In her interview, Dr. Tegulapalle takes the viewer through the various tests involved in diagnosing breast cancer. When should you start your annual mammograms and how does family history and gene testing impact that decision. You will learn about the importance of annual mammograms, as well as breast ultrasounds, breast biopsies and MRIs.
I’m Dr. Laksimi Tegulapalle. I’m a radiologist. I specialize in breast imaging. I went to college at Michigan and Michigan State University at the College of Osteopathic Medicine. I did my residency in Chicago at Cook County Hospital and I did my fellowship at North County Hospital in Chicago.
My job is essentially to diagnose breast cancer in women as early as possible. So, primarily that involves screening mammography and ultimately, if there is an abnormality; it involves biopsies and further evaluation usually with breast MRI. If a patient feels a change in their breast examination, there’s a new lump or skin changes or a thickening that they feel; they should bring this to the attention of their primary care physician and their primary care physician can do a physical examination. At that time, if there is a persistent abnormality; that patient needs to be seen as a diagnostic evaluation so we can do a mammogram or ultrasound as needed for the individual. So if there is a change in your physical examination, the first step is to call your primary care doctor so that they can evaluate you. Women often feel changes in their breast tissue over the course of their menstrual cycle. Any abnormality that seems out of the norm for you…if this is a change that is different from what you have noticed in the past; this is information that is important to take to your primary care doctor so that they can evaluate you.
We know that mammography saves lives. It is the single best test to evaluate for early breast cancers. There has been some controversy as of late, as to when to start screening mammograms and as to how often. We start screening at the age of 40 and continue on, on a regular basis for as long as necessary, and we think that they should. Because we know that the breast cancers that are diagnosed in these kind of women tend to be more aggressive breast cancers and that this is looking at morbidity; it’s not just looking at mortalities from breast cancer but what happens to these women when they’re 45 as to not being diagnosed until they’re 50. Women who have a strong history of breast or ovarian cancer may need to have screening mammography earlier. So, we look really at women and their primary first degree relative. So their mother, or sister. So if you have a mother or sister within the age of 50, we recommend that the daughter be screened 10 years younger than when their mother was diagnosed. So if their mother was diagnosed at 45; we really recommend they start screening at 35. So another thing to remember is, more women are diagnosed with breast cancer that don’t have a family history of breast cancer. Just because of the sheer number of breast cancer diagnosis. So not having a family history doesn’t protect you.
Genetic testing is an informative tool for us but it's not the only factor that we take into consideration when we tailor imaging screening to the patient. So, our goal is to increase the screening or to add to the screening for women who have an elevated risk of developing breast cancer. That elevated risk can be from having a strong family history and also having genetic mutation or it may be from having a strong family history but not having the genetic mutation. So, regardless of what it is that causes us to know that they have an elevated risk, we will alter or tailor the screening, that is, to the patient. So, for women who do have a genetic mutation abnormality, such as BRCA, then those women we know without a doubt that they need additional screening…meaning they have the mammogram but also have breast MRI. But there are women who have an elevated risk that don't have the genetic mutation, so for those women we also recommend additional screening.
Genetic testing is an informative tool for us but it's not the only factor that we take into consideration when we tailor imaging screening to the patient. A mammogram is essentially an X-ray of the breast. It helps us look at the breast tissue and evaluate for the possibility of breast cancer. The screening mammogram generally involves two images of each breast so it's essentially like a photograph of their breast. It does have radiation. It's a limited radiation and it helps us determine what the breast tissue looks like and if there is any abnormality. It's very useful for us as radiologists to compare current mammograms to old mammograms. That way we evaluate if there's any subtle changes occurring in the breast tissue. And we look for a number of factors on the imaging, not only masses that may have developed but also calcification and some distortion in the breast tissue itself.
Breast density really is a term that we use to describe how much glandular tissue is in the breast and the ratio compared to how much fatty tissue is in the breast. All women’s breasts are composed of fatty tissue and glandular tissue. But there is a range for women. On all mammography reports we describe the density of the breast tissue. That’s part of the information that needs to be used to evaluate whether or not additional testing is worthwhile for this patient. So if a woman does have extremely dense breast tissue, which makes our job a little bit more difficult in reading the mammogram; we may describe that and then add additional testing for that patient. But, it’s not necessary for all women who have dense breast tissue to have additional testing. We evaluate those mammograms, we compare it to their prior mammograms and if there is an abnormality; we do what we call is a callback. We bring the patient back for additional imaging. We bring the patient back for additional imaging, which may include more X-ray, more mammograms, or it may include ultrasound or both. Whey they're brought back as a callback, that is generally called a diagnostic mammogram. That's where we tailor the mammogram to evaluate the specific area that we were concerned about on the screening study itself. So that may mean one image or more images and it may or may not include ultrasound. If at that time there is an abnormality, then we'll decide whether or not it's something warrants biopsy.
Screening mammograms are done on an entire population of women so sometimes there are what are called false-positives, meaning the mammogram shows an abnormality that turns out to be completely normal breast tissue or a benign finding that has nothing to do with breast cancer and does not confirm an increased risk of developing breast cancer. So that's often what people hear when we say false positive. There is anxiety to being brought back for additional studies. There is a lot of anxiety about breast cancer in general. We hope to keep women at ease until there is something to be concerned about and to understand what the real risk is, and if a screening mammogram is positive, in that there's an abnormality, that does not mean necessarily that it's positive for breast cancer, but we need to do additional tests to find out.
