Understanding Your Breast Cancer Pathology Print

Breastpath.comUnderstanding Your Breast Cancer—The Pathology Report 1

Understanding Your Breast CancerThe Pathology Report

My hope is that this report gives you

information that is thorough and easy

to understand. And, that it helps you

to discuss your diagnosis with your

physician, ask questions and participate

in your care and treatment.

By Pathologist J.B. Askew, Jr., M.D., P.A.Board Certified by the American Board of Pathology

in Anatomic and Clinical Pathology

Founder, www.Breastpath.com


Notice of Disclaimer:

Breastpath.com’s Understanding Your Breast Cancer—The Pathology Report is an educational report onlyand not meant to be a substitute for medical care or advice. The information is not a second opinion. Itshould not be used for diagnosis or for treating a health problem or disease.

If you have or suspect you may have a health problem, you should consult your health care provider.

© 1999-2010 J.B. Askew, Jr., M.D., P.A. All rights reserved.

I. A Letter from J.B. Askew, Jr., M.D., P.A. ................................................................ 3Board Certified by the American Board of Pathologyin both Anatomic and Clinical Pathology

II. Understanding Your Breast Cancer—The Pathology Report ...................................... 4

III. Tubule Formation ...................................................................................................... 5

IV. Mitotic Count ........................................................................................................... 6

V. Nuclear Grading ....................................................................................................... 7

VI. Understanding Scarff-Bloom-Richardson Histologic Grading ................................... 11

VII. Secondary Measurements for Invasive Breast Cancer .............................................. 12

VIII. The Importance of Margins ..................................................................................... 14

IX. Images of Benign (Noncancerous) Breast Tissue ...................................................... 17

X. Frequently Asked Questions ................................................................................... 19

XI. Internet Links for More Information ........................................................................ 21

XII. The Importance of a Multidisciplinary Breast Team .................................................. 24

XIII. Breast Health Guidelines from the American Cancer Society .................................... 25

XIV. Medical Glossary .................................................................................................... 26

XV. J.B. Askew, Jr., M.D., P.A. ..................................................................................... 31Founder of Breastpath.com

XVI. Bibliography ........................................................................................................... 33

Table of Contents


From Breast Pathologist J.B. Askew, Jr., M.D., P.A.Founder of Breastpath.com

Dear Breast Patient,While speaking at community classes on breast cancer, I was astonished by the numberand level of questions about the pathology report that I received from breast cancerpatients in the audience.

I realized that something very important was missing in the understanding of thesewomen. They needed an explanation of how their diagnosis was determined, not inclinical language, but in terms that they could understand—and the significance to thempersonally of the information in the pathology report

This gave me the idea for Breastpath.com.

I recently noted a large number of questions about details on the pathology report fromwomen who had been diagnosed with breast cancer coming to me via Breastpath.com.This led me to believe that a series of Reports might be beneficial to many women withthis diagnosis.

My hope is that this report gives you information that is thorough and easy to understand.And, that it helps you to discuss your diagnosis with your physician, ask questions andparticipate in your care and treatment.

My best wishes to you,

J.B. Askew, Jr., M.D., P.A.


Understanding Your Breast Cancer—The Pathology Reportby Pathologist J.B. Askew, Jr., M.D., P.A.

This grading system has been popularized by Drs. Bloom and Richardson, and laterrefined and modified by Dr. Elston. The system incorporates three differentmeasurements of malignant (cancerous), invasive breast cells.

The three features are

1. tubule formation within tumor nests,

2. mitotic rate, and

3. nuclear grade.

These cellular and tissue characteristics aren’t linked together so that if one characteristicincreases, the other two automatically increase as well. Instead, these characteristics tendto happen independently, without being influenced by the other two. Take a similarexample of a person’s face. The eyes, ears and nose are all related to form the face, butthey all develop independent of one another.

Each characteristic, tubule formation, mitotic rate and nuclear grade, is graded 1, 2 or 3.These individual scores are then added up to the combined Bloom-Richardson score orhistologic grade. Later in this report, I will show you some examples of how the scoresare calculated.

Now we’ll discuss each one of the characteristics, tubule formation, mitotic rate andnuclear grade in detail, and I’ll show you microscopic images that will help yourunderstanding of the explanations.

Board Certified by the American Board of Pathologyin both Anatomic and Clinical Pathology


Tubule Formation

1 = greater than 75% of nests show tubule formation

2 = between 75 and 10% show tubule formation

3 = less than 10% show tubule formation.

When nests of tumor cells attempt to make tubules, the nests are “trying to reproduce thenature of the breast duct cells,” their native tissue of origin. With more tubule formation,the cells look more like the cells and tissue of origin, and the malignant cells appearmore differentiated. Differentiated describes how closely the tumor looks like the nativetissue. When a tumor is well differentiated, it looks very much like the native tissue. Alesser-differentiated tumor may have only subtle features of its native tissue, and anundifferentiated tumor has no features. The more the malignant cells look like their cellsof origin, the more differentiated the tumor is, the better the prognosis is predicted to be.

In contrast, the invasive breastlesion presented in the rightphoto shows no tubuleformation. Each nest of cellsmakes no attempt to formtubules.

Scoring — Three possible points

In the top photomicrograph,notice the nests of tumor cellsare forming clear, open spacesor tubules. Nearly every nest isforming orderly tubules.

Nest, forming tubules

Nest, no tubules


Mitotic Count

The mitotic count is literally the counting of cell divisions found in nests of tumor cells.This is done with the high power lens on the microscope, and the pathologist must makesure he or she counts true mitoses, and not something that looks like a mitosis.

The vast majority of normal cells in the body are in the so-called resting state. Thatdoesn’t mean these cells are sleeping, only that they are not actively dividing, makingtwo cells from one cell. This is the act of mitosis.

In contrast, malignant cells continue to multiply, sort of “out of control.” The degree ofcell division may be measured by observing the number of mitoses in a given area. Whatpathologists do is identify 10 areas under the microscope, using the high power lens(40X), and count all the mitoses or cell division figures that they see.

What you see above is a high-powered microscopic view of four mitoses, or celldivisions, in a row!


1 = 1 - 10 mitoses in 10 fields ( microscopic views of 10 different areas of cells)

2 = 11 - 20 mitoses in 10 fields

3 = greater than 20 mitoses in 10 fields

PLEASE NOTE: The range of mitotic counts for scoring purposes depends on thecharacteristic of the microscopic lens used by your pathologist.


Nuclear Grading

Below are two identical images.

