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Second Opinion: Mammograms
Hosted by Abigail Trafford
Washington Post columnist

Tuesday, Jan. 30, 2000; 2 p.m. EST

Welcome to Second Opinion, a weekly column and Live Online discussion with Post Health columnist Abigail Trafford. To talk about mammogram rights is Dr. Gillian Newstead, MD, director of breast imaging at the New York University Medical Center.

Do women have "mammogram rights?" The mammogram is not like any old test. As a potential gateway to breast cancer, the very process is laden with anxiety. Mammography can save lives by detecting cancers when the tumors are at an earlier, more treatable stage. But it is a crude technique with misses and false alarms. A lot of women experience "mammogram anxiety." They should expect not just medical competence but also certain amount of attention to their psychological needs, especially if they are breast cancer survivors.

Dr. Gillian Newstead is the director of the NYU Breast Imaging Center which consists of multiple centers throughout the New York city area. She received her medical degree at the University of Edinburgh in Scotland in 1966. Dr. Newstead has received numerous awards and honors from the medical community and is board certified from the American College of Radiology. She has served on many committees, presented at many lectures, and has been published in national medical journals.

The transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

dingbat

Abigail Trafford: Hello everybody. You all have a mammagram story. Join us now to discuss the mammogram. Please send in your comments and questions.


Abigail Trafford: Welcome Dr. Newstead. Getting mammogram is an almost universal experience for women. Why is there so much anxiety with this test. Is the anxiety different for a woman who has no symptoms compared to a woman who's a breast cancer survivor?

Dr. Gillian Newstead: Most women are afraid to have a mammogram because they are worried they may have a cancer diagnosed. A woman already with breast cancer has an increased fear.


Abigail Trafford: What can mammogram centers do to address this anxiety?

Dr. Gillian Newstead: Friendly atmosphere and competent technologists can do much to relieve the fear.


Abigail Trafford: What about women who are getting a diagnostic mammogram. What about their anxiety level?

Dr. Gillian Newstead: Women with breast problems, when they come to the center are scheduled for a diagnostic mammogram have an increased level of anxiety about their lump or other symptoms. At The time of the examination the patient will meet the radiologist to discuss the findings and this will help to relieve anxiety.


Abigail Trafford: Women have a great fear of breast cancer. They fear it more than heart disease although heart disease is a much greater killer of women. Why is this?

Dr. Gillian Newstead: They have a great fear of losing their breast which results in disfigurement and worry how family members will react to their disease.


Ellicott City, Maryland: Thank you for acknowledging that anxiety is a natural part of breast examinations. This is the second year that I have been notified of my mammogram results by mail. In both cases, there was an abnormal finding. Panic and worry resulted from returning home from work in the evening to discover a form letter in my mailbox from a local radiology center.
Check box choices ranged from “your mammogram shows no signs of cancer” to "a finding in your right/left breast raises some concern and a biopsy is recommended, schedule an appointment with a surgeon.” I found this method of notification incredibly insensitive. Is there some agreement on how women should be notified if their mammogram indicates an abnormality?

Dr. Gillian Newstead: We usually notify our patients to return by letter and by phone call. The letter usually states that an abnormality has been detected on the screening study which needs further evaluation and that the patient should call the breast center to schedule a return appointment. The letter also states that most patients recalled to not have breast cancer.


Arlington: Any suggestions on how to encourage my mother to get a mammogram? We don't live in the same area, so I can't drag her kicking & screaming. I think she's afraid of the pain - do they still use the "squish till flat between cold steel" method?

Dr. Gillian Newstead: Most patients tolerate this procedure well and experience only mild discomfort. How about giving her a mother's day mammogram and have one at the same time yourself!


Cedar Rapids, Iowa: I know you know how uncomfortable, painful and embarrassing having a mammogram is. I am convinced that is why more women put off this procedure. Nevertheless, my question is: is there a better, newer, less painful procedure to test for breast cancer?

Finally, are most breast cancers detected through mammography or through self breast exams?

Dr. Gillian Newstead: Although some cancers are detected by self examination, the best way to find early cancer is still with a mammogram. There are new technologies being investigated such as digital mammography, but this technique still needs breast compression.


