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INNOVATIVE APPROACH TO FEASIBLY INTEGRATE HIGH RISK BREAST CANCER SCREENING INTO A PRIVATE RADIOLOGY PRACTICE BY RYAN POLSELLI
There are many considerations that go into a surgical plan. I cannot list them all and I do not pretend to know all of them. A breast surgeon is better equipped to answer this question for you. He or she should know the details of this answer and what would be best under any given circumstances. I defer to their expertise. I cannot understate this.
However, this is my understanding of general treatment guidelines for stage 0 breast cancer which is also known as DCIS, or in other words, cancer that is still contained within the ducts of the breast.
First, I have to make some assumptions here because the information was not provided in your question, but let's assume that you or someone you know was recently diagnosed with DCIS from a core needle biopsy.
This most commonly, but not always, occurs in the setting of stereotactic guided core needle biopsy of suspicious calcifications in the breast seen on a mammogram. Less commonly (about 10 percent of the time) DCIS can actually present as a mass and is then sometimes diagnosed with an ultrasound guided core biopsy.
In any event, as long as a lumpectomy is going to be performed (the most common surgical procedure for DCIS discovered on needle biopsy), sentinel lymph node biopsy can be skipped if it is not very “likely” that there is any invasive cancer that was missed on the original biopsy. This is fairly subjective and may take into account local and regional differences as well as surgeon and patient considerations and preferences.
Up to approximately 10 percent of the time (depends on the research that you read) what was believed to be DCIS from a needle biopsy actually ends up showing that there was an invasive cancer when lumpectomy is performed. In this case the traditional guidelines still recommend sentinel node biopsy. In this cases, many of these patients would then need a second biopsy.
In order to avoid this, if there is a larger area of suspicious calcification than what was biopsied originally biopsied, then a sentinel biopsy may be wise to perform at the time of initial surgery. On the other end of the spectrum, if a large core needle was used for the original biopsy and the entire area of suspicion was removed, it's not likely that the DCIS will be upstaged to invasive breast cancer at the time of surgery and sentinel mode biopsy may not be necessary.
Obviously there are many many more considerations that come into play so the final recommendations from surgeons may still differ from what I have described. Additionally, a lot of newer research is being published that challenges the status quo about stage 0 breast cancer and which may come into play when designing a treatment plan. Finally, guidelines are constantly being refined so there is always a certain lag time as general practice patterns catch up and this also can contribute to different recommendations.
As stated earlier in this answer for you, I strongly recommend that you visit with your surgeon and or oncologist to discuss the treatment plan that is best for you. I hope this helps.
Ryan Polselli, MD, Diplomate of the American Board of Radiology, Fellowship Trained Breast Imaging Radiologist
The above information is intended as general information and is not intended to be medical advice.
For more information about topics related to breast cancer screening and diagnosis, visit Dr. Ryan Polselli's blog, Mammography Matters. You can also obtain more information at his facebook page, Dr. Ryan Polselli. Please visit and like!
In short it depends. I will speak generically about this.
Different tumors, infections, cancers, organs, and types of needle biopsy techniques have different risks of needle track seeding. Any needle biopsy should take these risks into account and only be performed when the patient gives consent and the benefits of the biopsy outweigh the risks (which include needle track seeding). In this setting, as long as the technique is performed properly, even if seeding were to occur, it would not be considered by most in the profession of medicine to be a medical error. In some cases seeding is irrelevant.
However, failure of any of the above could potentially imply a medical error. For example, failure to consent a patient is considered an error. So is performing a biopsy when the risk outweighs the benefit (this can be subjective) or if the technique is performed improperly and causes potentially harmful seeding.
Two points of caution about this topic because we are not talking specifics. One, I don't want anyone to assume biopsy track seeding has occurred just because there is disease progression. It is common for us as humans to assign blame and or assign a cause and effect relationships where it doesn't exist.
