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Conversations with Our Patients and Neighbors

Dr. Jerome Schroeder is the Medical Director of Breast Imaging at Exempla Saint Joseph Hospital in Denver, Colorado.

17 August 2010  

As a diagnostic radiologist, I have been focusing primarily or exclusively on breast cancer imaging for the last 13 years.  While it seems pretty straight forward to me:  you turn 40 and you start getting yearly mammograms, I know that it isn't as cut-and-dry to the actual women who have to get one every year.  I've heard just about every question any woman has ever had about mammograms, but there are a few which I still get asked pretty often.  Among them are 1) Why do I have to get a mammogram? 2) Aren't there any other ways to image the breast? and 3)  How significant is it to have a family member with breast cancer?  

I'll start with the first. 

The main reason to get a mammogram is to detect a breast cancer at an early enough stage to cure it.  It is true that sometimes, no matter when we find a cancer, we cannot save the woman's life.  But we would rarely save a woman's life if women didn't get regular mammograms.  How many lives can we save?  Well, before the widespread use of mammograms by the early '90s, the death rate from breast cancer was very constant over the previous 50 years.  What we witnessed after several years of annual screening was a consistent decrease in the death rate by over 2% per year, a decrease that continues to this day.  The decrease in the death rate among women in their 40s has been over 3% per year since 1990.  In fact, if I detect a breast cancer on a mammogram before it can be detected by feel, then that woman has at least a 95% chance of cure.  Most experts believe that it is the early detection of breast cancer, more so than advances in treatment, which have accounted for most of death rate decline. 

"But mammograms hurt!  There's got to be a better way!"  

I hear this complaint fairly frequently, although I must say that most women admit after a dreaded mammogram that it wasn't as bad as they had anticipated.  In fact, timing your mammogram 7-10 days after the end of your menstrual cycle and/or taking a mild pain pill (like Tylenol or ibuprofen) before your exam can minimize the discomfort you may feel during the exam.   Requesting an experienced technologist and doing your best to relax during your exam can also decrease your discomfort.    

But what about doing a completely different exam instead of mammography?  The first thing to consider is that mammography is the only screening method for breast cancer proven to decrease the death rate from the disease.  All other exams that folks want to claim to be better than mammography must be proven over time to not only find more cancers, but prevent more deaths.  None to date have done so.  The most common additional exams done to image the breast are ultrasound and MRI.  Ultrasound is usually done as a secondary exam to mammography to clarify a mammographic finding or to define a clinically palpable finding.  In some select patients, it may have a role as an additional screening test to mammogaraphy.  Breast MRI, the test most likely to detect a breast cancer, is limited due to access and cost. It is a useful exam, however, in select patients as an additional test (often done after a diagnosis of breast cancer to rule out additional areas of disease) or as an additional screening test to mammography.  Notice that neither ultrasound or MRI replace mammography, but rather complement it. 

You may have heard about thermography.  In a word, it is useless.  It's approval by the FDA was only in terms of safety, not efficacy and it usually points to areas which have no disease and miss most areas of cancer.  In my opinion, not only is it a waste of money, it can be deadly if a woman decides to forgo a mammography completely in favor of this flawed test.  

Finally, I'm sure most of you have heard about genetic counseling or testing and that it may be able to determine if you are more susceptible to breast cancer than the average woman.  

The first thing to remember is that at least 85% of all breast cancers occur in women with no detectible genetic cause or clinical reason to get it.  In fact, your two most important risk factors are your age and your sex, two things which you can do nothing about.   

However, having said that, we are learning more and more about genetic predispositions to developing breast cancer and can now test for several genes which, if present, greatly increase a woman's chance of getting the disease.  

So how is it determined that you may have a genetic predisposition for breast cancer?  Most breast specialty imaging centers will have you fill out a family history questionnaire when you come in for an exam.   Some will put your answers through a risk assessment calculation to get a percentage likelihood of developing cancer in your lifetime.  This is especially true if you have several family members with breast or ovarian cancer, you are of Ashkenazi Jewish heritage, you have had an 'atypical' result on a previous biopsy or if you've never had children or had children at an older age.  Comprehensive centers may even offer genetic counseling with a certified genetic counselor and the ability to collect blood or cheek-scraping samples for the actual genetic testing.  Keep in mind, however, that even though you may test negative for a gene mutation, if your family history for breast cancer is significant enough, you still may have an as-yet un-testable genetic predisposition and you may be recommended to undergo more aggressive screening in addition to mammography (usually annual MRI or ultrasound, alternating with mammography, at six month intervals).  

