July 2003: Breast Cancer Screening

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Why is screening so important?

Question from julie16: Why is screening so important?

Answer —Cecilia Brennecke, M.D.: We've found over the last 40 to 50 years that survival is much higher when you pick up cancer in the early rather than the late stages. Performing screening mammography is an effort to pick up cancer before there are any symptoms, so screening, strictly speaking, is only for women who are not experiencing any kind of breast problems.

The research that's been done as far back as the 1960s shows that X-ray mammography is the only proven method for finding cancer before anyone suspects that it's there. That research was rigorously done and has never been disproved. This is truer now, I think, than it was in those days because the quality of the images we can obtain is much better and our awareness is much greater.

Diagnostic vs. screening mammograms?

Question from taylor: How is a diagnostic mammogram different from a routine or screening mammogram?

Answer —Cecilia Brennecke, M.D.: A routine or screening mammogram consists of four views—two views of each breast. The technologist takes the pictures, checks them for quality, and then you leave. With a diagnostic mammogram, you start with four standard views, and then supplement them with additional views, a physical exam, and ultrasound and MRI as needed. So a diagnostic mammogram is for women who are having a problem such as a lump or unusual nipple discharge or pain.

A diagnostic mammogram is generally read by the radiologist right after it has been done; ideally the woman does not leave the radiology facility until she has an answer about what is causing her breast problem. Usually the outcome is that everything is fine, but there is a higher incidence of finding cancer in that situation than in a screening situation.

Does digital mammography find DCIS sooner?

Question from Sindee: Does digital mammography detect DCIS earlier than conventional X-ray mammography?

Answer —Cecilia Brennecke, M.D.: X-ray mammography is the cornerstone screening method when it comes to finding cancer early. Digital mammography produces an X-ray image using digital technology, which is more like a TV monitor. The standard way of producing an X-ray image uses film, which is more like a movie. Film produces an image that is a little bit sharper than a digital image. Digital is still new, and companies that make the equipment want radiologists to buy it. When General Electric came out with the first digital equipment, the company did a lot of advertising, particularly during the Olympics, making all sorts of claims such as digital is the only way to go. A lot of people who were watching believed what they were hearing from GE.

However there's a study that's currently underway in which each woman who signs up has a mammogram with film followed by a digital mammogram. Both mammograms are done during the same visit and compared. The study is showing that there are fewer recalls with the digital method, but that the image quality is a little better with the film. (Note: A 'recall' is when you are called back into the office following a screening mammogram because the radiologist found an abnormality on the mammogram that requires further evaluation.) A key benefit of the digital method is that we can manipulate the image after it has been obtained. We look at the image on a computer monitor, and we can make it larger or smaller, brighter or dimmer. We can also magnify specific areas. With a film image, on the other hand, once the technologist has taken the image and processed it, it can't be changed. If it's too dark or light, that's it.

The bottom line is that although there are some manipulations we can make with a digital image, at this point digital is no better than film and it's considerably more expensive. Digital equipment is about 10 times the cost of film equipment, and at this point there's no proven benefit to the patient. I think it will eventually be the only way to have a mammogram, but the equipment and monitors still need to be improved. Unfortunately, when we buy new equipment, health care costs go up, so we have to be very cautious about how we develop and use new equipment. We have to be sure it's worth the cost, because the cost is in some way passed on to patients. Screening has to be low in cost in order to be effective. You can't charge a lot of money and expect women to be able to pay for a test every year.

Less painful screening test?

Question from Susi: A friend told me that mammograms are very painful, but that there is another method that is not painful. Do you know which test is she talking about?

Answers —Cecilia Brennecke, M.D.: Personally I have a mammogram every year, and I don't think it's painful. But it depends on the technologist. If it's painful where you go, tell the technologist she's hurting you and she can make an adjustment. If you are premenopausal, try to have your mammogram when your breasts aren't hurting, usually in the first half of the cycle. Some women take a Tylenol before they go in. Try refraining from caffeine if that makes your breasts hurt. I work in a center where my technologists only do mammograms. They don't do any other kind of X-rays, and they are good at what they do. So find a place where the technologists are good at what they do and they won't hurt you.