Two, there are many situations where needle track seeding never occurs and should not weigh into the consideration about whether or not to have a biopsy. For example, core needle biopsies of breast cancers do not result in seeding and concept of seeding in this case is irrelevant and should never deter anyone from having a breast biopsy. There are many other examples.
Ryan Polselli, M.D., Diplomate of the American Board of Radiology, Fellowship Trained Breast Imaging Radiologist
The terms BRCA1 and BRCA2 (sometimes pronounced "bracka" 1 and 2) generally refer to important portions of the human genome that make proteins in cells that suppress tumors (typically breast or ovarian cancer) by repairing DNA that may be damaged during the course of one's life. Any damage to the BRCA 1 or 2 gene segments therefore predisposes an individual to breast and ovarian cancer. Although there are many similarities between the two genes, there are many important differences that are important to understand.
In general, both BRCA1 and BRCA2 mutations have been found to increase the lifetime risk of breast cancer very roughly between 50 and 85%. BRCA1 mutations however result in a higher risk of lifetime ovarian cancer (up to 60% in some studies) than BRCA2 (up to 20% in some studies). There is also a predilection for the two mutations to present with different types of cancer with some differences between the sexes. For example, BRCA2 is more likely to produce ER+ (estrogen receptor positive) cancer. It is also (for less than definitive reasons) more likely to cause male breast cancer. BRCA1 is more likely to result in a more aggressive form of breast cancer typically known as "triple negative" breast cancers. Interestingly, prophylactic oophorectomy (removal of ovaries) is effective in decreasing the risk of breast cancer in the setting of a BRCA2 mutation but not BRCA1. This is believed to be the result of decreasing the estrogen levels which could encourage an ER+ breast cancer from BRCA2.
The incidence of BRCA1 and BRCA2 also varies by ethnicity. African Americans are more likely to have BRCA2 mutations while Caucasians are slightly more likely to have a mutation in BRCA1. I hope this helps anyone looking for a concise breakdown of some of the most important differences between these two genes.
-Ryan Polselli, M.D.
Breast Imaging Radiologist
ryan-polselli.com or ryanpolselli.com
BREAST CANCER: IS THE ER (ESTROGEN RECEPTOR) SOMETHING GENETIC OR ISBIT VARIABLE BASED ON MEDICATION?
The complete answer to your question is very complex. Isn't it always? I'll do my best to stick to what I believe is the essence of your question. For the purpose of this discussion, I will be referring to the Estrogen Receptor (ER) as it applies to both normal and cancerous breast tissue in the setting of chemotherapy. If I miss the point, elaborate and I'll attempt to provide a better answer for you.
Strictly speaking, the breast tissue Estrogen Receptor is both genetic AND variable in the presence of chemotherapy (and other medications).
I like to think of the Estrogen Receptors as the part of the breast tissue that provides the normal "stickiness" for the circulating estrogen in the body. The more Estrogen Receptors there are, the more the circulating estrogen in the blood stream will stick around and interact with the the breast cells. If the breast tissue is extremely "sticky" to estrogen, it is considered highly Estrogen Receptor positive (ER+). At any given time in life, the amount of normal "stickiness" that breast tissue has for estrogent will vary slightly. This is due to many different factors including the normal hormonal cycle, genetic background AND medication (among others).
When estrogen sticks around the normal breast tissue, it influences the breast tissue to behave in a certain ways. One of the normal effects of estrogen on the breast tissue is the stimulation of growth (note, this is sometimes noticed in patients as breast tenderness and fullness).
When breast tissue becomes cancerous, the genetic make-up of the cells changes and the cancerous cells begin to "break some of the rules of normal behavior." Evaluating these cells for the presence of Estrogen Receptors is useful to know in order to have an idea of how the cancerous cells are behaving. If the cancer is Estrogen Receptor positive (ER+), we can limit the amount of estrogen in the blood stream to try to prevent the cancer from growing. If the cancer is Estrogen Receptor negative, we can focus on other strategies. Note, with time, cancer can break additional rules and the receptor status can change.
I hope this helps answer your question!
