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PARKTOWN NORTH

MAMMOGRAPHY AND BONE DENSITY CENTRE

This modern state of the art center is conveniently situated in the Northern Suburbs of Johannesburg South Africa. It is in a garden setting in its own dedicated building with adequate secure parking. Its design is specific for mammography and Bone Density studies. It is staffed by dedicated specialized health professionals who are trained in the study of Breast and Bone disease and who deal with their patients in a most compassionate and professional manner. The growth and development of this dedicated specialized center arose out of the need to take care of the universally increasing incidents and risk of beast cancer and osteoporosis. To explain the important issues with regards to these diseases and more importantly to remove the fear, we shall explain further. Under the direction of Dr. Paul Sneider Mb. B.Ch.(Wits). DMRD. (RCP London & RCP England). DMR(D). (Wits). APSSA

Breast cancer is a condition when cell growth of breast cells gets out of control. As anywhere else in the human body, tissue cells are in a continuum of growth and death. In the breast, when this pattern of balance gets out of control, the cells proliferate in a haphazard way and a lump will form. Only when this lump grows large. size can it be felt by the human hand. Cancer growth in the breast is usually slow growing and this can take years of growth to reach this size. Just like cancer anywhere else in the body, if it is diagnosed in its early stage of development, the treatment options are simple and extremely effective. Early recognition will result in a cure rate of breast cancer in excess of 90%. Breast cancer is very common and the lifetime risk of a Western woman getting the disease is now about 1 in 7. It is the commonest cancer in women and worldwide, about 3.500.000 new cases will occur this year. Although it is common in women it also occurs in men in the ratio of 1:100.

A mammogram is the medical way of finding and demonstrating the human breast. Mammography is a staged event and may comprise the following: The first step is to have the X-ray based mammogram. Here, the breast is examined in a special machine designed for obtaining excellent images of the breast. Four pictures are taken of the breasts, each one taken in two directions. Processing of the images can be either analogue which are film based or digital which is all electronic. There is no proven difference in the accuracy or diagnostic efficiency of either method. The breast must be gently compressed and never ever hurt during the examination because it is soft and requires to be still for the picture taking and the compression improves the image quality. In a modern machine, the compression is computer controlled and is released the moment the exposure is completed. There are very strict criteria established for high quality mammography and this examination must only be performed by highly skilled and specially trained technicians and specialist doctors. Mammograms save lives and it has been proven that by having annual mammograms, the death rate for breast cancer will decrease by up to 50%. If the time period is extended to every two years, the death rate will be doubled. It is now recommended that every woman should have an annual mammogram therefore from the age of 40 years and because we are finding more and younger women getting breast cancer some people are advising women to start at 35 years. In excess of 90% of examinations, it will be necessary to complete a mammogram with an Ultrasound study. Here again, high definition dedicated apparatus must be used by a highly skilled operator and in SA this will invariably be a Doctor and not a technician. The reason for using ultrasound is because certain things can be seen with X-ray based technology and others only with Ultrasound. Each examination on its own therefore, is incomplete for mammography and would miss many breast diseases. The two together, however, complete the examination and result in about 90% accuracy. It is very important to realize that an X-ray mammogram on its own, whether analogue or digital, is an incomplete study and should not be done in the modern context of accurate diagnosis. In a small percentage of cases, if the above cannot make an exact diagnosis, the next stage would be a Breast Biopsy.

This is probably the most common reason for bringing a woman to the Mammography Department. As Churchill may have put it........it is an enigma wrapped up in mystery. Just about every woman sometime in her lifetime will experience breast pain or discomfort and this is probably the commonest reason for a woman to come for a mammogram. The bottom line is that it is very rare that we are able to demonstrate a cause for breast pain. Basically ‘bad things’ don’t cause pain and because there is no disease, there is no effective treatment other than simple pain killers. However, if the patient accepts that her breasts are normal, more than 50% will find that the pain disappears. Do not believe the nonsense of Hormones, Evening Primrose oil, mastitis, etc as a cause of breast pain. Hormones as treatment do not work. However, in very severe cases, Tamoxifen has been shown to have some effectiveness but side effects can be a problem with this treatment. Occasionally, there is a condition called lateral chest wall tenderness syndrome which is a rib condition, which can present with breast pain and can be effectively treated.