Marisa Weiss,, M.D., president and founder: Many women find the procedure somewhat uncomfortable, but as Dr. Brennecke said, it's unlikely to be painful.

Cecilia Brennecke, M.D.: Remember that many factors affect a person's experience of pain. Fear is a big factor; being afraid of the outcome, or of in the test, can heighten fear and pain. The technologist can calm you down and take it slowly. The mammogram has to press the breast tissue down tightly; it has to be tight because in order to get a sharp image, you want the X-ray to travel the smallest possible distance. Cancer can be the size of the head of a pin, and in order to detect it the breast must be compressed. However, your breast is only compressed for a fraction of a second.

There are plenty of tests that don't require compression. One is ultrasound. But ultrasound is not a screening tool because it cannot find the very early stage of breast cancer, which is what we call microcalcification. Microcalcifications are seen inconsistently on ultrasound. I love ultrasound; it's a fabulous tool in the breast, but we can't use it as a screening tool. MRI, interestingly, is performed lying down on your stomach with the breast immobilized. Now we've come to realize we can do the MRI if the breast is compressed, so we're back to compression.

Diagnostic mammograms after treatment?

Question from Nanc: After breast cancer and appropriate surgery, for how long should women have diagnostic rather than screening mammograms?

Answer —Cecilia Brennecke, M.D.: When a woman is a breast cancer survivor, I perform diagnostic mammograms on her for the rest of her life. I used to think that we should stop screening everyone at age 80, but I've changed my mind on this. That's because I see many women over 80, who are in very good health, and deserve to have the best care possible and to get screened. When you are a survivor, you should receive diagnostic mammograms forever. Medicare guidelines state that a unilateral mammogram—a mammogram done on a woman who only has one breast—is a diagnostic exam and not a screening exam.

Mammograms after mastectomy?

Question from Maja: It's been one year since I had a mastectomy and I am due for a mammogram. How are they going to view the mastectomy site?

Answers —Cecilia Brennecke, M.D.: About 20 years ago, some interesting research was done which showed that performing mammography on the side of the chest where a mastectomy had been done was of no benefit. If there was a new problem, the researchers found that it would be picked up first with a physical exam. That research was done on women who hadn't had implants or reconstruction.

More recently, research was done on women who'd had reconstruction; in many cases with a so-called TRAM flap procedure, in which abdominal fat and muscle are tunneled under the skin to the breast area. Researchers found that in a few of these women, there was evidence of breast cancer in the TRAM. It is very difficult to remove every cell of breast tissue during a mastectomy, and it's possible that a few remaining cells could be cancer cells that grew after the patient had a mastectomy. However, this situation is very unusual.

Marisa Weiss,, M.D., president and founder: Each one of you has a situation that is unique to YOU. You and your doctor should use the information we are giving you this evening to make the best screening and treatment decisions for YOU. If you've had mastectomy for a small cancer and all margins were widely free and clear and there was no lymph node involvement, the risk of recurrence in the area where the cancer developed is very low. If, however, you had a mastectomy for a large breast cancer, or one in which a significant number of lymph nodes were involved, the risk of local recurrence may be significant. In that situation, Dr. Brennecke, what is the best way to evaluate the area?

Cecilia Brennecke, M.D.: As you said, each woman is unique. If a woman wants me to perform a mammogram on her mastectomy side, with or without reconstruction, I'll do it, because that's what she wants. I can tell her what the data shows, but if she wants a mammogram, she should have it. In terms of how to evaluate a woman who had a large tumor, we can do a physical exam, mammogram, ultrasound, or any combination.

Marisa Weiss,, M.D., president and founder: What about MRI?

Cecilia Brennecke, M.D.: MRI can be very useful in certain situations. If there is a physical finding, such as a palpable thickening or lump, and the standard imaging of mammography and ultrasound are normal, or if there's intense scarring that makes the mammogram and ultrasound difficult to interpret, MRI may play a role by enabling us to see whether there is abnormal blood flow and contrast uptake in that area.

