Breast Friends Forever

Don’t be lulled into thinking you don’t need a mammogram—you do, every year

By Tammy DiDomenico

Dr. Stephen Montgomery has read more than 200,000 mammograms over the course of his 23-year career. As director of Crouse Hospital’s Breast Health Center, he’ll make time for a few more—if only he could convince women to make the appointments.

“I really wish there was something more I could do,” says a clearly frustrated Montgomery, who has been director of the center since 1995. “It’s a real conundrum.”

Montgomery and other diagnostic physicians have another reason for concern. It seems that those women who do not have a known genetic predisposition for developing breast cancer are generally more cavalier about screenings and self exams than those who do. They assume, wrongly, that many women who are diagnosed have familial cancers—those triggered by an inherited gene mutation.

The bottom line, says Montgomery, is that about one in eight women will develop invasive breast cancer over the course of a 90-year life span. He cites a 2003 report on “Breast Cancer and Environmental Risk Factors” published by Cornell University professors Barbour S. Warren, Ph.D. and Carol Devine, Ph.D., which indicates that 73 percent of cancers diagnosed are unassociated with an established family history, or an inherited gene mutation that would increase a woman’s risk for contracting the disease. The American Cancer Society, in data published on its website, puts the percentage of cases unrelated to family history closer to 85 percent.

“The dilemma is that the majority of patients with breast cancer don’t have a family history,” Montgomery emphasizes. “The ones who say, well, I don’t have a family history, so I don’t have to worry as much, are wrong. They are misinformed. This is a common misunderstanding about breast cancer.”

Montgomery suggests that women are too quick to find excuses, such as a lack of family history, for not getting screened in part because American society does not put enough value on the importance of the exam. “We need to get to a point where we will offer the screening to more women, at the appropriate intervals, make it easier for them to get it, and in the end if society paid for all the screens, they’d save a vast amount of money over what it costs to treat the unscreened woman,” Montgomery adds.

Montgomery recommends an annual mammogram for women beginning at age 40. The American Cancer Society recommends that women with an inherited risk should begin screening at age 30. Many local physicians recommend a baseline mammogram between the ages of 35 and 40.

Too many families know what can happen when the women they love do not get regular breast cancer screens. One East Syracuse husband, who asked to not be named out of sensitivity for his family’s privacy, watched his wife “Sydney,” battle the disease for four years. She was diagnosed with an invasive ductal carcinoma, endured a traumatic (and he claims, misguided, lumpectomy) that led to many complications, and withstood several rounds of treatment that seemed to do more harm than good. This feisty, adventurous woman, a mother of three, slowly became weak, housebound, dependent on supplemental oxygen, and chronically unable to sleep because of constant pain and fluid retention.

“It was heartbreaking,” her husband recalls. “During the last year, year and a half, it was all about trying to get through the day. By that point, the cancer had spread, and she was never able to get comfortable. The pain medications were so strong, she would constantly doze off; so she tried to limit her doses. But she was determined to be independent. For family and friends, it was hard because they wanted to help, but my wife was so protective of her dignity. We did our best to respect that.”

On a warm morning in August 2008 Sydney stopped breathing. Although she had planned to die at home, her husband knew he was unprepared for what that would entail. Shortly after being admitted to the hospital, Sydney slipped into a coma. Three days later, her husband and children said their goodbyes. She was 51.

No one in Sydney’s immediate family had been diagnosed with any form of breast cancer. Her husband recalls that her diagnosis came after she found a lump during a self exam. She had not had a mammogram in at least five years.

While Sydney had other risk factors that may have contributed to her cancer, her husband says because of the lack of family history, she never took her risks seriously—until there was no ignoring them. A stoic and quiet man, he’s an unlikely spokesman for the benefits of mammography, but he is buoyed—just slightly—by the knowledge that his wife’s illness has had a dramatic impact on the other women in his family. “Everyone gets their mammograms now,” he says. “It’s automatic; every year, without fail.”

RISKY BUSINESS

Misunderstandings that discourage women from getting screened can have dire consequences—not just for the individual woman, but for society, which has to shoulder the treatment costs of women who show up at emergency rooms undiagnosed, and presenting later stage symptoms of the disease.

“I saw one case two weeks ago,” Montgomery says. “A woman came in short of breath, with diffused metastatic disease; metastasis to the lungs, to the liver, to the bone, to the brain. This is a five-alarm disaster. She is not going to survive, and we are going to end up spending an inordinate amount of money to try to help this poor, unfortunate person.”

Montgomery says there are even misconceptions among those in the medical field about the degree of risk heredity represents to individual patients, and what those risks mean. To help discern those risk factors, he started a risk assessment program at Crouse. This model-based computer program offered through the National Cancer Institute, known as the Breast Cancer Risk Assessment Tool (the Gail model), was designed by researchers at NCI and the National Surgical Adjuvant Breast and Bowel Project as a tool for health care providers. The tool calculates a woman’s risk of developing breast cancer within the next five years and within her lifetime (up to age 90). This tool takes into account seven key risk factors for breast cancer, and patients can calculate their “relative risk for developing breast cancer” compared to the average woman in America.

“If the risk gets up into a certain percentage—20 percent—we recommend a screening MR {magnetic resonance} test,” Montgomery says. “We’re doing this to cull out those who have a ‘family history’ that’s really not valid from those who really do have a family history.” Montgomery says most insurance companies acknowledge the need for MR screening with that level of risk, and will cover the test.

“That’s been effective,” he notes.

“We’ve found many cancers that would not have otherwise been found—small ones. That’s what I want. If I can make that diagnosis at 10 millimeters or less, there’s virtually no impact on a woman’s life, even if it is a high-grade tumor.”

Montgomery says approximately two cancers a day are diagnosed at the Crouse Breast Health Center. “You grow weary of seeing the women present who did not get screened,” he says. His goal is to detect non-palpable breast cancer. “The reason for a mammogram is to find it before you

can feel it,” he says. “If you’ve felt it, odds are, it’s at a higher stage.”

Montgomery says anywhere from 5 percent to 15 percent of cancers will escape even his expert scrutiny. Dense breast tissue is particularly difficult to access with mammography. Montgomery advises that the best thing a woman can do to help ensure an accurate and discriminate reading of a mammogram is to go to a place that specializes in it.

And it’s so important that women of a certain age get screened annually. “Family history is an important screening tool for possible risk modification and we recommend that every person obtain information about their family history, including close and more extended relatives, males and females from both sides of the family and information about all cancers and medical conditions in the family,” says Bonnie Braddock, a certified genetic counselor at Upstate Medical University. “Then it is important that the individual review the family history with his or her physician. The potential role of genetics may then be based on personal and/or family history. Evaluating a family history for cancer risk is complex and genetic counseling is done on an individual basis.”

“I’m looking at 9,500 screens a year—and that’s the kind of place you want to go to,” he says. “Go someplace where people are reading a lot of mammograms. Experience is critical. Who’s reading the report is as important as the positioning, the exposure, everything else.”

Clinical breast exams are also important. It’s an exam that may have extended Sydney’s life. Crouse offers the exams from those who want one, free of charge. Crouse also has programs to help women who may need assistance in paying for breast screens.

Montgomery hopes that he and his fellow physicians can begin to chip away at the misconceptions about family history and breast cancer, and increase the number of women who get screened regularly. “It doesn’t matter what your family history is. Those who have a history are aware, and they know what the risks and benefits are. Those who don’t—it doesn’t mean you are off the hook. The paradox is that you are not. Your risk is lower than those with the family history but it’s outweighed by the absolute number of women who do develop breast cancer without a family history.”