Screening for Breast Cancer: Tools for Detection
(soft upbeat music) - [IModerator] It is our pleasure to be joined today by our speaker, Dr. Paul Sylvan on the topic of breast cancer tools for detection. Give us just a moment to turn this over and Dr. Sylvan we'll begin. Thank you.
- [Dr. Sylvan] Good afternoon. Welcome everyone and thank you very much for joining me today for this talk on screening for breast cancer tools for detection. Just a brief background about me. I came to Eisenhower like just this past August. I came here after being imaging director at the Scripps Polster Breast Care Center in La Jolla for the past 20 years. I did medical school and all of my residency training at Yale board certified in both radiology and internal medicine.
So thank you for joining me. So today I'm gonna be covering mammography, the benefits of screening, the screening recommendations and then I'll be talking specifically about 3D mammography and the benefits of that. And then we'll move on to talk about some other tools that we frequently use in the detection of breast cancer. So our ability to do mammography really began in the mid 1960s, but once we were able to do it the question became, is there any benefit from it? And so the first randomized controlled trial looking at the efficacy of screening mammography was done in the mid 1960s. That was the health insurance plan of New York trial.
And it demonstrated a one-third reduction in mortality from breast cancer at five years of followup and with the benefits persisting at 18 years of followup. So after the hip trial, seven additional randomized control trials were done. All of which involved randomizing women into two identical arms.
One arm was women who were invited to screening and the other arm, women who are not invited to screening. So if randomization is done properly, this should result in an equal number of breast cancers in both groups and an equal number of breast cancer deaths in both groups in the absence of screening. But if screening works, there should be fewer deaths in the invited to screen group than in the group not invited to screen. So taking the data from all the randomized trials together demonstrated overall about a 15 to 30% decreased mortality in women who were invited to screen. Only one trial individually didn't show a benefit from screening but that trial was fraught with problems.
And without going into details I'll just say that it has been discredited as many times the years. So the data from the randomized control trials was all analyzed based upon invitation to screen or no invitation to screen. But in reality what happened was, in the group of women who were invited to screen, not all of them actually went on and had their mammograms. This is referred to as non-compliance. It's like being prescribed a medication and then not taking it. And so the results non-compliance is that if a woman in that group went on and developed breast cancer and then died from breast cancer even though she never had a mammogram as far as the data analysis is concerned she was still countered in the invited to screen group.
And on the flip side of that is contamination, women who were in the not invited to screen group, who then chose on their own to go outside the trial and have a screening mammogram. And some of these women had mammograms that detected a breast cancer and the mammogram ended up saving her life. But nonetheless, as far as the data is goes she's counted in the not invited to screen group even though she actually had a mammogram. So the upshot of all this is that deaths tend to be overestimated in the invited to screen group and underestimated in the not invited group. The mortality benefit from screening is actually significantly greater when using women who are actually screened rather than just those who were invited to screen. So the largest trial with a longest follow-up period was the Swedish two County Trial.
And this demonstrated a 63% mortality reduction from breast cancer and women who had actually been screened and a 50% mortality reduction in women who had been invited to screen. So now when you take the data from the randomized control trials and break it down into the subgroup of women ages 40 to 49, this demonstrated an 18% mortality reduction from breast cancer in women in that age group. On average 12.7 years of follow-up and there was greater benefit noted with increasing years of follow-up. In 2018, Laszlo Tabar, who's arguably the world's greatest authority on screening mammography, published a paper in cancer looking at how screening mammography affected the death rate from breast cancer. And what he showed was that there is a 60% reduced mortality risk of dying from breast cancer within 10 years of diagnosis among women who have been screened and a 47% reduced risk of mortality between years 11 and 20 after diagnosis in women who had been screened.
So overall there's unequivocal evidence of significant mortality reduction as a result of screening mammography. Again, the longest followup was the Swedish two County trial demonstrating a 63% mortality reduction in women who are actually screened and Tabar's paper again showed a 60% decrease risk of dying from breast cancer within 10 years of diagnosis in women who had participated in screening. So, okay screening work. The question is when to screen, how often to screen, when to start and when to stop. So we know the data from the randomized control trials and there have been other trials that were not randomized but also have shown similar findings.