The risk of breast cancer in the Western Woman is increasing and the lifetime expected risk is now approximately 1:7. You can have your personal risk assessed with a simple computerized program...........THE GAIL RISK. If there is a strong family history one can be tested for a Gene Dislocation such as BRCA 1 or 2. This must be done in a specialist Genetic Clinic where specialized counseling and advice can be given if the test is positive. Known increased risk factors for Breast cancer are: • Genetic...Family history of first degree female relatives • No childbirth • Obesity • Alcohol abuse.....more than two units of spirits per day • Early menarche and late menopause

It is very important to realize that more than 80% of all abnormalities found in the breast are benign and do not require any treatment. There are benign tumors which are mostly found in teenagers and young women....called fibro adenomas and are mostly left alone after the diagnosis has been made. The other common benign lesions seen are cysts. These are simply collections of fluid and are always benign. They should never ever be operated upon as they are easily treated as an outpatient procedure in the Mammography Department. They are diagnosed with Ultrasound. Breast cysts are treated with image guided needle aspiration using local anesthetic and simultaneously injecting air into the cyst. The air reacts with the cyst walls which then stick together. Never allow a Doctor to put a needle into your breast unless the insertion is guided and visualized with ultrasound in real time. It is important to distinguish one sided nipple discharge or if it comes out of both nipples. The latter is usually from a generalized condition such as Pregnancy or even a small pituitary (Brain) tumor which can be treated with medicine. Unilateral nipple discharges are almost always benign.......even if bloody. The cause for these are easily found by doing a nipple smear to determine if any abnormal cells are present or by doing a Galactogram to demonstrate the milk ducts. The simple benign tumour which may result in a bloody discharge is called a Duct Papilloma and is easily treated.

For nipple discharge there is galactography where we demonstrate the breast milk ducts. It is a painless procedure but requires expertise by the operator and specialized equipment. A nipple smear is done by smearing the nipple discharge onto a slide for the laboratory. Where the nature of a discharge is studied. Ductal Lavage is an expensive and time consuming procedure for investigating risk. Nowadays it is seldom done.. MRI is reserved for difficult problems and is an expensive diagnostic study. Unfortunately at present, it is still associated with too many false positive results which can result in unfortunate over-treatments.

This is a very elegant technique for making an exact diagnosis. Several methods are now available and they are outpatient procedures done in the Mammography Department. It is unnecessary nowadays to perform a surgical biopsy in hospital to achieve a diagnosis. The most elegant, sophisticated and simple method is called an image guided Fine Needle Biopsy. Using either Ultrasound or Stereotaxis for guidance, a very thin needle is placed into the suspicious area with great accuracy. It is painless as local anesthetic is used and there are no after effects or possible complication other than a small bruise. Only cells are extracted and a highly specialized Pathologist is required to interpret the results. Rarely, other needle based technologies can be used using thicker needles with or without suction to obtain larger tissue samples. These of course may result in complications and excessive bleeding which could be a problem. These techniques are quick and office based. There is no need for a patient to take off from work and no recovery time is required. Mostly they are done with the patient sitting in a chair.

This plays a very important role in treatment options for Breast Cancer. When Surgery is performed in its treatment, one of the options used is for the postoperative breast to be as close as is humanly possible to the natural breast and remarkable results are now being obtained. The objective is to do the re-constructive surgery simultaneously with the surgery for treatment of the disease and the patient will wake up after surgery with a ‘breast’ in position almost as it was before the operation. Several different reconstruction options are available which are continuously improving.. Cosmetic surgery is very common. Many women don’t ‘like’ their breasts and want them larger or smaller or lifted. Increasing their size is done by inserting silicone or saline prostheses. Every woman over the age of 35 years must have a mammogram before having cosmetic surgery due to the risk of breast cancer. Breast reduction surgery is good because of the obvious size and weight advantages but importantly, it has been shown that the breast cancer risk diminishes after a reduction procedure. Because these operations are considered not to be medically relevant, third party payers will not consider payment by the Medical Aid.

As for cancer elsewhere, surgical removal is the principal method of treatment and that is why early detection is so important because the smaller the cancer, the easier and smaller the operative procedure and the more effective the cure rate. Re-constructive surgery is offered simultaneously. Better results and smaller surgeries are obtained by using dedicated breast surgeons rather than surgeons who do occasional breast operations. In mammographically detected small breast cancers, it would be rare to have a mastectomy. A lumpectomy is the norm. Radiation therapy and Chemotherapy are also used and the need for these is beyond the scope of this discussion.