This is a full color, highresolution image.

On this image, the color hasbeen subtracted, and the nucleienhanced.

You will notice that in the black and white image, the nuclei are uniform, round andevenly placed—in short, each nucleus looks like its neighbor. Low power is best toappreciate the uniformity and monotony of this type of pattern. This pattern represents alow nuclear grade proliferation or growth.


Nuclear Grading

This is a high grade proliferation.

Notice the nuclei (the small dark “dots”) in the black and white image are not uniformilyround. Also, they are not evenly spaced, because the cells themselves are larger and moreirregular. Some nuclei are larger and have open features, sometimes showing a largenucleolus, while others are darker. None of these nuclei look exactly or even closely liketheir neighbors.


To visualize nuclear variation of high grade proliferations, often it is necessary to go tohigher power on the microscope and look closely at the following features:

1. nuclear outline, smooth vs. jagged edges

2. nuclear density, finely vs. coarsely granular

3. nuclear size compared to neighbors

4. nuclear shape compared to neighbors

5. presence of nucleolus

1

2

3

3

4

4

5

1

Nuclear Grading

2


This exercise should enable you to now appreciate how low grade nuclei are identified,especially when compared to nuclei from the other end of the spectrum, with high gradefeatures. As you would expect, the intermediate nuclear grade proliferations are inbetween the extremes of low and high grade.

This is a test: Which is high grade, and which is low grade?

Nuclear Grading

To summarize, there are three nuclear grades, low, intermediate and high.

The nuclear grading scores are determined by careful attention to the following:

1. nuclear outline, smooth vs. jagged edges

2. nuclear density, finely vs. coarsely granular

3. nuclear size compared to neighboring cells

4. nuclear shape compared to neighboring cells

5. presence of nucleolus

Summary

The points correspond with the nuclear grade that is assigned according to the Scarff-Bloom-Richardson Histologic grading scale—

1 = low

2 = intermediate

3 = high


Answers to above: Top image: low grade; bottom image: high grade.


Score

123

Understanding Scarff-Bloom-Richardson Histologic Grading

Now you have a better understanding of the individual elements, tubule formation,mitotic count and nuclear grade, that go into the calculation of the Scarff-Bloom-Richardson Histologic grading score. Let’s see how the total score is calculated and whatthe definition of the total score means.

Once the tubule formation, mitotic count and nuclear grade have been scored, the scoresare added, and the total score (lowest score is 3 and highest score is 9) is compared to thefollowing table—

• 3 to 5 corresponds to low grade malignancy

• 6 to 7 corresponds to intermediate grade malignancy

• 8 to 9 corresponds to high grade malignancy

You now know the histologic grade of the cancer.

These categories help predict the aggressiveness of a particular invasive malignantcarcinoma (cancer).

In general, the carcinomas that score low histologic grade also have higher ER/PRreceptor studies, lower replication rates (S-phase & Ki-67) and behave “better.” Incontrast, the high grade malignancies tend to have the opposite scores and measurements,and tend to behave “worse.”

We talk more about ER/PR and replication rates in the Secondary Measurements sectionon the following pages of this report.

Score

123

TubuleFormation

75% or more10 - 75%10% or less

MitoticCount

1 - 1011 - 20greater than 20

NuclearGrade

LowIntermediateHigh

Score

123


Secondary Measurements for Invasive Breast Cancer

ER/PR

In general, ER and PR are two markers. They show the presence or absence of hormonereceptors on cell nuclei. Hormone receptors receive and interpret messages sent by thehormones estrogen and progesterone. These hormones stimulate the growth of normalbreast cells as well as some breast cancer cells.

If a tumor is estrogen-receptor positive (ER-positive), it is more likely to grow in a high-estrogen environment. ER-negative tumors are usually not affected by the levels ofestrogen and progesterone in your body. Tumor cells are reported as positive if more than5% of malignant (cancerous) cell nuclei show positive staining. ER-positive tumors areassociated with a more favorable response to hormonal therapy.

Even for women who have stopped menstruation, estrogen is an important consideration.Even though the ovaries no longer produce estrogen after menopause, the adrenal glandsproduce another hormone that is converted into estrogen by the body, and that estrogencan still stimulate tumor growth.

S-phase/Ki-67

These two tests estimate the replication (cell division) rates of the malignant cells.S-phase uses mathematical models for this calculation, and its accuracy is not high. Incontrast, Ki-67 is considered more reproducible and measures cells in various states:resting, preparing to divide, dividing and rearranging after division.

These tests attempt to measure the percentage of cells that are multiplying. The morecells that are undergoing cell division, the more aggressive the malignancy is predicted tobehave.

Values — S-phase/Ki-67

S-phase Ki-67 Value

<5%5.5 - 7.5%>7.5%

=/<10%>10 to =/<20%>20%

favorableborderlineunfavorable

Values — ER/PR

>5% = favorable

1-4% = borderline

0% = unfavorable



Her2-neu HercepTest

This test measures genetic material called oncogene. A reliable test entered the marketabout ten years ago. In about 25-30% of breast cancers, it is detectable in increasedamounts. The test stains a protein that is increased because of an increase in the Her2neugene. The more protein that is produced by the malignant cells, the more intensely it willstain with the HercepTest.

Her2-neu FISH

There is another test, Her2neu FISH, that uses a fluorescent antibody to stain the Her2neugene on the chromosome within the malignant cell nucleus. This is a more expensive test,but many physicians treating breast cancer patients believe it is a better. What theHer2neu test offers when positive is a target for chemotherapy. These newer tests open thedoor for chemotherapeutic drugs that garget or aim their “killing effect” on the verymalignant cells producing this abnormal protein. This is just the beginning of molecularbiology and the individualization of treatment approaches for breast cancer patients.

2 = weakly positive

3 = strongly positive

0 = negative

1 = negative

Values — Her2-neu

0 -1.8 ratio = Negative

1.9 – 2.2 = Boderline

>2.3 = Positive

Values — Her2-neu FISH


From the pathologist’s point of view, many of these secondary markers are reflected inthe complete surgical pathology report. For example, the ER/PR values, when stronglypositive, most often correspond with low histologic and nuclear grades (pages 6-10). Lowreplication rates in S-phase and Ki-67 most often coincide with low mitotic count (page5). Ploidy status may be predicted by histologic and nuclear grade, but not always.

The one new available marker that has no histologic correlation is the Her2-neu protein.This is truly a new marker that may be helpful in women with certain breast cancers underspecific circumstances.


