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{August 22, 2010}   Re-imagining Imaging

As my regular readers know in recent blog posts I have been exploring breast imaging issues. I had my first thermography appointment this week and I have to admit, it was a bit anti-climatic after all this build-up. After changing into a lavender colored gown on my top, the appointment started with a health history review and time for questions, after which I sat on a swiveling stool in front of an infrared camera while my practitioner took six pictures from different angles. I was in and out within half and hour. The best part was seeing the colorful images of my breasts displayed on the laptop monitor looking kind of like a topographical map. Although the images are produced instantaneously, they need to be interpreted by a qualified doctor, so I had to wait for my results.

All my research indicates that thermography can indicate the earliest signs of breast cancer, is radiation-free, pain-free and poses no health risks whatsoever. It actually detects the activity of abnormal cells and has the ability to accurately assess younger women with dense breast tissue for whom mammography is notoriously unreliable. Oh by the way, it is also the least expensive screening technology available. So why isn’t it the dominant breast cancer screening modality? Why isn’t it even recommended by most physicians?

Thermography, also known as digital infrared imaging, is based upon the principle that chemical and blood vessel activity in both precancerous and the area surrounding a developing breast cancer is almost always higher than in normal tissues. This activity frequently results in an increase in regional surface temperature of the breast. Thermography uses ultra-sensitive infrared cameras and sophisticated computer software to detect, analyze, and produce high-resolution images of these temperature variations, which may be the earliest signs of breast cancer.

In the race for better imaging spearheaded in the 1970’s thermography showed promise, but was sidelined by the conventional medical establishment by the 1980s. I found several different explanations for this.

  1. Early Mistakes – In Beyond Mammography, Len Saputo recalls that breast thermography became available in the 1960s, before clinical trials of its effectiveness were completed and before there was a clear understanding of how to interpret the images. A relatively high rate of unnecessary surgeries resulted, leading the technology to be “sidelined by mainstream medical practice for several decades”.
  2. Technology improvements – When I asked the technician who performed my thermogram the reason that thermography was not used more often, she replied that the medical infrared imaging cameras and computer technology had improved greatly over the past decade making it much more suitable now for widespread use.
  3. Inappropriate Comparison – According to the American College of Clinical Thermology, when thermography was first explored for breast imaging during the 1970s, it was tested and evaluated as a competitive strategy to mammography. In 1974 a major project on breast screening called the Carolina Breast Cancer Detection Project that included thermography concluded that mammography should become the primary imaging modality. In fact, the two tests are complementary and both have a place in the detection of breast cancer. Mammography is a structural test that looks at the anatomy of the breasts, density changes and lumps, masses and calcifications. Thermography, on the other hand, measures the activity of the tissue by how much heat is generated. Clinical studies show that in women under age 50, thermography alone is more sensitive (better at detecting suspicious tissue) than mammography, finding 90% of cancers vs. only 70% for mammography alone. However the two modalities combined offer 97% sensitive detection of breast cancer!
  4. Insurance Coverage Revoked – Also according to the American College of Clinical Thermology, while thermography’s role in breast imaging was being explored, it was also being used in other diagnostic roles. It became popular to use in court as a visual proof of pain in accident and injury lawsuits. In response, the insurance industry lobby succeeded in removing insurance coverage for thermography in the United States.
  5. Economic/Political Issues – Thermography is inexpensive and because it is inherently safe and doesn’t involve any radiation, requires no regulation or an expensive clinical environment to administer. Screening mammography and the associated follow-up tests (e.g. ultrasound, biopsies) represent an $8 billion industry which might be threatened if thermography was more prominent.
  6. Too Early Detection – Thermograms can pick up changes that precede cancer. When it was first tested on younger women, abnormalities were detected that mammograms couldn’t find. At the time, these were considered “false positives” and led to a mistrust of thermography. It turned out that a large percentage of the women who had these so-called “false positives” developed breast cancer years later. “Thermography’s only ‘error’ was that it was too accurate too early and the results couldn’t be corroborated at the time.” Thermography can provide an early warning signal before tissue actually becomes cancerous. However, if a woman has an abnormal thermogram that no other test can corroborate, the conventional medical establishment still will likely discard it as a “false positive”. Currently there is no protocol (other than surgical removal) in the conventional standard of care for what to do about something that is not cancerous but might become cancer in the future.

What Next?

