In this video we explore the process of breast imaging and they types of imaging that are appropriate for different ages and situations.
Most women that come to a breast center for evaluation of say a lump, actually don't have breast cancer. But we take all lumps seriously and work them up. So they will get whatever seems most appropriate, again, it might be based on their age. At a younger age, we might start with just an ultrasound. And then, at middle age and older, we would probably do a combination of mammography and ultrasound to work up a lump and help determine whether that is something that needs to be investigated further, or if it's just a normal finding, and they can go back to routine care. The way it works in a breast center is the patients are referred in and then the diagnostic radiologist or the breast radiologist will then direct the care from there. And they will determine which are the best tests and we don't want to do any tests that are unnecessary. So if we can get the answer with an ultrasound, we might be able to get the answer there and stop. Or if we need to do both a mammogram and an ultrasound, we would do that. If after that part of the work up we determine that there is a concern and we need to get some tissue from an area of concern, then we would talk to the patient about proceeding with a biopsy. When a woman comes to a breast, she gets a work up and will function the same way in the Twin Cities, the patients received their results while they're there. So they don't leave without knowing. So they have either they get their results that, hey, it's good news. This lump is not a cancer, nothing to worry about. Have another mammogram in a year. Or hey, there's a concern and we recommend a biopsy. And we may be able do that biopsy that same day or if that's not convenient for her bring her back in a day that's convenient for her. And so your OB/GYN and or family doc who refer for you in to see us has given us permission to just proceed with all the steps necessary. So we just go as far as we need to and then when appropriate, make the referral to the surgeon if that's what's needed next. The biopsy that the radiologist does at the breast center is called imaging guided corneal needle biopsy. It's a minimally invasive procedure that's done by a breast radiologist. It's done to get a little piece of breast tissue to sample an area that we've determined is abnormal, either based on something that we're seeing or the ultrasound or both. We use local anesthetic. We use lidocaine to it to numb the breast, and then we make a tiny incision. I don't even call it an incision because it's so tiny. I call it a little knick in the skin just large enough to get a needle through and then we just take a few small pieces of tissue from the area. And then we send it to our colleagues in the pathology department and they look at it under a microscope and tell us what is going on in that area. It's minimally invasive and it sounds scarier than it actually is. And I mean there's always anxiety around it. I wish patients knew how easy it was and patients come in and they're so nervous about it and then I'm done with the procedure and they can't believe that it's already done, because there's minimal discomfort and they're like, oh, my gosh, I can't believe that you're done. That was it and I was so scared. So it's really quick and easy procedure and the beautiful thing is we get results the very next working day most of the time. So there's also very little time to wait for them to get the news about what the diagnosis is. After you've been treated for your breast cancer, there's a surveillance period. And generally speaking, if you have any remaining breast tissue, you'll require a mammogram every year. Now it could be that your doctor may also order an MRI. Not all patients need an MRI and you're a medical oncologist, and other members of your care team will determine whether or not an MRI would be beneficial in your case. The important thing to remember is that your care team, your medical oncologist, your surgeon will determine and tailor what's best for you in terms of imaging. Our goal is to prevent you from having any unnecessary tests and imaging following the treatment of your breast cancer. An MRI is a test using magnetic waves to determine the anatomy and structure of the breast tissue. What it does is it's a very test to determine whether or not there is any breast cancer in either breast. It's a test that requires about half an hour of lying on your stomach. It's also it requires an injection of some contrast or dye and it's tolerated fairly well by most patients. Some patients experience claustrophobia with an MRI and if that's the case, we can provide medication to help overcome that situation. The best modality we have for screening for breast cancer, either before treatment breast cancer or after, is the screening mammogram. It's enjoyed a very long history. It has been proven to decrease the mortality rate of breast cancer. It is the gold standard for what we use to screen women for breast cancer. Ultrasound is used in certain cases, if we would perhaps see an abnormality on your mammogram or on your MRI. If you'd had a screening MRI, than we would perhaps go to ultrasound to further evaluate that particular situation. Following treatment of your breast cancer, you should know that there is a whole team of physicians and others that are dedicated to making sure you are well taken care of. Part of that process will include imaging studies. Your doctor and your care team will assure that the imaging studies that are ordered are appropriate for you and your situation. Sometimes when women undergo these imaging studies after their treatment of breast cancer can be a time of anxious, a time of nervousness and that can be normal. The radiology technologists and the radiologists will all assure that this process goes smoothly for you.