DNA and Ploidy

These two tests are “two sides of the same coin” for practical purposes. DNA may bemeasured by two techniques: flow cytometry or image analysis, Both methods determinethe amount of nuclear DNA material in normal, or native, cells and compare it to what ismeasured in the malignant cells. The categories are diploid, aneuplo---id and tetraploid.The most favlorable determination is diploid, which is the same as normal tissue. Amalignant tumor that is diploid would be expected to behave less aggressively. Ananeuploid malignancy would be expected to have a more aggressive behavior.

Values — DNA and Ploidy

Diploid = favorable

Tetraploid = borderline

Aneuploid = unfavorable


The Importance of Margins

In the case of malignant breast lesions, these are basically two options for surgicaltreatment: limited resection, which is called lumpectomy, or wider resection, which iscalled mastectomy. When these limited resections are performed, the margins, or edges,of the excision are very important. They must be examined carefully and thoroughly.

When the entire breast is removed in mastectomy, there is only one margin, the deepmargin. It is located along the chest wall.

However, when a lumpectomy is performed, it is the partial removal of the breast withthe abnormal tissue (lesion) contained within. How close the lesion (tumor) is to one ormore of the margins becomes very important for treatment considerations followingsurgery. The surgeon, radiation oncologist and medical oncologist rely on the pathologistto thoroughly examine all margins of the lumpectomy specimen.

Once the lesion is found within the lumpectomy, the closest margin, or distance, to themalignancy is measured and documented in the pathology report. It is becoming morecommon to measure and document both the closest margin of ductal carcinoma in situ(DCIS), cancer found within the breast duct, and the invasive component, cancer that hasleft the duct and invaded the surrounding tissue.

Margins

This is a whole mount slide of a margin. The orange ink is on top. The tumor is growingupward, with multiple bulging areas, extending toward the inked margin.

tumor

normaltissue

ink(alongsurgicalmargin)



The pathologist provides all critical measurements about the location of the tumor withregard to how close the malignant proliferations are to the edge of the excision, both non-invasive and invasive. The ink that the pathologist paints on the outside of the excisedtissue actually represents the place where the surgeon cut out the tumor. The ink becomesthe actual margin between what was excised (cut out) and what was left in the breast.

So the margin measurements indicate to the treating physicians how close the breastcancer was to the margin where the surgeon cut. A good margin now is considered to beat least 1 centimeter, or a little less than 1/2 inch, of normal breast tissue between thetumor and the margin of excision.

Some breasts have only DCIS, so the margin measurements would only include closemargins for DCIS. In a similar fashion, if only an invasive tumor is present, the marginmeasurements would include only close margins. When both DCIS and an invasivelesion are present in the same excision, then the pathologist should include close marginsfor both cancerous growths. As an example, this could result in one margin of DCISalong the inferior margin and another close margin of the invasive component along themedial margin, an entirely different area from the close DCIS margin.

This is a low power microscopic photograph demonstrating the leading edge of the tumor,on the left, approaching the inked margin on the right. The tumor nests have caused alocally heavy inflammatory cell response, which surrounds the actual tumor cell nests.Hence, the densely blue appearance of the tumor location. Notice how neighboring tissueis so different. The exact measurement is indicated by the red line. If this were the closestmargin in a lumpectomy, it should be recorded in the surgical pathology report. Becausethe tumor cells are recognized as “foreign,” there is a heavy inflammatory cell response.The combination of tumor cells and inflammatory cells makes the actual area where thetumor is growing appear very dense. Compare the tumor area density to thenormal breast tissue immediately next to the tumor.

tumor

ink(alongsurgicalmargin)

margin


Ink and Margins

It has become fairly common practice for pathologists to literally paint the excised tissuewith ink. We often use India ink to coat the entire outer surface of an excised specimen tomark the actual outer surface margin.

In lumpectomies, the entire surface is inked. In mastectomies the deep margin may beinked if appropriate. We may also use colored inks to identify specific areas or locations.

The inks must survive overnight tissue processing so that when the microscopic slides aremade, the pathologist can see the inks under the microscope. Since the inks are placed onthe specimen before it is cut into and examined by the pathologist, it can be safelyconcluded that inked margins represent surgical margins.

This is important for analysis of how close the malignant process is to the margin of theexcised tissue. This information should be contained in the pathology report and may bestated in measurements such as centimeters and millimeters.

When is a Margin too Close?

This measurement is not clearly defined. There were some initial reports that, as long asthe tumor did not touch the ink on the margin, the margin was acceptable.

However, as time and experience have shown, margins of one centimeter are better.

Most pathology reports will provide the measurements, but offer no comments onadequacy unless the margin is or is essentially involved. When breast cases are presentedat pre-treatment planning conferences at breast disease treatment centers and hospitals, itis usually the surgeons, medical and radiation oncologists who decide on the adequacy ofthe margins as reported by the pathologists.



collagen

Images of Benign (Noncancerous) Breast Tissue

It may be helpful for you to compare cancerous tissue with noncancerous, or what iscalled benign, breast tissue to get an even better picture of the disease. Compare thefollowing high resolution microscopic views of benign breast tissue to those of canceroustissue found earlier in this report on pages 4-9.

The image above is a high resolution image of essentially normal, fatty breast tissue underlow power on the microscope. All of the clear spaces shown as white represent fat. It isthis resilient tissue that gives the breast its external, natural form.

The pink tissue is collagen, fibrous tissue that creates the fibers that offer support for theglands and ducts of the breast. You will notice that most of the tubules and ducts aresurrounded by pink fibrous tissue. Firmer breasts have more fibrous tissue present. Densebreasts have lots of fibrous tissue present.

As natural estrogen levels decrease, so does fibrous tissue, creating a greater fatcomposition in the breast.

This image shows clusters of small ducts, which are present in lobules. These are thelocation of milk production after pregnancy, when many lobules of glandular tissuedevelop in response to hormones. These lobules of glandular tissue are called acini. Thesmall lobular ducts drain into larger tubules, called interlobular ducts, which ultimatelyempty into the nipple or lactiferous ducts.

fat

collageninterlobularduct

smalllobularducts

smallerlobularducts


Images of Benign (Noncancerous) Breast Tissue

Microcalcifications occur in many forms in breast disease. Microcalcifications arecalcium deposits found within the breast tissue. They may occur in both benign andcancerous conditions. There are subtle patterns of these calcium deposits that experiencedmammography radiologists can detect.

