What am I Missing?

Last week (To Beam or Not to Beam) I discussed the pros and cons as well as my thoughts and feelings about regular breast screenings using mammogram, MRI or thermogram. This week I had the opportunity to discuss this topic with two prominent doctors in the field of medical imaging at a social occasion. They understood my reluctance to continue to subject my breast to the ionizing radiation of mammograms and felt that an MRI was the alternative of choice for me, as it generates a comprehensive picture with radio waves which are not harmful. They were not supportive of thermography because in their opinion, the image produced is just not detailed enough and that “it would be a pity if you missed something.” This got me thinking, just what might be missed if I choose to monitor my remaining breast with thermography instead of mammograms and/or MRIs?”

Mammography is the standard breast cancer screening technique and is used to detect both invasive and non-invasive (known as in situ) breast cancers. It works by passing x-rays through the breast onto a sensor to create an image. The manner in which breast tissue passes or absorbs the x-rays determines what the radiologist sees on the mammogram.

When reading a mammogram a radiologist looks for shadows, distortions, tissue density, masses and tiny specks of calcium deposits called microcalcifications. Although microcalcifications are not cancerous or dangerous in themselves, they indicate the possible presence of cancer cells contained within the milk ducts, called ductal carcinoma in situ (DCIS). The incidence of DCIS increased rapidly through the 1980s and 1990s, primarily a result of the increased use of screening mammography. In 2001 DCIS accounted for about 19 percent of all cancers found compared to less than 4 percent prior to 1984. The diagram on the left, from an article by Dr. Susan Love, shows the breast duct and tubules and a cross-section of a duct demonstrating DCIS.

Magnetic Resonance Imaging (MRI) images are formed by passing high intensity radio waves through breast or other tissue in the presence of an extremely strong magnetic field. MRIs are more detailed and sensitive than mammograms and allow the radiologist to see indications of in situ cancer cells themselves. Recent studies suggest MRI may be better than mammography for finding the more dangerous DCIS lesions which might someday become invasive cancers. MRI is also better at imaging dense breast tissue, more common in younger, premenopausal woman like myself. Earlier this year, the American Cancer Society recommended that certain high risk women should add MRI to their screening regimen.

If a radiologist reading a mammogram or MRI finds something that looks suspicious in the image, he or she may recommend further tests or monitoring, or recommend a biopsy. In themselves imaging methods can only indicate the possible presence of disease; microscopic examination of the tissue by a pathologist is the only way a diagnosis is made. While it does make logical sense to find cancer at this early, easily curable stage, it comes with certain costs. Both imaging methods are subject to false positives leading to biopsies that determine that cancer is indeed not present.  If DCIS is found, there is pressure to undergo considerable treatments that may be harmful, even though DCIS might never progress to invasive cancer.

After biopsied DCIS cells are examined microscopically, they are categorized as either “high-grade” (likely to become invasive) or “non high-grade” (likely not to cause harm). I was surprised to learn this, as I had frequently read that there is no way to determine which abnormal cells will progress beyond the in situ condition to become invasive versus those which will remain harmless. The thing is, there is not 100 percent certainty that a non-high grade DCIS will not become invasive, so the recommended treatment for all DCIS is lumpectomy and radiation (or if it is widespread, mastectomy). Five years of hormonal treatment may also be recommended. Since DCIS is very curable, with 98 percent of women surviving, it is debatable whether the benefits from radiation and/or tamoxifen outweigh the associated risks, some of which are life threatening. In fact, there is considerable controversy surrounding the treatment of DCIS, in part because for so many women it would never cause any harm even without treatment.

I am not suggesting it is better to wait until breast cancer is in a later stage to find and/or treat it. But I do question the emphasis on finding the signs of cancer earlier and earlier and then applying treatments that cause harm (biopsies, surgery, radiation treatments, etc.) for conditions that may not ever develop into invasive cancer. And I do worry that perhaps the cumulative ionizing radiation from mammograms actually contributes to the development of cancer, especially in women like myself who are under 50.

Wouldn’t it be great if imaging could provide an indication of the health of breast and other tissue in addition to searching for signs of disease? All screening methods today are about finding disease rather than assessing tissue health, but thermography has potential. It measures the heat produced as a metabolic by-product. Perhaps one day we can detect generalized inflammation (not just tumors) which might be addressed by adjusting nutrition, supplements and/or lifestyle before disease occurs. While we wait for that kind of technology, I rely upon blood work to give me an indication of overall health. I use the absence of blood tumor factors, manual breast examination and imaging to establish that nothing abnormal is going on.

If I had to choose between mammography or MRI for breast screening, I guess I would go with the MRI. Having had invasive breast cancer and family history, I fall into a category of risk that would probably result in my insurance company covering the cost of the test. However, despite the recommendations of my doctor friends and my oncologist, I am still reluctant. This may sound strange, but having faced breast cancer already, I am not afraid to miss something small, like the presence of DCIS. When I take a step back from the current cultural obsession with early detection, I find the whole emphasis of searching for and eradicating disease antithetical to the way I view my health.

I realize that conventional medicine is not in support of thermography, but to me, as a health care consumer, it makes sense. First, it does no harm because it works by passively measuring the heat produced within tissues, rather than bombarding the body with radiation. If my thermogram, blood work or manual breast examinations show anything worrisome, I can follow up with further imaging through conventional means (i.e. MRI). I reason that:

1. My careful attention to nutrition, supplements, exercise and other alternative practices will keep my tissues healthy.
2. The combination of three screening techniques (thermography, blood work and manual self-exams) gives me a very good chance of catching anything deleterious early enough to treat it.
3. There is a high percentage chance that anything missed by such screening is benign or non-invasive (like DCIS).

For me it’s a trade-off. The small increased risk of missing something important is, in my humble opinion, worth it. I will avoid the potential worry and discomfort of false positives and unnecessary biopsies associated with more sensitive imaging. Last but not least, thermography is in sync with my health priorities and principles (set out in Baby Steps). Throughout my cancer treatment and healing I have chosen a path less traveled that supports the health of my entire being. I want to take this path for monitoring the health of my remaining breast. For this reason I have booked an appointment for my first breast thermogram on August 17. I’m excited to have taken this step as it is something I’ve been thinking about for over five years. I will let you know my thoughts as I actually have my thermogram and continue my research and look forward to hearing your feedback on the issues I am raising.

The amount of material easily accessible on these topics is incredible. At times this week I felt buried in on-line articles, unable to remember where I had read this or that.  I hope you take the time to click on today’s links. The articles I chose to reference are all scientific, trustworthy and accessible!