At the moment there is a resurgence of interest in thermography due to the accumulation of clinical research, improvements in infrared imaging technology and the growing realization that mammography is not an effective option for pre-menopausal women. Thermography could play an important role in the development of a real breast cancer prevention strategy, acting as an early warning system by detecting tissue changes that reflect the early cancerous process. Studies on thermography have demonstrated its ability to warn that this process is underway 8-10 years before any other test can detect it – even before the cells become cancerous. At this early stage, preventive measures such as nutritional supplements, increased exercise and a lifestyle that reduces cellular inflammation and acidification would have time to take effect before cancer ever formed. In addition, thermographic baseline studies are appropriate for women as young as age 20 or 25 whereas harm from the mammogram’s ionizing radiation is cumulative and much worse for younger women.

Robert Kane, a lecturer and thermal imaging interpreter, suggests that the popularization of thermography will have to occur at the grassroots level due to the current political, funding and insurance issues. For my part, I can whole heartedly endorse my first experience of thermography. Three days after my test I received a call from the owner of Advanced Thermal Imaging offering an overview of my results (they had also been mailed to me in a report that morning). I did not realize the undercurrent of stress I had been holding until I heard the words “nothing suspicious”. I was informed that there is “an irregular heat pattern on the left side of my left breast” that although not of concern at this time, should be monitored given my previous history. The fact that there is a way to assess and follow the health of my breast tissue and the lymphatic area on the side where my breast tissue was removed feels very reassuring.

You can find the articles I used to reference this post embedded in the text. I recommend you check them out if you are considering thermography for yourself. A list of approved thermography clinics can be found here. The photo is from the Advanced Thermal Imaging website.

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{August 1, 2010}   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!



{July 24, 2010}   To Beam or not to Beam

My annual breast screening appointment date is coming up in September. In Between Two Worlds, I reported that I’d already decided not to have another mammogram. At that time I agreed with my oncologist’s urging to have an MRI instead. Almost immediately I felt uncomfortable with that decision and now I don’t know what to think or what I’ll do as this deadline approaches.

First, let me explain my dilemma with respect to having another mammogram. Having already had breast cancer, I have a higher than average risk of getting it again. An annual mammogram is the “gold standard” for detecting breast cancer at an early stage. Therefore, I should be happy to have one annually (and my oncologist certainly holds this position). However, mammogram machines deliver a powerful x-ray, according to one source perhaps 1000 times stronger than a chest x-ray, sending ionizing radiation, a known carcinogen, into the breast tissue. Since mammograms have difficulty detecting cancer in dense breast tissues, I am often subjected to additional radiation as the radiologist works conscientiously to take extra views of my breast in the hopes of not missing anything. Having already demonstrated the predisposition to develop cancer in the breast, I reason that it is unwise for me to continue to expose myself to known carcinogens. Experts think that in part, it is the cumulative exposure to radiation over a lifetime that increases the risk of cancer from that cause. Therefore, it seems to me that any time is the right time to stop such exposure.

Even though annual mammograms are considered the Standard of Care, as I recounted in The Ninth Life, mammograms are by no means fool proof. The false positive rate is significant, 95 percent of women who are called back for additional screening do not have cancer. Two out of every three women who end up being referred for biopsies do not have cancer. The false negative rate is also noteworthy, with about one in every five cancers missed by mammograms.

So what about the MRI? An MRI makes a clearer, more detailed image than a mammogram, so it should be a better screening tool, right? An MRI doesn’t use x-rays. Rather, the patient is given a contrasting agent (like gadolinium) by injection and then put into a powerful magnetic field and probed with radio frequencies. There is no scientific evidence that these frequencies of electromagnetic radiation cause cancer or are otherwise harmful. The contrasting agent can cause reactions in persons with kidney problems, but otherwise, this test seems less deleterious than the mammogram, although it is lengthier, more expensive and more uncomfortable in my opinion. Unfortunately it also increases the risk of false positives and could lead to unnecessary biopsies and the associated anxiety, cost, time and discomfort.

This is at the heart of my distress as I approach the crossroads in September. I don’t want to subject myself to additional carcinogenic radiation through a mammogram. Neither do I want to expose myself to the anxiety of an MRI which is a stressful test in itself and runs a greater risk of a false positive requiring a biopsy to disambiguate. I am especially sensitive to anxiety because of my propensity toward mood and sleep issues (as I reported in Good Night Sweet Princess). In fact, after having a colonoscopy a few years ago at the recommendation of my OB/GYN and GP, it took me about three months to reestablish my equilibrium. I treat the havoc in my life that results from anxiety as a very real side effect of such a test.

Which leaves me where? Do I want my remaining breast to go unmonitored? With my history, completely opting out of breast screening seems like a foolhardy idea. Thankfully there are three options which do not have any negative health effects. The first is the old standby – manual self examination. This is actually the way I discovered my cancer, so even though it is not a method of early detection, I believe it is still a worthwhile practice. If I find something manually, I can have a sonogram, although at that point a mammogram would also be recommended. A sonogram, also known as ultrasound is quick, not uncomfortable, requires no contrasting agent or ionizing radiation. It creates an image which can distinguish between a solid tumor and fluid filled cyst. The third harm-free alternative is a relatively new imaging method is thermography.