Richmond, Va.: Please explain what you mean by "women should expect a certain amount of attention to their psychological needs" during the mammogram process, "especially breast cancer survivors." I agree but would like to hear what you mean. Thanks Ellen

Abigail Trafford: The woman I wrote about had the following experience. A breast cancer survivor, she was in for her post treatment checkup. The radiologist, without examining her, thought he saw something suspicious on the other breast and told her to contact her surgeon. I think the radiologist should have contacted her surgeon and helped her deal with the news--not pack her off to the waiting room and fend for herself. It all turned out to be a false alarm. but for a day, she went through psychological hell. Dr. Newstead--what's your view on how to pay attention to women's psychological needs?

Dr. Gillian Newstead: When women come to the breast center for a diagnostic evaluation, they often undergo further testing which may or may not include ultrasound and needle biopsies. Communication with the physician is the best way to reduce patient anxiety and full explanation of the findings and discussion with the referring physician is needed.


reston, Va.: What about the use of sonigrams, does it give more results?

Dr. Gillian Newstead: Ultrasound is a helpful method for further evaluating mammographic findings or palpable lumps and gives additional information than can be seen on a screening mammogram. We use it extensively in our diagnostic work ups. It is not yet recommended for screening.


Abigail Trafford: Dr. Newstead, this may sound naive--but why does the mammogram hurt so much. People have said that if men had to go through this, they'd demand a better test. How can the mammogram technology be improved? What is the false positive, false negative rate? How can that rate of false findings be improved?

Dr. Gillian Newstead: Compression of the breast is needed to separate out normal breast structures from small cancers. Therefore, discomfort during compression is part of the examination. The false negative rate should be between 5-15%.


Arlington, Va.: I was diagnosed with breast cancer last summer and have had surgery, chemo, radiation and now starting tamoxifen. Unfortunately, the lump I felt did not show up through mammography, rather through an ultrasound. We were told that mammography is effective 85% of the time. Questions: Why couldn't all lumps show up on mammograms? Are mammograms only picking up tissues of certain density or some other characteristics? Thanks.

Dr. Gillian Newstead: In younger patients or patients with dense breasts, small cancers may be hidden. Ultrasound may find cancers in these patients which cannot be seen on the mammogram.


Washington, D.C.: I've read about the use of ultrasound and MRI as diagnostic modalities. What progress is being made in those areas?

Dr. Gillian Newstead: Ultrasound has improved greatly over the last 5 years and we also use MR in patients particularly with dense breasts and a breast cancer diagnosis to map out the tumor most effectively.


Pembroke Pines, Fla.: I am 46. I had my last mammogram a year ago with negative results. My family does not have a history of breast cancer or any cancer, for that matter. Do I still need to have a yearly mammogram?

Dr. Gillian Newstead: Absolutely, mammogram is needed every year for early diagnosis.


Abigail Trafford: Dr. Newstead, there was a Canadian study recently that suggested breast examination by a professional was as effective as mammograms in detecting breast cancer and (I believe) in reducing deaths. What's your view? What entails a professional breast examination?

Dr. Gillian Newstead: I do not believe that physical examination and find breast cancers as small as can be found on mammography. Physical examination by a physician or nurse is an important adjunct to mammography as some breast cancers are not seen on mammograms.


Silver Spring MD: It's not fear of breast cancer that deters me, it's the extremely uncomfortable process required to get the mammogram. An MRI would certainly produce equal or better results with little or no discomfort. But the money considerations seem to be of larger importance to insurers than to the extreme discomfort and outright pain that some women feel during the mammogram.

Dr. Gillian Newstead: Mammograms are still the best proven way of early diagnosis. We have no statistics on mammography screening with MRI yet. WE expect some early results on screening projects in Europe and the U.S. within the next 2 years. The expense of MR precludes its use as a widespread screening tool at the present time.


VA: I don't want my mammogram performed by a male technician. It's not that I think the tecnician is "up to anything" or is less competent, I just really don't feel comfortable with it (I don't see a male gynecologist, either). Is there any way I can request a female technician in advance? I know I will probably get lashed out against for asking this, but this is a real concern for me.

Dr. Gillian Newstead: In my experience there are very few male mammography technologists in the United States although there are many in Europe. You can always ask the facility when you make an apt. and request a female technologist.


Abigail Trafford: Dr. Newstead: what is the false positive rate? The rate of finding what looks like a cancer that turns out not to be a cancer?

Dr. Gillian Newstead: The patient's who undergo some type of breast biopsy in the United States today have approximately a 20% chance of having breast cancer based upon published data. This number however varies considerably depending on the experience of the facility in question. Some facilities report 50% of their patients with a cancer at biopsy with low false negative rates.


