Mammography Is Best For Breasts

By Dr. Michael Click
Interviewed by Melissa Moniz
Wednesday - November 25, 2009
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Where did you receive your schooling and training?

I went to Columbia University College of Physicians and Surgeons in New York City. The Army paid for me to go there, and so when I finished the Army sent me to Tripler and I did my residency training there. After I finished my residency training as a radiologist, I had the opportunity to take over the breast imaging section at Tripler. I wanted to stay in Hawaii, so they gave me that opportunity. I spent four years running the mammography department there. During that time I helped established the Breast MRI program there, and then when I got out of the Army, I had an opportunity to go to Dartmouth Medical School. I worked there for two years as a chief of its breast MRI section. Then I came back to Hawaii and am now here at Queen’s.

Can you discuss breast imaging and the newest technologies available for patients?

Sure. That’s a twofold question, actually. Breast imaging really is mammography, because mammography is the only imaging technology that has been shown to save lives. So at this point I still think mammography has to be considered as the basic study, and is the one recommended for all women. Even the most conservative people admit that between the ages of 50 and 70 every woman should have a mammogram at least every other year or every third year. I feel very strongly about that because mammography saves lives and will catch cancers. Breast cancers cannot be prevented and we can only cut it out to cure it, so that means the sooner we find it the more likely we are to save lives. Mammography is breast imaging, really. I really emphasize that because if you look at the population of Oahu, there are a million people on Oahu; that means 500,000 women. If you look at the census figures, that means there are about 150,000-200,000 women who should be getting a mammogram every year. So here at Queen’s we are quite busy, and we are doing less than 25,000 women a year, so that means only about half of the women who should be getting a mammogram are getting one.

In terms of alternative imaging, there’s so much research going into that field because breast cancer is the No. 3 cause of death among women in the country. It’s a very prevalent disease. There are all these new techniques that are being tested, such as ultrasound, CAT scans, MRIs, stress imaging, and here on the Island there’s also thermography being offered by local doctors. These are all alternative technologies. Unfortunately most of these are in the experimental phase or research phase. So even, for example, ultrasound of the breast, there is no scientific data that shows that an ultrasound is as effective as mammography in finding cancer and saving lives. Same thing is true with MRI. There’s a lot of data that shows that MRIs can see cancers that mammography cannot, but there’s no data that shows that it makes a difference and that we should be doing that for everybody. MRI is a very powerful tool. It’s an imaging study that allows us to see the entire breast and the anatomy of the breast, and that’s very powerful because it’s been shown that when an MRI is negative, the likelihood that a woman has a breast cancer that the MRI misses is less than 2 percent. So it’s 98-99 percent sensitive. Now there are breast cancers that mammography picks up that an MRI does not. But that topic is still under a lot of research right now. But part of the problem with MRI is that it is so sensitive, meaning that approximately 50 percent of all MRIs are positive. That is why MRI results in many additional imaging studies, callbacks and biopsies of the breast.

So would it be ideal for women to get both a mammography and a MRI done?

First, there’s no medical data to prove that MRIs are going to save lives. Second, if every woman got an MRI, that would mean that the number of biopsies that we would do would go up a hundred fold. Third, there’s the question of expense. No one wants to pay a health insurance premium that would cover the cost for every woman to get an MRI. Imagine we have 100,000 women on the Island and each gets an MRI every year. Let’s just say that’s a $2,000 study (but it’s really more than that), so $2,000 multiplied by 100,000 is a lot of money. And we’re talking about a test that isn’t really proven to be more beneficial than a mammogram. At this time, women who should be getting a breast MRI include all women who have been shown to have the genetic mutation of the BRCA gene, because women with that gene are at high risk of getting breast cancer. Some women who have extremely high risk - even though they don’t have a genetic mutation - should also have an MRI. Extremely high risk are, for example, women whose mother and sister had breast cancer. But in terms of an average woman who has an average history, mammograms will find their cancer and will actually make the difference. Therefore the additional risks by doing an MRI would-n’t make sense. It’s always important to weigh out the risk and benefit ratio.

If you are high risk, does that mean you would get a mammo-gram earlier than your 50s?

Unfortunately there is no good guideline for that. Most people would say that if your mother had breast cancer at age 45, you should probably start getting mammo-grams at age 35. Again, it’s a tradeoff, because the younger the woman the less helpful the mammogram is. So going back, for those women, they should be getting an MRI.

Does having breast implants make it harder to detect breast cancer?

Absolutely. Each woman is different, and it all depends on how the woman is built, how big the implants are, and how and where they are put in. I’ve had many women come in and tell me that their plastic surgeon told them that it won’t make a difference, but basically that’s a lie. The fact is that many women cannot do a good self-exam with implants because their breast is distorted by the implants. And many doctors cannot do as good a clinical examination. The mammogram cannot see as much of the breast because the implant hides breast tissue, so for those patients really the only exam that will allow to see the entire breast is an MRI. But many insurance companies are very clear that they will refuse to cover that cost, because implants are cosmetic surgery.

What’s the reason that the recommended age to start getting mammograms regularly has recently been changed from age 40 to 50?

Actually the recommendation of the American Cancer Society is age 40, but the actual medical research literature that was done shows that the benefits start at age 50 because most women have menopause at age 50. Therefore, after menopause the breast is not as dense and the mammograms work better. Although we’ve all heard of young women who get breast cancer, most women who get breast cancer do so in the ages of 55-65; those are the peak years.


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