Ryan Polselli, M.D., Breast Imaging Radiologist
This answer is for general informational purposes only and is not a substitute for professional medical advice. Always seek the advice of your doctor before starting or changing treatment.
There is so much confusion about this question! I want to try to answer for both healthcare professionals AND patients in the simplest way that I know.*
In the past, the general answer was simple..."When you turn 40, get a mammogram every year until you die."
In 2009, a group of healthcare professionals, the US Preventative Services Task Force (aka USPSTF), gave their best attempt at crunching some numbers to determine the value of the mammogram in terms of risks and benefits.
Their recommendation was..."Beginning at age 50, get a mammogram every other year until 74."
Once they came out with their recommendation, all hell broke loose in the medical field and there has been confusion ever since.
So what happened? Why is there not agreement?
Both groups have argued back and forth about the science and statistics...the sensitivity, specificity, true and false positives, receiver operating characteristic curves, and various other concepts requiring an advanced degree to understand...
However, the essence of the difference between the two groups boils down to a difference in human values of what is actually harmful versus what is actually beneficial.
The USPSTF places more emphasis on the harm that arises from unnecessarily diagnosing and treating a suspicious area of the breast (the so called false positives) than the benefit that arises from diagnosing and treating a cancer. The result is a recommendation for fewer mammograms.
While this may not sound that bad, the problem is what follows as a result. The USPSTF acknowledges that with a decreased frequency of screening mammograms beginning later in life, more women will lose their life to breast cancer.
And so it goes...
In general, the opinion of those close to breast cancer will strongly favor the traditional recommendation.
This is why the official recommendation of the American Cancer Society remains..."When you turn 40, get a mammogram every year for as long as you are in good health."
Ryan Polselli, M.D.
Breast Imaging Radiologist
Web: Ryan Polselli
*Please note, high risk patients should see their doctor and may have different recommendations
The discussion resulting from Angelina Jolie's decision to undergo elective mastectomy has generated a few questions that should be clarified.
Angelina Jolie has a known defect in her genes that puts her at a higher risk for developing breast cancer than most women. The defect occurs in a part of her genetic makeup that has been labeled BRCA1. The BRCA1 genetic defect carried by Angelina Jolie gives her up to an 80% chance of developing breast cancer at some time in her life.
There are many other known genetic defects that can put a person (including males) at a higher risk for developing breast cancer. All of these defects are relatively uncommon. Roughly, the defects occur in less than 2-3% of the population, although there is variation between different races. The presence of the genetic defect does not imply that a patient will definitely get cancer. Likewise, the absence of any known genetic defect does not imply that a patient will not get breast cancer.
Genetic testing for the presence of the more common known genetic defects in the sequence BRCA1 (and BRCA2) can be determined with a blood test. However, this test typically costs several hundred to a few thousand dollars. Without a very strong family history of breast cancer (breast cancer in multiple first degree relatives) or breast cancer diagnosed at a young age (typically under the age of 40-50), it is very difficult to get insurance to pay for the test.
One option to manage this high risk is known as prophylactic bilateral mastectomy. A breast surgeon can remove the majority (but not all) of the breast tissue in both breasts. Because the majority of the breast tissue is removed, there is significantly lower risk for developing breast cancer. However, breast tissue that is too close to the skin, muscle or other vital structures cannot be completely removed. Therefore, there is still a small risk of developing breast cancer after the surgery. Also, the surgery is much more complicated than most breast surgeries such as breast augmentation and carries a higher risk of serious complication.
Once the majority of breast tissue has been removed and the area has healed (many months), there are options to reconstruct the breast and give a more normal appearing breast contour which include breast implant augmentation. However, this reconstructive process is much more complicated than typical breast augmentation and the end result is never as aesthetically pleasing.
I commend Angelina Jolie for publicly sharing her experience with us and undoubtedly inspiring many women facing similar decisions.
Hope this helps answer a few questions!
Ryan Polselli, M.D.
Breast Imaging Radiologist
Web: Ryan Polselli