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What You Really Need To Know About Dense Breasts

From left: 1) a breast of normal density showing fat (white), fibrous tissue (pink) and glands within the rectangle, while a cancer is present (circle). This illustrates the fact that cancer can occur in breasts of any density; 2) an extremely dense benign breast without any fat, composed of pink fibrous tissue and minimal amounts of glands; 3) an extremely dense breast involved by cancer (infiltrating haphazard small glands), in contrast to Fig 2, but very similar in appearance, demonstrating the subtle similarities. (Courtesy Michael Misialek)

From left: 1) a breast of normal density showing fat (white), fibrous tissue (pink) and glands within the rectangle, while a cancer is present (circle). This illustrates the fact that cancer can occur in breasts of any density; 2) an extremely dense benign breast without any fat, composed of pink fibrous tissue and minimal amounts of glands; 3) an extremely dense breast involved by cancer (infiltrating haphazard small glands), in contrast to Fig 2, but very similar in appearance, demonstrating the subtle similarities. (Courtesy Michael Misialek)

By Michael Misialek, M.D.
Guest Contributor

Reading the pathology request on my next patient, I saw she was a 55-year-old with an abnormality on her mammogram. Upon further investigation I discovered she had dense breasts and a concerning “radiographic opacity.” The suspicion of cancer was high based on these findings and so, a breast biopsy had been recommended. As I placed the slide on my microscope and brought the tissues into focus, I immediately recognized the patterns of an invasive cancer. Unfortunately the suspicion had proven correct.

Just a few patients earlier, an almost identical history had prompted another breast biopsy. This time the results were far different, a benign finding and obviously a sense of relief for the woman. Every day these stories unfold; the never ending workup of abnormal mammogram findings. Both radiographically and microscopically, it can be challenging at times sorting out these diagnoses, particularly in the face of dense breasts.

But what, exactly, are dense breasts and why are they suddenly in the news?

Breast Tissue 101

Breast tissue is actually made up of three tissue types when viewed under the microscope. The percentage of each varies between patients. There is fat, fibrous tissue (the supporting framework) and glandular tissue (the functional component). This is what I actually see under the microscope. Cancer can occur in fatty or dense breasts. It can be toughest to assess when the background is dense.

Biopsy, considered the gold standard in diagnosis, may even prove difficult to interpret when in the background of dense breasts. Dense breasts can hide a cancer, making it more difficult to detect both by mammogram and under the microscope.

Breast density has taken a lot of heat recently. A new study published in the Annals of Internal Medicine found that not all women with dense breasts and a normal mammogram warranted additional screening, as was previously thought. Understandably this report has received much attention. The authors found nearly half of all women had dense breasts. This alone should not be the sole criterion by which additional imaging tests are ordered since these women do not all go on to have a cancer. Clearly other risk factors are at play.

Confusion All Around

This is confusing for patients and doctors alike, especially when it seems as if screening guidelines are a moving target. Recently, the American College of Physicians issued new cancer screening guidelines: among these was mammograms, being recommended every two years. This too is getting a lot of press.

The American College of Radiology, American Cancer Society, Society of Breast Imaging and American College of Obstetricians and Gynecologists recommend yearly mammograms beginning at age 40. Continue reading

Pathologist: What Women Need To Know About Breast Biopsy Accuracy

A breast biopsy which illustrates the grey zone of pre-cancer (Courtesy of Dr. Michael J. Misialek)

A breast biopsy which illustrates the grey zone of pre-cancer (Courtesy of Dr. Michael J. Misialek)

By Michael J. Misialek, MD

If you’re a woman who has ever had a breast biopsy, you may be asking yourself a few serious questions:

“How do I know if my breast biopsy is completely accurate?” And, “Who is the pathologist reading the biopsy, and what is their level of training?”

Many more patients are asking these and similar questions following widespread media coverage on a Journal of the American Medical Association (JAMA) study, which casts doubt about the accuracy of interpreting these biopsies.

Let’s break the study down and ease some anxiety. Perhaps most importantly, this provides a great opportunity to learn about one of the lesser know medical specialties, pathology…which is what I do.

The JAMA study, “Diagnostic Concordance Among Pathologists Interpreting Breast Biopsy Specimens,” revealed the following key finding:

• Overall agreement between individual pathologists’ interpretations and that of an expert consensus panel was 75 percent, with the highest agreement on invasive breast cancer and lower levels of agreement for ductal carcinoma in situ (DCIS) and atypical hyperplasia.

What this means is that the agreement between a general pathologist and an expert was excellent for breast cancer (those with the ability for metastasis), but varied significantly for early cancers and high-risk pre-cancers.

While the study’s findings may not be surprising to physicians who understand the challenges of diagnosing complex breast cases, news of the article could lead to unnecessarily heightened anxiety for patients and the public as breast cancer is a highly publicized and pervasive disease.