Often, they can predict what kind of disease is associated with a specificmicrocalcification pattern seen on mammogram. Of course, to be sure, a biopsy should beobtained in most instances. More often now, using stereotactic imaging and biopsytechniques, breast tissue with microcalcifications can be sampled without surgery orgeneral anesthesia in an outpatient setting.

This microscopic image shows cyst formation of breast ducts with “saturn-like”microcalcification rings beautifully displayed in multiple locations. Usually themicrocalcifications are brittle and often chip or crack when cut with the sharp knife usedto make microscopic slides.

These microcalcifications are calcium phosphate. Other microcalcifications, which are notblue but more crystalloid in appearance, are composed of calcium oxalate.

calcifications


Q. What does “SBR/5 with Lobular Carcinoma in Situ” mean?

A. The SBR/5 very likely relates to tumor grading, and refers to the Scarff-Bloom-Richardson method of scoring, or grading, tumors. Please see page 10 for anexplanation of how the total score is calculated in this breast tumor grading system.

Lobular Carcinoma in situ relates to a kind of non-invasive process involving certainsmall ducts in the breast. It develops within the milk-producing glands (lobules) of thebreast and does not penetrate through the wall of the lobules.

Although researchers think that most cases of lobular carcinoma in situ do notprogress to invasive lobular cancer, having this type of cancer places a woman atincreased risk of developing an invasive breast cancer later in life. Women with thiscondition should be carefully followed by their physicians.

Lobular carcinoma in situ (LCIS) is considered a “marker” condition. Surgery is notnecessary but increased surveillance is recommended, meaning a commitment by thepatient to regular mammograms and likely ultrasound studies of both breasts. This“marker” condition means both breasts are at risk for developing a malignant lesion inthe future.

Therefore, “SBR/5 with Lobular Carcinoma in Situ” would be a Scarff-Bloom-Richardson score of 5, low grade invasive malignancy, with an additional finding of a“marker” condition labeled Lobular Carcinoma in Situ.

Q. What is the significance of the findings noted in the pathology report from my breastsurgery?

A. The pathologist is a physician who specializes in identifying diseases by studyingcells and tissues under a microscope. The pathologist who completed your reportstudied cells and tissue taken during your surgery. The pathologist determines if thecells are cancerous (malignant), precancerous (premalignant: at high risk of becomingcancerous) or benign (harmless).

The pathologist then wrote a report for your surgeon detailing the findings of thisstudy. Your surgeon and other physicians involved in your care, will use this report toassist in developing plans for your treatment.

Frequently Asked Questions


Parts of a pathology report include

1) Demographics: Patient and physician identifying information, such as name, address,birth date, date of procedure.

continued from previous page

2) Anatomical Pathology Diagnosis: The most important part of the report; what thepathologist’s diagnosis is and all pertinent clinical information that will be needed foryour treatment. This section contains the following:

• Histology: Type of cancer and arrangement of the cells.

• Grade: How abnormal the cells appear; how aggressive the cancer appears to be.Emphasized more recently in the pathology literature. One of the most populargrading systems is the modified Scarff-Bloom-Richardson grading scale.

• Stage: The size of the cancer and how far it has spread.

See pages 3-10 of this report for a thorough explanation of the above.

3) Procedures/Addenda (ERA/PRA/DNA): Secondary measurements related to invasivebreast cancer. (See pages 11-12.)

4) Clinical History/Pre-Operative Diagnosis: Initial diagnosis prior to the pathologist’sdiagnosis.

5) Procedure: How the cells were collected.

6) Specimen(s) Received: What was received by the pathologist following the procedureand when it was received.

7) Gross Description: Frequently referred to as “the gross.” What the pathologist saw,measured and felt when examining the tissue with the naked eye without a microscope.

8) Microscopic Description: What the tissues looked like to the pathologist uponexamination under the microscope.

Although the information in the report is precise and clear, the pathology report is writtenin a language for your surgeon or physician using medical terms unfamilar to patients. Wehope this Report helps to explain some of this terminology.

Frequently Asked Questions


American Cancer Society

Providing the public with accurate, up-to-date information on cancer is a priority for theAmerican Cancer Society. The Society provides information on all aspects of cancerthrough a toll-free information line, web site, and published materials.National Cancer Information Center 1-800-ACS-2345Cancer Information Service onlinehttp://www.cancer.org/

Association of Cancer Online Resources, Inc. (ACOR)

The heart of ACOR is a large collection of cancer-related Internet mailing lists , whichdelivered over 1.5 million e-mail messages last week to subscribers across the globe. Inaddition to supporting the mailing lists, ACOR develops and hosts state-of-the-artInternet-based knowledge systems that allow the public to find and use credible informa-tion relevant to their illness.http://www.acor.org/

Avon Breast Cancer Crusade

The Avon Breast Cancer Crusade, founded in 1993, is a U.S. initiative of Avon Products,Inc. Its mission is funding access to care and finding a cure for breast cancer, with aparticular focus on the needs of medically underserved women.http://www.avoncompany.com/women/avoncrusade/

BreastBiopsy.com

News of a breast biopsy raises many emotions and concerns. We understand. But it’simportant to remember that 80% of breast biopsies do not turn out to be breast cancer. It’salso important to know that you have options when selecting a biopsy procedure. This siteis dedicated to evaluating your choices to help you talk with your doctor about the breastbiopsy procedure that is right for you. Biopsy techniques include stereotactic, ABBI,MIBB and Mammotome.www.breastbiopsy.com

Breast Cancer Fund

In response to the public health crisis of breast cancer, the Breast Cancer Fund identifies –and advocates for elimination of – the environmental and other preventable causes of thedisease. Founded in 1992, the Breast Cancer Fund works from the knowledge that breastcancer is not simply a personal tragedy, but a public health priority that demands actionfrom all.www.breastcancerfund.org

Breastcancer.org

Providing an online community, the latest breast cancer research, and essentialinformation from over 50 breast cancer experts. Our commitment to you is to maintainthe highest standards of medical excellence and integrity. Our goal is to meet your needswhile respecting your privacy and individuality.www.breastcancer.org

Internet Links for More Information


Breast Cancer Basics on Everydayhealth.com

EverydayHealth.com is the leader in online health information. We’re here to help youmanage your own and your family’s conditions and overall well-being through personal-ized advice, tools, and communities. We’re committed to bringing you the most credibleand relevant health information available online, and to giving you the best possible userexperience. Our information is easy to understand and incorporate into your life everyday. There’s much to explore on EverydayHealth.comhttp://www.everydayhealth.com/breast-cancer/understanding.aspx