With a cancer diagnosis often comes questions about whether a person will still be able to build a family after cancer treatment. Here we explore fertility preservation options.
[MUSIC PLAYING] If you're seeing me for the very first time, it means that you've just had a new diagnosis handed to you, and you're probably learning and dealing with this new diagnosis. Your health care team has probably mentioned the option of fertility preservation in the event that you survive your treatment and the cancer is in remission or gone. When patients survive their cancer, one of their main concerns is, can they build a family? And you have that option right now to decide if you would like to preserve your eggs or your embryos, depending on your situation, for your future use. In many ways, it's like an insurance policy. You're going to make an attempt to preserve some hope in the future that you can have your own biological children. The first thing that we do is to get an assessment of ovarian reserve. And we do that with a blood test and an ultrasound. The ultrasound will show us how many follicles there are on the ovary, and the blood tests will correlate that ultrasound finding. If the level is extremely low, it's unlikely that we'll be getting enough eggs or embryos to work with, and a different alternative might be chosen. If you have enough eggs, then you would be able to proceed with the chosen treatment, and we would initiate stimulation with medications that cause the ovaries to make follicles. We watch those follicles grow, and when they're ready, we use one final shot. 36 hours later, we go into the ovaries, into the follicles, and we take the eggs out. The actual egg retrieval process is done with a vaginal ultrasound and a needle guide. So we use a monitor, and we can see that the needle is going into each follicle. We use suction to take the fluid out of that follicle into a test tube, and then we go into the next follicle and aspirate the fluid out of that follicle and so on until all the follicles are empty and all the eggs are in the lab. The lab searches under a microscope to find the eggs in the follicular fluid that we sent to them. Because they're so small, they're microscopic, you can only see them under the microscope. And then once they find the eggs, they prepare them for freezing. It's an elaborate process in the lab to freeze the egg. The egg is the largest cell in the body, and so it has a large water content to it. And the freezing process is called a fast freeze or vitrification. And we utilize the fast freeze in order to remove as much water as we can from the egg before we freeze it. And then hopefully, we get better post-thaw survivabilities and fertilization rates and success rates. Some patients are afraid that the procedure might hurt, but actually it's much easier than it's ever been in the past. In the past, the needles used to be big, and now they're small. All the needles are subcutaneous. And they can be combined. So for this purpose, you can actually do IVF with about 15 small shots total and then have the eggs taken out under IV sedation, so that part doesn't hurt at all. We know that the age of the egg donor is very important as far as quality and quantity of the egg. And the more eggs that can be banked, the better chance for success. For frozen eggs, we thaw the eggs, we fertilized them with the male sperm, and we document fertilization. We watch the embryos grow for five days. And on the fifth day, we transfer hopefully one embryo into the uterus and can freeze the remaining embryos for the future use. Because the cancer patient has unique needs, we have a system in place where they call and can be seen the same day if not the next day. Some breast cancers have a genetic etiology. The one that I'm thinking of is the BRCA gene, the BRCA1 and 2, or the BRCA mutation. And that little mutation on the gene is measurable, and there's a marker for it. So when patients who have the BRCA, they know that they have the BRCA mutation, come through IVF for fertility preservation, we can test the embryo and find out if the embryo has the BRCA mutation or not. And then in the future, we can choose to transfer only the healthy embryos. It's called preimplantation genetic diagnosis. And that's the way that we find out if the embryos are healthy or not. And when the results come back, some of the situations could be that all the embryos are affected and that you have no embryos to transfer. That's a possibility. Sometimes, it comes back that embryos two, four, and six are healthy, and embryos one, three, and five are unhealthy, and then we know which embryos to transfer, and that's the perfect situation. 1,000 consecutive technical steps have to occur in order to properly get the eggs out, the embryos, fertilized, frozen, thawed, implanted to carry out a successful pregnancy. All fertility preservation is, is an insurance plan offering hope, but it's not a guarantee or a promise of success. We really want patients to look back without any regrets and know that they at least tried to push the odds in their favor. One hardship for choosing egg or embryo cryopreservation is the cost. The cost of IVF is high. And it's often not covered by insurance. There are programs that you can apply to that help pay for the medications. And there's also medical credit cards for medical expenses where people can finance their cycles through. It's always wonderful to be on the front lines of medicine and try to figure out what's right for every patient, but this technology isn't always right for everybody for whatever reason. All we do is help them try it on and see if it fits and then teach the patients about alternatives. It might be too expensive. It might be too invasive. It might be too late. There may be lots of reasons why it's not a match. It doesn't mean that they're actually going to go forward, but they're going to come and hear and learn about it and decide if it's right for them.
