ROLE OF POSITRON EMMISION

MAMMOGHRAPHY IN DETECTION OF BREAST

CANCER

By

HASNAIN RAZA SHAH (10437)

M.JAVAID BABAR (10449)

Session (2010-2012)

Supervised by

Dr.Rao Afzal

DEPARTMENT OF PHYSICS

The Islamia University of Bahawalpur Pur

DECLARATION

We hereby declare that the report being presented is our own work; this

study does not incorporate without acknowledgment any material previously

submitted for a degree or diploma in any university; and that to the best of

our knowledge and belief it does not contain any material previously

Published or written by another person where due reference is not made in

the text.

HASNAIN RAZA SHAH ______________________________

M.JAVAID BABAR _____________________________

ACKNOWLEDGEMENT

First of all thanks to ALLAH ALMIGHTY who gave the strength to

complete this detail report, without His grace it was impossible to perform

even a single action.

Special thanks to respected Dr.Rao Afzal Who helped a lot in every

fold of project. This report could not be accomplished without his kindness,

help and supervision

CERTIFICATE

Certified that this project titled “ROLL OF POSITRON EMMISION

MAMMOGHRAPHY IN DETECTION OF BREAST CANCER BREAST

CANCER” has been carried out by HASNAIN RAZA SHAH &

M.JAVAID BABAR, under my supervision in Medical Physics Research

Group, Department of Physics, and The Islamia University of Bahawal Pur.

In my opinion the quality of this study can fulfill the scope of the project,

carried out for the partial fulfillment for the degree of MSc. Physics, in the

Department of Physics, The Islamia University of Bahawal Pur, Pakistan.

Dr. Rao Afzal

Professor

Department of Physics

The Islamia University of BahawalPur

Submitted through

Professor Dr.Aftab Ahmed

Chairman

Department of PhysicsThe Islamia University of BahawalPur

Chapter 1

1 INTRODUCTION

1.1 Cancer

“Cancer is a class of diseases in which a group of cells display uncontrolled

growth, invasion, and sometime metastasis”.

These three malignant properties of cancers differentiate them form benign

tumors, which are self limited, and do not invade or metastasize. Most cancers form a

tumor, but some like leukemia do not.

Cancer may effect people at all ages, but the risk for most varieties increases with

age. Cancer causes about 13% of all human deaths. Cancer can affect all animals[1].

Figure 1.1: Cancer Picture [2]

1.1.1 Types of Cancer

There are several types of cancer. Some are given below.

i. Baldder cancer ii. Bone cancer

iii. Brain cancer iv. Prostte cancer

v. Skin cancer vi. Ling Cancer

vii. Thyroid Cancer viii. Breast cancer

ix. Cervical cancer x. Colon cancer

xi. Head and Neck cancer etc. [3]

1.1.2 Types of Tumors

There are tow basic types of tumors

i. Malignant tumor

ii. Benign tumor

Malignant tumors are those which are cancerous but benign tumors are not

cancerous [4].

1.1.3 History of Cancer

The oldest known description and surgical treatment of cancer was discovered in

Egypt and dates back to approximately 1600 BC. In the 16th and 17th centuries, it becomes

more acceptable for doctors to dissect bodies to discover the cause of death. The first

cause of cancer was identified by British surgeon Percivall Pott, who discovered in 1775

that caner of the scrotum was a common disease among chimney sweeps. In the 18 th

century, it was discovered that the ‘cancer poison’ spread from the primary tumor

through the lymph nodes to other sites. This view of the disease was first formulated by

the English surgeon Campbell De Morgan between 1871 and 1874 [5].

A report on the mortality of British Doctors “followed in 1956. Richard Doll left

the London Medical Research center, to start the Oxford unit for Cancer epidemiology in

1968. Another very early surgical treatment for cancer was described in the 1020s by

Avicenna (Ibin Sina) in the canon of medicine [6].

1.1.4 Signs and Symptoms

Symptoms of cancer metastasis depend on the location of the tumor. Roughly,

cancer symptoms can be divided into three groups.

(a). Local Symptoms

Unusual lumps, bleeding and pain, compression of surrounding tissues may cause

symptoms such as yellowing the eyes and skin.

(b). Symptoms of Metastasis

Enlarged lymph nodes, cough, bone pain, fracture of affected bones and

neurological symptoms.

(c). Systematic Symptoms

Weight loss, fatigue and wasting, excessive sweating and anemia. Cancer may be

common or uncommon cause of each atom [7].

1.1.5 Stages of Cancer

There are 0-4 stages. The lower the stage, the treatment outcome will be better.

Stage 0: Pre-cancer

Stage 1: Small cancer found only in that organ where it started.

Stage 2: Larger cancer that may or may not have spread to the lymph nodes.

Stage 3: Larger cancer that is also in the lymph nodes.

Stage 4: Cancer in a different organ from where it started [8].

