Brian Wojciechowski, M.D., practices medical oncology in Delaware County, Pennsylvania at Riddle, Taylor, and Crozer hospitals and also serves as Breastcancer.org's medical adviser. A native of South Philadelphia, he trained at Temple University School of Medicine and Lankenau Medical Center. Dr. Wojciechowski is a sought-after speaker on the topics of medical ethics and the biology of cancer.
A recent study found that the number of women having 3D mammograms has increased dramatically in the last four years. Still, 3D mammograms are not available everywhere.
Listen to the podcast to hear Dr. Wojciechowski explain:
- the difference between 2D and 3D mammograms
- why 3D mammograms are a standard of care, but not the standard of care
- how to find a center that offers 3D mammography, if you decide you would like one
Running time: 11:07
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Show Full Transcript
Jamie DePolo: Hello! Welcome to the Breastcancer.org podcast! I’m Jamie DePolo, senior editor at Breastcancer.org. Our guest is Brian Wojciechowski, M.D., who practices medical oncology in Delaware County, Pennsylvania at Riddle, Taylor, and Crozier hospitals. Dr. Wojciechowski also serves as Breastcancer.org’s medical advisor. A native of south Philadelphia, he trained at Temple University School of Medicine and Lankenau Medical Center. Dr. Wojciechowski is a sought-after speaker on the topics of medical ethics and the biology of cancer.
In this What My Patients Are Asking podcast, we’re going to talk about the increasing popularity of 3D mammograms.
Dr. Wojo, welcome to the podcast!
Dr. Wojciechowski: Great to be back!
Jamie DePolo: Before we talk about the boost in popularity or the increase in numbers of people getting 3D mammograms, which I want to explain are also called digital breast tomosynthesis, digital tomosynthesis, or just tomosynthesis – which is hard for me to say three times in a row – that’s the way the research papers are talking about it. Can you explain to all of us how a 3D mammogram is different from the more conventional 2D mammogram?
Dr. Wojciechowski: So all mammograms involve X-rays, low doses of X-rays to take pictures of the breasts and try and pick up breast tumors early. The thing about 3D mammograms is that it actually uses a sequential stack of images or slices of the breast to create a three-dimensional picture, which minimizes the masking effect of the overlying normal breast tissue. And it enables doctors to improve cancer detection, meaning it could pick up cancers earlier, and simultaneously reduces the false-positive rates, in other words [it] reduces callbacks, the dreaded call back, because it minimizes the masking effect of the normal overlying tissue. Now it uses low doses of radiation, but it uses about twice the dose of radiation of a regular two-dimensional mammogram. But this does not go above the FDA safety limits.
Jamie DePolo: My understanding too -- I believe this is correct – [is] that 3D mammograms can be better at detecting breast cancer in dense breasts.
Dr. Wojciechowski: Yes, yes. That’s what we’ve learned from the studies as well.
Jamie DePolo: Now there was a recent study in JAMA Internal Medicine, and it found that the number of people having 3D mammograms was 12.9% of all mammograms in 2015, and the rate jumped to 43.2% in 2017. And the study said that this happened even though major guidelines don’t recommend 3D mammograms and that there was no level I evidence that 3D mammograms were better than 2D mammograms, which I’m not sure that I agree with because it seems I’ve seen studies showing that they’re better, and as you just explained, they do seem to be better. And in … last year, 2018, screening guidelines from the American Society of Breast Surgeons said that 3D mammography is the preferred way to screen for breast cancer. So this seems very confusing to me as a layperson. It’s like the medical experts are sort of duking it out here. So what do you tell your patients when they ask about this?
Dr. Wojciechowski: So you can definitely say that 3D mammograms are better than 2D, it just depends on what you mean by better, how you define it. So the major societies that write the guidelines, they’re looking at what are the outcomes? Does the earlier detection result in women living longer and more lives being saved by 3D mammograms, and does the increased dose of radiation translate to harm over the long haul? Admittedly, we don’t know the answer to those two questions. So that’s the standard that the major societies are using when they are saying, well it’s not yet the standard of care.
There’s no question that there’s fewer call backs, fewer false positives, and more early detection -- but early detection doesn’t always mean that you’re saving a life because if a tumor is caught very early with a 3D mammogram, it might’ve been caught a little later with the 2D, but it’s still going to be caught pretty early. So those guys are just waiting for the long-term outcomes.