But computer modeling has also been done to look at that. So a lot of this was done by the cancer intervention and surveillance modeling network called CISNET. And what the model show is that, annual screening women ages 40 to 74 results in about a 40% mortality reduction.
When you screen every other year beginning at age 50 and continuing through age 74 about a 23% mortality reduction. And then a hybrid model in between where you screen every year from age 40 to 50 and then every other year after age 50 about a 31% mortality reduction. So this curve also comes from that CISNET model. They call it an efficiency curve.
And we're just gonna focus on this solid black line. So everything on the solid black line is considered to be efficient as far as screening goes everything below the line is considered not efficient. This is plotting on the y-axis the life years gained as a result of screening mammography and on the X axis, the number of mammograms that a woman would have over the course of her lifetime in order to achieve that benefit. So looking down at the lower left, where it says B 50, that means by any or every other year screening, beginning at age 50.
So you see women in this group would have about 11 or 12 mammograms over the course of her life. And the total life years gained is about 150 life years gained per thousand women screened. And then when you follow this to the upper right corner where it says A 40 which stands for annual screening beginning at age 40, significantly more mammograms. You might have 31 or 32 mammograms over the course of your life but significantly more life years gained, now about 220 life years gained.
So this a bar graph, I just wanna go over this briefly and we'll just focus on what's highlighted in red. So this is plotting the percent, the number of cases of invasive female breast cancer. And then on the bottom, it's showing it by age group. So in red are two age groups that we want to focus on. On the left is 45 to 49 on the right is 50 to 54.
And you can see that there are a few more cancers in the 50 to 54 year old age group but not many more. They're really quite similar. Now this is looking at the distribution of breast cancer deaths based upon age at diagnosis. And again, the age groups were on the bottom, same two age groups, 45 to 49, 50 to 54. These are even closer than on the previous slide and they're really quite similar in terms of the number of deaths in these two groups. And then finally, this is looking at the distribution of life years lost as a result of death from breast cancer based upon age of diagnosis.
And here you'll see that there were four bars in red. The two on the left represent a women in their 40s. So 40 to 44 on the left, 45 to 49 next to it and then the two in red on the right, represent ages 50 to 54 and 55 to 59.
And what this shows is that the greatest number of life years lost as a result of dying from breast cancer or lost by women in their 40s. So overall in terms of screening recommendations, no significant change occurs at age 50. There's nothing magical about that age.
Breast cancer incidence, mortality and life years loss are all on a continuum as we just looked at on those bar charts. The mid to late 40s looked very similar to 50 and above in ages 40 to 44 are a little lower than 45 to 49, but not by much. And finally the most life years lost are lost by women in their 40s.
So now I wanna talk about the screening recommendations. The United States Preventive Services Task Force, USPSTF's gets a lot of press. This organization makes recommendations, not only regarding screening mammography but also screening for other cancers such as colon, lung, prostate, cervical cancer. The organization was created in 1984 and consisted of 16 volunteers. Note that not a single one of these volunteers was an expert on breast cancer. They made initial recommendations for screening in 2002 which were updated again in 2009 and 2016.
And right at the moment they are currently being updated again. So in 2002, USPSTF's recognized a 15% mortality reduction as a result from screening women in their 40s. And they recommended that screening should start at age 40, that it should be done every one to two years.
They said that there was no clear benefit to annual versus biennial screening. That's actually not true but that's what they concluded. But nonetheless, so their recommendation was to screen every one to two years, beginning at age 40. In 2009 they made a substantial change in their recommendation. They now recommended screening every other year, beginning at age 50 and continuing through age 74. They said that prior to age 50 screening should be an individual decision.
They still recognize that there was a 15% mortality reduction as a result of screening women in their 40s. 2016 really no change. Again screening every other year beginning at age 50, individual decision prior to age 50. So looking at the various organizations and what they recommend as far as screening the American College of Radiology, Society of Breast Imaging, National Comprehensive Cancer Network, National Consortium of Breast Centers, American Society of Breast Surgeons, all recommend annual screening beginning at age 40. They all say that screening should continue as long as health is good.