1.1.6 Causes of Cancer

Nearly all cancers are caused by tobacco, smoke, radiation and chemicals.

1.1.7 Oncology

“The branch of medicine concerned with the study, diagnosis, treatment, and

prevention of cancer is called oncology” [9].

1.2 Treatment for Cancer

The treatment for cancer is usually designed by a team of doctors or by the

patient's oncologist and is based on the type of cancer and the stage of the cancer. Most

treatments are designed specifically for each individual. In some people, diagnosis and

treatment may occur at the same time if the cancer is entirely surgically removed when

the surgeon removes the tissue for biopsy.

Although patients may obtain a unique treatment protocol for their cancer, most

treatments have one or more of the following components: surgery, chemotherapy,

radiation therapy, or combination treatments (a combination of two or all three

treatments).

Individuals obtain variations of these treatments for cancer. Patients with cancers

that cannot be cured (completely removed) by surgery usually will get combination

therapy, the composition determined by the cancer type and stage.

Palliative therapy (medical care or treatment used to reduce disease symptoms but

unable to cure the patient) utilizes the same treatments described above. It is done with

the intent to extend and improve the quality of life of the terminally ill cancer patient.

There are many other palliative treatments to reduce symptoms such as pain medications

and antinausea medications.

1.3 Breast Cancer

Breast cancer originating from breast tissue, most commonly form the inner lining

of milk ducts or the lobules that supply the ducts with milk. Cancers originating form

ducts are known as ductal carcinomas. And those originating form lobules are known as

lobular carcinomas [10].

Figure 1.2: Breast Cancer

1.3.1 History of Breast Cancer

The French surgeon Jean Louis Petit (1674-1750) and latter the Scottish surgeon

Benjamin Bell (1749-1806) were the first to remove the lymph nodes, breast tissue, and

underlying chest muscle. The French surgeon Bernard Peyrilh (1737-1804) realized the

first experimental transmission of cancer by injecting extracts of breast cancer into an

animal. Their successful work was carried on by William Stewart Halsted who started

performing mastectomies in 1882 [11].

The first case controlled study on breast cancer epidemiology was done by Janet

Lane – Claypon, who published a comparative study in 1926 of 500 control patient of the

same background and lifestyle for the British Ministry of Health [12].

1.3.2 Stages of Breast Cancer

There are basically five stages of breast cancer. These are given below.

Stage 0: Cancer cells remain inside the breast duct, without invasion into normal

adjacent breast tissue.

Stage 1: Cancer is 2 centimeter or less in size and is confined to the breast (lymph

nodes are clear).

Stage 2A: The tumor is larger than 2 centimeter but no larger than 5 centimeter

and has not spread to the axillary lymph nodes.

Stage 2B: The tumor is larger than 2 centimeter but no larger than 5 centimeter

and has spread to the axillary lymph nodes.

Stage 3A: No tumor is found in the breast cancer is found in axillary’s lymph

nodes that are sticking together or to other structures, or cancer may be found in

lymph nodes near the breastbone.

Stage 3B: The tumor may be any size and has spread to the chest wall and / or

skin of the breast and may have spread to axillary’s lymph nodes that are clumped

together or sticking to other structure or cancer may have spread to lymph nodes

near the breast bone.

Stage 3C: The cancer has spread to lymph nodes either above or below the

collarbone and the cancer may have spread to axillary’s lymph nodes or to lymph

nodes near the breastbone.

Stage 4: The cancer has spread to other parts of the body [13].

1.3.3 Signs and Symptoms

The first symptom of breast cancer is typically a lump that feels different from the

rest of the breast tissue. More than 80% of breast cancer causes are discovered when the

women feels a lump. The earliest breast cancers are detected by a mammogram [9].

The other symptoms are, change in breast size or shape, swelling, skin dimpling,

nipple, inversion, or saponaceous single – nipple discharge, warmth and redness

throughout the breast. Pain is an unreliable tool in determining the presence or absence of

breast cancer [14].

1.4 Risk Factors

The primary risk factors that have been identified are sex age lack of childbearing

or breast feeding and high hormone levels.

The additional risk factors include a high fat diet, alcohol intake, and

environmental factors such as tobacco use, radiation, endocrine disruptors and shift work.

And medical risk factors include:

A woman who had breast cancer in one breast has an increased risk of getting

cancer in her other breast. N her other breast.

In woman’s risk of breast cancer is higher if her mother, sister or daughter had

breast cancer before age 40.

Some woman have cells in the breast that look abnormal under a microscope.

Having certain types of abnormal cells increases the risk of breast cancer.

Breast cancer is diagnosed more often in Caucasian woman than Latina, Asian or

African American women.

1.5 Screening

Screening is the investigation of a great number of something looking for those

with a particular problem or feature. Since the rate of women who are dying from breast

cancer has been steadily increasing, because it wasn’t detected early enough, which is

why it is important for woman, to know about the various screening methods that can

detect a mass which may indicate breast cancer [11].

