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RSNA News - September 2004RSNA Hosts Media Briefing on Women's Breast Health
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| (from left) Stephen A. Feig, M.D., Philip O. Alderson, M.D., Etta D. Pisano, M.D., Steven A. Harms, M.D., Stamatia V. Destounis, M.D., and Robert R. Kuske, M.D. |
Nearly 40 medical news reporters participated in RSNA's media briefing on women's breast health in late July at Mount Sinai Hospital in New York City as five imaging experts presented the latest information about breast cancer screening, diagnosis and treatment.
Some of the reporters, from organizations including The Wall Street Journal, New York Daily News and Fitness magazine attended the briefing onsite, while others, including reporters from CNN, The Chicago Tribune and Atlanta Journal Constitution, participated in the Webcast or audio conference.
Hedvig Hricak, M.D., Ph.D., RSNA Board Liaison for Publications and Communications, told the reporters that through their stories, the public will understand that quality care begins with quality diagnosis, and that radiology is the driving force behind the rapid development of image-guided radiation treatment and follow-up. "Radiologists and breast imagers are the unsung warriors of finding cancer. Together, they have changed the course of breast cancer diagnosis and treatment," she said.
Philip O. Alderson, M.D., vice-chairman of RSNA's Public Information Committee, moderated the briefing.
Breast Cancer Screening
Stephen A. Feig, M.D., a professor of radiology at the Mount Sinai School of Medicine and director of breast imaging at Mount Sinai Hospital, explained the importance of annual screening mammography for women over the age of 40.
"The stage of breast cancer at diagnosis has changed remarkably," he said. "Ductal carcinoma in situ (DCIS) used to be almost a rarity. In 1980, DCIS accounted for only three percent of all breast cancers. In the latest survey, 2001, 21 percent of all new breast cancers in the United States were DCIS."
Dr. Feig explained that as a result of diagnosing breast cancer early, the mortality rate from breast cancer has gone down. While the latest figures show that 70 percent of American women age 40 and over have undergone mammography in the past two years, Dr. Feig urged healthcare providers, including primary care physicians and employees of mammography centers, to get the word out to more women about the importance of screening mammography. "Initiatives need to be explored, such as annual reminder cards like the ones received from the dentist," he said, adding that more also needs to be done about increasing reimbursement, increasing the number of breast imaging specialists and increasing the number of mammography centers.
New Screening Technologies
Etta D. Pisano, M.D., director of the Biomedical Research Imaging Center at the University of North Carolina in Chapel Hill, described ongoing trials of imaging technologies being considered for breast cancer screening.
Among those trials is the Digital Mammographic Imaging Screening Trial, the largest trial to compare digital mammography with screen-film mammography. Dr. Pisano said the results of this trial will be available next spring. "We are looking very carefully at those results. We are in a follow-up period right now," she explained. "We believe this study will be powerful enough to tell whether digital mammography is better, the same or worse than film in finding breast cancer in an average-risk population."
Investigators also will determine cost-effectiveness and quality-of-life measures. "It is possible that digital may not be significantly better than film in finding breast cancer, but if we can reduce false-positives or we can reduce costs, that might be an important reason to implement screening with digital mammography even if the diagnostic accuracy is no different," she said.
Dr. Pisano also described the Contralateral Breast Screening with MRI trial, the Screening Breast Ultrasound in High-Risk Women trial and the Treatment Monitoring with Dynamic MRI trial. These trials are sponsored by the National Cancer Institute through the American College of Radiology Imaging Network.
CAD for Mammography
Stamatia V. Destounis, M.D., a radiologist at the Elizabeth Wende Breast Clinic in Rochester, N.Y., released the results of a retrospective study appearing in the August issue of Radiology showing that a computer-aided detection (CAD) system helped radiologists detect 71 percent of the cancers that were considered missed during a double reading.
"Out of the 52 cancers that we felt we missed, the computer marked 37 (71 percent) one year or more before we found it," Dr. Destounis explained. "Why didn't we find the cancers? About 65 percent were in dense breasts. Identifying breast cancer in dense breasts is challenging—it's like looking through a snowstorm."
Dr. Destounis says CAD has some downsides. For every mark CAD made that turned out to be a cancer, there were two marks that were false-positives. Also, the radiologists consistently found a lot of cancers that CAD didn't even mark. "CAD cannot stand alone. It cannot replace the doctor," she said.
Dr. Destounis and her colleagues are now writing a paper on a prospective study they conducted using CAD.
Brachytherapy
During the last portion of the two-hour briefing, two leading breast cancer specialists described new breast-conserving treatments.
Robert R. Kuske, M.D., from Arizona Oncology Services in Scottsdale, described a technique he pioneered in 1991 that is now gaining a lot of national attention—breast brachytherapy.
Dr. Kuske says brachytherapy has presented "the first paradigm shift in the treatment of localized breast cancer in more than a century." Brachytherapy involves placing tiny radioactive seeds in and around the lumpectomy site after a successful surgical removal.
"By putting radiation snug up against the tissues that harbored the cancer, you can deliver a very highly effective dose of radiation that conforms to the tissues that need it, and avoids exposure to surrounding tissues that do not need it," he explained. "Since the radiation is inside the breast, you can deliver six-and-a-half weeks worth of radiation treatment in four or five days. Brachytherapy has the dual advantage of not just reducing radiation exposure but also shortening treatment time."
Results of a national trial on breast brachytherapy, recently presented at the American Society of Clinical Oncology meeting, showed a three-percent recurrence rate at four years with brachytherapy. "The usual recurrence rate with breast-conservation therapy is one percent per year with external radiation," says Dr. Kuske.
While the results have been very promising thus far, longer follow up and clinical trials, including comparison with other techniques are essential. Dr. Kuske will serve as co-principal investigator of an upcoming Phase III clinical trial comparing brachytherapy with external beam radiation therapy.
Ablation Therapy
Steven A. Harms, M.D., from the University of Arkansas for Medical Sciences, and colleagues have successfully performed more than 50 thermal ablations of breast cancer in patients over the past few years with very positive results.
"Thermal ablation provides, perhaps, a glimpse at the end of the tunnel of what might happen in the treatment of breast cancer, combining two very important emerging technologies—high quality breast MRI and minimally invasive therapy," explained Dr. Harms. "The combination of these two is very powerful in the detection of breast cancer and the treatment of breast cancer without disfigurement."
Thermal ablation is an outpatient procedure that uses local anesthesia. "Most of the patients we treated resumed normal activities the next day," he said. "This is a far cry from what we think of as traditional breast cancer treatment."
There are three types of thermal ablation: radiofrequency ablation, laser ablation and cryotherapy. Dr. Harms' work mainly includes laser ablation guided by MR imaging.
Fifty of the patients Dr. Harms has treated with ablation therapy also underwent subsequent lumpectomy or mastectomy as part of the experiment protocol. Three patients were treated with laser lumpectomy and did not have surgery; there has been no cancer recurrence in these patients at four to five years post follow-up.
Dr. Harms says additional tools, clinical trials and physician training are needed before thermal ablation therapy for breast cancer can become a routine treatment.
The Webcast of the media briefing has been archived and is available on the Internet until the end of October at www.rsna.org/media/briefings/2004/index.html. The press releases, photos and PowerPoint presentations from the media briefing also are available on the Web.
Note: The Institute of Medicine of the National Academies recently released the report, "Saving Women's Lives: Strategies for Improving Breast Cancer Detection and Diagnosis." For more information, go to www.iom.edu/report.asp?id=20721.
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