Thursday, June 14, 2018

Mammogram : Getting it right matters

Master health checks have become very attractive for providers and patients. A set of tests are put together under various packages ranging from 600 rupees to 25,000 or called bronze, silver, gold, diamond and platinum checks!!!

A mammogram or ultrasound or both are thrown in for women depending on age.

mammography in chennai

The films and reports are usually packaged very nicely and given to the patient. The interpretation, reporting, and discussion of the results are usually discussed by general medical or gynaecology colleagues. They may not be equipped with the decision making tools and hence the patient is left with a lot of anxiety and stress seeking second or third opinions.

What can go wrong with Mammograms?


1. Technology:

Using the right technology has its advantage. Digital technology, tomosynthesis, workstation that has a high resolution helps in spotting early disease. There are tools to measure breast density and computer-aided diagnosis which add to the information.

The newer machines also deliver less radiation dose and the resolution is fantastic. Like the 18 megapixel camera as against the 3-megapixel cameras of the earlier versions.

Many centres may not have all the facilities. Although this is a disadvantage, a good mammogram can still be done with older analog machines with a little attention to detail.

Older machines have to pass the QA and QC and calibrated periodically to ensure radiation dose is not exceeding the permissible limits and safety. AERB monitors these details. But seldom these are done properly.

2. Technique of performing mammogram

A. Compression: Unfortunately the test involves some breast compression which might be uncomfortable. The compression can last up to 4 to 5 seconds.
If the compression is inadequate then the image quality will suffer.

B. Positioning: The entire breast has to be included in the study. If the whole breast is not included then parts of breasts will not be imaged. There is a risk of missing details or cancer in the area which gets missed out in the image. This leads to a false negative mammogram. A missed opportunity to detect cancer. So the technologist’s role is very important in ensuring a good mammogram.

It can be very intimidating for a woman to undress in front of a stranger in a cold room for the procedure. As rule mammograms are always done by a lady technologist. A good technologist can make the entire procedure comfortable and painless for the patient.

C. Interpretation: the mammograms should be read in a room where there is very little distraction with suitable lighting. The monitors displaying the images should be medical grade monitors with resolution of at least 5 megapixels.


What the mind doesn't know the eyes cannot see.

Training to understand the normal anatomy, physiology, pathology and imaging features is important to recognize the various breast conditions.

mammography in chennai
Mammographic interpretation needs specialist radiologists. Otherwise, there is a serious risk of missing cancer diagnosis and creating false alarms. It is also important to compare with previous studies to see if there is any new change.

Diagnostic mammograms in conjunction with breast ultrasound and MRI sometimes will give all the necessary information to plan surgery.

Even in the best of health, there is a 10% probability of missing cancer, therefore mammograms should not be just another master health check. And when cancer is diagnosed mammogram provides a roadmap for further surgical planning.