1.6 Methods for Detection of Breast Cancer

There are many methods for the detection of breast cancer. For example, x-ray,

CT-scan, mammography, ultrasound, PET and MRI etc.

The first method for the detection of breast cancer is called mammography. This

method is highly praised in the medical field because of how accurate it can be as well as

the speed at which the test is done. The reason that this method is so accurate is that it can

detect smaller lumps that a doctor may not notice while doing manual check [10].

The second method for the detection of breast cancer is an MRI machine. This is

also an extremely accurate way of checking for breast cancer, because it too can detect

small lumps or masses that may indicate the presence of cancer. The sooner you get these

tests done, the better your chances will be surviving, so you can live a long and healthy

life [15].

The third method for the detection of breast cancer is CT scan. The CT scan is an

x-ray test that produces detailed cross sectional images of your body. Instead of taking

one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around

you while you lie on a table. A computer then combines these pictures into images of

slices of the part of your body being studied. In women with breast cancer, this test is

most often used to look at the chest to see if the cancer has spread to other organs. CT

scans take longer time than regular x-rays.

The fourth method for the detection of breast cancer is Ultrasound. This test uses

sound waves and their echoes to produce a picture of internal organs or masses. A small

microphone like instrument called a transducer sends out sound waves and picks up the

echoes as they bounce off body tissues. The echoes are converted by a computer into a

black and white image that is shown on a computer screen. This test is painless and does

not expose you to radiation.

The fifth method for the detection of breast cancer is PET. A PET scan is useful

when your doctor thinks the cancer may have spread but doesn’t know where. The

picture is not finely detailed like a CT or MRI scan, but it provides helpful information

about your whole body. So far, most studies it isn’t very helpful in most cases of breast

caner, although it may be used when the cancer is known to have spread.

The sixth method that can be used for the detection of cancer is x-ray. If the

cancer is inside the bones of the chest than x-ray can not detect cancer.

The seventh method for the detection of breast cancer is computer aided detection

(CAD). It involves the use of computers to bring suspicious areas on a mammogram to

the radiologists attention. It is used after the radiologist has done the initial review of the

mammogram [15].

But out method for the detection of breast cancer is MRI. Its detailed is given

below.

1.7 Mammography

A mammogram is an x-ray picture of the breasts. It is used to find tumors and to

help tell the difference between noncancerous (benign) and cancerous (malignant)

disease.

Figure 1.3: Mammography [16]

1.8 Type of mammography

1.8.1 Computed Tomography Laser Mammography

CTLM) is a Imaging Diagnostic Systems,. This medical imaging technique uses

laser energy in the near infrared region of the spectra, to detect angiogenesis in the breast

tissue. It is optical molecular imaging for hemoglobin both oxygenated and

deoxygenated. The technology uses laser in the same way computed tomography uses X-

Rays, these beams travel through tissue and suffer attenuation.

A laser detector measures the intensity drop and the data is collected as the laser

detector moves across the breast creating a tomography image. CTLM images show

hemoglobin distribution in a tissue and can detect areas of Angiogenesis surrounding

malignant tumors, that stimulate this angiogenesis to obtain nutrients for growth [17]

1.8.2 Digital Mammography

Digital mammography is a specialized form of mammography that uses digital

receptors and computers instead of x-ray film to help examine breast tissue for breast

cancer. The electrical signals can be read on computer screens, permitting more

manipulation of images to theoretically allow radiologists to more clearly view the

results. Digital mammography may be "spot view", for breast biopsy, or "full field"

(FFDM) for screening [18]

Figure 1.4: Digital Mammography

1.8.3 Xeromammography

Xeromammography is a photoelectric method of recording an x-ray image on a

coated metal plate, using low-energy photon beams, long exposure time, and dry

chemical developers [19]

Figure 1.5: Xeromammography [20]

It is a form of xeroradiography.

This process was developed in the late 1960s by Jerry Hedstrom, and used to

image soft tissue, and later focused on using the process to detect breast cancer [21].

CHAPTER 2

2 MAMMOGRAPHY

Mammography is one of the most oversold and understudied technologies in medical

history. To continue to assert that mammography will save lives flies in the face of huge

numbers of studies on the topic.

2.1 Mammography Introduction

A mammogram is a special x-ray examination of the breast made with specific x-ray

equipment that can often find tumors too small to be felt[1]. A mammogram is the best

radiographic method available today to detect breast cancer early. It is ideal and

indispensable for women older than 40 years, for whom the risk of breast cancer is

increased.

A mammogram is an X-ray test that produces an image of the inner breast tissue on film.

This technique, called mammography, is used to visualize normal and abnormal

structures within the breasts. Mammography, therefore, can help in identifying cysts,

calcifications, and tumors within the breast. It is currently the most efficient screening

method to detect early breast cancer.