Breast Cancer Network of Strength(formerly known as Y-Me Breast Cancer Organization)Breast Cancer Network of Strength provides immediate emotional relief to anyone af-fected by breast cancer. The mission of Breast Cancer Network of Strength is to ensure,through information, empowerment and peer support, that no one faces breast canceralone. YourShoes™ is Breast Cancer Network of Strength’s peer support program thatincludes a 24/7 breast cancer support center staffed by trained breast cancer survivorsproviding peer support through a toll-free hotline, e-mail and support groups.http://www.networkofstrength.org/

Breast Cancer Treatment Guidelines for Patients

NCCN.com is the new consumer website of the National Comprehensive Cancer Net-work (NCCN), a not-for-profit alliance of 21 of the world’s leading cancer centers. Thegoal of this website is to educate patients with cancer to engage in more informed conver-sations with health care providers so they can live longer and better quality lives. Thiswebsite helps patients, families, friends, and cancer survivors. After studying the researchresults on breast cancer treatment, a panel of these experts has agreed upon specific, state-of-the-art recommendations for treating women with the disease. These patient guidelineswill help you better understand your cancer treatment and your doctor’s counsel. We urgeyou to discuss them with your physician.www.nccn.com

The Breast Center at Johns Hopkins

The Johns Hopkins Breast Center is a comprehensive, multidisciplinary breast careprogram, offering a full spectrum of clinical and support services, from screening anddiagnosis to treatment and counseling. The Center provides innovative, integrated, highquality and cost-effective breast care. As part of the world-renowned Johns HopkinsHospital, the Breast Center stands at the forefront of breast cancer research and treatment.http://www.hopkinsbreastcenter.org/

Cancer.netOncologist-approved cancer information from the American Society of Clinical Oncol-ogy.http://www.cancer.net/




National Breast Cancer Coalition

Since 1991, the National Breast Cancer Coalition’s trained advocates have lobbied at thenational, state and local levels for public policies that impact breast cancer research,diagnosis and treatment. Our grassroots advocacy effort has hundreds of member organi-zations and tens of thousands of individual members working toward increased federalfunding for breast cancer research and collaborating with the scientific community toimplement new models of research, improving access to high-quality health care andbreast cancer clinical trials for all women, and expanding the influence of breast canceradvocates in all aspects the decisionmaking process.http://www.stopbreastcancer.org/

National Cancer Institute

From the U.S. National Institutes of Health, find information on types of cancer, cancertopics and clinical trials.http://www.cancer.gov/

National Consortium of Breast Centers, Inc.

The National Consortium of Breast Centers, Inc. (NCBC), began in 1985. The focus is onthe development, implementation and expansion of breast center programs to allowprofessionals to be informed of the most up-to-date breast care techniques and optionsavailable to their patients. With the addition of private sector businesses and corporationsas part of the membership, breast health professionals are also kept informed aboutadvances in equipment, technology, drugs and services available to them to improvepatient care. Search for breast health facilities around the country, consultants to breastcenters and companies that offer breast health products and equipment to breast centersand patients.http://www.ncbcinc.org

Susan G Komen for the Cure

Susan G. Komen fought breast cancer with her heart, body and soul. Throughout herdiagnosis, treatments, and endless days in the hospital, she spent her time thinking ofways to make life better for other women battling breast cancer instead of worrying abouther own situation. That concern for others continued even as Susan neared the end of herfight. Moved by Susan’s compassion for others and committed to making a difference,Nancy G. Brinker promised her sister that she would do everything in her power to endbreast cancer forever. That promise is now Susan G. Komen for the Cure®, the globalleader of the breast cancer movement, having invested nearly $1.5 billion since inceptionin 1982.http://ww5.komen.org/

American Journal of Pathology

The American Society for Investigative Pathology is a society of biomedical scientistswho investigate mechanisms of disease.http://ajp.amjpathol.org/


The diagnosis and optimal treatment of breast disease requires the expertise of manyspecialty physicians, nurses and other health care professionals. These individualscombine their expertise and resources to ensure the highest quality of care for eachpatient. The team members provide experience, innovation and compassion to patientswho require a full range of diagnostic and treatment services.

Mammography, specialized imaging work-ups, biopsies and biopsy results, physicalexaminations and each patient’s individual emotional, physical, spiritual and socialconsiderations are reviewed by members of this multidisciplinary breast team.

Ultimately, a recommendation regarding optimal treatment is made and discussed with thepatient. This treatment may include, but is not limited to, surgery, medical oncology,radiation oncology, radiology, pathology, plastic surgery, behavioral medicine and nursing.Often these comprehensive breast centers have unique services and features that are alsorecommended to the patient, from patient education to counseling and support, to alymphedema program or other important patient care service.

While many or most of these services exist in most health systems, the idea of a breastcenter is to organize these services into a coordinated, integrated, multidisciplinaryapproach that benefits the patient to the fullest. The direct interaction of these services issynergistic, providing much higher quality care to the patient than she would receive fromthe same specialists working in isolation.

Breast centers can be geographic, with all services available under one roof, or they canbe virtual, organizing the interaction of diverse services located at different locations.

The most important aspect is the result: A team of care givers who collaborate in theirconsultation and care for the patient.

On our campus in northwest Houston, we have a breast center within the HoustonNorthwest Hospital as well as one across the street, TOPS Comprehensive Breast Center.Every week we meet for 1.5 to 2 hours for the sole purpose of discussing each woman’sbreast disease. Gathered at the large table are breast radiologists, breast surgeons,radiation and medical oncologists, and a pathologist or two.

We discuss and plan each woman’s treatment from the very beginning after the biopsyresults are known. We endeavor to meet her individual needs and desires for treatmentprovided that it is reasonable based on the extent and nature of her disease. These featuresare presented with projected breast mammograms and histology results from the biopsiesand fine needle aspiration cytology preparations. All of this information is discussedabout each woman and treatment recommendations are made. The time allotted to eachwoman’s case is based on its complexity.

The Importance of a Multidisciplinary Breast Team


American Cancer Society Recommendations for Early Breast Cancer Detection• Women aged 40 and older should have a screening mammogram every year.

• Between the ages of 20 and 39, women should have a clinical breast examination bya health professional every three years. After age 40, women should have a breastexam by a health professional every year.

• Women aged 20 or older should perform a breast self-examination (BSE) everymonth. By doing the exam regularly, you get to know how your breasts normallyfeel and you can more readily detect any signs or symptoms.