Thermography measures the amount of heat emitted by the body, in this case the breast tissue. Abnormal cells are usually hotter because they require a greater blood supply and therefore show up on the color image that is formed. The upsides are that it is a comfortable procedure with no negative side effects. It also seems that it can detect abnormalities in the breast tissue before a mammogram and has a lower false positive rate. The downsides are that although a thermogram is relatively inexpensive, it is not currently covered by medical insurance and is therefore an out of pocket expense for the patient. Second, thermography is unregulated so one has to be careful to use a reputable provider. Fortunately we have a provider who visits a nearby office monthly. Finally, the vast majority of radiologists and oncologists are not trained in this technology, and will not make recommendations based on its results. Therefore, the thermogram is sent to a center to be read by properly trained radiologists and will not be read by the radiologist who has followed my case since 2005.

As I said in Baby Steps, my first principle in making decisions about my health and healthcare is “First, do no harm.” For this reason, I’m reluctant to have another mammogram or an MRI for purely screening purposes. There is more research on this that I want to understand fully and I will report on what I discover in future blogs. In the meantime, I do intend to have a series of two thermograms to establish a baseline that any future changes in my breast tissue can be measured against. The thermogram satisfies my final principle: “if a treatment causes no harm whatsoever and I want to try it, then it is fine, even if there isn’t conclusive scientific evidence for its effect on cancer.”

I’m not 100% sure of any of this and I am certainly not making recommendations about what anyone else should do. For now, it’s what feels right for me and I’m being consistent with my principles and priorities in making my own health choices.



{February 21, 2010}   Between Two Worlds

It’s easy to be part of the alternative camp if you haven’t had to deal with a life-threatening or seriously debilitating condition. Faced with cancer, entering the conventional system seems to offer some security. Treatments are standardized and backed up by objective statistical research, or so it seems.

When my first treatment protocol of minimal surgery supported by alternatives was not successful, I wanted an oncologist on my team. At first he was reluctant to have me as a patient given that I did not want the tools in his doctor’s bag – chemo and estrogen inhibiting drugs like tamoxifen. He stuck by me even though I chose not to follow the “Standard of Care” and over the years has provided reassurance and on a couple of occasions calmed my nervous worries about unusual lumps.

I had an oncology appointment this past week. I asked Chuck to come because I was anxious about broaching the subject that I no longer want to have an annual mammogram. It’s not that I find it difficult – the pain of my breast being squeezed is momentary, the technicians are friendly and I receive immediate results in person from my radiologist. It’s the nagging feeling that the annual dose of ionizing radiation to my breast tissue that has already demonstrated susceptibility to cancer, might eventually cause cancer.

Early on in the interview my oncologist proposes to schedule my next mammogram for September. I accept the need for some surveillance for my one remaining natural breast and have been looking into thermography. This technique uses infrared heat to map body temperature and is an “especially well-suited tool for breast screening”, according to the literature I received from Advanced Thermal Imaging. It was approved by the FDA in 1982, but never gained prominence and therefore has not had the extensive research that mammography has had.

Lack of research is the main objection of my doctor. He reminds me of my high risk of getting cancer in my other breast and points out it would be tragic if a cancer went undetected because I refused to have mammograms. He believes that mammograms are completely safe. As he speaks, I am thinking about how dentists used to assure us that amalgam fillings containing mercury were safe, but I don’t argue. I simply continue to state my truth: “I don’t want to have mammograms anymore.”

“We could schedule your mammogram and then see how you feel when the time comes”, he suggests. Eventually, after a fairly lengthy negotiation we reach a compromise. I agree to have an MRI instead of the annual mammogram. MRI’s are becoming more widely accepted in breast screening. The downsides of an MRI include: inconvenience, cost, risk of false positives and the requirement for an injection of a contrasting agent called gadolinium. The upsides for me are that I had an MRI in 2005 so I have a baseline from which to compare current images and the radiologist who is familiar with my history will read the results.

As I write about this, I remember that the MRI was a horrible test and not really something I want to repeat, certainly not annually. So the questions arise: are mammograms really as dangerous as alternative proponents would have us believe, is thermography a viable alternative and is gadolinium safe? We have some months to do some research and will keep you updated on our findings.

Taking responsibility for my own health is extremely challenging. Sometimes I think it would be so much easier to have taken that “blue pill”, to trust the conventional system and believe everything that the doctor says. My path is to find a place where I can stand on my own two feet, neither in one world nor the other. From here I can tune into my own inner knowing, augmented by research, to make decisions that are right for me.

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