1. I am perfectly well...........early cancer has no symptoms 2. There is no breast cancer in my family...........about 80% of all breast cancers are spontaneous. 3. All mammograms are the same......not true.......Ensure you get a high quality mammogram as is legally required in the USA or Sweden. Following upon this mammograms must be accurate and should not be covered with a report saying they are inaccurate etc. which is common practice in SA. 4. The X-ray dose is large........completely untrue......the background radiation can be larger especially if you are traveling in a modern jet aircraft at high altitude. 5. Mammograms hurt.......if properly done with modern equipment, this is totally untrue. 6. My Doctor says he can feel small lumps and that small breasts don’t get breast cancer........totally untrue ……..because by the time a lump is felt, the cancer has been growing for a very long time and by far, the most lumps discovered are by the patients themselves. Therefore don’t be reassured when a Health Professional tells you that your breasts are normal with only a hand examination.

1. I am perfectly well. I don’t have a breast lump, why should I have a mammogram? Because this will demonstrate small abnormalities which cannot be felt by the human hand. 2. Won’t the mammogram hurt? Definitely not. 3. Surely the X-ray dose will harm me especially if it is every year? The X-ray dose is so small in a mammogram that it is far less than the background radiation that you may receive in a shopping center or an aircraft flight. 4. I know I will have to have a mastectomy and lose my femininity and my companion relationship? Regular mammograms would rarely require a mastectomy as the modern treatments mostly ensure breast conservation. 5. Having breast cancer means I am finished. Is there a cure? Of course there is as has been proved by regular annual mammograms from the age of 35 years. The cure rate is over 95% 6. I am terrified because I have found a lump in my breast? Don`t stress because more than 80% of all breast lumps are benign.

$Osteoporosis means soft and fragile bones. The skeleton is dynamic in that bone is continuously being laid down and taken away by highly specialized bone cells. This process is normally in balance. When more bone is taken away than laid down, Osteoporosis occurs. Osteoporosis is a silent symptom less disease and the only time you will be aware of it, is when a complication occurs resulting in a fracture. Strange as it may seem, when a baby is born it has little bone in its skeleton. Increasing bone content is deposited in the skeleton which reaches a maximum at approximately thirty years.$

We need to diagnose bone content and quality. The latter is difficult to assess accurately Bone content is measured which can be assessed without difficulty. For this we use a DEXA scan which uses a highly specialized X-ray machine, which in turn uses a very low dose of harmless X-rays to measure the bone content in the skeleton. This is measured in Grammes per square centimeter. As defined by the WHO, the results are issued as a statistic which is related to a database, derived from the maximum bone content at the age of 30. These are called T-scores. Bone loss cannot be assessed on a conventional X-ray film unless extremely severe. A CT scan can make the diagnosis however, but this is cumbersome and expensive. Because osteoporosis is symptomless all women at about age 50 are advised to have a DEXA scan and men at about 60. All middle aged people requiring tooth implant posts, should be DEXA scanned prior to surgery because osteoporosis of the jaws are so common and can result in ‘post’ failures.

$Osteoporosis affects approximately 33% of menopausal women. Osteoporosis results in fractures which, with advancing age, become painful, debilitating, deforming and even fatal. There will be 400,000 potentially preventable osteoporotic hip fractures in the European Community this year. These require hip replacement therapy and about 20% are fatal. Thus, osteoporosis is a major social problem worldwide and is usually under-diagnosed because it is symptom less. Hence, it is referred to as the silent killer. Osteoporotic fractures are commonly seen e.g. the Dowager Hump in the spine, fractures around the wrists and hip fractures. In our society approximately 10% of women aged 50 years may have a symptom less spinal fracture. More osteoporotic fractures occur in women than breast, ovarian and uterine cancer combined!$

$Men also get osteoporosis but at a later stage and the reason we see less in men, is simply because they do not live as long as women. The hip fracture incidence in men however, approaches that in women.$

$• Mostly unknown and poorly understood. We do know however that there is a sharp increase in the incidence of Osteoporosis after the female menopause and this g is thought to be due to Estrogen deficiency • Lifestyle is important especially with regard to diet and exercise. • Lack of Vitamin D and sunlight • Certain diseases such as Parathyroid tumors and Rheumatoid Arthritis • Alcohol abuse and certain drugs especially Cortisone • Veganism • Disuse e.g. bedridden disease, treatment of fractures, Astronauts in zero gravity$

$• Try and determine the cause especially in young persons • Hormone Replacement Therapy • Specific Drugs such as: - the Alendronates, 1 tablet weekly - Zoledronic Acid, 1 injection annually - Forteo a parathyroid extract, very expensive but effective and reserved for serious cases with fractures • Education, especially in the prevention of falls • Calcium supplementation and Vitamin D • Weight bearing exercise$

The Parktown North Mammography and Bone Density Centre 29 1st Avenue East (Corner 7th Avenue) Parktown North (At Rosebank Corner) Johannesburg Tel: +27 11 442 7964 Fax: +27 11 768 5116 Email: admin@mammography.co.za