Embracing Progress

Breast Cancer Diagnostic Tools

Breast cancer detection has made tremendous strides with recent advancements in diagnostic tools, offering more accurate, personalized, and timely screenings than ever before. From traditional mammograms enhanced by artificial intelligence (AI) to advanced techniques for dense breast tissue like breast MRI, ultrasound, and Automated Breast Ultrasound System (ABUS), technology is transforming early detection. The value of this blog lies in its comprehensive overview of these innovations, including new tools such as abbreviated breast MRI, contrast-enhanced mammography (CEM), elastography, and genetic screening. And there are always new tools on the horizon! We'll also explore age-appropriate screening guidelines, how risk factors differ across diverse populations, considerations for those at higher risk—including men and transgender individuals—and the role of AI in improving outcomes. This holistic look at the latest diagnostic advancements equips you with the knowledge to make informed decisions about your breast health.

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Advancements in Diagnostic Tools

1. Mammogram

Mammograms have long been a cornerstone of breast cancer screening and continue to play a pivotal role in early detection. They have become even more precise and effective in recent years. The technology has evolved to include digital mammography and 3D mammography (tomosynthesis). These advancements have improved the accuracy of detecting breast abnormalities, especially in women with dense breast tissue. According to the National Breast Cancer Foundation, mammograms can frequently detect breast cancer at an early, treatable stage, potentially reducing mortality rates. In fact, mammography has contributed to a 40% reduction in breast cancer deaths in the United States over the past three decades.

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2. Artificial Intelligence

Advancements in breast cancer diagnostics have seen a significant leap with the integration of artificial intelligence (AI). AI systems are enhancing radiologists' ability to detect cancer earlier by identifying subtle signs that might be missed by the human eye. In a study published in The Lancet Oncology, mammograms read by AI detected 20% more cancers than those reviewed solely by radiologists. AI is also helping reduce false alarms; a study in Nature reported nearly a 6% decrease in false positives in the U.S., sparing patients unnecessary stress and costly follow-up tests. AI tools like iBRISK are showing promise in predicting whether flagged abnormalities are benign, potentially preventing needless biopsies.

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Furthermore, AI's ability to predict breast cancer risk with greater accuracy than traditional models may revolutionize personalized screening strategies. Although widespread adoption requires further research and training diversity, the future of AI in breast cancer screening holds promise for more accurate, timely, and personalized diagnostics. In the U.S., AI-assisted breast imaging is not yet widely available, and there isn't an online directory to search for it. If you're interested in AI-assisted imaging for screening or monitoring, ask your care team what is available locally.

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3. Breast MRI, Breast Ultrasound, and Automated Breast Ultrasound System (ABUS) for Dense Breast Tissue

Depending on their availability in your area, you can use any of these options as an enhanced way of looking for potential cancerous tissue. A Breast MRI, Breast Ultrasound, or ABUS should always be done in combination with a mammogram. If you have dense breasts it is advisable to augment your mammogram with one of these diagnostic tools because a routine mammogram is often not effective at detecting possible cancerous tissue. Dense breasts also increase the risk of breast cancer. A doctor’s order specifying that you have dense breasts as the reason for ordering this second tier of diagnostic testing may be required for insurance to pay for it.

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Fortunately, Breast MRI (Magnetic Resonance Imaging) has emerged as a powerful complementary tool, particularly for women with dense breasts. This technology offers a more detailed view, increasing the chances of identifying small tumors that may go unnoticed on mammograms. Studies show that breast MRIs’ have detected an estimated 14 additional cancers per 1,000 women, with no additional radiation exposure. The American Cancer Society highlights the benefits of breast MRI, especially for those at a higher risk of breast cancer. When used alongside mammography, it improves the overall accuracy of early detection. The cost of a breast MRI can vary dramatically depending on geography and where it is performed (hospitals use an MRI machine for other purposes, outpatient imaging centers, breast centers or women’s health centers, etc.).

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Another critical advancement in breast cancer diagnostics is the use of Ultrasound, either Automated Breast Ultrasound System (ABUS) or Hand Held Ultra Sound (HHUS). Ultrasound has the advantage that it does not use radiation and provides different types of information than an MRI does. In some parts of the United States ABUS is readily available. ABUS is a valuable tool that complements mammography and is an alternative to a breast MRI. Studies show that the test results from ABUS and Breast MRIs are in almost perfect agreement. An ABUS is particularly valuable for women with dense breast tissue, as it provides additional information about the breast's composition beyond what a mammogram may offer. Hand Held Ultra Sound (HHUS) is very dependent on the experience of the radiologist in reading breast imaging specifically, a specialized skill. According to a limited study published in a Portuguese obstetrics and gynecology journal which compared readings using both ABUS and HHUS, ABUS results are extremely effective in terms of their ability to identify potential cancerous tissue, especially in light of the variability of skill sets in radiologists using HHUS and reading the results. Buying ABUS equipment does require financial outlay and training but the outcome and benefit seem to be worthwhile. In those situations where ABUS is not available and a radiologist trained in reading breast ultrasounds is available, HHUS may be a viable alternative.

