breast cancer

Dr. Jonathan sims, a radiologist with Oregon Imaging Center, looks at a 3D mammogram of a breast cancer patient who has undergone surgery and now shows no signs of the cancer’s recurrence.

Imagine finding a lump in your breast — it’s large, and you can feel it with your fingers. So you go to a clinic for a breast exam, and the doctor sends you to an imaging center for a mammogram.

You expect a quick diagnosis — after all, it’s a large lump — but the radiologist finds nothing on the scan.

The radiologist orders an ultrasound, the next step in breast cancer imaging, but still can’t see it.

The tumor is seemingly invisible, concealed in a web of connective tissue and glands.

That’s what happened to Lisa Van Liefde in 2003, when she was diagnosed with breast cancer at 46 years old.

“That was almost as scary as the diagnosis — knowing that it was there but that it didn’t show up,” she said. “Then the question was, ‘Who knows if had it been there on my previous mammogram?’ It must have been a smaller size and it was missed.”

Van Liefde had something called “dense breast tissue,” a normal physiological condition that increases a woman’s risk of developing breast cancer. It’s common — about half of all women older than 40 have dense breast tissue, according to the National Institute of Health. Younger women tend to have higher breast density, which lessens with age.

Extremely dense breast tissue can make screening for breast cancer nearly impossible.

“The person with dense breasts has an increased number of glandular elements, meaning that their breasts are able to produce more milk — and that’s a good thing — but when it comes to breast cancer, it’s a bad thing,” Dr. Jonathan Sims, radiologist at Oregon Imaging Centers in Springfield, said.

It’s just as important a risk factor as having direct family history with cancer, he said.

Inconspicuous cancers in dense breasts might go undiscovered until they grow large enough to be found in a breast exam. But with the implementation of new screening technologies, risk assessments, increased awareness of breast density risk, and regular self and clinical breast exams, even difficult to find breast cancers can be found early, Sims said.

A game of genetic Russian Roulette

Van Liefde followed the American College of Radiology and Society of Breast Imaging’s guidelines: annual mammograms for all women 40 or older.

The biggest benefit of regular mammography screenings is that higher frequency increases the chances of catching breast cancers at their very beginning stages, when they are smaller and easier to treat, Sims said.

But, like Van Liefde’s case, nothing is simple about breasts or detecting their cancers, he said.

“It’s not just one disease. There are about 15 different types of breast cancer, and they all look different,” Sims said.

Breasts fluctuate and vary more than other parts of the body that get cancer — each woman’s breasts are physiologically unique, and they change throughout a woman’s monthly menstrual cycle and over her lifetime, Sims said.

“So you’re trying to find something that looks variable in a process that is completely variable from individual to individual, and variable within each individual woman based on her lifecycle. That is extremely, extremely complicated,” he said.

In dense breasts, webs of fibrous and glandular tissue block the X-rays of a mammogram, sometimes hiding lurking cancers.

Whenever a cell divides, it must copy over a billion DNA instructions to another cell, according to Dr. Benjamin Cho, oncologist at Willamette Valley Cancer Institute in Eugene.

“When you do that, mistakes can be made. And when those mistakes are made, every once in a while a mistake can cause a cancer,” Cho said. Mutations in cells occur all the time, but most are eliminated by the immune system.

When a woman’s breasts are dense, there are “more and more elements that are participating in the genetic Russian Roulette,” Sims said — meaning she has a higher chance of developing breast cancer.

Navigating Breast Cancer: Dense breasts increase cancer risk, hamper effective screening

Imagine finding a lump in your breast — it’s large, and you can feel it with your fingers. So you go to a clinic for a breast exam, and the doctor sends you to an imaging center for a mammogram.

You expect a quick diagnosis — after all, it’s a large lump — but the radiologist finds nothing on the scan.

The radiologist orders an ultrasound, the next step in breast cancer imaging, but still can’t see it.

The tumor is seemingly invisible, concealed in a web of connective tissue and glands.

That’s what happened to Lisa Van Liefde in 2003, when she was diagnosed with breast cancer at 46 years old.

“That was almost as scary as the diagnosis — knowing that it was there but that it didn’t show up,” she said. “Then the question was, ‘Who knows if had it been there on my previous mammogram?’ It must have been a smaller size and it was missed.”

Van Liefde had something called “dense breast tissue,” a normal physiological condition that increases a woman’s risk of developing breast cancer. It’s common — about half of all women older than 40 have dense breast tissue, according to the National Institute of Health. Younger women tend to have higher breast density, which lessens with age.

Extremely dense breast tissue can make screening for breast cancer nearly impossible.

Navigating Breast Cancer: A month-long series

One in eight women will face breast cancer during their lifetime, each with their own unique and challenging journey to negotiate a path to wellness. For Breast Cancer Awareness month, The Register-Guard is offering each week in October pragmatic information about breast cancer — especially for those at risk — and will provide some insight into the experiences of local women suffering from a diagnosis. This week we look at how screening for breast cancer can be complex. Coming topics will explore how women approach careers and finances while struggling with breast cancer.

“The person with dense breasts has an increased number of glandular elements, meaning that their breasts are able to produce more milk — and that’s a good thing — but when it comes to breast cancer, it’s a bad thing,” Dr. Jonathan Sims, radiologist at Oregon Imaging Centers in Springfield, said.

It’s just as important a risk factor as having direct family history with cancer, he said.