Now it is true that the use of 3D has jumped really quickly, and the way that our FDA works is that they tend to be very liberal about adopting new technology, even before it’s fully proven, unlike a lot of the sister organizations in Europe, for example.
Jamie DePolo: I’ll give you an example from my own experience. Where I go to get my mammograms, they switched to 3D mammography probably 3 or 4 years ago, and getting a 2D mammogram was not an option. It was like, “This is what we offer. We believe that the 3D mammogram is the best way to get a mammogram, and that’s what we’re offering.” And then other friends of mine have told me that when they went to get a mammogram, they were offered a choice. They said, “Well we now have 3D mammography technology. Would you like that or would you like the 2D one?” And my friends were very confused because they just wanted what was best for them. So if somebody asks you about that, if someone is given a choice, what do you suggest?
Dr. Wojciechowski: Well I live and work in a northeast metropolitan area outside a major city, so 3D mammograms are standard where I am. But I do think it’s important to stress the fact that they’re not yet the standard of care, they are a standard of care, but 2D mammograms are still an acceptable standard of care.
I think someone needs to go into it educated and just being aware that we don’t know the long-term effects. We don’t know if it’s more likely to save a life, and we don’t really know the long-term effect of the extra radiation. Although, it’s still a low dose of radiation. It’s not something that I worry about. So I do think that both are still acceptable standards of care.
Now 2, 3, 4, 5 years from now we’re going to have the results of large studies that will tell us, you know, what are the long term effects, and I think once those are out we can make a much stronger recommendation and determination as to how necessary it really is.
Jamie DePolo: Thank you … for pointing out that you’re in a major metropolitan area in the northeast. That also was in the study. It found that 3D mammograms are more popular in the northeast and the northwest regions of the United States, and the southeast regions had much slower growth and overall use of 3D mammograms.
Also, that the areas that had a high percentage of 3D mammograms were more likely to be wealthy and educated, which sort of, without saying it directly, kind of speaks to disparities in care, that certain areas are going to have the latest and greatest and other areas are not.
So … from your knowledge, do you think that 3D mammograms are widely available? If someone in the southeast did really want to have a 3D mammogram, would it be difficult to find?
Dr. Wojciechowski: I think in certain areas of the country, some women would have to travel quite far to get one. Not where I’m at but maybe in areas of the deep south for example. I mean I would like to see the technology available to every woman on Earth, but I think like any new technology there’s going to be more access and availability in more affluent areas because of, you know, financial resources and the demand of patients.
But again, I want to reiterate that the 2D mammogram is still an acceptable standard of care, and I think at least right now I would not be losing any sleep if my patients were getting 2D as opposed to 3D.
Jamie DePolo: And do you think that the differences in 3D mammogram availability could possibly increase the differences in breast cancer outcomes that have been noted between more wealthy and less wealthy populations? … I know you just said that they’re fairly equal as far as finding cancer eventually, but do you think it could contribute to any disparities?
Dr. Wojciechowski: So we don’t know the answer to whether or not it will result in more lives saved right now. I think it certainly could if 3D is shown to be that effective. We won’t know for another few years. What I can tell you for certain is that where 2D mammograms predominate over 3D mammograms there’s going to be more call backs, and certain cancers will be detected later.
Now does that mean … is there a meaningful difference? Does that mean that will translate into a life saved? We just don’t know right now.
Jamie DePolo: To wrap up, if someone did really want to have a 3D mammogram, whether because she had dense breasts, or had a strong family history, and just wanted something found as soon as possible, is there some sort of registry or place online where somebody can go to find a center that offers them, or is it really just sort of calling around?
Dr. Wojciechowski: I think you have to call the local hospitals and just ask them point blank if they offer the 3D mammograms. I’m not aware of a nationwide registry.
Jamie DePolo: The FDA doesn’t keep a list? That’s what I didn’t know, if the FDA kept a list or not.
Dr. Wojciechowski: That’s a good question. I really can’t say for sure.
Jamie DePolo: Okay, we can do some research on that.
Thank you so much, Dr. Wojciechowski, we really appreciate your insights on this, and I guess the bottom line is that we don’t know all the … outcome information yet so right now, 3D mammograms and 2D mammograms, they’re both good and everyone should have a yearly mammogram.
Dr. Wojciechowski: That’s it!
Jamie DePolo: Alright, thank you!
Dr. Wojciechowski: Alright, bye bye.