Early Detection and Prevention- Q&A with Dr. James Frost, MD.
We’ve all heard the saying “Early detection is the best prevention”, and it could not be truer. When it comes to breast cancer diagnosis, the earlier it is detected, the better chances the patient has for successful cancer removal and cure.
Dr. James Frost is a board-certified general surgeon with a special interest in treating patients with benign and malignant breast disease.
Q: What are some of the first signs of breast cancer?
A: Because of early detection, intervention, and postoperative treatment, breast cancer mortality has been decreasing.
Today, most breast cancers are diagnosed after an abnormal screening mammography. Over the last five years, 3-D mammography has replaced previously standard 2-D mammography as a method of screening. This has led to a 30% reduction and recalls, and increased sensitivity of abnormalities. Any abnormality on screening leads to recommendation for diagnostic mammography with or without concomitant ultrasound. This increases the accuracy of the negative reading to 98%.
MRI can serve as a further diagnostic tool when abnormalities on mammogram and or ultrasound continued to be confusing.
Abnormalities on imaging include:
- Clusters of microcalcifications that are new compared to previous mammograms
- Asymmetric densities or irregularities
- Skin thickening, skin changes, or any kind of retraction of nipple, areola, or other areas of the skin
- New nodules
If the patient does not go for screening, then one must rely on physical findings. Most commonly a physical finding of breast cancer would be a palpable mass. Other signs could include: asymmetry in the breasts, an area of retraction or thickening including nipple or areolar changes, a new discharge from the nipple, or a new lump in the axilla.
The most important thing to realize is that mammographic findings occur earlier then her physical findings. Therefore, screening examination which detects very early abnormalities can lead to early diagnosis and cure.
Q: Do some patients experience no symptoms?
A: Most patients with the diagnosis of breast cancer never experience symptoms. Symptoms such as pain or ulceration are limited to patients with advanced disease.
Q: How is breast cancer detected?
A: Because we have achieved excellent methods of screening, the majority of breast cancer today is diagnosed by performing a core needle biopsy of an abnormality found on screening and then on diagnostic imaging.
Core needle biopsy is when a needle is inserted under anesthesia into the breast and takes samples. This can be performed under stereotactic guidance, which is by mammography, under ultrasound guidance, or under MRI guidance. This contrasts with 30 years ago, when many breast cancers were diagnosed by open surgery followed by frozen section, followed by definitive surgery.
The value of core needle biopsy in establishing diagnosis has been well documented. By establishing diagnosis with the needle, it allows the physician to offer the patient all possible alternatives to achieve not only cure but acceptable cosmesis.
– Treating patients with neoadjuvant chemotherapy to shrink the tumor and convert an only mastectomy option to a breast salvage option.
-Treating with neoadjuvant chemotherapy to confer a positive axilla to a negative axilla endoscopy avoiding complete axillary lymph node dissection.
-Allow genetic testing to determine if the patient would best be served by mastectomy and reconstruction
Q: When should women start routine breast cancer screenings?
A: I recommend that the average risk patient start breast screening at the age of 40. I also believe that after age 40, the patient should receive annual screening mammography and clinical breast exam.
Patients with a history of a genetic abnormality in the family should receive genetic counseling and possibly genetic testing. A patient with a deleterious gene should consider starting screening abdomen earlier age, possibly by age 30. Also, patients with a deleterious gene, after genetic counseling, may wish to consider prophylactic surgery.
Q: What is the first step you take once breast cancer is diagnosed?
A: New patients who have received a biopsy diagnosis of breast cancer are seen in our office. A complete history including family history is obtained, and then the patient receives a complete physical examination.
Many patients are sent for an MRI to rule out any undiagnosed disease within the effective breast and to rule out disease in the contralateral breast. All patients receive genetic testing and are considered for plastic surgical consultation. A complete discussion is had regarding the patient’s options regarding the extent of surgical management, and the need for adjuvant care including possible radiation, chemotherapy, hormone therapy, or plastic surgery reconstruction.
Q: How can women lower their risk for breast cancer?
A: Average risk women can lower their risk of breast cancer by maintaining healthy weight, regular exercise, and avoiding excessive alcohol. Routine breast self-examination, annual mammogram, and annual clinical breast exam can detect early disease.
Patients with family history of breast and or ovarian cancer should receive evaluation to see if they are high risk. Patients who were deemed to be high risk (a risk greater than 20%) should be considered for earlier initiation of screening, annual MRI, genetic counselling, and genetic testing.
Q: What do you hope for the future of breast cancer treatment and prevention?
A: In the perfect world, we would be able to diagnose breast cancer on imaging alone. In the perfect world the management of diagnosed breast cancer could be achieved with medical management alone without the need for surgical intervention. In this perfect world, all patients with breast cancer would be cured.