The ultrasound; much like when women have ultrasounds when they are pregnant uses sound waves to traverse the tissue and look for any abnormalities. It shows slightly different information than the mammogram itself does. The ultra sound is used only when we think that it can provide additional information to what the mammogram has already shown us. We also use an ultrasound whenever a women or a woman’s doctor notices a new change in her clinical exam. Including possibly a mass, if you and your doctor notice a mass in your breast, then we will possibly use a mammogram to evaluate it but also use ultrasound because an ultrasound helps us determine the nature of the mass itself.
MRI may be used as a screening tool for the breast in those women are at high risk for developing breast cancer, but it's also very useful in terms of evaluating the extent of the disease when a woman is diagnosed with breast cancer. So, if a woman is diagnosed with the breast cancer, for example, in the left breast, we will do the MRI to evaluate both breasts so we can determine how much tissue is involved but also to screen the opposite breast. We know that sometimes, in a small percentage of cases, breast MRIs can show us additional findings, even in the opposite breast, that are concerning that they're not able to be appreciated on mammogram or ultrasound alone.
So, each woman doesn't have the exact same type of mammogram. We do tailor the mammogram to fit the woman herself. If at the time of the mammogram and ultrasound, if we see a finding that we think warrants a further tissue analysis, then we would recommend a biopsy. Biopsies of breast abnormalities can be performed with ultrasound; they can be performed with mammography, which is what we call stereotactic biopsy, or with MRIs-guided. A stereotaxic-guided biopsy actually just means that the abnormality is best seen with mammogram and therefore we use mammogram or X-ray to target the area for biopsy itself. So, for most women, most times stereotactic biopsies the women will be laying on her stomach; the breast comes through a small opening in the table; and the X-ray unit is below her. She again will be awake and alert through the whole procedure. We don't give the patient anything that makes them sleepy or drowsy so they can drive to the procedure and drive home if necessary. It's nice if they have someone there with her but it's not required.
Our goal when we do a biopsy is to obtain a small piece of tissue from the area that was abnormal so that the pathologist can analyze it and give us a definitive diagnosis. Whether that is done in the outpatient setting, radiology guided, or through surgery is a decision to be made based on each individual. If we're able to see the abnormality with ultrasound, we most often will attempt to do an ultrasound-guided biopsy. What does that mean? It means that the woman, whose been laying on her back in the same position she's in when we do the ultrasound analysis itself, that she's awake and alert the whole procedure. We don't give her any medication that would cause her to be sleepy or drowsy so oftentimes she's able to come to the office and leave the office on her own. It's not required that she have someone there with her. We give local anesthesia, generally lidocaine. We place the needle into the breast. That initial needle will be felt, but once that medication takes effect, which is very quickly, they should not feel anything sharp, and they will only feel the discomfort of us working. Watching the ultrasound, we take a few samples through the abnormality itself. Oftentimes we'll mark the area with a small metal clip that goes inside the lesion. That clip will stay in place unless surgery is needed and then it will be removed at the time of surgery. It's there as a marker. It helps us know that this area was biopsied, and if there is a malignancy, then helps us know the area exactly to treat. It's something that we can see on the mammogram so on all future mammograms you'll know that this area was previously biopsied, and we're able to put that in our analysis, as well, when we do future mammograms. Generally speaking so this is something that's going to vary from center to center, but generally speaking pathology reports are available at our center within one to two business days. We'll know at that time whether this is a malignancy, whether it's a benign finding, or if it's something that we call atypical. What treatment is needed depends on the specific pathology itself. When the radiologist does the procedure, we also look at the pathology report; we go back and review all the imaging; and we make sure that the pathology findings fit or match what we would have expected from the imaging. If it doesn't, then additional testing might be needed, and at that point we may send the patient to a surgeon to just have the area removed if that's necessary.
So the procedure itself can be very anxiety provoking for our patients. We know that. Women are anxious to start with about the possibility of having a breast cancer. The procedure itself is often an unknown. We like to warn patients of what the next step is; prepare them for the next step along the way; but sometimes the equipment itself makes some noises or often there's a clicking sound. Again, we like to prepare them, but the anxiety itself or the stress of the procedure itself can sometimes make the procedure more uncomfortable. But it's important for patients to communicate with their radiologist during the procedure; if they're uncomfortable or they're feeling anything that anything painful, to let us know so we can try and address that without just going through the procedure without addressing it because no radiologist wants their patient to be uncomfortable during the procedure. And we understand that it's a stressful procedure for the patient. The patient should expect some bruising or some discomfort. Women bruise to different degrees, so for some women there may be little to no bruising, and for some women there may be more bruising but if there is any excessive pain or discomfort or if there's any bleeding, then they should contact the radiologist or the center to find out what the next step is. We encourage women, as radiologists to bring forward any changes they experience.
Breast cancer diagnosis and treatment has improved a great deal. And we know that by diagnosing breast cancers earlier that the treatments are both tolerated and women do better. Most of us know women who were diagnosed with breast cancer and most of those women do really well. Our goal is to diagnose these cancers as early as possible so that women can have treatment and go on leading productive lives.