Q&A: Ellis answers questions on breast health

Oct. 24--Gundersen Lutheran's Norma J. Vinger Center for Breast Care is trying to become a nationally recognized model of interdisciplinary breast care, known for its approach to early detection, efficient diagnosis and individualized treatment as well as comprehensive followup care.

Dr. Richard L. Ellis, a clinical breast radiologist and center co-director, said interdisciplinary breast cancer care -- in which staffs from multiple disciplines streamline and integrate their work -- makes a difference.

Ellis said preliminary results have demonstrated that with the implementation of early detection and supportive interdisciplinary breast care, medical centers such as Gundersen Lutheran can achieve a 20 percent to 40 percent reduction in total cost of treating breast cancer when compared with the traditional, disconnected approach.

"It is our responsibility to not only improve quality of care and outcomes but to be fiscally responsible," he said. "Interdisciplinary care, in our experience, makes it possible to accomplish all three."

Ellis, also an assistant radiology professor at the University of Wisconsin-Madison and the Medical College of Wisconsin in Milwaukee, had been associate professor of radiology at Southern Illinois University School of Medicine in Springfield.

He completed his medical fellowship in breast imaging at the University of Alabama-Birmingham and has been a National Institutes of Health/Howard Hughes research scholar.

Ellis was asked to answer some questions about breast health.

Here is his perspective:

Q: Are physicians detecting breast cancer early?

A: With a greater percentage of women age 40 and older participating in annual screening mammography, monthly self-breast examination and annual clinical breast examination, breast cancer is being detected earlier -- and often smaller -- than ever. The size of a malignancy at the time of detection is the key to predicting long-term results and largely determines whether radiation and/or chemotherapy will be recommended following surgery. Detecting cancer while it is still confined to the breast is the goal of screening mammography.

Women ages 40 to 50 frequently ask, "Why do I need to get a mammogram every year?" Although women of this age have breast cancer less frequently than women ages 60 to 70, the type of tumors found in younger women tend to be faster growing and more aggressive. Annual screening affords a better opportunity than screening every two years to detect breast cancer while still small and confined to the breast.

Q: What are the limitations of screening mammography?

A: With the aid of screening mammograms, radiologists can identify about 80 percent to 85 percent of all breast abnormalities, including the six most common forms of breast cancer and a myriad of benign (noncancerous) tumors. To help identify the 10 to 15 percent of tumors not detected by screening, monthly self-breast exam and an annual clinical breast exam by one's health-care provider remain important.

For women over age 40, an annual screening mammogram, an annual clinical breast exam and monthly self-breast exams are the best approach to early detection.

Paget's disease, which is a special form of breast cancer involving the skin of the nipple and inflammatory breast cancer involving the skin of the breast, is frequently not detected with screening mammography. Paget's disease frequently presents as etching and skin rash-type changes involving the nipple and areola. Inflammatory breast cancer is commonly mistaken for mastitis, with the skin overlying the breast becoming thinned and red. These type of skin changes should be brought to attention of your health-care provider.

Q: What is a healthy approach to my monthly breast self-examination?

A: Many women skip monthly self-breast examination because their breasts are lumpy. They wonder, "How can I find a new lump with all these others in the way." Still, those lumps represent what's normal in your breasts, so get to know them. How big are they and where are they from month to month? You won't notice changes if you aren't checking. Changes in lump size, nipple retraction or skin thickening that continue for a couple of months deserve medical attention, even if you've had a recent normal mammogram or breast ultrasound.

Ask the basic question, "Do my breasts feel about the same as last month?" If the answer is yes, don't worry yourself. If the answer is no, then continue to evaluate the area over the next one to two months. If you remain concerned after a couple months, consider further evaluation by your health-care provider.

Q: What can I do to reduce my risk of breast cancer?

A: Not much. Lifestyle changes like a healthy diet and exercise reduce the risk slightly, as do pregnancy and breast-feeding. Most risks for breast cancer can't be controlled, especially since the greatest risk is just being female. Family history and having the BRAC1 or BRAC2 gene are the next highest predictors of breast cancer potential. Other uncontrollable risks of less importance are the age at which a woman begins to menstruate, menopause and race. Factors that cause relatively small increases in risk include having no children, taking oral contraceptives or postmenopausal hormone replacement therapy, drinking alcohol, eating a high-fat diet and becoming obese.

Q: Have surgical options improved for women with breast cancer?

A: Although rates of survival based on type of surgery have not changed dramatically over the years, the appearance of the post-surgical breast has. Today, thanks to earlier detection of smaller, confined cancers, more women are offered the choice of lumpectomy, not just mastectomy. Less tissue has to be removed around a smaller lump. After lumpectomy, radiation therapy is most often recommended to reduce the likelihood that another cancer will develop in the same breast. With a very small breast cancer and appropriate surgery, some women's risk of developing breast cancer again is so low that radiation therapy may be of little benefit. Radiation oncologists on our team review each patient's level of risk to help them make an informed choice.

Mastectomy's old look -- the flattened, disfigured chest common 30 to 40 years ago -- has been replaced with more shapely alternatives, thanks to improvements in reconstructive surgery. For example, skin-sparing mastectomy (removal of the tumor, breast tissue, nipple and areola, leaving the overlying skin) has become a favored option for many women. The breast is re-filled and re-shaped with the patient's own tissue, frequently from the abdomen, or a breast implant.

Q: What about chemotherapy, hormonal therapy, and radiation therapy?

A: These are adjuvant therapies, that is, additional therapies that increase or aid the effect of surgery. If breast cancer has spread beyond the breast, which is called a metastasis, then treatment in addition to surgery is usually required to help arrest and control the disease. Chemotherapy and hormonal therapy are medical treatments that help destroy or control the growth of cancer cells, while radiation therapy aims special type X-rays at and near the area where cancer was removed.

The more advanced the cancer, i.e., its size and degree of spread, the greater need for additional treatment beyond breast surgery. Small, localized cancers of the breast are less likely to require or benefit from adjuvant therapies. Patients are fully informed about their risks and potential benefits by the medical and radiation oncologists on our team so they can make informed decisions about whether to undergo chemotherapy, hormonal therapy or radiation.

Q: What is the breast cancer gene and what does it mean?

A: Body organs, including breasts, are composed of cells. These in turn are made of proteins, lipids, DNA and RNA. The cell's blueprint, coded in its DNA, determines each cell's role and function. If a cell has a breast cancer gene, such as BRAC1 or BRAC2, it may develop "a mind of its own," taking over normal breast tissue to grow at all costs. Patients may think because they have no family history of breast cancer, they don't need to be concerned. Unfortunately, statistics say otherwise. Of 100 women diagnosed with breast cancer, approximately 75 will have no family history of breast cancer. Having no family history does not mean you are immune to breast cancer.

To ask Dr. Ellis a question, click here.

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Copyright (c) 2006, La Crosse Tribune, Wis.

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