Expert Speak: Current Trends in Mammog Screening


Dr Subhash Ramani, Professor and Radiologist, Tata Memorial Hospital joins us today in ExpertSpeak, to discuss the current updates in Mammography and Breast Imaging. His Specialization and Expertise is in Breast Imaging, and he is Member of Breast Cancer Working Group Tata Memorial Hospital, Mumbai. He has given several scientific presentations on Mammography & Breast Imaging, at State, National, and International meetings, and has written several informative articles in print media (Savvy Magazine, News papers (TOI, Sakal Marathi), & web sites (auntminnie.com) on Mammography. He is Member (Scientific Committee) of Mammology, (The Official Journal of the Indian Breast Group), and is on the Editorial board of aunt minnieindia.com (aumntminnie.com).

Hello Dr Ramani, and welcome to EXPERTSPEAK. TO start off, when did you first start Breast Imaging, and how has it changed since then, until today?

After doing a course in course in Breast Imaging in 1996 at Johns Hopkins , (Baltimore, USA), it was only after I joined the Tata Memorial Hospital in July 2000, that I started doing Breast Imaging in its true Multidisclipinary way!

Since 2000 things have changed a lot till today. There are many more Mammography Units all over the country both in Public & Private hospitals/Institutions. All medical Colleges now have Mammography Units. Untll 2003, there were no guidelines for the practice of Mammography. It was only in 2003 that the competent authority( after doing a survey of 20 units in Mumbai) came out with the guidelines:Vide BARC/RPAD/MPSS/MAMMO-1 .General Recommendations for Radiation Safety in Mammography Facility. Radiological Physics and Advisory Division, BARC, April 2003.

Now all Mammography Units have to be prototype approved! More and more Radiologists are practicing Mammography. With technology taking a giant leap we have Digital Mammography units with CAD and the latest addition is Tomosynthesis with Digital Mammography.

Is there an increase in the women who undergo breast imaging as a screening tool?

Let me clarify the concept of screening: In the developed countries there is a well organized, regulated Breast Cancer Screening program with strict quality control & assurance testing at several levels (including the Equipment, Radiographer, Radiologist, Viewing box, films, processor, outcome audits, & CME), which is Monitored by competent authority (ACR, FDA, NHS etc), and is funded by Insurance /Medicare & reimbursed by the Government. Women at normal risk are invited for screening mammography.

What is the current screening protocol for Mammography?

The developed countries have a standard protocol for screening by Mammography! In India we do not have any such protocol. With increased awareness, changing lifestyle and increased affordability many women undergo Mammography for early detection of Breast cancer. This type of screening practiced in India has been called Opportunistic Screening!

What is being practiced in opportunistic screening is copying and pasting the protocols of the developed nations. The Breast Cancer Working Group of TMH in its Breast Cancer Guidelines (Evidence Based Management for Breast Cancer) , Breast cancer Screening states:

Periodic screening by mammography results in reduction of mortality from breast cancer of about 30%, in women above age of 50.

No convincing evidence of benefit in women < 50 years.

Mammography breast cancer screening programme is however not sustainable in developing countries.

Screening mammography will not be cost effective in developing countries where the incidence of cancer is considerably lower. In urban India , for example ,1000 to 1500 women will have to be screened to detect one cancer, compared with 100-150 in the USA. Furthermore, because of the younger age structure of our population most of our patients are below age 50, where mammography is less effective. Self referred women who wish to undergo Screening Mammography for early detection of breast cancer, cannot be denied the benefit of this modality.

However the high level of expertise and attention to quality control that is required for these women to obtain the true benefit of mammography may not be available in many developing countries.

Women should get their mammograms done at a facility that:

Has a mammography unit approved by the AERB.

Follows the general recommendations for radiation safety in mammography facility(RPAD,BARC).

Use a facility that utilizes exemplary technique and is interpreted byhighly trained film readers.