Mt. Rainier: My feeling, as a major introvert, is that doctors are much better at communicating with people who are quick at opening up. I always go in intending to ask questions and supply more information, but I'm not comfortable with strangers and doctors seldom give me enough time or prodding to get to that point. Don't [know]what can be changed, given time is money, just my two-bits.

Abigail Trafford: Dr. Newstead, Isn't part of being a good doctor getting people to open up and get to the point? Shouldn't doctors ask questions to get women to open up? I don't think the whole burden should be on the woman, who's often scared or who may just be an introvert. What do you think?

Dr. Gillian Newstead: I agree that doctor's communication skills are important and patients are nervous when meeting the physician. Some of my patients bring a list of questions with them and we take time to answer them so that nothing gets forgotten at the time of the visit.


Alexandria, VA: Dear A,
Read your article this afternoon. I am glad/relieved that someone finally published an article advocating compassion for women when they undergo this test.

I personally believe that ALL women should be treated with compassion. Last year, at [an area] radiology clinic, I had a terrible experience. I have really poor vision. This time when I went in for the mammogram, the technician told me to throw the robe/smock on the bed with my glasses and walk to the other side of the room with the machine. She seemed very angry when I explained that I would be unable to even find the machine. In addition, I am very uncomfortable standing naked to the waist in front of a stranger and totally unable to see. Well, I kept my glasses on and she proceeded to position me for the first x-ray. This was when I discovered just how angry that she was. She slammed the top of the machine down so hard and used so much pressure that I had blood blisters. I complained to her supervisor (about the rough and uncompassionate treatment) and did not get any positive feedback (or even an apology) that this behavior would not occur again.

It is certainly true that cancer survivors should be able to bring a support person with them. And I do believe that cancer survivors should have first priority. However, remember that anyone receiving a screening mammogram could be the next cancer victim and should be treated with compassion. To sum it up: Everyone should get at least a cup of compassion with each mammogram, but a cancer survivor should receive a cup and a half of compassion.

Needless to say, I am searching for a different place to do my next mammogram. It would be nice to have a listing of the places that perform this test. Even better, a list with ratings for compassion (sort of like we do with movies - 5 stars equal lots of good things and 1 star means go somewhere else).
s

Abigail Trafford: What should a woman look for to find a 5 star breast imaging center?

Dr. Gillian Newstead: When a patient presents for a screening mammogram, she often will only meet the secretarial staff and the technologist. The competence and demeanor of the technologist are very important in making the patient feel comfortable and helping to relieve anxiety. Sensitive handling of the patient's concerns during this examination is very important. If the patient experience undue discomfort, she should communicate this to the technologist and perhaps the examination can be tailored slightly to reduce discomfort.

As far as finding a 5 star mammography center it is important to talk to your physician and friends in order to get their recommendations and review their experiences.


Bethesda, MD: A recent, large randomized trial in Canada showed that women who received screening in the form of a careful (annual) clinical breast exam were no more likely to die from breast cancer than women who received mammography in addition to the clinical exam. The physical exam only group, however, had fewer lumps detected overall, and therefore fewer false positives. What do you think of physical exams as an alternative for women who for whatever reason won't accept mammography, or for younger women with denser breast tissue? Thanks.

Dr. Gillian Newstead: I recommend physical examination of the breast for women of all ages and for women in the breast cancer screening age group, as an adjunct to mammography. False positive mammography results are best reduced by careful diagnostic evaluation by an experienced breast imaging radiologist. Young women at high risk for breast cancer are being screening with ultrasound in some national trials.


Vienna, Virginia: I just recently finished radiation treatments
for DCIS. I now have to wait six months until I can have a mammogram. Any sugguestions for the interim waiting period?

Dr. Gillian Newstead: Just follow your post radiation instructions - no further imaging is needed until 6 months at which time your mammogram will assess the post surgical and radiation changes and be used as comparative studies for future examinations.


Washington, DC: HI:

What are the symptoms of breast cancer? I am 28, don't have a history in my family of breast cancer. But i do have pain sometimes. What should i look for? Any other signs?

Dr. Gillian Newstead: Examine your own breasts so that you know what your own tissue feels like. Then examin monthly looking for any new lumps. Breast pain is very common and usually not significant unless it is in one spot and does not change with the menstrual cycle.