Do silicone implants obscure mammograms?

Question from Mary: Do silicone implants used in reconstruction surgery obscure radiographic exploration for recurrence?

Answer —Cecilia Brennecke, M.D.: X-rays cannot penetrate silicone, so silicone implants do limit our ability to see. This is also true for women who have not had cancer but who have had breast augmentation surgery. But if the implant is placed behind the pectoral muscle, our visibility is not limited. So it is beneficial to have the implant placement behind the area where breast tissue would be.

Self-exams and mammograms valuable?

Question from Arachne: There's been quite a bit of "news" recently suggesting that mammograms and breast self examination are not particularly valuable in discovering breast cancer. Is this true?

Answers —Cecilia Brennecke, M.D.: No. Look to see who wrote the articles; they are not doctors, they are reporters. They are writing to get attention, and they do get attention. I'm married to a reporter, so I know these things.

Marisa Weiss,, M.D., president and founder: But these reports were written in response to a re-dredging of data.

Cecilia Brennecke, M.D.: Those studies would have dwelled in obscurity; the public would not have known anything about them. One of the grandfathers of screening mammography was Swedish. The researchers who were questioning all the screening epidemiology were a couple of Danes, and these guys question everything and look for fault. But they never got written up in the New York Times before. It's frustrating to have something that you know works, and to have somebody telling women not to bother with it.

Marisa Weiss,, M.D., president and founder: There is no perfect test, but these tests are still very useful, and when they are used in combination, we can do a very good job of early detection.

Cecilia Brennecke, M.D.: That's right. In the best hands, mammography is about 85 percent effective in picking up cancer. But if a woman feels there is something wrong with her breast and the test comes back showing that everything is normal, she may think she can ignore what she thought she felt. That's not a good idea; she needs to take things a step further. One of the hardest things about breast cancer is the emotional overlay. It's a very emotional part of the body. I have had women tell me they'd rather have their colons removed than have a biopsy of the breast. It seems obvious to me that if you touch your breasts, you will know more about yourself than if you don't touch your breasts. Women, particularly those under age 40 and not having routine screenings, should be very aware of how their breasts feel, and if they don't feel right, they should bring it to their doctors' attention. Younger women with breast cancer get picked up very late because they're not doing self exams, and are not getting any screening tests because they're so young.

Mammography is of limited use if the breast tissue is dense, and there's no way to know how dense your breasts are until you've had a mammogram. Your breast can feel lumpy and sore and firm (cystic or fibrocystic), but when we do a mammogram, it may not be a difficult breast to interpret. Younger women tend to have breasts that are harder to interpret on a mammogram, but that's by no means universal. Thinner women tend to have breasts that aren't fatty. Fat is our friend on a mammogram. It helps us out when we're trying to find early cancer because it looks different than the way cancer looks.

Clinical breast exams better taught?

Question from Kathy: The American Cancer Society (ACS) has done a very good job instructing women on the proper technique for BSE (breast self exam). Are the doctors that are attending medical schools today being taught to do a better CBE (clinical breast exam) than their predecessors?

Answers —Cecilia Brennecke, M.D.: I'm part of a group in Maryland that travels around the state and teaches the "Mammocare" method to practicing physicians, usually primary-care physicians. That work is funded by the CDC (Centers for Disease Control) because Maryland has a very high breast cancer rate. I don't know what medical schools are doing about it, but in my breast center, we offer clinical breast exams performed by the radiologist, and it's a highly sought-after service.

Marisa Weiss,, M.D., president and founder: I have patients who complain to me that their doctors do poor breast exams, and they don't know what to say or how to handle it. I think it may be important for you to say just before the exam starts that you really need the doctor to do a very careful exam, that it's very important to you, and that you are really depending on him or her to do this in conjunction with your own self exam as well as mammography and other tests, as needed. Making this request may make a significant difference, but if the doctor does not respond in a way that is satisfactory to you, maybe you should find another doctor, or at least make sure there are enough other doctors on your team who are providing this important part of your examination.