Does soft copy reporting on Dedicated Diagnostic Medical grade Monitors which have per pixel viewing modes, for those facilities having Digital Mammography.

As far as technologies and different imaging techniques are concerned, what role does MRI have in Breast Imaging today?

The role of Breast MRI: Screening breast MRI is not recommended at the current time in the general population of asymptomatic women.

The American Cancer Society Recommends Annual MRI Screening : BRCA mutation, First-degree relative of BRCA carrier, but untested, lifetime risk ~2025% or greater, as defined by BRCAPRO or other models that are largely dependent on family history. ??Other well accepted indications are : Implant Integrity, Axillary adenopathy, primary unknown MRI may be indicated in patients presenting with axillary adenopathy and no mammographic or physical findings of primary breast carcinoma. MR has been used for other indications where evidence is not robust to support the same. ??Breast MR facility should perform simultaneous imaging of both breast, on dedicated breast coils, at least 1.5 T magnet. The ability to perform MRI-guided biopsy is absolutely essential to offering Breast MRI, as many cancers (particularly early cancers) will be identified only on MRI In addition the facility must have access to expertise in breast imaging diagnosis and intervention and access to conventional breast imaging technology including mammography, breast ultrasound, stereotactic biopsy, and ultrasound-guided biopsy(ACR). ??The Radiologist must have expertise, knowledge and experience in Breast MR and also well versed in the interpretation of mammograms and US images which enables the comparison of mammographic and US findings with findings on breast MR images.

Breast MR imaging does not replace conventional imaging (ie MG, BUS) and physical examination. There is no role for breast MR imaging in the differentiation of benign from malignant findings at mammography, US, or clinical examination.

Are there likely to be any new imaging techniques that will help us in diagnosing breast cancer faster?

Currently the only modality validated for early detection of breast cancer is Mammography! There are no recommendations for screening with non mammographic imaging techniques (except high risk patients ACS Guidelines).

MRI & BUS screening may someday help in finding cancers that mammography misses, but, at this point in time we have no proof that screening with any test other than mammography will save any lives. Screen film mammography remains the reference standard, despite its limitations. The presence of a rare miss should not discount the value of a validated useful technique (mammography).

In the setting of a palpable abnormality Triple assessment is mandatory!

Standard clinical practice dictates that all breast lumps require complete triple assessment: Clinical examination, Imaging and a Tissue diagnosis, using either cytology or histology (because 9- 20% of cancers that are palpable are not seen on Mammography)!

In this age of market driven health care, expensive diagnostic procedures must be justified by their impact on treatment selection and benefit to the patients!

There is increasing need for services for women who have no idea how to educate themselves to know what a quality mammogram is! The key is not just producing a film. It is caring that the films that you are producing have the quality for a radiologists to make a diagnosis that is as close to 100% ( as possible) the first time. It takes more than leading technology to make a difference.It takes the passion, dedication and commitment of a special group of people,who are part of an elite group of centers, committed to raising the standard of care for all women.

Compared to other Radiologists in other fields, is reading mammograms more stressful?

Reading Mammograms in an Institution like TMH is routine work - as stressful as other modalities! Each day is a new learning experience due to the varied spectrum of presentation of breast cancer. This has helped me grow in Breast Imaging thanks to the Multidisclipinary approach that we follow at TMH.

I attend Joint Clinics with other members of the breast cancer working group, where patients are seen by the Breast Surgeon, Medical & Radiation Oncologist, along with Radiologist as a team so that a joint decision is taken resulting in optimal patient care.

If so, then what are your stress busters?

Stress busters - Reading, following up the cases, making teaching files, archiving interesting teaching cases, doing an audit of what my report has been with the final outcome! Giving talks on Breast Cancer Imaging at various meetings, conferences, to educate the radiologist practicing Mammography in India the need to use evidence based medicine in Breast imaging, and the importance of multidisclipinary approach to breast cancer management.

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