If a change occurs, such as development of a lump or swelling, skin irritation or dimpling,nipple pain or retraction (turning inward), redness or scaliness of the nipple or breast skin,or a discharge other than breast milk, you should see your health care provider as soon aspossible for evaluation. However, remember that most of the time, these breast changesare not cancer.

Although there are some features of a mass that suggest whether it is likely to be benignor cancerous, women examining their own breasts should discuss any new lump withtheir health care professionals.

Experienced health care professionals can examine the breast and determine whether thechanges you have noticed are probably benign or whether there is a possibility they maybe due to a breast cancer. They can determine when additional tests are appropriate to ruleout a cancer and when follow-up exams are the best strategy. If there is any suspicion ofcancer, a biopsy will be done.

The American Cancer Society believes the use of mammography, clinical breastexamination, and breast self-examination, according to the recommendations outlinedabove, offers women the best opportunity for reducing the breast cancer death ratethrough early detection.

This combined approach is clearly better than any one examination. Without question,breast physical examination without mammography would miss the opportunity to detectmany breast cancers that are too small for a woman or her doctor to feel but can be seenon mammograms.

Although mammography is the most sensitive screening method, a small percentage ofbreast cancers do not show up on mammograms but can be felt by a woman or herdoctors.

Breast Health Guidelines


Adenoma—A benign (noncancerous) tumor of glandular tissue that may compress tissuenext to it as the tumor grows in size. These tumors usually stay contained (remainlocalized) and are often well defined, having a particular appearance to an experiencedbreast radiologist on a mammogram. They are also a major cause of false positivereadings on mammograms.

Atypical—This means not typical or normal. Atypical cells are abnormal cells, but notdefinite or obviously malignant.

Benign—Not cancerous; does not invade neighboring tissue or spread to other parts ofthe body. Does not cause harm.

Benign breast changes—Noncancerous changes in the breast. Benign breast conditionscan cause pain, lumps and nipple discharge, among other problems.

Breast biopsy—The removal of a sample of breast tissue or cells for examination by atrained pathologist.

Breast density—Glandular tissue in the breast common in younger women, making itdifficult for mammography to detect breast cancer. As a woman ages or matures, thebreast tissue becomes fattier, and mammography is easier. Supplemental estrogen keepsthe breast in a more “youthful condition.” The consequence is that women on estrogenreplacement often have dense breasts, which make small and subtle mammographicchanges more difficult to interpret.

Calcifications—Small deposits of calcium in breast tissue that can be seen onmammograms.

Carcinoma—Cancer that begins in tissues lining or covering the surfaces (epithelialtissues) of organs, glands, or other body structures. Most cancers are carcinomas.

Carcinoma in situ—Cancer that is confined to the ducts, where it began, and has notspread into surrounding tissues.

Clinical breast exam—A physical breast examination by a health practitioner.

Medical Glossary


Core needle biopsy—In a core needle biopsy, imaging technology is often used to guidea special biopsy needle to the lesion, so a sample can be obtained without surgery. Thesample is then sent to the pathologist for examination and diagnosis.

Diagnostic mammogram—A diagnostic mammogram is an x-ray of the breast used todiagnose unusual breast changes, such as a lump, pain, nipple thickening or discharge, ora change in breast size or shape. A diagnostic mammogram is also used to evaluateabnormalities detected on a screening mammogram. It is a basic medical tool and isappropriate in the workup of breast changes, regardless of a woman’s age.

Digital mammography—A technique for recording x-ray images in computer code,which allows the information to enhance subtle, but potentially significant, changes.

Ducts—Channels or tubules that carry body fluids. Breast ducts transport milk from thebreast’s lobules out to the nipple.

Ductal Carcinoma in Situ (DCIS)—Cancer that is confined to the ducts of the breast.

Excisional breast biopsy—An excisional breast biopsy is a surgical procedure in whichan incision is made above the lump that is to be removed. Tissue immediately around thelump will also be removed for a complete biopsy analysis and microscopic examinationby a pathologist.

Fibroadenoma—Breast tumor, usually benign (noncancerous), made up of bothstructural (fibro) and glandular (adenoma) tissues.

Frozen section—A procedure performed during surgery. The tissue in question appearsabnormal to the surgeon. This tissue is sampled, sent to the pathology lab, quick frozen ina liquid to -20 degrees C. The frozen block is transferred to a precise machine for makingultra thin slices of tissue. Tissue slices are cut that are about four microns thick—so thinthat light can pass through them. The slices are placed on glass slides, stained with redand blue stains, cover slipped and ready for analysis by a trained pathologist under themicroscope. This takes about 15 minutes. A frozen section provides a quick preliminarydiagnosis that helps the surgeon decide what to do next. The final diagnosis requiresadditional permanent sections that take overnight to process.

Medical Glossary


Incisional breast biopsy—An incisional breast biopsy is a procedure in which the doctorsurgically removes part of a lump found in your breast for testing and microscopicexamination by a pathologist.

Infiltrating or Invasive cancer—Cancer that has spread into nearby tissue. When cancerhas traveled to lymph nodes or other parts of the body, it is called a metastasis.

Lesion—A general term that indicates a change in the structure, composition, appearanceor feel of any body tissue. It may be benign, malignant or from some other cause. It issimply a noticeable change from normal, and, usually, it is discrete or localized.

Lobes, lobules, bulbs—Milk-producing tissues of the breast. Each of the breast’s 15 to20 lobes branches into smaller lobules, and each lobule ends in scores of tiny bulbs. Milkoriginates in the bulbs and is carried by ducts to the nipple.

Lumpectomy—A lumpectomy is the removal of a breast lesion that usually has beendiagnosed already by needle core biopsy. A cut is made near the lesion, and it is removedin one piece, leaving the remaining breast intact. It is then sent immediately to thelaboratory for examination by a pathologist. The procedure represents breast conservingsurgery because only a segmental or partial resection is performed. Hence the synonymfor this surgery is segmental or partial mastectomy.

Lymphatic system—The two most important functions of the lymphatic system, which ismade up of tissues and organs, are the maintenance of fluid balance in the body and thebody’s immune system. Lymph nodes “drain” the breast, and are often the first placebreast cancer spreads when it leaves the breast proper.

Malignant—Cancerous. Malignant tumors can invade surrounding tissue and may spreadto other parts of the body.

Mammogram—An x-ray of the breast.

Mastectomy—Surgery to remove breast tissue; it may be total, modified radical or partial(lumpectomy or segmental) mastectomy.