Mammography can be used to discover a small cancer in a curable stage; however, it is

not foolproof. Depending a woman's age and other factors, approximately ten to fifteen

percent of breast cancers are not identified by mammography, and these cancers are often

found by physical examination.

A woman may experience significant distress, anxiety, and fear associated with the

mammogram and with the prospect of discovering a tumor. Be reassured that the

procedure itself is relatively simple. Most breast disorders are not cancer, and even in the

remaining number of cancer cases, more than 90% are curable, if detected early and

promptly treated[1].

Although mammograms, like many other medical tests, are not 100% accurate,

scheduling a regular mammogram represents the best radiological way to find breast

changes early before there are any obvious signs or symptoms of cancer. Several studies

show that mammogram can reduce breast cancer deaths by more than a third.

Mammography started in 1960, but modern mammography has existed only since 1969

when the first x-ray units dedicated to breast imaging were available. By 1976,

mammography as a screening device became standard practice. Its value in diagnosis was

recognized. Mammography continues to improve as lower doses of radiation are

detecting even smaller potential problems earlier[2].

2.2 Types of Mammography 2.2.1 Screening Mammography

Screening mammography is done in a woman who has no complaints or symptoms of

breast cancer. The goal is to detect cancer when it is still too small to be felt[3].

2.2.2 Diagnostic Mammography

Diagnostic mammography is done in a woman who either has a breast complaint (a lump

or a nipple discharge) or has had an abnormality found during screening mammography.

It is more time consuming and expensive[3].

2.2.3 Computed Tomography Laser Mammography

Computed Tomography Laser Mammography is an Imaging Diagnostic Systems. This

medical imaging technique uses laser energy in the near infrared region of the spectra, to

detect angiogenesis in the breast tissue. The technology uses laser in the same way

computed tomography uses X-Rays; these beams travel through tissue and suffer

attenuation[3].

A laser detector measures the intensity drop and the data is collected as the laser detector

moves across the breast creating a tomography image.

2.2.4 Digital mammography

Digital mammography is a specialized form of mammography that uses digital receptors

and computers instead of x-ray film to help examine breast tissue for breast cancer. The

electrical signals can be read on computer screens, permitting more manipulation of

images to theoretically allow radiologists to more clearly view the results. Digital

mammography may be "spot view", for breast biopsy, or "full field" (FFDM) for

screening[3].

2.2.5 Xeromammography

Xeromammography is a photoelectric method of recording an x-ray image on a coated

metal plate, using low-energy photon beams, long exposure time, and dry chemical

developers.

It is a form of xeroradiography.

2.2.6 Process of Mammography

Before scheduling a mammogram it is recommend that you discuss any new findings or

problems in your breasts with your doctor[4].

The best time for a mammogram is one week following your period. Always inform your

doctor or x-ray technologist if there is any possibility that you are pregnant[4,5’6].

Do not wear deodorant, talcum powder or lotion under your arms or on your breasts on

the day of the exam. These can appear on the mammogram as calcium spots.

Describe any breast symptoms or problems to the technologist performing the

exam.

If possible, obtain prior mammograms and make them available to the radiologist

at the time of the current exam[5].

Ask when your results will be available; do not assume the results are normal if

you do not hear from your doctor or the mammography facility[6].

2.3 How does the procedure work?

X-rays are a form of radiation like light or radio waves. X-rays pass through most

objects, including the body. Once it is carefully aimed at the part of the body being

examined, an x-ray machine produces a small burst of radiation that passes through the

body, recording an image on photographic film or a special digital image recording plate.

Different parts of the body absorb the x-rays in varying degrees. Dense bone absorbs

much of the radiation while soft tissue, such as muscle, fat and organs, allow more of the

x-rays to pass through them. As a result, bones appear white on the x-ray, soft tissue

shows up in shades of gray and air appears black[6].

Until recently, x-ray images were maintained as hard film copy (much like a

photographic negative). Today, most images are digital files that are stored electronically.

These stored images are easily accessible and are frequently compared to current x-ray

images for diagnosis and disease management.

2.4 How is the procedure performed?

Mammography is performed on an outpatient basis.

During mammography, a specially qualified radiologic technologist will position your

breast in the mammography unit. Your breast will be placed on a special platform and

compressed with a paddle (often made of clear Plexiglas or other plastic). The

technologist will gradually compress your breast[7].

Breast compression is necessary in order to:

Even out the breast thickness so that all of the tissue can be visualized.

Spread out the tissue so that small abnormalities are less likely to be obscured by

overlying breast tissue.

Allow the use of a lower x-ray dose since a thinner amount of breast tissue is

being imaged.

Hold the breast still in order to minimize blurring of the image caused by motion.

Reduce x-ray scatter to increase sharpness of picture.

