- Еуромедик, Булевар уметности 29, Београд
MAMMOGRAPHY
Др Сава Стајић
In our community, an increase in the number of patients with malignant breast diseases is evident. Thus, according to the available data of the Institute for Health Protection – Batut, Belgrade and the Central Cancer Registry of the Institute of Oncology of Vojvodina, breast cancer accounts for 26% of the total number of women suffering from malignant diseases, while from the total number of women who died who had a malignant disease, about 18 % of those who had breast cancer. Over 4,000 women with breast cancer are registered annually in Serbia, and that number is expected to increase by 2020.
One of the most frequently asked questions
This is precisely why the public’s attention is directed towards diagnostic methods in the detection of diseases. The focus is on mammography – a diagnostic method for detecting breast diseases that uses very low doses of X-rays. The examination is performed by a trained radiological technician, and both breasts are imaged from two directions. The examination usually takes a few minutes. The technician must properly position each breast during imaging, using compression (pressure) during imaging, which takes only a few seconds and is used to obtain the smallest possible volume of the imaged breast, which leads to a clearer image and more accurate diagnosis. The review is not easy and quick to do. This is precisely why mutual understanding, cooperation, and the relaxation of each woman during filming are necessary. Considering that every woman has a whole series of questions and doubts, it is very important to talk and examine the breasts before the mammogram.
One of the most common questions is whether mammography as a method is harmful, because it uses X-ray (h) radiation, and whether there is an adequate substitute for mammography in the early detection of tumors?
Comparing data on ionizing doses during lung and breast imaging, mammography, especially on digital devices, has at least twice the lower doses compared to classic radiography of the lungs and heart, at least four times lower doses compared to imaging of the lumbar spine, and even ten times lower doses compared to to imaging the chest with a computerized tomography – scanner. Breast imaging is performed on a digital mammogram with minimal doses of ionizing radiation and with so-called “soft compression” during imaging. The advantage of the digital mammogram in our environment is particularly highlighted through the system for sending, archiving and image processing, the so-called PAKS. It must be emphasized that there is no real substitute for a mammographic examination. It is neither ultrasound nor magnetic resonance. Breasts change with age, fat tissue is replaced by glandular tissue and only mammographically, such breasts become more visible in order to distinguish small tumors. The biggest advantage of mammography is in the detection of microcalcifications, which are very small irregular grains of calcium dust, which accumulate in glandular ducts or in glandular tissue as the first sign of breast cancer. During the examination, great attention is paid to the appearance and spread of the remaining glandular tissue in the breasts, and the existence of asymmetry between the breasts is especially noted. In order to increase the diagnostic accuracy of mammographic examinations, additional mammographic techniques have been introduced in recent years, such as tomosynthesis (display of the breast in multiple sections) and contrast mammography (mammographic imaging after intravenously administered iodine contrast, as in imaging with a scanner). The practice is for the radiologist to complement the mammographic examination with a targeted ultrasound examination, where we also use the most modern ultrasound techniques, such as micropure and elastography. It should be emphasized that the accuracy of ultrasound in detecting malignant breast disease is significantly lower (below 60%) compared to mammography examination (over 75%). A mammographic examination supplemented with ultrasound increases the accuracy of diagnosis to over 85%, while with a breast examination with magnetic resonance, the accuracy in detecting breast cancer increases to over 95%. Many women also have a dilemma as to why examinations are not performed only with magnetic resonance imaging. It must be emphasized that the mammographic examination is performed quickly and easily, it is cheap and repeatable, which is especially important for the general population, and the images can be easily read by an expert in another institution, city and country. Magnetic resonance examination is difficult for the general population, takes a long time, is expensive, difficult to repeat, requires the administration of a contrast medium, and sometimes additionally requires ultrasound clarification of some details.
Our experiences indicate that 20 to 25% of women between the ages of 45 and 70 have not had a mammogram, and about 50% of women in the mentioned population do not regularly go for mammograms, instead of every other year, they come every three to five years. Correct breast self-examination is performed regularly by only every fourth woman. It can be seen from the previous data that one of the biggest misconceptions in our community is that one mammographic examination is enough and that this is the end of the diagnosis of breast disease. In the case of a negative mammographic finding (absence of signs of malignant disease), the next control is scheduled for two years at the latest. This means that women between the ages of 45 and 70 should have at least twelve planned examinations.
Unlike those women who are afraid of radiation, there are patients younger than 40 who insist on a mammographic examination without any real clinical need. It should be explained that malignant tumors mostly occur in women over 45, also in younger women, the glandular tissue is well preserved, so such breasts are not easy to read mammographically, and the population under 40 is protected from unnecessary radiation in order to preserve the birth rate.
On the other hand, our experience in conducting diagnostic mammography with a high suspicion of malignancy in about 7% of women, with the referral of over 12% of patients for a mammographic examination in six months, indicates the need to conduct an examination of early detection of breast cancer in the wider population.
Many are confused by the difference that is insisted upon in the implementation of diagnostic and so-called screening mammography. It is technically the same diagnostic examination, but the reading approach is different. In the case of diagnostic mammography, patients are referred for a mammographic examination, sometimes for monitoring reasons in order to detect the disease early, sometimes because of a clinical finding that indicates a change in the breast that can be felt, or because of a painful breast, and sometimes also because of a family (hereditary) burden of malignant breast diseases. The assessment of the mammographic findings can range from negative (1 and 2), a check-up is required in six months (3), or suspicion of malignancy of varying degrees (4a, 4b and 4c), as well as confirmation of malignancy (5). As a follow-up to the diagnostic mammography, an ultrasound examination of the breasts can be performed.
All women of a certain age (from 45 to 69 years old) are invited for screening mammographic examinations, and the basic assessment of the mammographic findings is reduced to a negative finding (no signs of malignant disease) in the form of grades 1 and 2, i.e. the existence of suspicion of malignancy , in the form of grade 4 and 5, which requires urgent further, mostly surgical treatment. In a very small number of cases, the mammographic findings do not lead to a conclusion (grade 0). Unlike diagnostic mammograms, screening mammograms are read by at least two radiologists independently, and subsequently, in case of disagreement, an additional expert examination of the findings must be performed. Screening mammography requires a much greater commitment to mammography, better organization, a higher level of knowledge, decision-making, and stricter criteria in assessing the quality of findings, that is, errors. Missed cancer is a terrible mistake, although the finding on mammography does not have to be decisive in the detection of every tumor, but on screening mammography it is also a mistake for a large number of women to call for an examination because of a falsely suspicious finding.