Medical Glossary


Microcalcifications—These calcium deposits in the breast are tiny, and there may bemany that show up on a mammogram. They may be random or appear in clusters, andthey may vary in size and shape. The worrisome aspect of microcalcifications is that theymay be associated with malignant growths, either DCIS or invasive lesions. Thesecalcifications may also show up in benign disease. Consequently, most, but not all,microcalcifications need to be further examined by special techniques that may includeneedle core biopsies. The radiologist who read your mammogram may request additionalmammography views for further evaluation. If you have any questions or if results of yourmammogram are unclear to you, discuss this with the radiologist. If you still havequestions, you may want to seek a second opinion.

Mitotic count—The counting of cell divisions found in nests of tumor cells. An indicatorof a breast cancer, it is one of the measurements used in Scarff-Bloom-RichardsonHistologic Grading. See page 5 for a complete explanation.

Needle biopsy—See Core needle biopsy

Needle localization and biopsy—In this technique, mammography is used to locate abreast abnormality, which is then marked with a wire inserted under the skin into the areaof breast that is causing concern. Right afterward, the surgeon uses the wire to find theabnormal spot in the breast so that he or she can remove it for microscopic examinationby a pathologist.

Nuclear grading—An indicator of a breast cancer, a nuclear grade for a breast cancermay be assigned according to the Scarff-Bloom-Richardson Histologic grading scale. Thisis based on the appearance of the cell nuclei in the tumor. See pages 6-9.

Palpation—Method of “feeling” with the hands used during physical examinations.Palpating the breast for lumps is a crucial part of a physical breast examination.

Pathologist—Pathology is the medical science and specialty practice that deals with allaspects of disease, but with special reference to the essential nature, the causes anddevelopment of abnormal conditions, as well as the structural and functional changes thatresult from disease processes. Pathologists serve as consultants to their clinicalcolleagues, make diagnoses on biopsy material, run laboratories and interpret tests. Theyserve as educators for the hospital staff and have been termed “the doctor’s doctor.”Stedman’s dictionary, 22nd ed. Williams and Wilkins, Baltimore, 1972.

Medical Glossary


Radiologist—Radiology is the discipline of medicine that uses electromagnetic radiation(such as an x-ray) and ultrasonics (such as ultrasound) for diagnosing and treating injuryand disease. A mammogram is an x-ray image of the breast.

Risk factors (for cancer)—Conditions or agents that increase a person’s chances ofgetting cancer. Risk factors do not necessarily cause cancer. They are indicators that arestatistically associated with an increase in the likelihood of getting cancer.

Screening mammogram—A screening mammogram is an x-ray of the breast used todetect breast changes in women who have no signs of breast disease. It usually involvestwo x-rays of each breast. Using a mammogram, it is possible to detect a tumor thatcannot be felt.

Stereotactic breast biopsy—In this breast procedure, digital mammography andcomputerization are used to localize the breast mass or abnormality. Two images atdifferent angles are taken that allow the computer to calculate the coordinates of theabnormality. The surgeon or radiologist inserts a special vacuum-assisted needle into themass or microcalcification, and biopsies are taken. The pathology specimens are then sentto the pathologist for analysis and diagnosis.

Surgical biopsy—The surgical removal of tissue for microscopic examination anddiagnosis by a pathologist. Surgical biopsies can be either excisional or incisional.Surgical biopsies are most often performed while the patient is anesthetized and in anoperating room. In contrast, a needle core biopsy is an outpatient procedure, performedwith local anesthesia only.

Tubule formation—How well the nests of tumor cells in the breast are able to formtubules. An indicator of breast cancer, it is one of the measurements used in Scarff-Bloom-Richardson Histologic Grading. See page 4 for a complete explanation.

Tumor—An abnormal growth of tissue. Tumors may be either benign or cancerous.

Medical Glossary


Dr. Askew has more than 37 years of experience in pathology and is in private practice inHouston, Texas.

With a special interest in Breast Pathology, Dr. Askew has provided Pathology Leadershipfor the continuing development of the comprehensive, multidisciplinary breast centerservices of a large (500-bed) acute care hospital in Houston.

In addition to speaking to community groups, Dr. Askew is a speaker at national meetingsof physicians and medical professionals to promote the inter- and multi-disciplinaryapproaches to breast disease, especially breast carcinoma. He has participated in physicianpanels at the National Breast Consortium Annual Meeting. He has spoken at Dr. LaszloTabar’s Multidisciplinary Conferences since 1996.as well as presented the pathologyaspects of all cases at multidisciplinary Continuing Medical Education symposiums heldin Houston, Texas.

While speaking at community classes on breast cancer, Dr. Askew was astonished by thenumber and level of questions about the pathology report that he received from breastcancer patients in the audience. Dr. Askew realized that something very important wasmissing in the understanding of these patients. They needed an explanation of how theirdiagnosis was determined, not in clinical language, but in terms that they couldunderstand and the significance to them personally of the information in the pathologyreport. Hence, Breastpath.com.

CredentialsBoard Certified by the American Board of Pathology in both Anatomic and Clinical Pathology

AcademicBachelor’s Degree, Zoology, 1964 Medical Degree, 1969University of Southern California Baylor College of Medicine

Internship in Pathology, 1969-70 Residency in Pathology, 1970-1973University of Kansas Baylor College of Medicine

American Cancer Society Fellowship in Pathology, 1970-1971Baylor College of MedicineRobert E. Fechner, M.D., Chief of ServiceThe Methodist Hospital, Houston, TX

Surgical PathologistWoman’s Hospital and The Methodist Hospital, Houston, TX, 1976-1981Houston Northwest Medical Center, Houston, TX, 1981 to present

Board Certified by the American Board of Pathologyin both Anatomic and Clinical Pathology

J. B. Askew, Jr., M.D., P.A.


Professional SocietiesAmerican Society of Clinical Pathologists College of American PathologistsHarris County Medical Society Houston Society of Clinical PathologistsTexas Medical Association American Medical Association

Honors"For Distinguished Service to the Education Foundation," 1979American Society of Plastic & Reconstructive Surgeons, Inc.

