Undiagnosed Breast Clinic

MD Anderson Cancer Center
Date: 06-29-09  

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Lisa Garvin: Welcome to Cancer Newsline, a weekly podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing your family's cancer risk. I'm your host Lisa Garvin. Today we're talking with Doctor Theresa Bevers, who is the Medical Director of the Cancer Prevention Center here at MD Anderson. Welcome Doctor Bevers.

Theresa Bevers: Thank you.

Lisa Garvin: Today we're going to be talking about a service as the Cancer Prevention Center does provide for women, it's called the Undiagnosed Breast Clinic. Explain what that means exactly.

Theresa Bevers: Well it is for women who have a breast concern that is as yet undiagnosed. So we're talking about women who maybe have found a lump themselves, or their doctor has found a lump in their breast. They maybe have had an abnormal mammogram, or ultrasound, or breast MRI. And further evaluation, and possibly even a biopsy has been recommended. They can come to the Undiagnosed Breast Clinic, and we will do that diagnostic evaluation.

Lisa Garvin: I always thought that when you got a mammogram they could tell you whether it was a benign hyperplasia, or, so you would actually provide more detail than the initial results.

Theresa Bevers: Well the mammogram is, a screening mammogram, the intent of it, is just a quick look at the breast to see if there is some problems that requires further diagnostic evaluation. Now sometimes with a mammogram we are able to identify that the finding on the screening mammogram is completely benign, and no further diagnostic evaluation is needed. An example of that may be if calcifications are found on the mammogram. And these are just deposits of calcium in the breast tissue, which can be related to pre-cancer of breast, but can also be due to benign fibrocystic changes. Sometimes we can get some additional views and say, these are purely benign, related to fibrocystic changes, and we don't need to do anything else about them. But if we were, say, to find a mass on the mammogram, then we need to go to the next step, which is an ultrasound. The ultrasound allows us to distinguish if the mass is a solid mass or if it is a fluid filled mass or cyst. And by that evaluation determine if it needs a biopsy or not.

Lisa Garvin: Is it hard to get a woman to come to a cancer center for that kind of diagnosis and further treatment, as opposed to like a primary care physician?

Theresa Bevers: Actually, many women when they have an abnormality of the breast are very interested in getting into a cancer center, because they're concerned. If this is cancer I want it diagnosed by the cancer center, so I'm set up and ready to go on for treatment. Alternatively, if it turns out to be benign, then I have the reassurance that a specialist has seen this, reviewed it, and has said it is benign, and then I'll feel more comforted.

Lisa Garvin: What sort of services beyond, I mean you've mentioned ultrasound, what other sorts of diagnostic tests would they possibly go through?

Theresa Bevers: Well the vast majority of women who come in, the only testing we need is mammogram with or without an ultrasound. Sometimes we will need to do a needle biopsy of a finding, either on the mammogram or on the ultrasound. A lot of women have concerns about these needle biopsies, saying, if I have a needle biopsy will it spread cancer? We have absolutely no evidence that is spreads cancer, and it enables us to make a more timely diagnosis. And it also leaves more treatment options open to us if we were to find cancer. Some other diagnostic testing that we may consider, although these are much less frequently used is, MRI of the breast, and maybe a ductogram or galactogram to evaluate discharge from the nipple.

Lisa Garvin: I know, too, when we were talking about the needle biopsy, I've heard from black women who are concerned about keloid scaring.

Theresa Bevers: Sure. Sure. That actually would favor doing a needle biopsy, while the puncture site where the needle went in may develop a keloid. If a keloid forms for that, it is almost certainly gonna form for a scar left from a surgical biopsy, and would be a much bigger keloid. So by having the needle biopsy you would get a smaller keloid or potentially avoid it.

Lisa Garvin: How many people do you see in the Undiagnosed Breast Clinic every year here at MD Anderson?

Theresa Bevers:  Well we have 10 appointments every day in the Undiagnosed Breast Clinic, a physician and nurse practitioner work together to see these patients. They have diagnostic testing generally set up on the day that they are seen. So we are able to do a history on the patient, we will do a physical exam. If they have had outside imaging done, we will actually review those films with the radiologist to develop a diagnostic plan or work up that is recommended. Then the patients can go off and have that workup with mammogram, ultrasound, biopsy, whatever may be needed. And then we'll see her back at the end of the day. In some cases, we are able to tell them the diagnosis that same day. Not always. Certain types of biopsies we can get the results the same day. Other types of biopsies take 2 to 3 days to get the results. Of course most women want to know the same day, but the advantage of the biopsy that takes 2 to 3 days is that it actually gives us more information. And based on that we can better determine, sometimes, if it is completely benign or if it is in fact cancer, we can get some prognostic markers from them.

Lisa Garvin: And I know you can probably only ballpark the figures, but would you say that you've caught many cancers in early stages through the clinic?

Theresa Bevers: We, we have. A large number of, of cancers are diagnosed every year in the Undiagnosed Breast Clinic. We see, given the numbers that we have, over 2,000 patients a year on average. There is about a 10 to 13% yield of cancers from that population. So that's certainly much higher than what we see in the average screening population. But clearly the vast majority of women are benign; don't have a cancer. The vast majority of women who do come in are caught early. They are coming in with something that maybe is found only on their annual mammogram isn't even palpable. There are a few women who are coming in at a more advanced stage, but typically they've been aware of this, and there are many different factors that have led to them delaying getting in for evaluation.