Cecilia Brennecke, M.D.: I agree. The gynecologist is the primary-care physician for many women. Their area of expertise is not the breast but the pelvis, and they may not be comfortable with the breast exam. I agree with Marisa that you should impress upon the doctor that this is important to you. The breast exam is not an easy exam to do, and that may be why they're not doing a good job, or are doing a cursory job.

Marisa Weiss,, M.D., president and founder: When you examine your own breast, you can expect to feel "neighborhoods" or regions that have distinct variations. For example, the upper outer quadrant may feel like a scouring pad or a collection of grapes.

Cecilia Brennecke, M.D.: I always need food analogies, Marisa!

Marisa Weiss,, M.D., president and founder: This scouring pad comparison is very useful because I haven't found a piece of food that describes a cloud-like region that is consistently very firm. I think that gefilte fish would also be a good alternative description.

Cecilia Brennecke, M.D.: I use oatmeal and tapioca. If you feel a rock in the oatmeal, it doesn't belong.

Marisa Weiss,, M.D., president and founder: It's like the Sesame Street images—which of these things does not belong with the others?

Cecilia Brennecke, M.D.: When you feel the upper outer quadrant—which is the area between the nipple and the armpit—and it feels lumpier than the rest of the breast, that's normal. The same area on the other breast should feel somewhat the same. Not exactly the same, but somewhat the same.

Marisa Weiss,, M.D., president and founder: At the very bottom of the breast, just above the crease or the fold, where an under wire would rest, the breast may have a very smooth or thick consistency, like the rind of a piece of fruit. It's thick and smooth and the edge of it can feel like a ridge. Don't expect our descriptions to fit your breasts exactly. Our only message here is that the breast tends to have different patterns of consistency, depending on the area. Get to know how your own breast tissue feels, and if you have any questions, bring them to the attention of your doctor.

Cecilia Brennecke, M.D.: I think women are afraid of the self exam because it's difficult. They're afraid that they would not find something that is important, or they would find too much and bother the doctor. But it's free and it works—you just have to practice. I think NOT doing something that could save your life is a lost opportunity.

Are dimples on the breast common?

Question from Trudy: I didn't find a lump, but a dimple. Is this common?

Answers —Cecilia Brennecke, M.D.: We talked about what you feel with the self exam, but an important part is to look in the mirror and look for a dimple. The breast should be outwardly round—it should curve outward and not pull in. A dimple is a pulling in of the skin, and it may occur when you raise your arm or lean forward. When you lean forward and raise your arm, the breast should stay outwardly round; it should not pull back in. That may be a sign of cancer, and it should be checked.

Marisa Weiss,, M.D., president and founder: If you've had breast surgery before and you have some scars, you might find that the breast will pull in around a scar. Of course, this is a different situation. Anything that is new or different about your breast is important to make note of. You may also see changes in the color of your breast, such as pinkness or redness. You may see a rash on your breast. Some women may notice that their nipple is getting crusty or irregular. You may also notice a discharge out of the nipple. All of these changes are important to bring to the attention of your doctor. Another important finding is enlargement of the breast. There is a very unusual type of breast cancer called inflammatory breast cancer that involves enlargement of the breast, pinkness or redness of a significant part of the breast, or thickening of the skin, and only half the time is there a lump to be felt.

Cecilia Brennecke, M.D.: We should stress here that breast enlargement alone is not necessarily a sign of inflammatory breast cancer. I see a lot of women who are worried about a change in breast size, and inflammatory cancer is rare. If the breast doesn't have any of those other features, if it still looks soft and pale and the color is normal, there may be nothing to worry about.

Does a radiated breast feel different?

Question from Nett: After one breast has been radiated, should they still feel similar?

Answers —Cecilia Brennecke, M.D.: Dr. Weiss is the expert on that, but in my experience it's very common that a radiated breast may be firmer after treatment.

