were “normal.” Therefore, it’s not so unusual for a surgeon to be interested in the MRI revolution. For you see, MRI adds the “physiologic parameter” I mentioned above – by injecting the contrast agent gadolinium, cancer is “enhanced.” Thus, the ‘diffuse’ cancers (lobular and some ductals) show up as a result of the contrast, especially when hundreds of images are taken with MRI. MRI has been available for the rest of the body for over 20 years. Even with contrast, it was delayed in its introduction for routine clinical use for several reasons: 1) there was no “normal” breast pattern to serve as a baseline, i.e., there’s an infinite number of “normals.” Thus, it is actually far easier to learn brain anatomy on MRI than breast anatomy. 2) there were competing technologies related to timing of contrast vs. morphology of contrast; and while these issues are not completely settled, great advances have been made and technologies have been merging. 3) until recently, there was no way to perform a reliable MR-guided biopsy. The needle would appear on the MR image, but it wouldn’t be exactly where it needed to be because of a distortion artifact. With this problem now behind us, MRI is ready for expanded clinical use. Here’s my short-term vision: The work-up for breast cancer will be a needle biopsy, then the next step is a MRI, then the patient will meet the surgeon who will have an accurate map of the problem. Published studies indicate a major change in surgical plans in 10-20% of patients who undergo pre-op MRI. If 200,000 women undergo surgery each year for breast cancer, is it really possible that we’re doing the wrong surgery on 20-40,000 women each year?! Yes, it is. Even a fraction of that number is unacceptable. It’s time to pull our heads out of the sand, and operate on what’s really in the breast, not what a grossly inaccurate measure of tumor involvement (mammography) indicates. And here’s my long-term vision: With MRI of the breast having 95-100% sensitivity for the detection of breast cancer, we need a pre-screen with a blood test ... desperately. It will come. Someone will do it, or perhaps the combination of several tests will detect early breast cancer. When it happens, this is what you’ll see for screening: Mammography AND the blood test. If the blood test is positive for cancer, but mammograms negative, patients will have screening ultrasound and MRI performed. HOWEVER, if a blood test is found with near-100% sensitivity, Screening Mammography will become a thing of the past. Only those women with positive blood testing will undergo diagnostic mammography, ultrasound, and MRI to locate the problem already identified by the blood test. It was 1990 when I latched onto breast MRI as our answer to so many problems. While false-positives and high cost will still be with us, improvements will occur. Meanwhile, the rate of “missed cancers” will start to fall. When the screening blood test is found, the rate of “missed cancers” will drop precipitously for then we can better identify asymptomatic women who need this “new” modality.
OTHER PUBLICATIONS, EDITORIALS, and WHITE PAPERSHigh Risk Screening with Breast MRI (Seminars in Breast Disease) Pre-op Breast MRI – Technology vs. Methodology (Breast Diseases) Rationale for a Blood Test to Detect Early Breast Cancer (white paper) High-Risk Screening MRI outcomes at Mercy (white paper) Pre-op Breast MRI (editorial for American College of Surgeons News)
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