And as long as life expectancy at least five to seven years, the society of breast surgeons says as long as life expectancy is 10 years. The USPSTF we talked about at length, the American College of Physicians and American Academy of Family Practitioners strictly adhere to the USPSTF's guidelines. And so again, those groups all recommend biennial screening. Every other year screening beginning at age 50, individual decision to start prior to age 50 and screening continuing through age 74.
The USPSDF actually says that there's not enough data to recommend for or against screening after age 74. So they don't really take a position on that. The American Cancer Cociety recommends screening starts at 45 with the option to start at age 40. They recommend annual screening ages 45 to 54 with biennial screening after that.
And they also recommend screening as long as health is good and life expectancy, 10 years. And finally the American college of Obstetrics and Gynecology says that screening should be offered starting at 40 but in any case should definitely start by age 50 can be annual or biennial. And then after age 75 it should be a discussion with your doctor whether to continue or not. So we have a number of different organizations that are making different recommendations. And the question is why are they different? Well, it really depends on how the data was analyzed, what the priority is. Is the goal to maximize live saves or to minimize harms? Is it to be efficient or to maximize benefits? So, you are left with the question of what you should do.
So for me, the answer is clear. The goal is to decrease mortality, maximize life year saved and find early stage cancers when they're most treatable. So remember a lot of these studies that have been done are population studies that do a cost benefit analysis to the society as a whole.
They look at how many dollars it's worth to save one life. But that has nothing to do with really what's best for you individually. So it's really up to you to make a decision that what you want out of screening mammography and what your goal is.
If the goal is to maximize life year saved and decrease mortality, then annual screening at age 40 achieves that goal. So before I turn to other modalities that we have to look for breast cancer, I wanna talk a little bit about breast density because really these other tools that we have are frequently used in women with dense breasts. So, this whole question of breast density really began as a grassroots movement by a single woman in Connecticut back in the 1970s, She was diagnosed with breast cancer, discovered that she had dense breast tissue, found out that dense breasts was a risk factor for breast cancer. And she was upset that nobody had ever told her about it. So as a result of this grasSroots movement, almost every state in the country now has a law mandating that women be informed as to their breast density. So dense breast tissue is an independent risk factor for breast cancer.
When we look at a mammogram, there are four categories of density that that patient gets assigned into. And they have different sensitivities for detecting breast cancer. So, women with fatty breasts, there's about an 81 to 93% sensitivity for finding breast cancer.
Scattered fibroglandular density is about 84 to 90%, both of those are considered not dense, those two groups. and then in the two dense groups, heterogeneously dense breast parenchyma, 69 to 81% sensitivity for finding breast cancer. And in the extremely dense breasts, 57 to 71% When looking at women over 40, taking a whole group about 36% fall into the heterogeneously dense category about 7% extremely dense. But know that this is really not an exact science between 12 and 18% of women are actually reclassified into a different group at the next reading of their mammogram sometimes by the same radiologists who read it the previous time.
There can be quite a bit of overlap. And that overlap is particularly great in the two middle groups where most women form a false scattered fibroglandular densities and a heterogeneously dense. So when you compare women with extremely dense breast tissue to fatty and so these are the groups at the ends of the spectrum which comprise a smaller number of the women overall, there's about a four to five times increased risk of breast cancer in the extremely dense group versus fatty. But when you look at the two middle groups, heterogeneously dense versus scattered fibroglandular, this comprises about 79% of all women.
There's about a one and a half times increase risk of breast cancer in the heterogeneously dense group versus scattered fibroglandular densities. And even comparing extremely dense and scattered fibroglandular density is about one and a half to two times increased risk Interval are defined as cancers that occur within 12 months of the previous mammogram. And interval cancers are 13 to 18 times more common in women with extremely dense breasts than women with fatty breast. So now I wanna turn to digital breast tomosynthesis. You all are familiar with it as 3D mammography has gotten a lot of press these days.