The study confirmed that the majority of breast pathology diagnoses, especially at either end of the spectrum (benign disease and invasive breast cancer) are accurately made by practicing pathologists regardless of practice setting. The overall rate of agreement for invasive breast cancer cases was 96 percent.

Issues with diagnostic disagreement mainly center on the borderline cases, between atypical hyperplasia, that is, pre-cancer, and DCIS, early cancer.

Why does this matter? Overdiagnosis can lead to unnecessary surgery, treatment and anxiety. Underdiagnois can lead to a delay in treatment. The bottom line is that experience matters.

Factors that contributed to greater disagreement included: a low case volume, small practice size, nonacademic practice and high breast density.

The study has many weaknesses. Chief among them was that only a single slide per case was given to each pathologist. As a practicing pathologist, this never happens. I will review multiple slides, often ordering several additional deeper sections and ancillary special stains, studying each carefully. This practice was prohibited in the study.

Additionally, the study cases were a mixture of core biopsy and excision specimens. A core biopsy is obtained using a needle, often by a radiologist, in which a small core of tissue is removed. An excision is a “lumpectomy” which is done in the operating room where a large section of breast tissue is removed. Diagnostic criteria vary between a needle core and excision. Often times it is not necessary to render an exact diagnosis on the core biopsy, but rather recognize an abnormality and recommend an excision for which additional tissue will clarify the diagnosis.

Even the experts disagreed in the study (75 percent initial agreement then 90 percent after discussion).

This illustrates the fact that pathology is both a science and art. Experts may stress slightly different criteria in their pathology training programs. The “eye of a pathologist” is a difficult measure to quantify and is dependent on multiple factors that best function in real time, not an artificial study.

Another weakness is that there is no evidence that the experts were more accurate in predicting outcomes than test subjects. Perhaps most importantly, a second opinion was not allowed in the study, even when study participants indicated uncertainty. These are in fact the very cases that would most likely have been shown around, sent out for consult and further worked up.

It is not realistic to introduce such a large caseload of breast biopsies that are heavily weighted towards atypical hyperplasia and DCIS. Since these borderline cases represent only a small fraction of breast biopsies in actual practice, diagnostic agreement in routine practice is higher than that reported in this study. No clinical information other than patient’s age was given to the study pathologists, and no imaging findings were included. In actual practice, integration of the clinical setting and imaging findings is routinely used in making a diagnosis.

The findings are not unique to pathology. All of medicine has grey zones, where controversy often exists. The study does have an important message for pathologists. As noted in the accompanying editorial, it should serve as a “call to action.” A better, more reproducible definition of atypical hyperplasia is needed.

The article highlights the need for an active quality management program in surgical pathology that includes targeted review of difficult or high risk cases. The College of American Pathologists (CAP) and the Association of Directors of Anatomic and Surgical Pathology have been developing an evidence-based guideline expected to be released in May to provide recommendations to reduce interpretive diagnostic errors in anatomic pathology.

The CAP is proactively addressing educational opportunities through advanced breast pathology training programs designed to provide a route for pathologists to demonstrate their expertise regardless of the setting in which they practice.

Patients can take steps to help ensure their breast biopsy is read accurately:

o Inquire about the pathology laboratory that will examine your tissue sample. Is the laboratory accredited? The CAP accredits more than 7,600 laboratories worldwide and provides an online directory for patients. Continue reading

Got A Headache? Study Finds Flaws In Treatment, ‘Alarming’ Rise In Imaging Tests

(19melissa68/Flickr)

(19melissa68/Flickr)

Sometimes less really is more. A case in point: the treatment of routine headaches.

Doctors are increasingly ordering pricey, advanced imaging tests and referring patients to specialists, which, it turns out, offers little help to headache sufferers, a new study concludes.

Researchers from Boston’s Beth Israel Deaconess Medical Center suggest that patients might be better served (and the health care system might save money) by instead focusing more on lifestyle changes for people seeking headache relief.

For the study, published online in the Journal of General Internal Medicine, researchers used a nationally representative database to analyze practice patterns among physicians treating headache patients.

I asked the lead author, John N. Mafi, MD, a fellow in the Division of General Medicine and Primary Care at BIDMC, to sum up the bottom line results. Here (slightly edited) is his emailed response:

“…We found alarming rises in use of advanced imaging (CT/MRI), referrals to other physicians (presumably specialists), and a decline in first-line recommended life-style modification counseling, meant to prevent headaches. We also saw no change in use of discouraged medications, with opioids and barbiturates ordered in about 18% of visits throughout the study period.

These findings represent alarming trends in the management of headache, and to me, they reflect a larger trend in the U.S. healthcare system where over-hurried doctors are ordering more tests, more medications, more referrals to specialists and less time talking and connecting with their patients.

