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Hill Air Force Base, UT 84056-5206
The recent article [1] on nonpalpable breast cancers found concurrently during mammography for palpable findings was excellent. I am curious whether the authors believe their conclusion—that in the clinical setting of a palpable mass, mammography should be performed in both breasts to evaluate for clinically occult malignancy—applies to women who are already in annual screening programs or women under age 40.
Because the women in the study population were referred for screening, most were probably over 35 years and had not undergone mammography in the last 12 months. The finding that the incidence of nonpalpable masses in these women was similar to that in a screening population is well proven; it is also the expected result. My question is whether a woman with a mass who either has undergone a bilateral screening mammography in the last 12 months or is under 40 years needs to undergo bilateral mammography. The authors suggest that this woman is no more likely to have a nonpalpable mass than a demographically matched counterpart without a mass. If we would not screen the counterpart, why screen the asymptomatic breast tissue of the woman with a mass? Should we start with bilateral mammography if the last mammogram was obtained 6 months ago or the woman is under 40? If we focus only on the mass with sonography, unilateral mammography, or percutaneous biopsy (or a combination of these techniques) do we truly limit or eliminate the opportunity for early detection of breast cancer? The cost of applying your conclusions to already screened women may be small. A single short-interval screening of asymptomatic breast tissue is less likely to find an interval cancer than an annual screening but is only a single examination. In younger women, however, there is significant potential for detecting indeterminate or probably benign "incidentalomas" that will require biopsy or follow-up examinations at 6, 12, and 24 months.
Bilateral mammography is justified as a follow-up to a focused evaluation in some patients. If a mass is confirmed malignant, the woman enters a higher risk demographic group and needs the asymptomatic breast screened before definitive therapy to preoperatively stage the tumor and search for additional primaries. Screening may also be useful for the same reasons if focused evaluation is inconclusive and the mass will be excised. However, particularly in a younger woman, an initial focused examination with sonography, unilateral mammography, or percutaneous biopsy (or a combination thereof) makes sense. It may confirm a benign diagnosis, effectively ending the workup. It avoids the cost and anxiety caused by vexing incidentalomas. It saves a younger woman from the radiation exposure from the initial examination and possibly three additional follow-up examinations. It reduces the chance of a false-positive, known to be higher in younger women. The cost? We will miss some potentially curable early cancers. These rare cancers are the same ones we have already decided do not justify screening of older women every 6 months or of women under age 40. But if (as you have shown) the risks are indeed the same, the screening recommendations should be the same as well.
References
Duke University Medical Center Durham, NC 27710
UCSF Medical Center San Francisco, CA 94143-1667
We thank Dr. Markel for his comments and questions about our article [1]. In response to his question, yes, we currently perform bilateral mammography on women with palpable breast masses, age 40 or above, to screen the contralateral breast for clinically occult cancer. This practice reflects our belief that the risk of the additional radiation, the potential for false-positives, and the added cost are outweighed by the potential benefit of early cancer detection.
In his letter, Dr. Markel is really asking two separate questions: the first, what do we suggest for women with interval palpable masses (whether we image one or both breasts)? and the second, what do we suggest for women younger than 40 with a palpable mass? In response to the first question, we typically perform bilateral mammography for women age 40 or above who are 9-11 months postscreening because there is almost the same likelihood of finding an unsuspected malignancy in the contralateral breast as at 12 months. Moreover, these women will not have to return in 1-3 months for contralateral screening. For women 4-8 months after screening, we may or may not perform bilateral mammography, depending on specifics of the case as well as the patient's willingness to return in 4-8 months (we lean toward unilateral mammography if less than 6 months after screening and bilateral if more than 6 months after screening). However, we perform only a unilateral examination if a woman has recent (within 3 months) technically acceptable mammograms available for review because the likelihood of finding a clinically occult malignancy in the contralateral breast in so short an interval is highly unlikely.
Dr. Markel also asks about our imaging strategy for women under 40 who present with a palpable breast mass, specifically about whether we perform unilateral or bilateral mammography on these women. For women in the 30-39 age group, we typically perform bilateral mammography in the setting of a palpable mass because we accept average-risk asymptomatic women for screening in this age range (although we do not encourage screening for patients below age 40). The major reason for not performing mammography in young women (i.e., under age 30) is the extremely low pretest probability of disease and minimal concern over radiation carcinogenesis, although the radiation risk is indeed somewhat higher. Therefore, for women with palpable masses who are under age 30, we perform sonography alone if there is no specific clinical concern about malignancy (the usual clinical setting is differential diagnosis of fibroadenoma versus cyst). However, we perform mammography if there is clinical suspicion of malignancy based on physical findings. However, to our knowledge, no specific data address this issue so it is important to realize that this practice varies among institutions and radiologists, without one correct answer.
Furthermore, to clarify, our study does not suggest (as Dr. Markel states) that women with benign palpable masses are no more likely to have a contralateral cancer than asymptomatic women; rather, our study indicates that mammography of the contralateral breast detects malignancy at a similar rate, size, and stage of other screening-detected breast malignancies. If these malignancies are not diagnosed at the time the palpable mass is evaluated, they may present as interval malignancies or diagnosis will be delayed until the next screening examination. We believe that based on the data presented in our article, bilateral mammography should be routinely performed on the age-appropriate woman who presents with a palpable breast mass to allow the earliest detection of other clinically occult malignancies.
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