Physician's Recognition Award, May 1988-1991American Medical Association

The Pathology Continuing Medical Education Award, May 1988-1991

2004 Local Hero Award, April 2004Eighth Annual BMW Ultimate Drive for the Cure,benefitting the Susan G. Komen Breast Cancer Foundation

PresentationsBreast Seminar Series Laszlo Tabar, M.D., Course DirectorInterdisciplinary Breast Conferences Phoenix, AZ, Oct. 9-12, 1996 Palm Desert, CA, Oct. 8-11, 1997 San Diego, CA, April 1-4, 1998 Scottsdale, AZ, Sept. 16-19, 1998 San Diego, CA, Feb. 24-27, 1999 Rancho Mirage, CA, Sept. 14-17, 2000 San Diego, CA, August 8-11, 2001Multidisciplinary Breast Conferences Houston, Texas, Feb. 26, 2000, Ductal Carcinoma In Situ Houston, Texas, Mar. 3, 2001, Breast Cancer in the 3rd MillenniumCommunity Breast Education Series Houston, Texas, Spring and Fall, since 1997 Topic: Understanding Your Pathology Report

PublicationsAskew, J.B. (2009) Private Practice Pathology, Breast Care, and Economics. SeminarsinBreast Disease, 11(3):129-135.Askew, J.B. "Regional Breast Disease Working Group: Another Dimension of BreastCare," Seminars in Breast Disease, 11(1):9-11 2009.Askew, J.B.; Fechner, R.E.; and Jensen, A.B. "Epithelial and Myoepithelial Oncocytes.An Ultrastructural Study of Salivary Gland Oncocytoma," Arch. Otol. 93: pp. 46-54,1971.Fechner, R.E.: Bentinck, B.R.: and Askew, J.B. "Acinic Cell Tumor of Lung.A Histologic and Ultrastructural Study," Cancer 29: pp. 501-508, 1972.

Founded Breastpath.comSpring 1999

J. B. Askew, Jr., M.D. (cont.)


Ackerman’s SURGICAL PATHOLOGY, by Juan Rosai, M.D., Eighth edition, ©1996, Mosby.

Atlas of Tumor Pathology, Tumors of the Mammary Gland, Paul Peter Rosen, M.D. & Harold A. Oberman,M.D., ©1993, ARMED FORCES INSTITUTE OF PATHOLOGY.

Ductal Carcinoma In Situ of the Breast, Melvin J. Silverstein, M.D., Editor, ©1997, Williams & Wilkins.

PATHOLOGY OF THE BREAST, Second Edition, by Fatten A. Tavassoli, M.D., ©1999, Appellation &Lang.

American Board of Pathologyhttp://www.abpath.org/

American Cancer Societyhttp://www.cancer.org/

American Journal of Pathologyhttp://ajp.amjpathol.org/

National Cancer Institutehttp://www.cancer.gov/

National Comprehensive Cancer Networkhttp://www.nccn.org/

National Consortium of Breast Centershttp://www.breastcare.org/

Contact InformationJ.B. Askew, Jr., M.D., P.A.Founder, Breastpath.com714 FM 1960 W., Suite 206Houston, TX [email protected]

All Content © 1999-2001 J.B. Askew, Jr., M.D., P.A. All rights reserved.

Bibliography


National Consortium of Breast Centers, Inc.Position Statement on Mammographic Screening

The National Consortium of Breast Centers’ Board of Trustees has given their consent to the following positionstatement reflecting their stand on the issue of mammographic screening, in response to the recommendations madeby the US Preventive Services Task Force. National Consortium of Breast Centers, Inc., Position Statement regarding the Mammography ScreeningRecommendations of the United States Preventive Services Task Force (USPSTF)

The National Consortium of Breast Centers (NCBC), the largest national organization devoted to the inter-disciplinary care of breast disease, requests the USPSTF rescind their new position on mammography screening. The U.S. Preventive Services Task Force (USPSTF) published a paper detailing model estimates of potential benefitsand harms to women screened for breast cancer with mammography.1 They provided an updated USPSTFrecommendation statement on screening for breast cancer for the general population that alters currently acceptedguidelines for women over 40 years old.2

The NCBC opposes the new guidelines as written. We cite specific evidence that screening mammographyleads to early detection which leads to improved survival.3 In every country starting population screening, mortalitydeclines coincide with onset of screening, not systemic therapy. These USPSTF models are not based on sound data,namely different denominators in the “harms” vs. “benefits” groups leading to invalid comparisons. Recent datafrom randomized controlled trials reveal significant mortality reductions evident approximately five years afterscreening programs were initiated. The reductions in age-adjusted, disease specific mortality (30-40%) since 1990define screening program benefits not seen in the prior six decades. In the United States, these mortality declinescontinue at a rate of approximately 2% per year. 4 This mortality improvement counts as a remarkable public healthachievement.

In addition, the USPSTF panel (comprised almost exclusively of primary care physicians) did not include breastimaging specialists nor was it represented by any of the multiple other specialists who collaborate to optimize patientoutcomes. These specialists include pathologists, surgeons, medical oncologists, radiation oncologists,reconstructive surgeons, technologists, geneticists, nurse navigators, educators and others.The NCBC does not understand the assumptions used by the USPSTF to value human life. We note the citedliterature was selective and failed to acknowledge equally powerful and credible peer-reviewed literature, whichsupports currently accepted breast cancer screening guidelines.

We would also like to note that quality of life has a significant value, not just survival. It is well established thatif we discontinue mammography for women in their 40’s, the cancers eventually detected will be larger, more likelyneed more aggressive surgery, more likely need chemotherapy and more likely lead to other significant socio-economic concerns.

The NCBC requests input into future guideline development and vows to work with government, scientists andindustry to keep the process transparent and keep the focus on the patient. We recommend further efforts targetscreening, risk assessment, education and awareness regarding the implications of positive and negative screeningfindings. Funding for further research is imperative and supported by the controversy these articles have generated.

Finally, we note the USPSTF article states, “whether it will be practical or acceptable to change the existingU.S. practice of annual screening cannot be addressed by our models.”1 The NCBC agrees with this comment andfinds their screening guideline suggestions unacceptable. The NCBC believes many women’s lives will be placed atrisk if current screening guidelines are altered. We respectfully request the Task Force rescind their position on thisspecific women’s healthcare screening policy.

References:1. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 738-747. 2. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 716-726. 3. Tabar L, Vitak B, Chen HT et al. Beyond randomized controlled trials: organized mammographic screeningsubstantially reduces breast cancer mortality. Cancer 2001; 91: 1724-1731. 4. American Cancer Society, Breast Cancer Facts and Figures, 2009-2010.

© 2009 by the National Consortium of Breast Centers, Inc.


by J.B. Askew, Jr., M.D., P.A.Founder, Breastpath.com

714 FM 1960 W., Suite 206Houston, TX 77090

[email protected]

To order additional copies of this report, visit our website atwww.breastpath.com.

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