Seeking genetic counseling and testing following a breast cancer diagnosis can alert us to cancer risks a person may face that are not obvious based on family history. In this video, our manager of Genetic Counseling Services explores the benefits.
[MUSIC] You know, for the newly diagnosed breast cancer patient who is overwhelmed, and their physician says, you know, I think you ought to go see someone in genetics. They often will say, why? Why? First of all, why now?, you know. I'm not having any more kids. Or why me? Why? I have cancer. What good is it going to do me now? And that's a great question, because it's an overwhelming time, and there are some really good reasons why a person may benefit from visiting with a genetic counselor. And while, probably, only 5% to 10% of breast cancer is due to a major inherited risk, meaning that the woman inherits a gene that's not working for mom or dad, that may never create a cancer risk. But as a single thing, really increases the probability. Once I have cancer, if we can find those people, it often will alert us to cancer risks they may face that are not obvious, based on their family history. For breast cancer, it may suggest their risk of getting a brand new cancer in the other breast is much higher than average women would face. And then they say, well maybe I want mastectomy instead of lumpectomy or radiation. They may face hidden risks for things like ovarian cancer with one of the more famous breast cancer genes, BRCA1, that Angelina Jolie has. But there are other breast cancer genes, that also create substantial risk for other cancers. That maybe we, knowing that, we could offer them a tailored screening and prevention program to either find that cancer early or prevent it. Recent discoveries have shown us that treatments may be tailored, based on the underlying reason why someone has had a cancer. So sometimes a woman who has breast cancer due to a certain mutation, may benefit from special therapies that, otherwise, may not be helpful, And finally, there is the family. That if I can figure out why I have cancer, then my brother, sister, son, daughter, aunt, uncle, cousin can say, do I share that risk or don't I? And that can be done more cost effectively. And then we can tailor screening prevention for those who really need it. And that overtreat or an over screen those who don't. So it can be of great value. And genetic counseling doesn't always involve genetic testing. Sometimes we're just assessing based on family history. But if we know what's causing their cancer, we can be proactive rather than reactive. And that's really the goal of cancer genetic counseling, in a context of a newly diagnosed breast cancer patient. That was new genes played a complex role in disease, diabetes, cancer, heart disease. But starting in the early 90s, we realized that genes could play a major role in some common diseases. And I was working in women care and high risk pregnancy, and got very interested in hereditary breast and ovarian cancer syndrome. So really started the risk assessment and testing program in the Piper Cancer Institute. And so really these two genes BRCA1 and 2, everything we know about them is just a little over 20 years old. But what's really important for women and physicians to know, is that those two genes, when they're not working, BRCA1 and 2, account for less than half of heritable breast cancer. So there are other genes. So I know, because I've met some women who have breast cancer at a very young age, and they say, oh I had that BRCA test, and it's normal. So my kids don't have to worry. No. If that test is normal, it's never bad news. But it's usually no news. Because if that test is normal, we know, we still don't know why you have cancer. And it may not be those two genes, but depending on how suspicious we were, there might be other genes. And there are new gene tests now. There are gene panels that can look at 20, 30 breast cancer genes for the cost of just doing those two genes. Because the cost of genetic, the technology of doing genetic testing is becoming cheaper and cheaper. Well, first it's a little bit about the process. So not everybody that comes to see a genetic counselor will have a genetic test. Either because they may choose not to. And that's OK, as long as they know what they're saying no to. And not everybody has the same genetic test. Some there's no test that's indicated, yet we might be able to inform them about cancer risks for them and your family. But if they choose to do it, usually the most common tests are back in two or three weeks. So it isn't enough time for them to help with some decision making about surgical decisions post diagnosis. Some of the more broad genetic tests may take longer, and may be more geared towards longer term benefits of risk for other cancers, or risks or helps for families. So we try that. And for some people that might have new adjuvant therapy or may have already made their surgical decision, this may be really important to them, but they may not need the resut as quickly. So we are committed to see a patient