So tomosynthesis was first FDA approved in 2011, but in order to be FDA approved, it had to be demonstrated that there was a benefit from this new technology. And so studies were done comparing tomosynthesis to standard digital mammography and showed an increased cancer detection rate of 1.2 to 2.5 per thousand women screened. So that may not sound like very much, but when you look at women who are screened with standard digital mammography, we detect overall about four to five cancers per thousand women screened So tomosynthesis added between 25 and 50% additional cancers detected compared with a digital mammography without the 3D.
Tomosynthesis were shown to result in an increased cancer detection rate and a decreased recall rate from screening in women with both dense and fatty breasts. In fact, most of the cancer detection, the improvement in cancer detection in women with dense breast was in women with heterogeneously dense breast. It was actually not a statistically significant improvement in cancer detection in women with extremely dense breast although there was a decreased recall rate in that group. So I wanna turn to ultrasound now, 'cause we use ultrasound very widely at this point. And there was an important study published a number of years ago called the ACRIN 666.
This was an American college of radiology trial and women who were enrolled in this study had dense breasts and were at increased risk for breast cancer. And the question they asked is what would be the benefit of adding an annual ultrasound to a mammogram for three consecutive years? And then as a sidebar from this main question they said, what would happen if we added one round of MRI after three consecutive years of negative mammogram and ultrasound. And what Akron 66 showed was that, 4.3 additional cancers were found per 1000 women. So remember I said that about five cancers per 1000 women were found from standard digital mammography. So this was almost as many additional cancers found with ultrasound than found with mammography. I wanna remind you that this was a group of women who had all been identified as having increased breast density and we're at high risk of breast cancer.
These ultrasounds resulted in about 5% additional biopsies over the biopsies that were recommended based upon mammography alone. And the malignancy rate for the ultrasound guided biopsy was lower only about 7.4% of the lesions biopsied under ultrasound guidance turned out to be malignant compared with about 38% malignancy rate in mammographically detected lesions that went on to biopsy. So I wanna say a few words about automated whole breast ultrasound. This is commonly referred to as 3D ultrasound.
We get asked about this and I'm sure you read about this. The advantages of this is that it's a more consistent technique and it's not operator dependent. So with standard handheld ultrasound we have the radiologist or ultrasonographer holding a transducer and looking systematically through both breasts but with 3D ultrasound, there's a very large transducer that's mounted on a mobile arm and that transducer is placed over the entire breast. And then images are generated in which our volumetric in three planes, axial, coronal and sagittal. It generates hundreds of images for each patient which makes it really quite tedious to look through. But the advantages of this is that it is a more consistent technique.
The disadvantages of a 3D ultrasound are that, in studies that have been done comparing patient comfort, patients prefer handheld ultrasound. It's not extremely uncomfortable but that is a large relatively heavy transducer that's placed on the breast with some compression. So it's less comfortable than handheld ultrasounds. And the 3D ultrasound does have some limitations.
It doesn't do a great job in the area right behind the nipple, which is also one of the areas that mammography has trouble with. At the periphery of that transducer, It doesn't do very well. And it doesn't see the axillary tail, that's the portion of the breast that extends up toward the armpit, nor does it allow evaluation of the axilla itself? Studies have been done looking at screening ultrasound in women with dense breasts. So there was a 2019 paper published.
The ultrasound in that paper could have been either handheld ultrasound or automated whole breast ultrasound. It demonstrated an increase cancer detection rate of between two and 2.7 per 1000 women. Of the cancers that were detected by ultrasound, 88% were invasive cancers, up to 92% node negative and the average size between seven and 14 millimeters. So in fact, these are the cancers that we want to find. These are small node negative invasive cancers that are most amenable to treatment.
There was an increase recall rate in this study above what was recalled from mammography about seven and a half percent from handheld ultrasound, about 10 and a half percent from automated whole breast ultrasound. And they also looked at the utility of ultrasound after 3D mammography specifically. And when this is done, there's still an increased cancer detection rate from ultrasound over 3D mammography of between one and two and a half cancers per 1000 women screened 3D ultrasound was looked at in a study asymptomatic women with dense breasts 15,000 women had both a screening mammogram and the automated whole breast or 3D ultrasound total of 112 cancers detected 82 of these detected by mammography.