Marisa Weiss,, M.D., president and founder: I agree. After breast preservation therapy, consisting of removal of the lump followed by radiation of the breast, the breast does feel somewhat different. There are changes associated with the surgery itself—the scar, the area where the tissue was removed from underneath. In addition, there tends to be fullness and sometimes a sense of heaviness that can persist for a significant period of time beyond completion of radiation.

MRI standard for previous cancer?

Question from Wondering: For those with a previous breast cancer, are breast MRIs the new standard as a supplement to mammograms, and how often are MRIs recommended?

Answers —Cecilia Brennecke, M.D.: MRI is a new technology for the breast and I don't feel that we've sorted out the exact use yet. Right now the accepted use of MRI is in the newly diagnosed woman, to check that breast for a second known site of a breast cancer on the same side, and to check the opposite breast for an unknown site of possible cancer. The use of MRI to screen breast cancer survivors is not yet accepted. It is a very expensive tool. It is difficult to interpret; there is a high rate of false positives—seeming abnormalities that show up on the exams and are not real abnormalities—like a false alarm.

Marisa Weiss,, M.D., president and founder: At the recent ASCO (American Society of Clinical Oncology) meeting, a very interesting report was presented on the role of MRI scans in women without a personal history of breast cancer but who were known to have a breast cancer gene abnormality. In this study, researchers compared MRI scanning to mammography and ultrasound, and in this high risk population, MRI scans seemed to be able to find small, invasive breast cancers earlier than mammography and ultrasound. Mammography seemed to be better at finding non-invasive (DCIS) breast cancers. There were nearly 2000 women in this study. This information is promising but still early.

Cecilia Brennecke, M.D.: I deal with MRI and I don't think we've sorted out exactly where it's going to fit in.

Marisa Weiss,, M.D., president and founder: In my breast cancer practice, I may choose to use an MRI scan of a woman who's had a breast cancer, if she has a difficult physical exam and a very dense mammogram, or one that's tricky to read. Of course, you need to individualize your care with your doctor. If you choose to have an MRI scan, it is important to go to a facility that specializes in MRI scanning of the breast in order to minimize the chance of a false alarm, and to maximize the chance of learning something useful from the study that will help your doctor take good care of you.

Cecilia Brennecke, M.D.: All the centers that perform mammography are accredited. They must pass a stringent set of tests that are performed by the FDA (Food and Drug Administration). But we don't have that oversight for MRI. In general, I would not use an open MRI for breast. You may want to try to find one that is associated with a breast center or a teaching hospital.

Marisa Weiss,, M.D., president and founder: At some of the universities in Philadelphia, there are actually clinical trials available in which they are following women with MRI, mammography and ultrasound. Participating in such a trial would be a good opportunity to take advantage of this test as well as to advance our knowledge about this important question.

Better screening for recurrence?

Question from tracey: I was diagnosed with breast cancer last year at age 41. I've finished eight cycles of chemotherapy and almost eight weeks of radiation. The problem is that I have no confidence in the ability of mammograms or physical exams to catch a recurrence. Is there a better screening method? Would I be safer having an annual MRI or PET scan?

Answers —Cecilia Brennecke, M.D.: In the early days of mammography, there was some discussion among physicians that the X-ray dose was possibly going to cause more cancer than was diagnosed. That was actually disproved, but it was quite controversial for a time. It even led to a recommendation that a screening mammogram be just one view of each breast because of the perceived fear of the radiation. There's actually been no evidence that breast cancer has been caused by imaging, and the dose has decreased since the beginning.

For this particular woman, I would advise her to continue to have a mammogram, a clinical breast exam, and ultrasound if needed for screening for breast cancer. These are still the most reliable tools that we have for detecting early cancer and recurrence. MRI at this point is a secondary tool. We don't have any evidence of its efficacy over time or how often it should be used. PET scanning is for the entire body rather than just the breast. PET can be used to check for metastatic disease, but not as a routine tool.

Marisa Weiss,, M.D., president and founder: In addition, PET scanning is not very good at finding small cancers, for example under 1 cm.

