Breast Cancer Detection Today: An Opinion

Philip R. Karsell, MD, John J. Gisvold, MD, and David F. Reese, MD Rochester, Minnesota

The family physician, more than most other physicians, is faced with rapidly increasing demands for breast cancer screening. The old standby, physical examination, is now accompanied by mammog­ raphy, xeromammography, and, more recently, thermography. In this paper, we present our opinion, based on the collective experience at the Mayo Clinic, regarding the use and effectiveness of the several modalities, including mammography, xeromammography, and thermog­ raphy, available for detection of breast cancer today.

Never before has awareness of several decades in spite of a steady routine physical examination, and usu­ breast cancer been so great. The decline in the general death rate over ally there will be no abnormal number of women specifically seeking the same period1 suggests that the findings. Increasingly often, he will be breast evaluation at the Mayo Clinic, varied therapeutic approaches over the asked to evaluate an abnormality and undoubtedly elsewhere around years have failed to provide the key to detected by the patient during self- the country as well, has almost cure. examination. Occasionally, an abnor­ doubled since the end of 1974. This Strax and his associates2’4 started a mality will be discovered during the surge in public interest was at least carefully controlled breast-screening course of mammography or thermog­ punctuated, if not prompted, by the program in 1963. Their program raphy in an asymptomatic and other­ fact that the wives of our president basically involved two groups of wise healthy patient. and vice-president both underwent women, one a control group that mastectomies within weeks of each received regular care and the other a A Reasonable Approach other. study group that underwent periodic What is a reasonable approach to Carcinoma of the breast is the physical examinations and mammog­ detection of breast cancer? Which major cause of death from malignant raphy. The early results in these patients should be seen often, and disease among women in the United study groups are the first ever to which ones can possibly be seen less States today. The fact that the death demonstrate a decreased mortality rate frequently? How helpful are mammog­ rate from this disease has remained for breast cancer, which certainly is an raphy and thermography? essentially unchanged over the past exciting turn of events in light of past Self-examination by the patient has experience with this disease. been and remains the most frequent The family physician, more than detector of breast cancer. Three of From the Department of Diagnostic Roent­ any other member of the health care four breast cancers seen at the Mayo genology, M a y o C lin ic , R ochester, M in n e ­ team, is faced daily with the task ot Clinic in 1972, and even a greater sota. Requests for reprints should be ad­ dressed to Dr. Philip R. Karsell, Department breast evaluation. Many times this will percentage in some series, were initi­ of Diagnostic Roentgenology, Mayo Clinic, ally detected as abnormalities by the Rochester, M in n 5 5 9 0 1 . take place during the course of a