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Wednesday, June 6, 2018


Breast cancer is the most common cancer affecting women in India. About 1 lakh new cases are being diagnosed every year in India. Majority of them present at a very advanced stage and consequent to this the morality is also very high.
Lack of awareness, reluctance to see medical professionals, fear of diagnosis, fear of losing the breast, fear of treatments like chemotherapy or radiotherapy are some of the reasons why women do not seek medical attention early.
Western world amidst debates about the benefit of screening started screening program in the 80’s and 90’s. A significant stage migration has been observed in countries where screening is done. Besides breast surgery has developed as a specialty in its own right in most parts of the western world. It is no longer a situation of where a surgeon is a jack of all trades operating from head to foot. Organ-based super specialization has lead to better outcomes in patient care.
Cancer care and its outcome in India is a lottery. About 50% of breast cancers that we see in the Metros are stage 1 and 2 breast cancers that are suitable to have their breast preserved. Nearly half of this group will have a mastectomy rather than breast preservation surgery for various reasons. An unconvinced surgeon about breast preservation is not likely to offer this procedure to his or her patients. There are myths among medical fraternity that,
  • Indian patients are not suitable for breast preservation and reconstruction.
  • Breast preservation surgery is associated with increased recurrence.
  • Indian women are not concerned about the body image as much as western women do.
  • Fear in the surgeon's mind that the woman may not come for regular check-ups after the procedure.
Surgeon’s awareness, and developing a specialty training in breast surgery is crucial to dispense with these myths. Positive versus negative counseling by a surgeon is an important factor in improving breast preservation rates.
Besides the surgeon factor, socioeconomic factors influence the decision for having a mastectomy rather than a breast preserving operation. Breast preservation entails radiotherapy subsequently and this involves time and money. Most patients in tier 2 and 3 cities do not have access to these treatments and cannot afford to stay in Metros for prolonged periods ( 3-5 weeks) for radiotherapy. This factor sways the decision in favor of mastectomy over breast preservation.
Another major influence in the treatment process is that the women rarely participate in the decision-making process in most families. It the husband or the near and dear who decide for the patient and it is often a case of mute acceptance of her fate and undergoes a mastectomy.
Breast reconstruction after a mastectomy again is largely ignored by both the oncosurgeon and the patient. Factors like availability of plastic surgeon with adequate training and multi-specialty involvement in the management influence the reconstruction rates after the mastectomy. Another major hurdle is our medical insurance procedures. Medical insurance companies consider breast reconstruction after a mastectomy as a cosmetic procedure and hence will not reimburse the same.
After a mastectomy there is very little support or help given to a woman to cope with a loss of her breast, many are not aware of the availability of prosthesis that can be used to improve body image. Faced with the deformity that occurs from a mastectomy, many women withdraw from social life and have a very poor quality of life after breast cancer surgery.
Improvements in public and surgeon awareness are likely to reverse the trend in the stage at presentation of the disease as well as the outcomes of the treatment.
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Today’s newspaper headlines reported that “fewer women needing chemotherapy” and another said, “70% of breast cancer patients do not need chemotherapy”. This caused a lot of confusion. I was inundated with phone calls and my clinic was flooded with concerned patients and /or their relatives wanting to check whether they should continue chemotherapy.
Let’s understand the context clearly. Before the advent of genomic tests, we traditionally used tumour size, grade, lymph nodal status and hormone receptor status to decide the need for adjuvant chemotherapy for early breast cancer (stage 1, 2 a). With the advent of genomic tests (i.e. Oncotype Dx etc ), we were able to stratify the patients with early breast cancer into a low, intermediate and high-risk group. By risk, we refer to the possibility of developing a recurrence of the breast cancer. The high risk group would be recommended chemotherapy. The low risk group will not need chemotherapy as the potential risk of relapse is very negligible.
The grey area is the intermediate risk group. It is frustrating for patients and clinicians when a definite answer cannot be provided, that too after spending a lot of money on these tests. We ended up individualising again based on the traditional prognostic factors like age and tumour size.
The results of the tailorX study which was published a few days back addressed this group. Patients falling in the intermediate risk category were randomized to chemotherapy and no chemotherapy treatment arms and after 9 years of follow up the recurrence rates were analysed and presented on June 3rd, 2018. According to this study results, in a select group patients with receptor positive, node negative early breast cancer who fall in the intermediate category adjuvant chemotherapy will not add to benefit over hormonal therapy. Chemotherapy can be avoided in this group.

So, this recommendation will not apply to her2 positive, triple negative and node positive patients.

To stratify the risk, genomic tests like Oncotype DX (which was used in this study) will have to be done. The paraffin block of the tumour tissue is sent to the lab in USA (this test is currently done only in the USA) and it takes about 3 weeks to get the result. It costs roughly about 4000 USD (ie) 2.72 lakh Indian rupees.
A vast majority of our patients in our country are diagnosed at an advanced stage. The relapse rates are higher in advanced breast cancer and therefore chemotherapy is still a very essential component of the treatment protocol. Contrary to this, in the western world, the vast majority of breast cancers are diagnosed early. Genomic tests and selectively administering chemotherapy based on risk based on genomic tests are widely practiced. Sadly this cannot be applied to a great majority of our patients because of the advanced stage at presentation and the costs of these tests.

Is there an alternative method to stratify risk?

In addition to traditional prognostic factors like tumour size, grade, lymph nodal status we look at the estrogen receptor (ER), progesterone receptor (PR), Her2 and Ki 67 values. The ER, PR, Her2, and ki67 together are tested currently by immunohistochemistry. Together they could potentially closely reflect the Oncotype dx risk stratification. It could be the poor man’s alternative to Oncotype dx.
The challenges with IHC 4 tests is with the subjectivity of Ki 67 values. Less expensive test kits which have more objective Ki 67values could be the answer and these have to be validated in clinical trials with Oncotype dx.
Breast cancers are heterogeneous. The treatment is largely individualized and the one size fits all is probably not applicable anymore. But one has to be very cautious when reporting results of these studies in the print and visual News media. The headlines like” 70 % of breast cancer patients will not require chemotherapy” can lead to misunderstanding on the part of patients and there is a serious risk of patients skipping chemotherapy and dropping out of treatment and follow up which result in poor survival outcomes.
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