Few medical tests create more anxiety among women than a mammogram. In addition to some short-term discomfort caused by the firm compression of each breast during the test, nearly every woman knows someone who has been diagnosed with breast cancer.
The test is a regular reminder: It can happen to you.
There can be uncertainty about what the results really mean. An image of breast tissue can be filled with a flurry of spidery white lines. It offers an opportunity for the tiny dots of early-stage breast cancer to hide. That means a spot that could signal breast cancer could be missed. Or tissue identified as possibly cancerous, and requiring a trip back for more tests or treatments, later turns out to be benign.
Little wonder that when a new technology, called tomosynthesis or 3-D technology, burst onto the scene in 2011 promising better results, it grabbed national attention.
The machine creates a series of images of the entire breast “like pages from a book,” said Dr. Nancy Neubauer, medical director of the Comprehensive Breast Center at Providence Regional Medical Center Everett. “That gives us an opportunity to find things that otherwise would be hidden in the breast tissue,” she said.
Carol Tranfaglia, 53, of Woodinville, is among those women whose doctors say their breast cancer was detected earlier with this new technology. In January 2012, Tranfaglia went to EvergreenHealth in Kirkland for her annual mammogram. Evergreen was one of the first health care organizations in the Puget Sound region to have the new 3-D technology.
A few days after her initial mammogram, Tranfaglia got a call asking her to come back for more tests.
There was a spot in the image of her left breast that concerned physicians. They offered to do a biopsy that day. Three days later, she got a call. The spot had been identified as invasive globlar cancer. “During my biopsy, the doctor said, ‘Even if we find cancer, it’s small enough to be very treatable,’” she said.
Surgeons removed a lump of cancerous tissue from her breast and she received radiation treatments. “If they hadn’t caught it so early, my course of treatment would have been much longer, including chemotherapy,” she said.
Evergreen installed its first 3-D unit in July 2011, just months after the machines were approved by the federal Food and Drug Administration. Evergreen now has four 3-D machines, including one installed last summer on its mobile mammography van, which makes stops in Monroe and the Skykomish Valley.
In the first two years, the 3-D technology is credited with finding cancers in 48 women before they would have been found on 2-D, the more traditional digital mammograms, said Dr. Kara Carlson, medical director of the EvergreenHealth Breast Center. “Mammograms are like fingerprints,” she said. “No two cancers look alike.
“Three-D has revolutionized the mammogram in the sense it does a better job,” Carlson said. The advantage of 3-D is that it prevents images of breast tissue from overlapping each other, hiding cancers that can spread, she said. “It’s a more effective tool than your standard 2-D mammogram.”
Did technology overtake science?
Advocates of 3-D technology say a June 2014 study in the Journal of the American Medical Association supports their assertion that it’s a better technology.
The national study found that with 3-D mammograms, the detection of invasive cancer — those types that spread — increased 41 percent while recall rates dropped by 15 percent.
It’s one of the reasons local health care organizations such as The Everett Clinic and Providence Regional Medical Center Everett added 3-D mammography this year. Both continue to use 2-D technology as well. “The denser your breast tissue, the more limited standard mammography is,” said Providence’s Neubauer.
While some see 3-D as breakthrough technology, others remain skeptical. They include Group Health, which uses 2-D for all its mammograms, and Susan G. Komen, a national organization long associated with the fight against breast cancer.
“Tomosynthesis in my view is an example of where the adoption of the technology got way out in front of the science,” said Dr. Marc Mora, Group Health’s chief medical officer. The concern is over the ability of 3-D machines to discriminate between cancers that are likely to grow and those that aren’t, he said.
“We’re excited about the potential,” Mora said. “At this point we’re not yet convinced that this new technology does the important things that we want new technology to do — reduce the burden of suffering or illness in women and certainly the mortality rate.”
Just this past week, a study on a different type of test, computer-aided detection software, or CAD, underscored his point. Researchers found that the widespread adoption of CAD, designed to help radiologists find cancer in mammograms, didn’t begin to live up to its hype. It does not improve breast cancer screening, according to a study funded by the National Cancer Institute. In fact, CAD could result in more missed cancers.
“It sounds great in theory,” said Diana Buist, a senior investigator at Group Health Research Institute, who participated in the study. The technology has been around for 15 years. This isn’t the first study that’s said it isn’t better than a radiologist simply examining a 2-D mammogram, “and it may be worse,” she said. “But we’re paying more for it.”
“The reason there’s a nice parallel with (CAD and) tomosynthesis is that it’s an example of new technology that takes off without clear evidence of its harm and benefits,” Buist said.
Washington’s Health Technology Assessment Program, which reviews what medical procedures it will cover for state health plans, did not approve 3-D mammograms for coverage, Buist said.
On its website, the Susan G. Komen organization also raises questions about 3-D mammography, saying it’s not clear tomosynthesis is a better tool than 2-D. Liane Michnoff, a Komen spokeswoman, said in an email that for now, “3-D technology is still under investigation.”
Women can still be comfortable using 2-D, which has a proven itself over time, Michnoff said.
Researchers hope tomosynthesis will benefit specific groups of women, such as those with dense breast tissue — about half of all women — and younger women, Buist said.
“Two-D mammography does not work very well for those women, and oftentimes they have the fast-growing tumors as well,” she said. “The big issue is, could facilities triage women on tomosynthesis versus 2-D? That’s something we’ve not had a chance to deal with.”
3-D “looks very promising”
Tomosynthesis machines are costly. Their price tag can hit about $750,000. For now, Mora said he wonders if money wouldn’t be better spent on intensive efforts to help ensure more women are getting regular mammograms. About 78 percent of Group Health members get regular 2-D digital mammograms. That still leaves 22 percent who don’t.
“There’s the allure around technology,” Mora said. “It’s the simple things that really matter — having a mammogram, making it easy for women.”
Three-D mammograms are more costly not only due to the equipment’s expense, but because radiologists have to look at more images. Their analysis takes about four times as long, said Providence’s Neubauer.
There can be out-of-pocket costs for patients with 3-D, while the cost of 2-D mammography is covered in health insurance wellness plans.
Robert Smith, vice president of cancer screening for the American Cancer Society, said he’s concerned about the emotional impact on women who are offered 3-D mammograms, even though not all of them can afford extra out-of-pocket costs. “That may result in some stress that they’re not getting the better exam,” he said.
Smith agrees that longer-term studies are needed on 3-D technology. “Not to be too pessimistic, it looks very promising,” he said. “The technology does appear to be doing a better job.” Still to be proven is whether the increased cancers the 3-D technology finds are less aggressive cancers, he said. “You want to compare the tumor size and grade” it finds, he said. “That will take additional work.”
Buist said it’s important for women to recognize that with any type of mammogram, there can be over diagnosis — finding things that never would have caused a woman’s death. “The idea of screening is you identify things that will save your life because you’ve detected and treated them,” she said.
One example is ductal carcinoma in situ or DCIS. The abnormal cells inside a breast’s milk duct are considered the earliest form of breast cancer. “We really don’t know which ones are OK to be left alone and which ones aren’t,” she said.
There are many stories of women’s lives being saved by mammograms, she said. What can be hard for the public to understand is there is no perfect technology for breast cancer screening, Buist said. “Fundamentally they’re thinking, ‘They can see everything. How could you miss something?”
For all the questions still to be answered about 3-D, there still are experiences among the eight million women who have been screened nationally using the technology — like those of Carol Tranfaglia.
“I was lucky it was a 3-D mammogram,” she said. “It was invaluable in catching the cancer early. I’m very grateful I am in an area where that kind of technology is available.”
Sharon Salyer: 435-339-3486; email@example.com.