You will be asked to change positions between images. The routine views are a top-to-

bottom view and an angled side view. The process will be repeated for the other breast.

You must hold very still and may be asked to keep from breathing for a few seconds

while the x-ray picture is taken to reduce the possibility of a blurred image. The

technologist will walk behind a wall or into the next room to activate the x-ray machine.

When the examination is complete, you will be asked to wait until the radiologist

determines that all the necessary images have been obtained.The examination process

should take about 30 minutes[5,6,7].

2.5 What does the equipment look like?

A mammography unit is a rectangular box that houses the tube in which x-rays are

produced. The unit is used exclusively for x-ray exams of the breast, with special

accessories that allow only the breast to be exposed to the x-rays. Attached to the unit is a

device that holds and compresses the breast and positions it so images can be obtained at

different angles[7]

.

Figure 2.1: Equipment looks Like

2.6 How does the procedure work?

X-rays are a form of radiation like light or radio waves. X-rays pass through most

objects, including the body. Once it is carefully aimed at the part of the body being

examined, an x-ray machine produces a small burst of radiation that passes through the

body, recording an image on photographic film or a special digital image recording plate.

Different parts of the body absorb the x-rays in varying degrees. Dense bone absorbs

much of the radiation while soft tissue, such as muscle, fat and organs, allow more of the

x-rays to pass through them. As a result, bones appear white on the x-ray, soft tissue

shows up in shades of gray and air appears black.

Until recently, x-ray images were maintained as hard film copy (much like a

photographic negative). Today, most images are digital files that are stored electronically.

These stored images are easily accessible and are frequently compared to current x-ray

images for diagnosis and disease management[4,5,6,7].

2.7 How is the procedure performed?

Mammography is performed on an outpatient basis.

During mammography, a specially qualified radiologic technologist will position your

breast in the mammography unit. Your breast will be placed on a special platform and

compressed with a paddle (often made of clear Plexiglas or other plastic). The

technologist will gradually compress your breast.

Breast compression is necessary in order to:

Even out the breast thickness so that all of the tissue can be visualized.

Spread out the tissue so that small abnormalities are less likely to be obscured by

overlying breast tissue.

Allow the use of a lower x-ray dose since a thinner amount of breast tissue is

being imaged.

Hold the breast still in order to minimize blurring of the image caused by motion.

Reduce x-ray scatter to increase sharpness of picture.

You will be asked to change positions between images. The routine views are a top-to-

bottom view and an angled side view. The process will be repeated for the other

breast[4,5,6,7].

You must hold very still and may be asked to keep from breathing for a few seconds

while the x-ray picture is taken to reduce the possibility of a blurred image. The

technologist will walk behind a wall or into the next room to activate the x-ray machine.

When the examination is complete, you will be asked to wait until the radiologist

determines that all the necessary images have been obtained.

The examination process should take about 30 minutes.

mammography remains the best and most accurate tool in detecting breast cancer, it is

still not foolproof or perfect. Some cancers can be felt on physical examination but be

invisible on the mammogram.

For that reason, women age 40 and older (or age 30 and older if there is a family history

of breast cancer) should have their breasts examined every year by a doctor or trained

health care professional.

By doing annual screening studies, small subtle changes in your breast can be found. It is

also important to continue to perform monthly breast self-examinations.

If you notice a lump, a thickening, or any change the month following your mammogram,

speak with your doctor right away. Do not wait until your next annual mammogram

appointment. Keep in mind that a mammogram does not provide future protection against

breast cancer[5,6].

Normal fatty breast with no unusual areas. Normal dense breasts with no

unusual areas.

Enlarged view of calcifications. Cancer may appear as an irregular area.

2.8 Microcalcifications

About half of the breast cancers found by mammography appear as clusters of

microcalcifications. These are very small specks of calcium that cannot be felt but are

visible on a mammogram. When they are clustered in one area in the breast, this could

indicate an early sign of breast cancer[9].

The average size of a malignant (cancerous) cluster of calcifications seen on an annual

screening mammo-gram measures 0.6 cm in diameter. Calcium deposits in the breast are

not caused by calcium supplements commonly used to prevent osteoporosis.

2.9 Breast Cancer Sizes Detected by Mammogram and Self-Exam at Our Facility

2.9.1 Mammogram

0.2 - 0.3 cm Smallest size of a breast cancer visible on a mammogram[10]

0.8 cm Mammograms can detect many other non-invasive cancers (such as DCIS) which

are less than 1.0 cm

1.1 cm Average size of cancer found on a mammogram

2.9.2 Self-Exam

1 cm Average size of cancer found by women who practice regular breast self-exam.

2.62 cm Average size of cancer detected in a physician physical exam for women who do

not practice regular self-exam[9,10].