To me this suggests that the visit-based model of healthcare is broken, Continue reading

Making Peace With My Abnormal Brain

(Andrew Ostrovsky)

(Andrew Ostrovsky)

By Dr. Annie Brewster
Guest Contributor

What you never want to hear from the radiologist: “I wouldn’t mistake it for a normal brain.”

Yet this is what I recently heard from my radiologist friend who kindly took a look at an MRI of my brain. Let me repeat: it was my abnormal brain under discussion here, and I’ll tell you, his assessment was tough to hear.

The state of my brain isn’t exactly news to me. I have had Multiple Sclerosis since 2001, and I have frequent MRIs. Moreover, as a physician at the hospital where I get my treatment, I have the dubious privilege of having complete and immediate access to my medical chart. As such, I often see the MRI images and read the reports before my neurologist does, and fortunately or unfortunately, I understand “medicalese.” (And I have radiologist friends.)

Every time I get an MRI, I devour these reports as soon as they become available on the computer, scanning optimistically for words like “stable.” I even hold onto the absurdly magical hope that old lesions will have disappeared, and that this whole diagnosis of MS has been a big mistake. Instead, I find mention of new “hyperintense foci of white matter signal abnormality” and “enhancing” lesions, “consistent with actively demyelinating MS plaques.” I fixate on words like “volume loss” and “atrophy” and in one preliminary report generated by a resident, I think I saw the word “diminutive.” Did I imagine this?

Despite the sting of these words, I am able to remain somewhat detached. As a doctor, I spend my days looking at radiology images and reading such reports.

Often — due to the formal and impersonal language that is used — it’s hard to remember that the body part being referred to is actually part of a human being. It is even harder to remember that it is part of me!

“I wouldn’t mistake it for a normal brain” penetrates deeper. I understand. My brain is under attack, and is irreparably damaged.

My first response is to mount a defense. I feel the need to tell you that my brain is still a good brain. It just has a few small blemishes. It still works! I recently passed the required ten year recertification medical boards (apparently I will never escape bubble tests), and I feel smarter than ever. I am the mother of four and the primary logistical organizer in my
household, and my (short term) memory is at least ten times better than my husband’s (no offense, honey). Furthermore, research has clearly shown that MRI findings do not necessarily correlate with clinical symptoms in Multiple Sclerosis. So there is no cause for alarm.

Also, the research is promising. Exhibit A is this massive MS conference currently underway in Boston with many great minds focusing their attention on new approaches, such as potential remyelinating therapies, to tackle the disease. (MS damages the myelin, the sheath around nerve cells, and remyelination would restore it.)

My neurologist, Eric Klawiter, at Massachusetts General Hospital, writes me this:

As a research community, we have gained a great deal of knowledge on the mechanism of remyelination and how that process can go awry in MS. There are several candidate compounds demonstrated to promote the body’s ability to differentiate precursor cells into cells that lay down new myelin (oligodendrocytes). It is yet to be established whether these candidate therapies will work best to promote immediate recovery from relapses or whether they will also be effective in the setting of remote demyelination.

Of course, any potential new therapies are years or more away and don’t do much for me right now.

So, underneath my bravado, there is vulnerability. Continue reading

Coming Soon To Your Smartphone: Where The Cheaper MRIs Are

Picture it: Your doctor tells you that you need an MRI. Okeydoke, you say, pulling out your smartphone and typing in your zipcode. Up pop the 20 closest high-quality imaging centers, and you choose the most convenient.

That’s my visualization based on a casual mention that Blue Cross Blue Shield chief Andrew Dreyfus made last week of a new app now in development. “We’re pretty close to delivering this,” he told a health reform forum at Suffolk.

He pointed out that MRI prices can range from $500 in a community imaging center to $1500 at an academic medical center. That’s certainly an incentive to help members find cheaper, free-standing centers. And we all have an incentive to seek lower cost care as we shoulder more of our own medical bills.

I asked Blue Cross for more details, and spokesperson Jenna McPhee responded that the “PILOT” app is indeed well along and should be ready for a small group of Blue Cross members to try out in the next couple of months.

The tool is designed to identify the closest free-standing imaging facilities (for MRIs, CT scans, and lab work) sorted by zip code proximity. While it does not provide specific cost information, it locates high-quality free standing imaging facilities that are lower cost than getting an MRI, etc. in a hospital setting.

Here are the key features:
Member starts search by entering a zip code
MRI Locator lists the closest free standing imaging facilities sorted by zip code proximity
Other features include:
Uses Google Maps
Member can map facilities and get driving directions
Ability to dial the facility with a click

My blue-sky dream: The app not only gives you locations, but tells you what the overall price would be at each center, and how big your co-pay would be. They can do it for gas station prices already. Maybe someday…

Lahey Radiologist On Lung Cancer CT: Good News And Hard Questions

Big news today on lung cancer, the number one cancer killer. A federal study of more than 50,000 current or former smokers found that low-dose “spiral CT” scans cut the death rate by 20 percent compared to screening with regular chest X-rays.