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On average, an ABUS exam can cost anywhere between $250.00-$399.00 to the patient depending on where you reside. It’s not a covered screening unless deemed medically necessary by your physician usually based on dense breasts. If the exam is not covered by insurance, the financial burden will fall on the patient to cover out-of-pocket expenses if they choose to move forward with testing. The cost of the actual screening system is roughly $300,000 to the clinic or hospital. Studies have shown it to be significantly effective as an adjunct to mammogram screening. The ABUS must be set up by an expert team of subspecialty-trained imaging physicians and technologists who will perform the whole-breast ultrasound. The scan can also be used with patients who have silicone and saline breasts. The exam will take approximately 15-20 minutes, including patient preparation, to complete. On average, even less time to interpret, depending on a negative or positive result, ranges from five minutes or more. However, this screening isn’t offered at all facilities. The breast MRI cost varies depending on the facility and location. Screening time can take up to 30-45 minutes to complete depending on if contrast dye is required. Patients typically wait about two weeks to get their results back.

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‍The George Washington University Hospital explains that ABUS enhances early detection, making it a vital asset in our mission to save lives. It helps physicians gain more insights into breast abnormalities, reducing the likelihood of missing potential cancerous growths. Most women find either form of ultrasound, HHUS or ABUS, to be fairly quick and comfortable. For those who struggle with claustrophobia, often experienced in MRIs, ABUS is a welcome alternative.

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4. Other tools to be familiar with: Abbreviated breast MRI or fast breast MRI

This is one of the newer techniques that is done with a standard breast MRI scanner that takes fewer images over a shorter time span compared to the traditional breast MRI. Gadolinium, a contrast, is given through an IV prior to taking images. Abbreviated breast MRI is now being studied as a possible screening test for breast cancer, especially in women with dense breasts. This technique is not yet widely used, but in the near future has the potential to be used more frequently as a breast cancer diagnostic tool.

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5. Contrast-enhanced mammography-CEM

Also known as contrast-enhanced spectral mammograph-CESM, this is a newer test where a dye contrast that contains iodine is injected prior to taking two sets of mammograms using two energy levels. The contrast is used to help enhance the images that show any abnormalities in areas of the breast beyond what was highlighted during the initial mammogram. It provides more detailed imaging and can assist with additional diagnostic assessment of the extent of a tumor in someone just diagnosed with breast cancer. It would be a second stage of diagnostic testing done after the initial mammogram in order to get additional information.

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6. Elastography

Elastography can be done as part of an ultrasound exam. The breast is compressed slightly, not nearly as much as is done in a mammogram, and the ultrasound displays how firm a suspicious area is. This test method may be able to prove if the area is more likely to be cancer or a benign tumor (non-cancerous). It helps to enhance what has already been seen in the mammogram because the two imaging technologies work in entirely different ways. It is different from the standard ABUS or HHUS test.

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7. Genetic Screening

Genetic screening consists of genetic testing accompanied by genetic counseling. It has transformed the way we approach breast cancer prevention and management by helping patients understand the results of their tests and the potential future outcomes. It can identify gene mutations, such as BRCA1 and BRCA2, which significantly increase the risk of developing breast cancer. Armed with this knowledge, patients can make informed decisions about preventive measures or more vigilant screening. These decisions are not easy, but having the information available to make these preventive decisions allows for women, often with their families, to make choices before being faced with the possibility of breast cancer itself.

The National Cancer Institute highlights the importance of genetic screening, as it not only aids in early detection but also assists healthcare providers in tailoring treatment plans. It's a powerful tool for those with a family history of breast cancer or identified genetic mutations. It is not something that everyone needs to participate in.

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Age-Appropriate Breast Cancer Screenings

Women Ages 20+:

Annual breast exam as part of a medical check-up or well-woman exam.
Monthly breast self-exams are recommended for all pre and postmenopausal women in their 20s and beyond. This self-examination is a simple yet essential step in early detection, as it helps women become familiar with the normal look and feel of their breasts.

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Women Ages 40+:

Annual mammogram screenings are advised for women of average breast cancer risk starting at the age of 40. Mammograms are a valuable tool in detecting breast cancer early when it is most treatable. If a woman has dense breasts, then the augmented tools highlighted above should be recommended as well.