Another 30 detected only by ultrasound. This was an additional cancer yield of 1.9 per 1000 women. Of the cancers found based on the mammogram about two thirds are invasive cancers with ultrasound about 93% of them Invasive cancers. Overall ultrasound increased the sensitivity for detection of breast cancer by almost 27% and increase the recall rate from screening mammography and from ultrasound by about 29%.
Only a couple of studies have been done looking at handheld ultrasound versus 3D ultrasound. Most of them in the diagnostic setting not in the screening setting. Like in the few published papers. There are, it turns out that the sensitivity for detecting breast cancer was a little bit better in the handheld ultrasound than with the automated whole breast ultrasound and the lesions that are detected tend to be slightly smaller with handheld ultrasound rather than with the 3D ultrasound. So now I want to turn to MRI. So remember this is going back to that Akron 6666 trial.
So after three consecutive years of a negative mammogram and ultrasound women were offered one MRI. And what was found was that there were an additional 14.7 cancers found per thousand women. This is four times greater than the yield from adding ultrasound to mammography.
In this study, half the women had MRI overall the women who chose to have the MRI tended to be younger and at somewhat higher risk. MRI is also used as a screening tool. We use it in women who have greater than 20 to 25% lifetime risk of breast cancer. So these are women with the BRCA gene, women who themselves may not have the BRCA gene but who have a first degree relative with the BRACA gene, women with other genetic mutations that are associated with these various syndromes such as lead for remaining Howden Ruvalcaba, a mantle radiation for Hodgkin's disease, done in young women that beginning about eight years after the radiation treatment ends there's a substantially increased risk of breast cancer in these patients. And then finally women with a very strong family history that puts them at over greater than 20% lifetime risk. Women with less than a 20% usually on the order of 15% lifetime risk.
Those with a personal history of breast cancer, women who've had biopsy proven high risk lesions such as atypical ductal or lobular hyperplasia, radial scar papilloma and a women with dense breasts. So we do use MRI in certain settings and women who fall into this group as well. What about screening with MRI in average risk with women not in dense and not in high-risk women but an average risk men. And so, the Germans have a huge experience with breast MRI. They did a prospective study looking at this and they found 15.5 additional cancers per thousand women and screened with MRI.
That is cancer is above what is found at mammography. So overall in this study 61 additional cancers were found, 48 of these in what's called the prevalence round. That was the first year that a woman had the MRI and then 13 detected in the next two rounds, the next two years of the MRI of the cancers that were of the 61 cancers, 60 of them were detected by MRI only. Only a single cancer was also detected by mammography and ultrasound. In this study, two thirds of the cancers that were found with the MRI were invasive one-third work DCIS called otherwise known as stage zero or insight to cancer. The median size of the invasive cancers was eight millimeters.
93% of these were not negative. About half of them were high grade, overall about 4.4% of the MRIs were read as suspicious. And they went onto biopsies and the biopsies that were done about 36% of these turned out to be cancer and about 24% of them turned out to be high risk lesions. I want to say a couple of words about abbreviated MRI which has just come about in the past couple of years.
So the typical MRI scan, the patient is on the table for about half an hour, sometimes slightly more. It's not very comfortable and they're lying on their stomach and they can't move at all and women don't like it very much. And so in response to this, trial was done looking at abbreviated MRI sequences. And these are scans that last total of five to 10 minutes depending upon how the scan is set up. So you lose some of the information. You don't get as many sequences, but the question is do you get enough information to make this worthwhile? So study was done looking at average risk women with dense breasts comparing abbreviated MRI to 3D mammography.
What was found in the first year there were 23 cancers detected in this study. Of those four 23 cancers, 22 of them were detected by MRI. Nine of them were detected by 3D mammography. There was a single early stage cancer that was detected by mammography but not by MRI.