Vienna, Va.: My wife went for a screening last week. She was menstruating and felt a knot the left breast. She reported this knot to the tech, who then refused the study and rescheduled her for a diagnostic exam. The diagnostic exam showed nothing in the left breast, but detected a mass in the right breast. Radiologist sent her back to primary care physician to discuss needle biopsy or surgical biopsy as next step. Now she has to go back to the gate-keeper for referral back to radiologist or surgeon while the mass continues to grow and blossom. Is she a human ping-pong or what? I'm thinking it's time to opt out of the HMO and use the Point of Service Benefit at a Women's Center like Georgetown has. Will this streamline the process? And what is wrong with the HMO process anyhow?

Abigail Trafford: This sounds like a health care nightmare being ping-ponged around. I thought HMOs were supposed to streamline access to services. Dr. Newstead, do you have any thoughts on how people can get comprehensive streamlined breast care?

Dr. Gillian Newstead: The best way to assure streamline care is to go to a comprehensive breast center which offers complete diagnostic breast care at one sitting. Unfortunately many insurance companies require preauthorization so this may be difficult.


Abigail Trafford: What percentage of women who have a screening mammogram receive a letter to come back for further evaluation? What percentage of those women have breast cancer?

Dr. Gillian Newstead: The recommended call back rate for breast centers should be less than 10% of all women screened. Approximately 2-4 per thousand women screened will have breast cancer diagnosed.


Abigail Trafford: What is the difference between a screening mammogram and a diagnostic mammogram-evaluation? Are women handled differently? Do they get more TLC? Should they?

Dr. Gillian Newstead: Screening mammogram is performed on women without any symptoms. She usually will not see a radiologist and if a mammogram is normal, will not return until the following year.

A Diagnostic Mammogram is performed on patients with an abnormal screening mammogram or on patients with symptoms. When the woman is recalled for diagnostic evaluation, she will receive whatever imaging studies are needed. At that time she will also consult with the radiologist who will explain the results and discuss any further studies if needed. A physical examination is usually performed at this time as well.


va: I want to bring someone in the room with me when I have my mammogram. Is this allowed? I would prefer to bring my husband. I think this would decrease my stress a great deal.

Dr. Gillian Newstead: It is not recommended that family members be in the room at the time of the study. Your husband may remain close by to give you moral support and to talk to the doctor if needed.


Washington, D.C.: Since she turned 40, my mom has faithfully gotten her mammograms every year. Last year, my father retired at 65 which allowed him to get Medicare. However, my mom, now 57, has no health insurance and is too young to get Medicare. Therefore, she has not seen a doctor for a little over a year.

She wants to go, but she can't pay $500 for a visit and lab test and we're still waiting to hear if she's eligible for Medicaid. Is there any way she can get a low cost or free mammogram in DC?

Abigail Trafford: George Washington University has a mammogram van that goes to neighborhoods and offers free screening. It is sponsored in part by the Cancer Research Foundation of America. Their telephone number in Virginia is: 703 836-4412. Dr. Newstead, what general advice can you give to women who need a mammogram but don't have the insurance or the funds? Do you offer fee or low-cost mammograms?

Dr. Gillian Newstead: Most cities offer free or low cost mammograms, some at certain times of the year. We offer no out of pocket cost mammograms to patients at NYU Medical Center during Breast Cancer Awareness Month in October and also at Bellevue Hospital Center and Gouverneur Hospital which provides screening mammograms to the underserved population.


Wilmington, Vt.: Is there a central list of mammography centers that offer services such as meeting with a radiologist immediately after your test is performed so that the long waitfor results, and the frequent re-test, are no longer part of the process (I use the Breast Center at Faulkner Hosp. in Boston, but it was only by word-of-mouth that I found it and it seems that many of the problems described today are solved with that sort of service) Thank you.

Abigail Trafford: This is a key point. Should every woman who has a mammogram find out the results in real time? Or only women who come for diagnositic evaluation?

Dr. Gillian Newstead: Some centers offer immediate results for screening patients. The financial situation is such however, that many centers cannot provide this service and the patient must return if additional views are needed. Ideally every patient, whether she is a screening or a diagnostic, should receive her results on the same day. The reimbursements for mammography however do not allow this at most centers.


Abigail Trafford: Do women over 70 need an annual mammogram. There are two schools of thought--what are the issues in this controversy?

Dr. Gillian Newstead: I believe an annual screening mammogram should be done on women over age 70. Their chances of developing breast cancer are higher than in younger women and they can benefit significantly from early diagnosis.


Mt. Rainier : Even my 'good' HMO, Kaiser Permanente that consistently gets good ratings, flunks the ping-pong test. Because I had a questionable mammogram two years ago, I have to make an appointment at the Kaiser across the city from me instead of my normal one. When I asked, they said they didn't have a doctor to read the 'grams at the closer Kaiser. A whole building of doctors, and none available to look at a mammogram?