2.9.3 Lumps and Masses

The other half of the breast cancers found by mammography appear as a mass or

abnormal density on the mammogram. Some cancers may be felt as a lump on physical

examination and be invisible on the mammogram. In these cases, ultrasound (sound wave

examination) is useful. This is especially true in dense, glandular breasts. A palpable

lump should never be ignored because it is not visible on a mammogram. Such lumps

should instead be aspirated, or drained with a needle. If the lump cannot be aspirated, it

should be removed or biopsied.

Mammography remains the state-of-the-art tool for diagnosing breast cancer.

Other techniques of visualizing the breast are useful, but do not replace the mammogram.

Breast ultrasound is extremely important for examining lesions, such as a fibrosistic

condition. The ultrasound can also locate abnormalities in the breast that will help to

direct a required biopsy. Also, an MRI (magnetic resonance imaging) can evaluate breast

tissue and identify areas of abnormality. The usefulness of the MRI in breast cancer

diagnosis continues to improve[7,8,9,10].

2.9.4 Mammograms for Breasts with Implants

Breast implants are used for augmentation (to make the breasts larger) or for

reconstruction after mastectomy. The breast implant is usually filled with a fluid material

such as saline, silicone or a combination of the two materials[9].

Because an X-ray beam is unable to penetrate the implant, special mammographic views

are required to visualize the breast tissue that are obscured by the implant. One view

requires that the technologist manipulate the implant by pulling the breast forward to

compress the breast tissue without the implant in view. This may be uncomfortable, but

does not harm the implant. Additionally, patients with breast implants will have standard

mammogram films taken, which are also harmless to the implant.

2.10 Dangers of Screening Mammography

Mammography poses a wide range of risks of which women worldwide still remain

uninformed.

2.10.1 Radiation Risks

Radiation from routine mammography poses significant cumulative risks of initiating and

promoting breast cancer [11- 13]. Contrary to conventional assurances that radiation

exposure from mammography is trivial- and similar to that from a chest X-ray or

spending one week in Denver, about 1/ 1,000 of a rad (radiation-absorbed dose)- the

routine practice of taking four films for each breast results in some 1,000-fold greater

exposure, 1 rad, focused on each breast rather than the entire chest [12]. Thus,

premenopausal women undergoing annual screening over a ten-year period are exposed

to a total of about 10 rads for each breast. As emphasized some three decades ago, the

premenopausal breast is highly sensitive to radiation, each rad of exposure increasing

breast cancer risk by 1 percent, resulting in a cumulative 10 percent increased risk over

ten years of premenopausal screening, usually from ages 40 to 50 [14]; risks are even

greater for "baseline" screening at younger ages, for which there is no evidence of any

future relevance. Furthermore, breast cancer risks from mammography are up to fourfold

higher for the 1 to 2 percent of women who are silent carriers of the A-T (ataxia-

telangiectasia) gene and thus highly sensitive to the carcinogenic effects of radiation [15];

by some estimates this accounts for up to 20 percent of all breast cancers annually in the

United States [16].

2.10.2 Cancer Risks from Breast Compression

As early as 1928, physicians were warned to handle "cancerous breasts with care- for fear

of accidentally disseminating cells" and spreading cancer [17] Nevertheless,

mammography entails tight and often painful compression of the breast, particularly in

premenopausal women. This may lead to distant and lethal spread of malignant cells by

rupturing small blood vessels in or around small, as yet undetected breast cancers [18]

2.10.3 Delays in Diagnostic Mammography

As increasing numbers of premenopausal women are responding to the ACS's

aggressively promoted screening, imaging centers are becoming flooded and

overwhelmed. Resultingly, patients referred for diagnostic mammography are now

experiencing potentially dangerous delays, up to several months, before they can be

examined [19].

2.11 Unreliability of Mammography

2.11.1 Falsely Negative Mammograms

Missed cancers are particularly common in premenopausal women owing to the dense

and highly glandular structure of their breasts and increased proliferation late in their

menstrual cycle [20,21] Missed cancers are also common in post-menopausal women on

estrogen replacement therapy, as about 20 percent develop breast densities that make

their mammograms as difficult to read as those of premenopausal women [22].

2.11.2 Interval Cancers

About one-third of all cancers- and more still of premenopausal cancers, which are

aggressive, even to the extent of doubling in size in one month, and more likely to

metastasize- are diagnosed in the interval between successive annual mammograms [22,

23]. Premenopausal women, particularly, can thus be lulled into a false sense of security

by a supposedly negative result on an annual mammogram and fail to seek medical

advice.

2.11.3 Falsely Positive Mammogram

Mistakenly diagnosed cancers are particularly common in premenopausal women, and

also in postmenopausal women on estrogen replacement therapy, resulting in needless

anxiety, more mammograms, and unnecessary biopsies [24,25]. For women with multiple

high-risk factors, including a strong family history, prolonged use of the contraceptive

pill, early menarche, and nulliparity- just those groups that are most strongly urged to

have annual mammograms- the cumulative risk of false positives increases to "as high as

100 percent" over a decade's screening [26].