Overall MRI detected 10 invasive cancers, four of them high grade that were not seen by mammography. So the limitations of MRI, it's a very expensive test. So in that regard, it's probably not gonna be good for routine screening for the entire population that may not be covered by insurance of abbreviated MRI is currently not covered and the places that offer it are usually offering it on a cash pay paces. Claustrophobia is a significant problem with MRI for those of you had it, you know that you're in a fairly narrow tube and it's not very pleasant.
And then finally it does require injection of a gadolinium contrast agent. So I just wanna digress for a minute and talk about gadolinium, since this is also something that you'll hear about and read about. A gadolinium (indistinct) kidney reactions although significantly fewer than (indistinct).
Iodinated contrast material that's routinely used for cat scans. Patients with significant renal impairment can not get gadolinium. They can get a very serious complication called nephrogenic systemic fibrosis that results in extensive skin thickening. In recent years it has become known that gadolinium is deposited in the brain.
So what that means is unclear and is under investigation but there is an entity now referred to as gadolinium deposition disease. It consists of a number of symptoms that are kind of difficult to prove (indistinct) and hard to get down that consistent pain that can be either central or peripheral within the body, headache, joint or bone pain or what is being called brain fog. (indistinct) is under investigation, gadolinium and we know is deposited in the brain but it's not known for sure yet what the clinical consequences of that are if any. Finally I'm gonna talk about contrast enhanced mammography.
This is not widely done throughout the country but it is being done more. But I specifically I wanna mention it because it is something that we offer at Eisenhower where actually the only place in the Valley that offers it in one of only a handful of places in Southern California. So what this is, is basically, it looks like a standard mammogram it's done on a regular mammogram machine. That positioning is the same, but images are obtained before and after injection of iodinated contrast material.
So this is not gadolinium. This is the same contrast material that's used for cat scans. The sensitivity for detecting breast cancer is extremely good and equal to that of a MRI. The specificity, which means the number of false positives is better than MRI, there are fewer.
It's a really good test for people who need an MRI but otherwise can't have it either because of claustrophobia or perhaps they have a pacemaker that's not compatible with an MRI scanner. So contrast enhanced mammography can be very useful in the patients who have had both contrast enhanced mammography and MRI, there is a preference for the contrast enhanced mammography is just an easier exam for them to tolerate. Contrast enhanced mammography has been looked at with screening. Two studies looked at the increased cancer detection rate in one 8.6 per thousand and in the other 13.1 per thousand.
So these are again increased cancers found above what would be expected to be found based on routine screening mammography. And there is more radiation than with standard mammography but not by much only about 20% more than with a digital mammogram. Adverse contrast reactions to the INH contrast about 0.82%. And one problem is that at the moment there's no biopsy capability. So if we find something on a contrast enhanced mammogram, we need to go back to ultrasound or MRI to try to identify that lesion so that we'll be able to biopsy it.
I expect that this issue will be resolved within a year or so because they are working on biopsy capability for this at the moment. So in summary, we talked about mammography. The benefits of screening. We talked about 3D mammography as an adjunct tool to help identify cancers above standard mammography. And we talked about ultrasound, MRI and contrast enhanced spectral mammography. I'm going to stop there and I'd be happy to answer any questions.
Thank you. - [Instructor] Okay, so if anyone has questions, you can either send it to me in the chat, or you can unmute yourself and ask. I actually have a couple here that I'm gonna read off to start.
But if you do have a question just let me know, okay? Is there an age where they actually stop screening, doing these screenings? Is there like a cutoff for that? - Yeah, so I mentioned that in the talk. So I will go over that again. So the United States Preventive Services Task Force, the American College of Physicians and the American Academy of Family Practitioners, recommend screening until age 74.
They don't specifically say that you should not screen after age 74. They say that there's not enough data to recommend for or against screening after age 74, but they, so their recommendations from those organizations are through age 74. For the American Cancer Society and the American Society of Breast Surgeons. They both say, "As long as you're in good health" "and life expectancy, at least 10 years." The American College of Radiology Society of Breast, Imaging National Consortium of Breast Centers and National Comprehensive Cancer Network says, "As long as you're in good health" "and life expectancy five to seven years," and the American College of Obstetrics and Gynecology says, "After age 75, discuss it with your doctor." So as you can see it, there's a variety of recommendations.