within a week of their diagnosis if they need that result to help inform their surgical decision. An analogy I often use in my patients is, if you think of breast cancer as a 16 ounce glass of water, for you to have gotten breast cancer, this glass had to be filled with risk factors to spill over the top. If you have a major inherited risk, you're basically can see through about 14 ounces in that glass. It wasn't enough to cause cancer, but as a single thing nothing puts more water in that glass. Hormone replacement therapy might pronounce in there, OK? So in terms of commonality. Now the problem is, when those genes aren't working, you don't just put water in the breast cancer glass. They often put water in some other glass. Like the ovarian cancer glass. And so that's why it may alert us, even if there is no family history of ovarian cancer. If that's what filled your breast cancer glass that's a real issue for you, and we don't want you to learn it. And have you beat breast cancer, and have you dying of ovarian cancer, when we could have done more and done something about it. And if we can figure out what filled your glass, then we can be proactive, rather than reactive. There's a lot of myths about genetics and genetic counseling, that genetic counseling isn't always about getting a genetic test. It's about informed decision making, doing right with what's right for you and your family. And it's certainly not for everybody. But if you think a genetic test might be worth considering, I strongly recommend sitting down with a genetic counselor. So they can be sure that you understand what that test can do, what it can't do, why it might help a newly diagnosed patient, and for who it might help and who it won't. And what it won't do. Some people-- it's not for everybody. And when a genetic test is normal, it usually is of limited value, unless we know we are testing you for what caused the cancer in your family. If you have cancer, and it's normal, we still don't know what caused your cancer and we might have more to offer in the future. But if we find something, that can be very powerful, very empowering.
Here we explore the different types of pathology reports you'll receive and what the findings will tell doctors. We also review the key information that these reports provide.
It's important to know that there are two different types of pathology reports. One pathology report will be from your biopsy. That has the preliminary information on a small sampling of your tumor. The second pathology report will be from your resections specimen, such as from your lumpectomy or mastectomy. That will have additional information that cannot be present on a biopsy report. The key items that you should look for in your pathology report are, number one, the diagnosis. Number two, the results of the special studies. And number three, stage. And that would be only present on your final pathology report from your mastectomy or your lumpectomy specimens. Stage is a term that is used to describe the extent of cancer in your body. So stage encompasses the size of the tumor, whether or not it has spread to any lymph nodes, and whether or not it spread elsewhere in your body. So stage is something that can only be given once you've undergone a mastectomy or lumpectomy, unless your doctor is making a stage based on the radiographic information alone. There are two broad categories of breast cancer, in situ carcinoma, which is typically ductal carcinoma in situ, or DCIS, and invasive or infiltrating carcinoma. DCIS is a type of breast cancer that's confined to the breast ducts. It has not spread outside the ducts and, therefore, it cannot spread to other sites in your body, including your lymph nodes. Invasive cancer has the ability to spread to other sites in your body. There are many types of invasive breast cancers. The most common types are invasive or infiltrating ductal carcinoma, and invasive or infiltrating lobular carcinoma. For DCIS, important things that you should look for in your pathology report are the size and the margin status. It's really important for DCIS to be entirely removed. Once it's removed on your lumpectomy or your mastectomy and it remains DCIS without evidence of invasion, this is a completely curable disease. For invasive breast cancer, what you should pay attention to are the size, whether or not it involves nodes, and the results of the special studies. The special studies include hormone receptors and HER2. Those are the predominant things that we do on all invasive breast cancers. Hormone receptors include estrogen and progesterone receptors. If a patient's tumor has these receptors, then any estrogen or progesterone in her body can potentially feed and nourish that breast cancer. Thus, these patients can be very effectively treated with various agents that block the estrogen consumption by the cells or block the production of estrogen within the body. HER2 is also present in many breast cancers, but far less than the hormone receptors. It's only present in about 20% of invasive breast cancers. And this is a protein