2.11.4 Over diagnosis

Over diagnosis and subsequent overtreatment are among the major risks of

mammography. The widespread and virtually unchallenged acceptance of screening has

resulted in a dramatic increase in the diagnosis of ductal carcinoma-in-situ (DCIS), a pre-

invasive cancer, with a current estimated incidence of about 40,000 annually. DCIS is

usually recognized as micro-calcifications and generally treated by lumpectomy plus

radiation or even mastectomy and chemotherapy [27]. However, some 80 percent of all

DCIS never become invasive even if left untreated [28]. Furthermore, the breast cancer

mortality from DCIS is the same- about 1 percent- both for women diagnosed and treated

early and for those diagnosed later following the development of invasive cancer [27].

That early detection of DCIS does not reduce mortality is further confirmed by the 13-

year follow-up results of the Canadian National Breast Cancer Screening Study [29].

Nevertheless, as recently stressed, "the public is much less informed about over-diagnosis

than false positive results. In a recent nationwide survey of women, 99 percent of

respondents were aware of the possibility of false positive results from mammography,

but only 6 percent were aware of either DCIS by name or the fact that mammography

could detect a form of 'cancer' that often doesn't progress" [30].

2.11.5 Costs of Screening

The dangers and unreliability of mammography screening are compounded by its

growing and inflationary costs; Medicare and insurance average costs are $70 and $125,

respectively. Inadequate Medicare reimbursement rates are now prompting fewer

hospitals and clinics to offer mammograms, and deterring young doctors from becoming

radiologists. Accordingly, Senators Charles Schumer (D-NY) and Tom Harkin (D-IA) are

introducing legislation to raise Medicare reimbursement to $100 [31].

If all U. S. premenopausal women, about 20 million according to the Census Bureau,

submitted to annual mammograms, minimal annual costs would be $2.5 billion [32].

These costs would be increased to $10 billion, about 5 percent of the $200 billion 2001

Medicare budget, if all postmenopausal women were also screened annually, or about 14

percent of the estimated Medicare spending on prescription drugs. Such costs will further

increase some fourfold if the industry, enthusiastically supported by radiologists,

succeeds in its efforts to replace film machines, costing about $100,000, with the latest

high-tech digital machines, approved by the FDA in November 2000, costing about

$400,000. Screening mammography thus poses major threats to the financially strained

Medicare system. Inflationary costs apart, there is no evidence of the greater

effectiveness of digital than film mammography [31], as confirmed by a study reported at

the November 2000 annual meeting of the Radiological Society of North America [32].

In fact, digital mammography is likely to result in the increased diagnosis of DCIS.

The comparative cost of CBE and mammography in the 1992 Canadian Breast Cancer

Screening Study was reported to be 1 to 3 [33]. However, this ratio ignores the high costs

of capital items including buildings, equipment, and mobile vans, let alone the much

greater hidden costs of unnecessary biopsies, specialized staff training, and programs for

quality control and professional accreditation [34]. This ratio could be even more

favorable for CBE and BSE instruction if both were conducted by trained nurses. The

excessive costs of mammography screening should be diverted away from industry to

breast cancer prevention and other women's health programs.

2.11.6 Needed Reforms

Mammography is a striking paradigm of the capture of unsuspecting women by run-away

powerful technological and pharmaceutical global industries, with the complicity of the

cancer establishment, particularly the ACS, and the rollover mainstream media.

Promotion of the multibillion dollar mammography screening industry has also become a

diversionary flag around which legislators and women's product corporations can rally,

protesting how much they care about women, while studiously avoiding any reference to

avoidable risk factors of breast cancer, let alone other cancers.

Screening mammography should be phased out in favor of annual CBE and monthly

BSE, as an effective, safe, and low-cost alternative, with diagnostic mammography

available when so indicated. Such action is all the more critical and overdue in view of

the still poorly recognized evidence that screening mammography does not lead to

decreased breast cancer mortality [28,31,33]..

Networks of CBE and BSE clinics, staffed by trained nurses, should be established

internationally, including in developing nations. These low-cost clinics would further

empower women by providing them with scientific evidence on breast cancer risk factors

and prevention, information of particular importance in view of the continued high

incidence of breast cancers, with an estimated 192,200 new U. S. cases predicted for

2001 [35], exceeding the number for any previous years. The multibillion dollar U. S.

insurance and Medicare costs of mammography, besides those in other nations, should be

diverted to outreach and research on prevention of breast and other cancers and on other

women's health programs.