The majority of the organizations that make recommendations are saying that, "As long as your health is good and life expectancy" "somewhere on the order of five to seven or 10 years" "that it's reasonable to continue screening." And I would agree with that. - [Instructor] Thank you. Another question we have, if we're not really worried about insurance and we're maybe a self-pay patient, do you recommend asking directly for the contrast enhanced mammography or the MRI, or is the process of mammogram ultrasound, those steps? Is that a good process? Which one would you recommend doing? - Well, so I think that at the moment for routine screening standard mammography is the way to go. The other tools, MRI and contrast enhanced mammography are really being used in a higher risk population.
So if you're, it's a different question if you're in a high risk group. So if you're in a high risk group with greater than 20% lifetime risk of breast cancer you should be having an annual MRI. And if you can't tolerate MRI then contrast enhanced mammography.
One thing I will say is that, if you're having a MRI or contrast enhanced mammography ultrasound is redundant, you don't need both. So ultrasound is a great tool to use in addition to screening mammography, it's inexpensive, it's very well tolerated. There's no radiation, there's no contrast objected. I mean, there's a lot of good things about ultrasound but if you're gonna be screened with one of those other things like MRI there's no need to do ultrasound as well. - [Instructor] Thank you. I have a couple more questions actually.
It's been rumored that it's harder to get good images when a patient has smaller breasts. Do you think that really, is that something real or can you get good results no matter the actual breast size? - Yeah, so I think that in general, the breast size doesn't matter very much. I mean, we basically the techs or the mammography technologists are all trained to pull in as much of the breast tissue as they can and having smaller breasts doesn't really preclude you from having a good quality mammograms.
- [Instructor] Wonderful, thank you. Does anyone else have a question they want to ask? I have one that's slightly off topic, but if there's any more questions related to this topic we'd be happy to answer them. Okay, so I'm gonna go ahead and ask this one. So like I said, it's slightly off topic, but would you be able to speak about the enlarged lymph nodes that people are getting from the COVID-19 vaccine? That's been a hot topic lately and if you could touch on that, that would be great.
- Sure. So as we know, vaccines can result in, they generate an immune, they elicit an immune response in the body, and these can result in large lymph nodes. It turns out that with most vaccines it's not much of a problem but it turns out that with the COVID vaccine, there's a in a substantial number of patients particularly after the second dose of the vaccine, you can get enlarged or swollen lymph nodes on the side of the injection. So the upshot of this, and these lymph nodes usually will go away within a few days and sometimes may take longer or a few weeks for them, but they generally will go away. But the reason that it's an issue is that, when we're reading mammograms, one of the things we look at are the lymph nodes.
And so if you see enlarged or abnormal appearing lymph nodes on a mammogram that is going to generate a call back, you're gonna call that patient back usually for an ultrasound so we can look at the lymph nodes under ultrasound. And then if there are abnormal lymph nodes it can go onto leading to a lymph node biopsy because enlarge lymph nodes, although rare can be one of the presenting findings for breast cancer. So what we're recommending now is that, women who are having routine screening mammograms, it would be best, if you've had the COVID vaccine recently to delay until about four weeks after the second dose of the COVID vaccine before you have your mammogram.
That's only for routine screening. If there's a problem, if a woman feels a lump in her breast or an area of or nipple discharge or any other symptom, that's different, that's a diagnostic mammogram and that cannot be put off that needs to be done. But as far as routine screening, we would recommend waiting for at least four weeks after the second dose of the COVID vaccine so that we can avoid having to call women back unnecessarily and do additional workup for something that would otherwise resolve on its own. - [Instructor] Wonderful, thank you so much for that information.
That's been on a lot of people's minds lately. Does anyone else have any questions or should we go ahead and wrap this up for today? Looks like we all complete then. Thank you so much doctor for your presentation. We appreciate your time.
- Thank you very much. - [Instructor] And thank you everyone who joined us and I hope everyone has a great day. (soft upbeat music)