Editor’s Note: This story was originally published on LiveWellNebraska.com
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By Bob Glissmann / World-Herald staff writer
The bad news for Sandra Sojka: Her mammogram detected breast cancer. The good news for Sandra Sojka: Her mammogram detected breast cancer.
A suspicious spot that showed up during a routine 2-D mammogram in March led a radiologist to order a newly available 3-D mammogram for Sojka, 54. That test enabled the radiologist to rule out the spot that initially raised a concern. But it revealed another small problem area in Sojka’s right breast. Sojka then had an ultrasound, an MRI and biopsies that confirmed that two spots were early-stage cancers.
Sojka was screened at Lakeside Hospital, the first hospital in the Omaha area to employ the 3-D technology. A University of Iowa researcher who helped on an early clinical trial of the technology said she thinks it will become the standard — if insurance questions can be resolved.
For Sojka, access to the 3-D test meant that she had not escaped the diagnosis she had been dreading since she was a young woman (her mother developed breast cancer in her 40s and again in her 70s). “I didn’t get through life without it.”
“But then, on the other hand,” she said, “without the 3-D tomography, I might be dead in a year. You have to put it in perspective.”
The 3-D screening, also called digital breast tomosynthesis, has been shown in recent studies to detect more cancers than do 2-D mammograms alone. It also generates fewer false-positive results, which usually require additional screenings.
As a result of her screening, Sojka had both breasts removed in April. An infection that developed required surgery in May to remove breast implants. Sojka now must wait until the end of this month to start a chemotherapy regimen that could stretch into September.
Dr. Katie Mendlick, who ordered the 3-D mammogram for Sojka, said she’s convinced that it’s “a great test.”
“This is probably the next step in mammography,” she said.
Radiologists must undergo eight hours of training on the technology, Mendlick said. Lakeside, she said, has had the machine since late January.
Tomosynthesis provides multiple 1-millimeter-thick images of the breast that can be reconstructed to provide a 3-D image. It allows doctors to detect tiny tumors they otherwise might miss using standard mammography.
Sometimes, Mendlick said, normal, overlapping tissue can look like a mass. With the thin 3-D images, she said, “we can see through, in multiple slices, that it is normal tissue and not a mass. It reduces false positives from mammography.”
Those false positives can cause a lot of anxiety for women who must come back in for another mammogram, said Robert Smith, an epidemiologist who is senior director of cancer screening for the American Cancer Society.
“There’s no question that women who are recalled for additional evaluation have to endure a period of time when they wonder whether they have breast cancer,” Smith said.
A study reported on in the June issue of the American Journal of Roentgenology found that adding 3-D mammography to regular mammograms significantly reduced unnecessary rescreening of patients by 37 percent while increasing the detection of invasive cancers by more than 50 percent. Those results echo the findings in recent large studies in Norway and Italy.
Dr. Stephen Rose, a Houston radiologist who led the study, said he has been practicing since 1986 and has been doing breast imaging almost exclusively since the early 1990s. “It’s the most exciting thing I’ve seen in my career,” he said.
While outcomes like Sojka’s and studies conducted by Rose and others bode well for the technology, physicians aren’t yet getting full reimbursement from insurance companies for the procedure.
Dr. Laurie Fajardo, a radiologist and radiology professor at the University of Iowa, said a separate billing code hasn’t been established in the U.S. for tomosynthesis. Because providers obtain both 2-D and 3-D images when they run the test, they are able to bill patients using the 2-D code, Fajardo said.
To pay for the added expense of the multiple 3-D images and the time it takes to review them, Fajardo said, her hospital in Iowa City charges women an extra $60. Lakeside adds up to $75 to the bill. Brodstone Memorial Hospital in Superior, Neb., which was the first hospital in Nebraska to get the machine in 2011, doesn’t charge extra for the 3-D tests, spokeswoman Karen Tinkham said.
All three use machines manufactured by Hologic, the only vendor with an FDA-approved breast tomosynthesis system.
Some medical practices have waited to buy the machines, which Fajardo said can cost anywhere from $350,000 to about $500,000, “because they’re not quite sure they will be getting paid.”
The American College of Radiology still is exploring how the technology fits into how providers evaluate breasts, said Dr. Carol Lee, a radiologist and member of the college’s breast imaging commission. More studies are needed, she said.
“Preliminary reports so far are promising in terms of increasing cancer detection and decreasing the recall rate from screening,” Lee said, but an increased radiation dose and higher cost from the screening are concerns. Also, she said, providers must ask, “Who should get it, and how often should it be used?”
Mendlick, from Lakeside Hospital, said the tests are suggested for women with dense breast tissue, a family history or personal history of breast cancer and anyone at higher risk of developing breast cancer.
Sojka said her breast cancer diagnosis means her 17-year-old daughter must start getting checked when she turns 25. But Sojka is optimistic. “I think in her future, things will be a lot better. Testing will be more advanced, even, than what we have now.”
Procedures go beyond curing breast cancer
Reducing the damage caused by radiation treatments and the time it takes for breast reconstruction are targets of two procedures performed at a Lincoln hospital.
Dr. Kevin Yiee, a radiation oncologist at St. Elizabeth Regional Medical Center, said a recent study found that women who underwent radiation treatment for breast cancer can experience hardening of the arteries of the heart even 20 years later. AccuBoost, a radiation therapy treatment now in use at the hospital, reduces the patient’s exposure to radiation by delivering the radiation to the tumor or as close to it as possible.
“With early-stage breast cancer, we’re curing 90 percent of the cases,” Yiee said. “What we’re focusing on now is not only the cure, but making sure they don’t have problems later on in life.”
At the end of what is typically six weeks of radiation treatment, Yiee said, patients are given a “boost” dose in which an extra amount of radiation targets the space where the tumor used to be to ensure that the cancer doesn’t return.
With the AccuBoost device, applicators are positioned on opposite sides of the breast, and radiation is directed parallel to the chest wall, reducing the exposure to organs.
Mammography equipment is used to identify the site in need of the boost dose. The AccuBoost treatment combines the imaging equipment and the radiation delivery system.
Other area hospitals use other devices to target tumors. Immanuel Medical Center in Omaha, for example, uses the TomoTherapy Hi-Art System, which lets doctors check the location of tumors before each treatment and then deliver radiation more precisely. It is often used on lung and prostate tumors, officials said, but it is also used for cancer in the left breast because of its proximity to the heart.
Plastic surgeons at St. Elizabeth also perform a procedure for breast cancer patients called one-step reconstruction. It allows women to leave the hospital after their breast cancer surgery with reconstruction having been completed. Dr. Mathieu Hinze said he and partner Dr. Todd Orchard have been performing the procedure for seven to eight years now, but it’s not commonly used in the region.
The surgery, Hinze said, still involves an implant, but instead of using tissue expanders, doctors use a collagen graft that is sewn to the lower edge of the pectoralis muscle. The graft is then wrapped around the lower 20 percent or so of the implant. Over time, he said, the graft connects to the muscle and the surrounding breast tissue.
Surgeons must save as much skin as possible during surgery to allow for the implant, Hinze said.
Doctors tell patients to restrict their motion for about a week, Hinze said, and patients can resume lifting heavy items and going to the gym in three weeks.
The procedure, he said, adds up to 1½ hours to a double mastectomy. That is much less time than a TRAM flap reconstruction, which he said can take three to four hours per side.
Hinze said using tissue expanders to stretch the skin and muscle to make room for a permanent implant can be painful, and the frequent trips to the doctor’s office are inconvenient.
“The goal,” he said, “is to get the patient through this experience as quickly as possible.”
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