The Breast Care Center at Exempla St. Joseph Hospital is a comprehensive center offering the full spectrum of breast imaging and breast cancer diagnosis with a full complement of supplementary services including high risk assessment, genetic counseling/testing, breast health education and nurse navigation, psychosocial services, financial assistance and breast cancer surgery and treatment. 

21 May 2010

How long should you have to wait to get the results of your mammogram?  What if you're called back for additional views?  Should you be offered an immediate appointment?  If you need a biopsy, does your facility offer same day procedures?  And how long should it take to get a biopsy report back?  If you're diagnosed with cancer, how quickly can you go through whatever testing is necessary before having surgery and beginning definitive treatment?   

For most women, getting their yearly mammogram is a quick and relatively easy process.  They're in and out in 20 minutes or so and, a few days later, they receive a results letter telling them that everything checked out normal and to return for a routine screening in one year.  That 'layman's term' letter is required to be postmarked no more than 30 days after the date of the screening exam.  Believe it or not, this is the only established timeline requirement which mammography facilities must follow.  The time that a woman must wait to be scheduled for additional views, undergo a biopsy and receive biopsy results and begin treatment should a cancer be found, is unregulated and is up to the individual facility.  

Mammograms are performed in a variety of settings, from free-standing general radiology or mammography-only clinics to comprehensive centers offering integrated screening and diagnostic exams, biopsies, surgery and treatment.  In general, the more comprehensive a facility is, the faster a woman can move through whatever testing and treatment is necessary.   

A comprehensive center staffed by dedicated breast imaging radiologists with immediate access to surgeons and other treatment personnel is usually able to tailor the time it takes for a patient to move from screening to diagnosis of a breast cancer to treatment and beyond.  A reasonable timeframe is the following:  

• No more than a 5 day wait to get in for a mammogram
• Screening exams should be read within 5 days; therefore, a results letter should arrive within 10 days or so
• You should get a direct call from the facility if you are required to return for additional imaging (a 'callback' exam)
• No more than a 3 day wait to be scheduled for a callback exam
• Results of a callback exam should be given directly to the patient at the completion of the exam
• No more than 5 days to wait to be scheduled for a biopsy
• Biopsy results should be called directly to the patient after one working day
• Upon the diagnosis of a cancer, additional testing prior to seeing a surgeon should take no more than 5 days
• The first surgical appointment should occur no more than 10 days after the original biopsy
• Surgery should be performed within 10 days of the first surgical appointment
• Additional treatment should begin immediately after surgery  

If the above timeline is followed, a patient should be able to go from a screening exam to surgery for cancer in about 30 days.    

There are obviously many factors which influence how quickly a patient can move through cancer diagnosis and treatment.  Some patients need more time to accept their diagnosis and plan their care.  Patients should be allowed to do so.  Team members like nurse navigators are invaluable in educating patients about when and why things need to be done and helping them to make decisions about their care.  

Comprehensive centers are the best equipped at tailoring a patient's experience through a breast cancer diagnosis with the ultimate goal of providing safe, efficient and effective care.  

16 April 2010

I was preparing cases for our weekly multidisciplinary breast conference last week and once more reviewed the films of a 40 year old woman in whom we diagnosed a breast cancer a month or so ago. By the time we saw her, she had been to half a dozen clinics throughout the city but was denied care because she was uninsured. We did her evaluation, and diagnosed her with an aggressive breast cancer. Additional studies done since we first saw her shows that the disease has spread to her liver, lungs and bones. It is unlikely that she'll survive five years. Could a diagnosis made 4 or 6 months ago have made a difference?

In another case, a woman in her 40's was diagnosed with treatable breast cancer. However, the aggressive chemotherapy that she had to undergo made her too sick to work. Because she couldn't work, she lost her job and because she lost her job, she lost her insurance and because she lost her insurance, she had to stop her treatment. I saw her a year later after she returned to her job and re-started her insurance. Unfortunately, her partially treated cancer had returned, bigger and more aggressive.

These types of cases frustrate me as a physician and sadden me as a person. The United States is, by most measures, the richest country in the world. Yet, according to the World Health Organization's ranking of the world's health systems, we rank 37th, just above Slovenia and Cuba (http://www.photius.com/rankings/healthranks.html).

After a year of rancorous 'debate' and endless speculations, the United States finally passed a Health Care Reform Bill, something that has eluded previous administrations. It's true that there are many confusing things in this bill which will take time to sort out and sink in. It certainly isn't a perfect bill, but it's a start.