The Associated Press reports: The difference was significant enough that the researchers ended the study early, but the National Cancer Institute said that “it’s not clear that all smokers should get the scans, which aren’t risk-free.”

We asked Dr. Christoph Wald, of the Lahey Clinic, for his take on the findings. What do they mean for the public?

It’s early days yet, he said, and it will likely take months for the full data to be published. But for people who fit the high-risk profile of the subjects of the study — ages 55 to 74, and with a smoking history amounting to the equivalent of a pack a day for 30 years — “We can say that if you do what they did in the trial, get three consecutive low-dose CT scans, you have a very significant mortality benefit over the next five ensuing years.”

Dr. Christoph Wald of the Lahey Clinic

Dr. Wald expects clinicians to take a look at which patients in their practice fit the high-risk profile of the patients in the federal trial, and the doctors may well recommend CT screening to those patients. “At this time, since there are no national guidelines, it’s between the physician and the patient to decide how they want to incorporate this good new information into their physician-patient relationship,” he said.

Now for the hard parts:

-What if you’re at lower risk than the older, 30-pack-year patients in the trial? Younger, or less of a smoker? The trial offers no guidance on whether to do spiral CT screening, Dr. Wald said.

-Cost: A spiral CT costs several hundred dollars, compared to a typical chest X-ray, which generally costs $50-$100.

-And here’s the really hard part: Currently, insurance does not generally cover CT for screening purposes, only if you have symptoms or a chest X-ray abnormality. That is likely to change with this excellent new data, but for now, Dr. Wald said, “There’s going to be a bit of a confict potential for the time being. If patients walk into our office on Monday wanting this screening CT, we’re going to have an issue because we can’t get paid for it. It will put the providers in a bad spot initially.”

Daily Rounds: Supreme Court Hears Vaccine Case; Keeping Patients On Drugs; Radiologist Downsizing; Hormones And Kidney Stones; Losing Your Memory In Retirement

Supreme Court to Consider Vaccine Case – NYTimes.com “The safety of vaccines is at the heart of a case expected to be heard on Tuesday by the United States Supreme Court, one that could have implications for hundreds of lawsuits that contend there is a link between vaccines and autism. “(The New York Times)

Express Scripts Seeks to Keep Patients on Drugs, Reduce Health-Care Costs – Bloomberg “Express Scripts Inc., one of the largest managers of prescription drug benefits in the U.S., introduced a program designed to cut medical costs by identifying the chronically ill patients most likely to neglect medicines within a year. Computer models that tag the potentially noncompliant will let St. Louis-based Express Scripts contact patients before they stop taking drugs.” (bloomberg.com)

Running a hospital: First bend in the health care cost curve Radiologists are losing their jobs, writes Beth Israel Deaconess Medical Center Chief Paul Levy: “Recent trends in radiology imaging portend a dramatic and rapid reduction in this segment of a hospital's business plan,” he writes. “Our Chief of Radiology summarizes our experience — common to other hospitals as well: ‘The biggest hit has been in CT, the modality we are most dependent on for revenue. We are about 10% down in CT cases from last year, due to a combination of patient and physician fears about radiation exposure, more prudent ordering of studies by physicians, leakage out of the medical center, and the introduction of physician incentive programs (to minimize the amount of imaging) by some insurers.'” (Running A Hospital)

Hormones linked with kidney stones in older women – Boston.com “Among more than 24,000 postmenopausal women taking either hormones or dummy pills, those using hormones were 21 percent more likely to develop kidney stones over about five years.” (Boston Globe)

Memory Decline Accompanies Earlier Retirement, Study Finds – NYTimes.com “The implication, the economists and others say, is that there really seems to be something to the “use it or lose it” notion — if people want to preserve their memories and reasoning abilities, they may have to keep active.” (The New York Times)

Top 10 Snippets In New Snapshot Of State’s Health Care Reform

“I live here. I already know all this. I feel it in my own medical care and insurance bills.”

That was my first reaction when I saw that the Center for Studying Health Systems Change had just put out a new report on how health care reform has affected Massachusetts, funded by the Robert Wood Johnson Foundation.

I was wrong. I found a motherlode of interesting nuggets in the overview, some little reported before, others the kinds of things that everybody knows but nobody much says. They come from a team of health care researchers who visited the Boston area in March and spoke with more than 50 health care leaders across the board, from doctors to benefits consultants to state officials, then followed up through the summer. Sometimes, I’m thinking, people say things when they’re speaking anonymously to a researcher that they might never say in public…Herewith some excerpts:

1.Doctors who own imaging centers are trying to sell them to hospitals, which can charge more Continue reading