There has been much recent discussion around breast cancer in areas of breast density in relation to detection, and the latest observations in the field of genetics. A veteran breast surgeon, Dr. Erica Giblin, took some time to share her thoughts on the impact of both.
Starting with breast density, Dr. Giblin acknowledged the simple fact that while a mammogram is a great device for breast cancer screening, it does have issues penetrating dense breast tissue. “The problem is that a mammogram renders dense breast tissue as white, but a cancerous tumor can also appear as a single white blob,” she said. “So you’re viewing white over white. There’s a common expression in radiology that trying to find cancer amid dense breast tissue is like trying to find a polar bear in a snowstorm.”
Dr. Giblin noted that supporting awareness of this issue is the fact that breast density is required on mammogram reports in 36 states. The reason is due to one patient in particular: Nancy Cappello, PhD. “Dr. Cappello was a woman who took care of herself, going in faithfully for her mammogram,” the surgeon explained. “Six weeks after a normal mammogram, during her annual health exam, her physician felt a lump in her armpit and breast. They couldn’t see anything in the mammogram because her breast tissue was dense. It turns out not only did she have breast cancer, but it had moved to the lymph nodes in her armpit. She’s the one who advocated for the breast density laws.”
Dr. Giblin explained that when dense breast tissue is present, the ability of a mammogram to detect cancer can fall below the 50 percent mark. “It’s actually worse than the flip of coin,” she added. “The problem is also that many women have a belief that dense breast tissue is based on your bra size—that a larger breast is denser. They also think by just touching the breasts, you can feel dense tissue in the form of lumps or bumps, etc. Neither of these is necessarily true.”
The physician highlighted several new technologies that are entering the arena to detect breast cancer, even through dense breast tissue.
An MRI is a very good tool for detecting breast cancer. The problem with traditional use of the scan is the 35-40 minutes a woman must stay in a very confined space while the scan is taking place. But an Abbreviated MRI can scan for breast cancer in as little as 8-10 minutes. “It’s really an MRI with a breast coil,” the surgeon said. “You’re still taking the pictures the same way, so you’re not buying any new software. It’s just a different way of actually looking at the pictures.”
A recent study shows preliminary results that while the cancer detection rate with mammography is roughly 4 cancers in 1,000 women, the cancer detection rate of an Abbreviated MRI screening is 25 cancers per 1,000 patients. “This is an exciting imaging modality that’s coming up the east coast and starting to spread its way west,” stated Dr. Giblin.
“Another option for women is 3-D mammography,” Dr. Giblin continued. “This mammogram is performed the same way that most women are used to, but it literally takes additional 15 to 75 images of the breast. It’s almost like a mini CAT Scan of the breast. So that’s been shown to have about a 25 percent improvement in detecting breast cancer in dense breast tissue.”
Genetics and breast cancer
Dr. Giblin went on to highlight some of the misconceptions that she is seeing with patients and their perceptions of genetics in relation to their risk of developing breast cancer. “While it’s true that the BRCA gene can increase a patient’s risk of breast cancer, the problem is that a lot of women think, ‘I don’t carry BRCA, so I’m fine.’ Well that’s not true. There’s a bunch of other genes on the gene panels, and at least another 21-25 genes that we can detect.”
“Another thing to keep in mind is that when we’re talking about female cancers, many women tend to only look at the female side of the family,” the surgeon continued. “But what they don’t realize is they get one gene from Mom and one gene from Dad. Patients need to consider all female and male family members to get a full picture of what is moving through the family, be it heart disease, diabetes or cancer.”
“Physicians need to sit down and have a full discussion with patients on what their genetic makeup is,” stated Dr. Giblin. “There needs to be dialogue around the lifetime risk of cancer so a plan can be developed to ameliorate that risk. For people with genetics that indicate a strong risk of breast cancer, they can consider nipple-sparing Mastectomies. If a patient does not want to go in that direction, they can consider increased surveillance with mammography and a breast MRI, both done in the same year. They could also potentially reduce their risk with a hormone blocking pill. What I advocate for women is go in and see a doctor or a specialist. We actually have calculations to determine a person’s lifetime risk and we can help determine if you should have genetic testing or not. Then a patient can make an informed decision on the different strategies to consider, because ultimately this is a personal decision.”
MarginProbe as a tool to fight breast cancer
Dr. Giblin added one final tool for patients to consider if they actually face a breast cancer diagnosis. MarginProbe is a device used during breast cancer surgery to identify positive margins, enabling immediate resection, and reduce the need for re-excisions. “When using MarginProbe on about 50 of our breast cancer patients, I’ve found that it dropped my re-excision rate from about 21 percent to 10-11 percent. This tracks with other results I’ve seen. As we are adding two additional surgeons to our program, I’m looking forward to comparing their results to mine.”
Erica Giblin, MD
- Medical Director, Breast Care Services – St. Vincent Medical Group, Indianapolis IN, Carmel, IN
- Breast surgical oncology fellowship at Anne Arundel Medical Center, Annapolis, MD and Johns Hopkins Medical Center, Baltimore, MD
- Cardiothoracic surgical residency at the Medical University of South Carolina, Charleston, SC
- General surgery residency at Tufts University School of Medicine, Baystate Medical Center, Springfield, MA.
- Medical degree from State University of New York, Upstate Medical University, Syracuse, NY
Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of Dune Medical.