2.12Mammography Quality Standards Act: Gains and Losses in Women's Health Care

Mammography is one of the best ways to detect breast cancer early enough that treatment

can be expected to lead to good outcomes. And because breast cancer is the leading non-

skin cancer in women and the second most common cause of cancer-related mortality in

women [33], encouraging regular mammograms is an excellent preventive strategy. At

least in part because of the increased demand for breast imaging, the federal government

has taken a marked interest in mammography services. Congress passed the

Mammography Quality Standards Act (MQSA) in 1992 to better regulate the field of

breast imaging. Specifically, the act sought to correct four areas of concern: [33] poor

quality equipment, [34] a lack of quality assurance procedures, [35] poorly trained

radiologic technologists and interpreting physicians, and [36] a lack of facility

inspections or consistent governmental oversight [37].

Whether or not the MQSA has succeeded in resolving these problems in mammography

remains an open question—there have been clear gains and losses in breast imaging as a

result of the act. This commentary will discuss several of these.

2.12.1 Standards and Access

Prior to the implementation of the MQSA, the quality of breast imaging varied greatly by

geography. Accreditation programs at the time were strictly voluntary; only half of all

mammography facilities had applied for accreditation by 1991, and only half of those that

applied had earned accreditation [38]. Many of the failures had to do with substandard

equipment that produced images that were difficult to interpret correctly. As a result of

the MQSA, equipment had to be upgraded or replaced to meet federal standards for

image quality. Ensuring a high-quality image reduces the number of scans women must

endure and enables physicians to report findings more accurately. Therefore, many

believe that the MQSA improved the standard of care for women having mammograms.

Of course, an increase in the standard did not come without cost. Mammography

facilities that could not meet the equipment or personnel requirements were forced to

close or merge with others. Often financial considerations drove these changes. There is

some evidence of long wait times for patients to access mammography services [39], but

it is not clear whether there was a significant decrease in overall access as a result of the

regulations and subsequent facility closures and mergers [40]. This point is particularly

applicable in areas with few mammography providers [41]. Regardless, it is clear that the

MQSA did not increase access for women. Given that many of the small, community-

based facilities that serve the health care needs of the poor and underserved are unlikely

to be able to afford the equipment and personnel required by the MQSA, access remains a

main area of concern.

2.12.2 Personnel

The MQSA established rigorous training and continuing education criteria for

radiologists and mammography technologists. In fact, some claim that the training and

reporting requirements are unique in medicine with respect to the governing of daily

practice [41]. The standards require interpreting radiologists to read 240 mammograms

during a six-month period to qualify for initial certification and then to read another 960

mammograms during the next two years [42]. Mammography technologists must, among

other things, perform 25 supervised examinations to qualify for certification and then

must perform at least 200 mammography examinations in the next 24 months to be

certified [42]. There are also quality assurance procedures to ensure compliance with

these and all other provisions of the regulations. Supporters of the act herald the

experiential requirements as a way to improve the quality of care for women by requiring

that mammograms be conducted and interpreted by individuals experienced with breast

imaging technology.

Despite these stringent requirements, some evidence suggests that the current standards

for radiologists are still insufficient. The more screening exams a radiologist interprets,

the more accurate she is likely to be [43], but one survey of radiology residents found that

they desired to spend less than one-quarter of their time on breast imaging [44]. The high

rate of litigation and lower rate of compensation associated with this area of the specialty

have been offered as possible reasons for decreased interest in breast imaging [45].

There is a corresponding shortage in mammography technologists. Some credit expanded

career opportunities, especially those with better compensation, for the shift away from

this predominately female career [45]. Satisfying the requirements for continuing

education specified by the MQSA often means attending sessions offered only during

uncompensated time at night or on weekends, which may serve as a disincentive to

choose this specialty [45]. No matter what the reason, staffing has not increased to match

the growing demand for high-quality mammography services.

2.12.3 3D Mammography (Tomosynthesis)

Mammograms are already one of the most important tools in the fight against breast

cancer.

About 40 million of them are performed in the U.S. each year, detecting between 80 and

90 percent of all breast cancers.

Now, there is a new advance. A woman in Boston became the first American to have a

mammogram using 3D technology (tomosynthesis) on Monday [46].

Digital tomosynthesis of the breast is different from a standard mammogram in the same

way a CT scan of the chest is different from a standard chest x-ray. Or think of the

difference between a ball and a circle. One is 3-dimensional, the other is flat.

Dr. Jennifer Ashton reports that the new 3D technology may help doctors more

accurately detect and diagnose breast cancer[46].

Dr. Elizabeth Rafferty, director of breast imaging at Massachusetts General Hospital "We

have the ability to not only just look at the breast but actually look through and around

structures we weren't able to see before,[47]."

Compared to the traditional 2D image, studies found it increases a doctor's ability to spot

cancer by 7 percent. The 3D mammogram also reduces the number of women called back

when a result is unclear.

However, some critics say it's more hype than help. The 3D mammogram uses more

radiation than a traditional mammogram. It's expected to be more expensive, though the

cost won't be set until it's widely available.

Right now the technology is approved by the FDA but not yet recommended by major

cancer groups or women's cancer groups.

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