4 0 7 THE JOURNAL OF FAMILY PRACTICE, VOL. 2, NO. 6, 1975 patient. Obviously, in concert with the about the associated radiation dosage. breast for significant abnormality. American Cancer Society, we as a The radiation concern is for the breast Carcinoma of the breast is bilateral in profession should continue to promote tissue itself, and not the gonads, seven to eight percent of cases and regular breast self-examination. because with carefully performed simultaneously bilateral in about two Periodic examination by a physi­ mammography, there should be little percent of cases. The clinically suspici­ cian — most often a family physician or no radiation to the body except for ous lesion may be only one of several — is also important. One cancer in six the breasts. The exact long-term signif­ abnormalities in the breasts and, in our 1972 series was detected by the icance of repeated small exposures to indeed, may be benign when a clini­ initial examining physician and was roentgen rays is unknown but a cally occult malignancy also is present. previously unknown to the patient. cautious approach is indicated. In our P atients who have undergone There are many opportunities for pro­ practice we are using the techniques mastectomy are at high risk and fessional breast examination during that require the least radiation should have routine mammography, at the course of a family physician’s day. exposure but still give meaningful least annually. Some physicians believe Advantage should be taken of these results. such examinations may be indicated occasions to detect early breast cancer. even more frequently. Mammography was first performed Who Should Have a Mammogram? The significance of a positive family in 1913, by Salomon, on a series of Mammography is not indicated as a history of breast cancer has been mastectomy specimens. Its use waxed routine screening measure in women widely studied and debated. We cur­ and waned over the first half of the less than 40 years of age. Women in rently believe sufficient evidence is century until Egan,5 in 1960, intro­ this age group have a low incidence of available to make this a high-risk duced a clinically useful technique, breast cancer. They also have signifi­ factor, especially when a primary reporting a 99 percent accuracy in the relative, namely, a mother, sister, or diagnosis of carcinoma. Since that cantly more dense breast tissue, as a rule, than older women; and mammog­ daughter, is involved. Annual mammog­ time, and increasingly so today, raphy is less accurate in this group raphy is indicated in such patients. mammography has been an accepted because of this dense parenchyma.6 Patients with large or lumpy, so- procedure in the diagnosis of breast In women older than 40, routine called fibrocystic, breasts or both are disease. screening by mammography, in addi­ not necessarily at high risk, but their One of the major drawbacks with tion to physical examination, is good breasts are often difficult to examine. mammography has been its lack of Mammography is a valuable adjunctive medical practice, even when they are widespread availability. More radiol­ asymptomatic. Currently, we recom­ procedure to physical examination in ogists are now performing mammog­ mend such screening on an annual basis. these patients. raphy, so it should soon be generally The whole problem of breast screening Finally, the worried patient should available in most areas. It provides the is being studied extensively, and it be allowed access to routine examina­ physician with an additional method may be that in the near future we will tion. It is always surprising — and a bit of evaluating both the symptomatic recommend less frequent examination, disturbing — to note how often pa­ and the asymptomatic breast. Mam­ especially in certain categories of tients sense the presence of an abnor­ mography is a difficult technique that mality in the face of a negative clinical women. Different frequency patterns needs the constant attention of a may be indicated for different cate­ evaluation. radiologist. Accuracy of detection of gories of women. Regular study of We believe mammography is pri­ carcinoma by means of mammography certain groups of women at higher risk marily an examination for cancer. The averages about 85 percent in reported and only occasional mammography in major goal of the study is to find series, and about ten percent of others may prove to be as effective as malignancy that is not suspected cancers found at mammography will attempting to screen all women every clinically. An attempt is made to have been clinically occult. year. Routine annual screening of all identify and evaluate all significant Frequently, malignancies found at women over the age of 40 is breast lesions. Some of these will be mammography will be smaller than impossible at this time owing to the obviously malignant; some will be those discovered by physical examina­ tremendous number of patients to be highly suspicious but not definitely tion. As with other cancers, smaller examined. malignant; and some will be indetermi­ lesions have a lower incidence of nate. We attempt to classify each such regional metastases, and the rate of lesion as malignant, probably malig­ survival is improved. At the present High-Risk Patients nant, indeterminate, probably benign, time, patients with carcinoma of the So-called high-risk factors for breast and benign and to convey our impres­ breast without axillary nodal metas- cancer are continually sought. A few sion to the referring physician in a n tases at the time of mastectomy have areas of general agreement prevail. concise, straightforward report. the best chance of survival. There are patients, generally thought Whenever possible, new studies We believe that mammography is to be at higher risk, for whom we should be compared with previous the best technique available today for recommend mammography at regular examinations. We often suggest a diagnosing breast cancer at a curable intervals, generally once a year. follow-up study in a few months for stage. In our practice it is used in We believe any patient who is to more complete evaluation of a process studying both symptomatic and undergo surgical breast biopsy should that may not be biopsied at the time. asymptomatic women. All forms of undergo mammography. This not only Mammography is most accurate in mammography require roentgeno­ will evaluate more fully the suspicious the fat-replaced breast, usually in grams and there is an ongoing concern breast but also will survey the opposite women who have borne children, and