Abigail Trafford: What can consumers do to get more responsive care?

Dr. Gillian Newstead: Reimbursement for mammography is too low and mammography services are undervalued. If reimbursement rates were more in keeping with the cost of the procedure, then centers would be able to expand and waiting times for appointments reduced. There is a national effort ongoing to lobby congress for increased payments for Medicare patients. You could support this effort if you feel that services need to be improved.


Arlington, Va.: I recently heard that women who used antiperspirants versus deodorants had a higher chance of getting breast cancer --due to the qualities of antipersirants, ie they minimize perspiration, the sweat has nowhere to go and gets trapped in lymph nodes. Any truth to this? Any thoughts?

Dr. Gillian Newstead: This is absolutely not true.


Alex, VA: Two day ago, i found some watery discharge coming out of my nipple. Not directly out of my nipple but the area that surrounds it (the dark part). I have heard that it is one of the sypmtoms of breast cancer. I am 29. I have found no lumps and have no other syptoms. The discharge is not coming out any more. That was the first and last time. should I be worried. I am very scared of Breast cancer. Please help.

Dr. Gillian Newstead: This does not sound like anything important. If you notice a bloody discharge coming from the nipple duct itself, then you should consult your physician and further testing could be done.


Abigail Trafford: Dr. Newstead. We keep hearing about the economic crisis facing mammography centers. Some breast imaging centers are closing. Others are increasing the waiting time to get an appointment. What is going on here? What is the situation at your center?

Dr. Gillian Newstead: We have closed one of our centers which was very successful because the insurance payments were insufficient to cover our costs. Unfortunately we cannot expand our current center and we must limit losses by limiting the number of patients we see. We have a four month wait for screening apts at NYU. We are working on a national effort to educate congress and women to the importance of appropriate reimbursement for breast imaging services.


Abigail Trafford: Isn't breast cancer relatively rare in women after age 70? And what about after age 80? Is there an age when a woman can stop having mammograms every year?

Dr. Gillian Newstead: No, breast cancer increases in frequency with age. The most important risk factor for breast cancer is being female and getting older.


Abigail Trafford: What should a woman do if she has a bad experience getting a mammogram? Who should she complain to? Can she get some help in real time--ie, if a technologist is insensitive, stop the procedure and go to the dest and complain? Demand to talk to the radiologist in charge?

Dr. Gillian Newstead: Mammography centers are regulated by the federal goverment which insists that a patient complaint mechanism be in place at every center. Write and lodge a letter of complaint to your center and ask for a response. Write the letter to the radiologist in charge of the center.


arlington, va: At age 34, I was diagnosed with bilateral breast cancer. (These palpable lumps were not visible on the mammogram, but confirmed by needle biopsies.) I had lumpectomies, chemo, and radiation therapy. Now I have to have annual mammograms, but my breasts are permanently tender from the radiation. Mammography didn't work for me before, and now it's even more uncomfortable. Any suggestions for the best method of monitoring my breasts?

Abigail Trafford: Are there alternatives to mammography for her?

Dr. Gillian Newstead: Most definitely consider screening with ultrasound and possibly MRI.


Abigail Trafford: Do women in their 80s have a higher breast cancer rate than women in their 60s? I thought the rate tapered off after age 75. Are cancers in older women less agressive than those in younger women?

Dr. Gillian Newstead: The woman with a lump at age 80 is more likely to have breast cancer than a woman at age 50. Breast cancers however are less agressive usually in older women. After the age of 75, the incidence does decrease slightly although most screening studies did not include women over the age of 75. I have many patients in their 80's and 90's who are screened regularly.


VA: RE the woman with the angry technician:

If she had walked out of the center BEFORE having the test (ie, as soon as she realized how nasty the tech was), would she have been charged?

Dr. Gillian Newstead: No, the patient should not be charged in this situation and the patient should report her experience to the chief radiologist at the center.


Abigail Trafford: Some women have "lumpy breasts.' They often get recalled for further testing, and it turns out that they have just that--lumpy breasts. Could they use an alternative to mammograms for screening?

Dr. Gillian Newstead: Ultrasound is often useful in these patients as an adjunct to the mammography examination. Physical exam is also important.


Abigail Trafford: Our time is up. So many questions! Thank you Dr. Newstead for your expertise. Thank you all for your questions and sharing your stories. The purpose is to make mammography better--medically and psychologically. Join us next week for another edition of health Talk.


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