Cecilia Brennecke, M.D.: It wouldn't be used for non-invasive disease.

Marisa Weiss,, M.D., president and founder: You may find that doctors in different institutions and in different parts of the world have different opinions and different styles of practicing medicine. For example, at Memorial Sloan-Kettering in New York, they are integrating MRI scanning into the follow-up of women who've had breast cancer personally, as well as in women who've not had breast cancer, but who are at high risk because of a known inherited gene abnormality. Until the role of MRI scans is better understood, it's hard to come up with strong recommendations one way or the other. It is a very useful tool under a number of different clinical circumstances. These tests in combination are likely to give you the best information.

It's also important for the test results of each of these studies to be correlated with the other studies. For example, you are likely to learn much more about the health of your breast if your radiologist is looking at both your ultrasound and your mammogram and combining the information. If you have each of these tests in two different institutions, it's possible you may not capture the full amount of information available.

Cecilia Brennecke, M.D.: The other thing that brings up is cases where a woman who has a mammogram at one facility, then changes facilities and doesn't recognize the importance of bringing past films to the new facility. We're looking for the most subtle change, and if we don't have the pre-existing mammogram, we can't look for change. You tie the hands of the person reading the film if you consider each film as a new start. That's something that is extremely common—women going from one site to another and not making it their responsibility to bring the films along with them.

Marisa Weiss,, M.D., president and founder: You need to bring your films or studies with you wherever and whenever you go to a new place. Bringing the written reports alone is not enough.

Screening 5 years post-treatment?

Question from Cyndal: What about when a breast cancer survivor reaches the magic five years and screening goes back to normal?

Answers —Cecilia Brennecke, M.D.: In my practice, breast cancer survivors are always given diagnostic mammograms. That is the standard, as far as I know, in terms of what we use for deciding whether someone is a screening or diagnostic patient, and that is set by the insurance companies. There are codes assigned, and a person with a history of breast cancer can have diagnostic mammograms forever.

Marisa Weiss,, M.D., president and founder: A careful exam of a person who's had breast cancer is essential. No matter how many years you are beyond your diagnosis, it's important for the technician to mark the scar on the surface of the breast so that the radiologist can focus in on that area with extra attention, as well as carefully evaluate the whole breast. This is one example of why you always deserve to have extra attention. If the scar tissue is prominent and stable even five years out and you go to a facility that does not pay attention to that area, it is possible that the radiologist might become unnecessarily worried about the tissue in the region of surgery.

Any little thing you can do to maximize the quality of your screening can make a big difference. Another advantage to continuing with diagnostic mammography is that you usually get the result of your mammography while you're there. This can vary from one place to another, but I think in general the chances of your being able to talk to the technician and the radiologist is better if you have a diagnostic study.

Screening for daughters of patients?

Question from MariaR: I lost my mother to cancer when I was 10. How can I check myself, or what do I need to see? I also have two daughters, and I am worried.

Answer —Cecilia Brennecke, M.D.: I start the daughter of a woman who's had breast cancer with screening mammography 10 years earlier than her mother's age at diagnosis. So if your mother was 40, you should start screening at age 30. Screening should include a mammogram and a clinical breast exam and ultrasound if it is needed. Regarding your daughters, they should begin having clinical breast exams at age 18-20, when they start going to a gynecologist, and they should start learning how to do breast self exams at about the same time.

Can mammograms spread tumors?

Question from Becca: Is it true that extreme pressure on the breast for a mammogram can break and spread small tumors?

Answer —Cecilia Brennecke, M.D.: No. The compression is necessary to get the X-ray image, and the compression does NOT cause any abnormalities of the breast. I have seen some bruising on occasion, but it has never been shown to cause or spread breast cancer.

Screening for bone pain after treatment?

Question from Nelly: I am 62. I've had a mastectomy, radiation, without chemo (2 nodes involved), and been on tamoxifen for about 4 years. I've been free of cancer until now! For the past four months, I have had bad but intermittent back pain—all in the spine—and pain in one coxofemural joint. How can I manage this? What exam/screening do you recommend? My oncologist said, "We're waiting."