that if it's over-expressed or there are too many copies in the cells, these tumors can be more aggressive. But the good news is there's a very effective type of therapy that can target those cells that have too much HER2, and it can directly kill those cells. So we want to identify which patients' tumors have too much HER2 to help determine the best treatment. There are also some very sophisticated tests that can be done on some patients' breast tumors, and these include the Oncotype DX test and the MammaPrint test, but you need to ask your oncologist to determine whether or not you're a candidate for this type of laboratory analysis. In summary, I think the most important thing is to first look at your pathology report and see whether or not it's a pathology report on your biopsy, which would be of a limited sampling, or is it the pathology report on your resections specimen, such as from your lumpectomy or your mastectomy specimen. The next thing, look on your pathology report and see whether or not this is in situ carcinoma or DCIS type of cancer, or is it invasive. Remember, if DCIS is completely removed, it's 100% curable. If it's invasive breast cancer, you should look at the tumor grade, and remember that that's not the same as tumor stage. Grades of tumor are from 1 to 3, with the grade 3 generally being more aggressive type tumors than a grade 1 tumor. You should look at the overall size of your invasive breast cancer, and you should pay careful attention to the ancillary studies or the special studies, such as whether or not your tumor is hormone receptor-positive or whether or not it's HER2-positive. Because if it's either positive for hormone receptors or HER2, this opens up a new avenue of treatment for your breast cancer. Lastly, I think pathology evaluation in your tissues is extremely important. And it's important for us as pathologists to be very thorough in the information that we give, because this information will be utilized by your oncologist and your surgeons in determining the most appropriate therapy for your breast cancer.
Get a better understanding of what receptors are and what their role is in telling doctors about a person's cancer and how it should be treated.
A receptor is a protein that is aligned on the cell that allows certain drugs, certain hormones, a variety of things, because there's many different types of receptors, to come into the cell and to affect the cell. And that's how the estrogen receptor works. There are three important receptors, and the only real receptors on the breast cancer cell are the estrogen receptor, the progesterone receptor, and a receptor that is called HER2/neu. And those receptors are receptors that tell us a lot about the tumor, a lot about the cancer. If the breast cancer cells have those receptors, that is generally a favorable sign. Because the breast cancer cell has maintained, if you want to think of that, has maintained some of its normal receptors, normal function. So estrogen receptors help us in other ways other than by telling us how this tumor might act. It also gives us an opportunity for treatment options. Because if you have an estrogen receptor on the cancer cell, then we can offer treatments, such as tamoxifen, or one of the other types of estrogen blockers that can be used in post-menopausal women, and they are called, a class of them are called aromatase inhibitors. So you have options for treatment that are not specifically chemotherapy, but are very beneficial. And the way those treatments work is that if you have an estrogen receptor on your cancer cell, the drugs that we're talking about in these two classes, the tomoxifen and the aromatase inhibitors, when we give that drug it blocks the estrogen receptor so that estrogens can't stimulate that cancer cell and the cancer cells die. If you don't have an estrogen receptor, if you're estrogen receptor negative, then we can't use that endocrine treatment and that's an extremely important part of the management of patients with breast cancer. The HER2/neu is a relatively new, and I'm sorry to use that as a pun, but it's a relatively new receptor. We've known about estrogen receptors for many, many years, and we've used some of these endocrine therapies for many, many years. The HER2/neu receptor has been utilized maybe for the past 10 to 15 years. And the importance of HER2/nue is that it is not a normal receptor on a normal breast cell. And so when a cancer cell changes from a normal breast cell to a cancer cell, it can attain this receptor. It can get this receptor and that is generally a sign that this tumor might be a little more aggressive. However, we have treatments now that are targeted directly at the HER2/neu receptor, called Herceptin, which does the same thing as the endocrine treatment does for an estrogen receptor. It blocks that HER2/neu and can almost negate the effect of the HER2/neu receptor on the breast cancer. So these are our three receptors that are extremely important and every patient should know what they stand for, and how we use them in managing patients with breast cancer.