These age-specific recommendations, in conjunction with the advancements in breast cancer diagnostics, offer a comprehensive approach to early detection and breast health. By following these guidelines, individuals can proactively take charge of their well-being, with the goal of achieving positive results and peace of mind in their breast cancer journey.

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Understanding Breast Cancer Risk Factors for Diverse Populations

Breast cancer does not discriminate; it can affect individuals from all walks of life. It's crucial to be aware of the specific risk factors and considerations for various populations. Let's explore how breast cancer risk varies for women at higher risk, men, and transgender individuals.

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Women at Higher Risk for Breast Cancer

Certain factors can increase a woman's risk of developing breast cancer. These factors include:

Family History: A family history of breast cancer, especially in close relatives like mothers, sisters, or daughters, can elevate the risk. Genetic mutations like BRCA1 and BRCA2, as mentioned earlier, can significantly increase the risk. Regular genetic screening and counseling are essential for those with a family history. If you know that you are at higher risk, let your doctor know and begin mammogram screening at an earlier age.

Race: Studies including recent data from the American Cancer Society, have shown that Black women have a 4% lower incidence rate of breast cancer than white women yet have a 40% higher death rate from breast cancer than white women. Overall black women have a higher death rate from breast cancer than any other race or ethnic group. Breast cancer is the second leading cause of death among Black and Hispanic women. The study’s authors point to equitable access to diagnostic tools and appropriate treatment in Black and Hispanic communities as the most likely cause of this huge disparity.

Age: Breast cancer risk generally increases with age. Women over 60 have a higher risk, so regular screenings are vital as one gets older.

Dense Breast Tissue: As we discussed earlier, dense breast tissue can make it more challenging to detect abnormalities on mammograms. This increases the importance of supplemental screening methods like breast MRI and ultrasound for women with dense breasts.

Reproductive History: Factors such as early menstruation, late menopause, and having children later in life can influence breast cancer risk.

Hormone Replacement Therapy (HRT): The use of HRT, particularly combined estrogen and progesterone therapy, can increase the risk of breast cancer. It's essential for women considering HRT to discuss the potential risks and benefits with their healthcare provider.

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Men and Breast Cancer

While breast cancer is less common in men, it can still affect them. Men should be aware of the following risk factors:

Age: As with women, the risk of breast cancer in men increases with age.
Family History: A family history of breast cancer can raise a man's risk, so genetic counseling may be recommended.
Klinefelter Syndrome: This genetic condition is associated with a higher risk of breast cancer in men.
Radiation Exposure: Previous radiation therapy to the chest area, such as for the treatment of other cancers, can increase the risk of breast cancer in men.‍
Hormone Imbalances: Conditions that lead to hormone imbalances, such as cirrhosis or obesity, may increase breast cancer risk.

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Transgender People and Breast Cancer

Transgender individuals have unique considerations when it comes to breast cancer risk and screening, and there is important information to consider:

Transgender Women (MtF): If you are a transgender woman (male sex assigned at birth, female gender identity) taking hormones, research suggests that your risk of breast cancer falls between that of cisgender men and cisgender women. It is recommended that you have screening mammograms every other year starting at age 50. However, it's crucial to discuss your individual risk profile with your doctor and develop a screening plan tailored to your unique situation.

Transgender Men (FtM): If you are a transgender man (female sex at birth, male gender identity) taking hormones, studies indicate that your risk of breast cancer is lower than that of cisgender women. If you haven't had top surgery, a gender-affirming variation of a double mastectomy, the recommended approach is to have screening mammograms every other year starting at age 50. As always, it's wise to engage in a conversation with your healthcare provider to assess your personal risk and determine the best screening plan for your specific circumstances.

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It's important to note that if you have legally changed your sex, you may not automatically receive breast cancer screening invitations. Therefore, working closely with your doctor to establish a personalized breast health plan is a proactive step to ensure your well-being.

Breast cancer awareness and tailored screenings are vital for all individuals, irrespective of gender identity. By staying informed and collaborating with healthcare professionals, transgender individuals can navigate their breast health effectively and with confidence. This approach ensures early detection, positive results, and peace of mind in the face of breast cancer.

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October’s Breast Cancer Awareness Month is a time to celebrate the progress we've made in the fight against breast cancer, and the advancements in diagnostic tools are a testament to our commitment to improving outcomes for patients and their families. As a Health Care Advocate with a passion for my clients' peace of mind, my goal is to anticipate their needs and provide them with the best information and support possible. The advancements in breast cancer diagnostics are a testament to our collective dedication to this mission. Together, we can continue to raise awareness, support those affected by breast cancer, and work toward a future where this disease is no longer a threat.

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Continue to take charge of your better health!

-Lee

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