Lisa Garvin: What about inflammatory breast cancer? The symptoms are different; it's a much more aggressive disease. Are you able to catch any inflammatory breast cancer cases through the clinic?

Theresa Bevers: We certainly are. We work very closely with our Inflammatory Breast Cancer Clinic that Doctor Cristofanilli runs, in making the diagnosis and getting them in promptly for treatment. We see a lot of women who present with concerns about it possibly being an inflammatory breast cancer, and in fact turns out to not be one. So the vast majority of women I see with that concern don't have that. They have a red breast for some other reason. But we do have a process that we go through to evaluate and work this up. We would certainly get a mammogram, probably an ultrasound, and a punch biopsy of the skin. Because that is where we will often make the diagnosis. By definition, the tumor is in the skin, and that's what makes the breast look inflammatory or inflamed, having that red swollen appearance. So the skin punch biopsy is very important. And so we will almost always do that. But the vast majority of women who come in, even though we do that, we're not able to find any cancer, and it generally turns out to be benign. But we'd rather get the workup done first, so that we're more certain. And then follow them. As opposed to watching them to see if it'll go away, and then find out much later that it was, in fact, an inflammatory breast cancer.

Lisa Garvin: Given the state of mammograms today, there's news saying, they're accurate, they're not so accurate. You know, what is the present state of mammograms today? How often should they be done? How accurate are they? False positives? Etc.

Theresa Bevers: Sure. Sure. And that's a really good question. This has been an area of controversy for many years. There have been numerous randomized control trials done on mammography. And randomized control trials are really the gold standard of testing a screening test to see if it is a good test or not. In fact, mammography is the most studied screening test for cancer that we have, having nine randomized control trials. The design of all the trials were different. The findings differ. So I think anybody could probably go in and slice and dice that information and come up with different conclusions. In general, it is felt by the vast majority of cancer prevention experts and breast experts, that mammography is beneficial. There are studies that have shown that the decline in the, in the mortality rate of breast cancer is due, not only to improved treatments for breast cancer, but also due to earlier detections, specifically from screening mammography. So there is a benefit. Now having said that, it is important to realize that no test, including mammography, is perfect. So the intent of mammography is to have a quick look at the breast to see if there is something that needs further workup. There are certain cancers that are not well seen on mammography. The denser the breast is, the more difficult it is to see an abnormality. That is why it is important to not only get the mammogram, but get an annual breast exam done around the time of the mammogram, and then to do these two things, the breast exam and mammogram, on an annual basis. So if something were missed one year, it would be picked up the next year. I think that there is a misunderstanding among the general population that mammograms should pick up every breast cancer. And they don't. They simply don't. We know that at it it's best it probably has a sensitivity of only around 80,maybe pushing it to 90%, and that's probably the most you could say, and that's probably even stretching it. So that means in any perfect scenario, 10 to 20% of cancers may not be seen. Okay? So, it's important to use multiple combinations of modalities, in this case the breast exam along with the mammogram, to make sure there's nothing that is being missed.

Lisa Garvin: What sort of message should we send to our listeners about the Undiagnosed Clinic? Who would be the best candidates for this? And how do they make an appointment, and so forth?

Theresa Bevers: Okay. Any women who has a breast concern that has not yet been diagnosed, or if they have had a breast concern that has been evaluated and they're not completely comfortable with the findings and wish a second opinion, can call the Cancer Prevention Center at 713-745-8040, and they would select Option 4 for the Undiagnosed Breast Clinic to register to be a new patient and be seen. There are several things that we are gonna want them to collect and bring in, or even possibly send ahead. If they have had any imagining done outside of MD Anderson, such as a mammogram, and or an ultrasound, or MRI, or any other imaging, we will want not only a copy of the report faxed to us, ahead of time if possible, but also bring the actual films in that day, so that we can look at them and see what's going on and better understand the problem. If they have already had a biopsy, it is beneficial to get those slides sent in, so our pathologist can review it. That helps up to provide them the best recommendations of what to do based on what we see.

Lisa Garvin: Great. Well it sounds like the Undiagnosed Breast Clinic is kind of peace of mind for women who are worried about any test they may have gotten about their breast. Do you have any final thoughts about undiagnosed breast and so forth?

Theresa Bevers: Well, I think exactly as you said, that is the goal is to be able to, not only accurately diagnose women, but give them peace of mind. As I mentioned before, the vast majority of women who are seen do not have breast cancer. So the conclusion of our visits will often be to turn to, what is the risk of developing breast cancer, and what would we recommend as far as screening recommendations and risk reduction? Should they consider medications to reduce the risk of developing breast cancer? Women who are seen and don't have breast cancer, do have the option of returning to the Cancer Prevention Center for their annual breast cancer screening if they desire.

Lisa Garvin: Great. Doctor Bevers thank you so much for being with us today. Again, for women who are interested in the Undiagnosed Breast Clinic, that number is 713-745-8040. If you have questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789, or online at www.MDAnderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.