4 0 8 THE JOURNAL OF FAMILY PRACTICE, VOL. 2, NO. 6, 1975 especially when they reach post­ activity - inflammation, abscess, be­ of all diagnostic breast biopsies done menopausal age. In totally fat-replaced nign or malignant neoplasm - may breasts, mammography should be vir­ at the Mayo Clinic result in a diagnosis result in an abnormal thermogram. On of carcinoma. tually 100 percent correct in the the other hand, if the abnormally diagnosis of carcinoma. Accuracy in warm blood drains into deep veins Conclusions detection is less in the dense only, there may be no detectable parenchymal breast, most commonly thermographic abnormality. What then is a reasonable approach to detection of breast cancer? We seen in premenopausal women. This Thermography is reported to be 61 suggest the following: type of architecture also is seen more to 80 percent effective in the detec­ E Promotion and encouragement of often in nulliparous women of all ages. tion of breast cancer.8,9 Isard and regular self-examination of breasts for associates8 suggest that even though all patients. Two Important Points an average 70 percent detection rate 2. Periodic breast examination of all Two very important points need to may not equal the percentage detected patients by a physician. be stressed: (1) mammography can by physical examination or by 3. Annual mammography for high-risk demonstrate breast cancer that is not mammography (82 percent and 85 patients. percent, respectively, according to the clinically detectable and (2) a nondiag­ 4. Routine screening mammography same article), thermography still has a nostic mammogram should never deter for as many asymptomatic patients place in breast screening. They stated, one from biopsy of a breast that is over 40 years of age as can be for example, that routine screening clinically suspected of containing a accommodated (on an annual basis with thermography followed by cancer. until the whole concept is replaced by Xeromammography is a technical sending all patients with suspected a better one). modification of the conventional tech­ malignancy on to mammography will 5. Thermography, where available, nique in which a charged plate is increase the cancer discovery rate at used in conjunction with mammog­ exposed in place of x-ray film. Electri­ mammography threefold. Such an raphy at each examination. cally charged blue powder is then approach would certainly decrease the 6. Expeditious biopsy of any sus­ dusted over this plate, and the re­ radiation exposure to women and picious lesion. sulting image is transferred onto would make mammography much Hopefully, in the near future, a safe plasticized paper by a combination of more available to problem patients. and highly effective mass screening pressure and heat. Because of the Thermography is still a new exami­ method will be determined for early physical properties of this system, the nation modality in our practice. We detection of breast cancer. At the imaging capabilities are slightly differ­ have not used it long enough to offer a moment, however, we physicians must ent from those of film. Xeromammog­ valid conclusion regarding its useful­ make optimal use of the techniques raphy has been acclaimed superior to ness in breast screening. Our initial currently available to evaluate the film techniques by many mammog- impression is not as favorable as that breast, reassuring those patients with raphers. Unequivocal scientific evi­ of some thermographers. At this benign disease and bringing to earlier, dence for this is not available. Both clinic we do both thermography and more effective treatment those with a film mammography and xeromammog­ mammography on all patients sent to malignancy. raphy are acceptable techniques when us for breast evaluation. We do not feel done properly. We use both techniques justified in using thermography alone at present, with xeromammography as an initial screening tool since we References being used in about two thirds of our have a large mammographic capability. 1 . Health Resources Administration, Where such a capability does not exist National Center for Health Statistics: Vital cases. and Health Statistics: Mortality Trends for and where thermography is available, Leading Causes of Death, United States 1950-69. Series 20, Number 16. Rockville, its use in conjunction with physical Md, US Department of Health, Education, What About Thermography? examination should be better than and Welfare, March 1974, pp 60-63 2. Shapiro S, Strax P, Venet L: Evalua­ Thermography has received much physical examination alone. Such us­ tion of periodic breast cancer screening with publicity in recent years. It is based on age, however, will result in a large mammography. JAMA 195:731-738, 1966 3. Shapiro S, Strax P, Venet L: Periodic the finding that blood leaving an active number of women with positive breast cancer screening in reducing mor­ process is warmer than blood leaving thermograms, and facilities must be tality from breast cancer. JAMA 215:1777- 1 7 8 5 , 1971 surrounding tissue and that the veins available to do mammography on such 4. Strax P, Venet L, Shapiro S: Value of patients. The place of thermography in mammography in reduction of mortality draining such a process will be notice­ from breast cancer in mass screening. Am J ably warmer thermographically. Its the early detection of breast cancer Roentgenol Radium Ther Nucl Med 117:686-689, 1973 appeal lies in the fact that no irradia­ has not been established in our 5. Egan RL: Experience with mammog­ opinion. Until it is, we will continue to raphy in a tumor institution: Evaluation of tion of the breast is required. Infrared 1.000 studies. Radiology 75:894-900, 1960 emissions from the patient are de­ offer it to our patients as an additional 6. Karsell PR: Mammography at the approach to early detection of cancer. Mayo Clinic: A year's experience. Mayo Clin tected and recorded. Thus we get an Proc 49:954-957, 1974 idea of the amount of heat present on In spite of the fact that physical 7. Payne WS, Taylor WF, Khonsari S, et al: Surgical treatment of breast cancer: the surface of the breasts. examination, mammography, and per­ Trends and factors affecting survival. Arch haps thermography are effective ways Surg 101 :105-113, 1970 Thermography only detects heat 8. Isard HJ, Becker W, Shilo R, et al: emissions and records temperature to evaluate a breast abnormality, it Breast thermography after four years and must be reemphasized that surgical 10.000 studies. Am J Roentgenol Radium differences, however. It cannot differ­ Ther Nucl Med 115:811-821, 1972 entiate between types of lesions. Any biopsy is the only definitive diagnostic 9. Byrne R: Thermography Training Course, February 1975 (unpublished data) process causing increased metabolic procedure. Between 25 and 30 percent

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