Inconspicuous cancers in dense breasts might go undiscovered until they grow large enough to be found in a breast exam. But with the implementation of new screening technologies, risk assessments, increased awareness of breast density risk, and regular self and clinical breast exams, even difficult to find breast cancers can be found early, Sims said.

A game of genetic Russian Roulette

Van Liefde followed the American College of Radiology and Society of Breast Imaging’s guidelines: annual mammograms for all women 40 or older.

The biggest benefit of regular mammography screenings is that higher frequency increases the chances of catching breast cancers at their very beginning stages, when they are smaller and easier to treat, Sims said.

But, like Van Liefde’s case, nothing is simple about breasts or detecting their cancers, he said.

“It’s not just one disease. There are about 15 different types of breast cancer, and they all look different,” Sims said.

Breasts fluctuate and vary more than other parts of the body that get cancer — each woman’s breasts are physiologically unique, and they change throughout a woman’s monthly menstrual cycle and over her lifetime, Sims said.

“So you’re trying to find something that looks variable in a process that is completely variable from individual to individual, and variable within each individual woman based on her lifecycle. That is extremely, extremely complicated,” he said.

In dense breasts, webs of fibrous and glandular tissue block the X-rays of a mammogram, sometimes hiding lurking cancers.

Whenever a cell divides, it must copy over a billion DNA instructions to another cell, according to Dr. Benjamin Cho, oncologist at Willamette Valley Cancer Institute in Eugene.

“When you do that, mistakes can be made. And when those mistakes are made, every once in a while a mistake can cause a cancer,” Cho said. Mutations in cells occur all the time, but most are eliminated by the immune system.

When a woman’s breasts are dense, there are “more and more elements that are participating in the genetic Russian Roulette,” Sims said — meaning she has a higher chance of developing breast cancer.

At The Cedar Clinic at Oregon Medical Group, another imaging center in Eugene, director and radiologist Dr. Michael Milstein uses a computerized risk assessment program to estimate a woman’s lifetime risk of developing breast cancer. It’s a system they implemented three or four years ago that most imaging centers use, he said, and consists of a series of questions and answers. Milstein looks for patients that fall into the “high-risk” category — 20 percent or higher.

For high-risk patients with dense breast tissue, he may recommend an ultrasound or Magnetic Resonance Imaging. MRIs aren’t a good screening tool for women with low to moderate risk because they can show too much detail, and harmless breast changes can look suspicious. But MRIs are useful for high-risk patients and evaluating the extent of already-diagnosed cancer, Sims said.

Breast cancer survivor Linda DeHart was breast cancer nurse navigator at Willamette Valley Cancer Institute and retired in 2012. She remembers many women who found lumps in their breasts that weren’t found with mammograms during her time there.

There was a disconnect between radiologists and primary doctors — many family practice physicians reported mammography results to patients, and weren’t aware of the issues with dense breast tissue, DeHart said.

“It took awhile for me to pick up on it,” she said. “They haven’t come to grips with dense breast tissue yet.”

In the time since Van Liefde’s initial diagnosis 15 years ago, 35 states have adopted laws within the last seven years that require radiologists to notify patients of their breast density or the risks of high breast density, including Oregon in 2014.

It’s a new focal point in breast cancer risk and detection, as radiologists search for ways to effectively address it.

A three-pronged approach

In an effort to improve diagnostics, many imaging centers are switching from 2-D mammograms to 3-D mammograms, something called digital tomosynthesis.

Some radiologists hope that this new type of mammogram will help catch cancers in dense breast tissue, and a 2014 study in the Journal of the American Medical Association shows that it increases cancer detection rates.

“It has allowed us to find more cancers at a smaller size,” said Sims.

The study also showed a decreased patient recall rate — meaning fewer patients were called back for additional screenings, which happens when something suspicious but unclear is noticed on a mammogram. 3-D mammograms give radiologists a more complete, detailed picture of the breast tissue, helping them distinguish suspicious abnormalities from benign changes.

Oregon Imaging Centers started using 3-D in 2015.

Their cancer detection rate has increased from 4 cancers out of every 1,000 screenings to 5 cancers out of 1,000. And their recall rate dropped by 2.5 percent — from 7.5 percent to 5 percent, said Jennifer Cantu, director of women’s imaging and outreach at Oregon Imaging Centers.

3-D is more expensive than a 2-D mammogram when paying out of pocket, and depending on where a patient goes it can cost $85 to $100 more, Cantu said.

However, most insurance companies now cover it, Sims said.

Both Oregon Imaging Center and Cedar Clinic provide 3-D mammograms to all their patients. But it’s not foolproof.

“Even 3-D could miss a cancer that’s growing in very dense tissue,” Milstein said.

Some types of breast cancer only present as a lump or thickening and don’t show up on mammograms or ultrasounds, according to Sims.

“That’s why self-breast exams and clinical breast exams are vitally important,” he said.

Sims recommends a three-pronged approach to breast cancer screening: yearly mammography starting at 40 years of age, monthly self-breast exams and yearly clinical exams.

“That three-pronged approach has taken the diagnosis of breast cancer from having a 40 percent mortality down to 4 percent — a 10 times reduction,” Sims said.

When Van Liefde found her lump, she’d had a recent mammogram.

“When they finally got the MRI and got the imagery it was like a hot dog — it was already so big and it was almost touching my chest wall,” Van Liefde said.

“But the bottom line is, it was a good-sized tumor and they couldn’t even see it.”

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