Answer —Marisa Weiss,, M.D., president and founder: If you have new pain in your back and your joints, and you are suffering without an explanation for why you're having pain, then you need to have further evaluation. In the U.S., a doctor might start with a bone scan to look at the health of your whole skeleton. Sometimes extra films are done of a particular area that may be of concern. If a person has back pain that's severe in a particular area, and also has numbness or a change in her ability to walk after having a diagnosis of breast cancer, an MRI scan would be very useful. Your doctor in Romania might also want to do a blood test to see what your calcium level is.

Of course there are many causes of back pain and joint discomfort besides breast cancer. If you've had breast cancer, your worst fears will always go through your mind. But low back pain is very common, as is arthritis. If you've had chemotherapy, particularly if you've been treated with a taxane, joint and muscle discomfort is not unusual. Some women experience joint and muscle discomfort while taking aromatase inhibitors. It sounds like you need to go back to your doctor and push him/her for some more answers, so you can have a better understanding of what's happening with your body.

New mammogram technology?

Question from Kells: What can you tell us about R2 technology and ImageChecker in mammograms?

Answer —Cecilia Brennecke, M.D.: Computer aided detection is a way to help the radiologist interpret the mammogram. Several studies have shown that a radiologist may detect more early cancer if a computer is also allowed to analyze the images as a second reader. I used this technology in the past, and found that it aided the general radiologists particularly. Many radiologists interpret mammograms as part of many different exams that they do, including CT scans, chest X-ray, bone films, etc. and having a computer as a second reader can help that radiologist be more accurate in reading mammograms. This is another advantage of the digital revolution making computer detection easier, but it is also available for standard film mammography.

New breast tissue on ultrasound?

Question from Grannie: Hi, I am a 4-year breast cancer survivor. On my last mammogram I was called back for an ultrasound and was told that they had found new breast tissue that was not there last year. Also, I am postmenopausal, and have lost a lot of weight since the mammogram a year ago. I had never heard of having new breast tissue at my age.

Answers —Cecilia Brennecke, M.D.: I would be suspicious of that as well. I don't know how old you are, but if you take estrogen, new tissue can appear on a mammogram. If you are not undergoing hormone replacement therapy, then a new area of tissue should be regarded with suspicion. I would ask for a biopsy. When you lose weight, the breast may be smaller and look more condensed on a mammogram, but a new area of tissue should not develop. What I do when there's an area of abnormality on a mammogram is solve it on the mammogram by doing additional views. I then go to ultrasound to see if I can tell if the area of concern is normal breast tissue or a cyst or a mass.

Marisa Weiss,, M.D., president and founder: Tonight we have talked a lot about tests—tests performed within the hospital as well as your own breast exams and your doctor's exams. If you find a lump in your breast that persists, even if the mammogram and ultrasound are read as normal, it's important to follow and evaluate the lump. We do have a tendency to favor technology over something as simple as your own breast examination. Of course, you want to be completely reassured by the normal test report, but again, about 20 percent of women are diagnosed with breast cancer based on a palpable or visible abnormality that is not seen by mammography. It's important to take this a step further with ultrasound or the other tests described above by Dr. Brennecke.

Cecilia Brennecke, M.D.: The other issue is that biopsy of the breast is a very simple tool. We don't want to do unnecessary biopsies, but if you or your doctor has a concern, and the imaging is negative, and the concern is real, you can't stop there—you have to obtain tissue. I do biopsies using imaging guidance. It's quick and painless, and gives you a diagnosis: normal, abnormal or needs to be evaluated by a surgeon. Trust your own instincts, and do not be swayed by a negative test.

Marisa Weiss,, M.D., president and founder: You make an important point with regard to the advances in, and the ease and accuracy of, biopsy techniques today. When the biopsy procedure is guided by high quality imaging, you are likely to obtain a good sample that accurately represents the area of concern. Also, the core biopsy can be done through a very small incision. The scars that biopsies caused in the past can usually be avoided today.