Here's a short synopsis on what this bill does (http://cnmnewsnetwork.com/14364/newhealthcare-reform-bill-summary-2010-facts-and-timeline-of-health-care-reform-changes/):

• In 2010
  • People with pre-existing conditions will be able to access health insurance
  • Lifetime maximums will be eliminated
  • Your insurance company cannot drop you if you become ill
  • Children can stay on their parents' insurance plan until age 26, long enough for most to complete a college degree or trade and land their first job
  • New plans written from now on have to provide preventative care without co-pays or deductibles
  • Certain retirees will receive a $250 credit to start to plug the 'donut-hole' in Medicare Part D.
• In 2011
  • Medicare must provide plans with preventative care with no co-pays or deductibles
  • Medicare Part D recipients will receive 50% off drugs which fall into the uncovered 'donut hole'
  • Insurance companies have to justify rate increases
• In 2014
  • An IRS penalty of $750 or 2% of income will be imposed on individuals who do not purchase health insurance
  • No one can be denied coverage for pre-existing conditions
  • Lifetime caps on benefits banned altogether
  • State-run Insurance Exchanges will be established
• In 2018
  • All plans must offer preventative care without co-pays or deductibles

To me, this shouldn't be a partisan or political debate, but a human one. What is the right thing for the citizens of this country? Is basic health care a privilege or a right? Through this legislation, I believe we are finally declaring that it is a right.

21 March 2010

Hi!  My name is Dr. Jerome Schroeder and this is the first posting of our new blog, "Ask Dr. Jerome."  I know that may sound a little pretentious, but I really want you to ask questions which you may have about breast cancer and breast cancer screening.  Believe me, there's a lot to talk about.  But you already know that... 

I arrived in Denver in 2002 to do a breast imaging fellowship year at the University of Colorado.  I left my job in northern California after 20 months because I wanted to focus only on breast imaging and breast cancer diagnosis.  You see, most mammograms in this country are read by general radiologists who squeeze in mammograms (pun intended) between all of the other things they have to read, like CAT scans, elbow films and chest x-rays.  This can distract them from concentrating on the mammograms they are trying to read which can result in missing something significant.  In fact, there are studies which show that radiologists who read only mammograms (or read thousands of them yearly) find more cancers and miss fewer important findings on the mammograms that they read.  You should ask at your clinic who's reading your mammograms.  

Many people have asked me why I decided to concentrate only on breast imaging and breast cancer detection.  I only have two non-blood-related aunts in my large family who have ever been diagnosed with breast cancer, so my family history wasn't the reason.  Partly it was because after I finished my radiology training, I realized that I missed direct patient contact.  Most radiologists never see the patient who belongs to the image and I bet you've never met your radiologist! I believe that a breast imager should be very involved with their patients, sort of like a 'clinical radiologist.'  Now, I may not see the average screening woman who has a normal exam, but if  you come in with a symptom or are called back for additional imaging, you will see me in person to learn the result of your exam.  And, of course, if you need a biopsy, I will see you through the entire process and be the one who discusses the results with you. 

The thing that really clinched the whole 'breast imager' for me, though, happened one day in the late '90s when I was working in my clinic at Holloman Air Force Base, near Alamogordo, New Mexico, where I was doing my three year payback to the military after residency.  We had recently diagnosed a small cancer in a middle-aged woman.  Several months later, after she had finished her treatment, she came into our clinic with a tee-shirt on which said, "Have you Hugged your Radiologist Today?"  I just felt I had just done my job, but she was profoundly thankful that we found her cancer when it was curable and it was at that moment that I realized the impact of what we had done.  Finding cancers on mammograms before they can be felt usually results in a cancer cure...I could save a life!   

After my fellowship year at the 'U,' I took a job a Kaiser which I held for five years.  Doing very high-volume mammogram interpretation and breast intervention there prepared me for what I embarked on 20 months ago when I joined the team at Exempla St. Joseph to build a comprehensive breast center.  We moved into our new home in late September last year and every day I come to work looking for the next opportunity to save a life!  

Now, dear reader, it is your turn to submit to me a question, an idea, a criticsm or a praise.  I will do my best to answer your inquiry and/or direct you to where you can find out more information.  This is not a forum through which to get medical advice, but simply to have an ongoing conversation about things that are important to you and me.  I look forward to getting to know you!  

 Send you question to Dr. Jerome Schroeder, Ask Dr. Jerome, click here.  

Jerome S. Schroeder, MD
Medical Director of Breast Imaging
Exempla Saint Joseph Hospital