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Hilton Head Monthly September 2021

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We Turned Our Pumpkins PINK

We turned our pumpkins PINK!

Let us know what you THINK!

Stop by to donate and vote for your favorite! All proceeds go to Volunteers in Medicine.

3-D mammography (also known as breast tomosynthesis) is the most significant advancement in breast imaging to occur in the last 25 years

As each of us has moved into the digital age, whether we embrace it or not, medicine and so many other areas of our lives have undergone dramatic changes. Many of these changes are improving our lives. In the world of medical imaging, the invention of 3-D mammography (also known as breast tomosynthesis) is the most significant advancement in breast imaging to occur in the last 25 years. The use of digital mammography in the 90’s was a step forward but it mostly improved the lives of the people who worked in the medical industry. However, digital mammography paved the way for 3-D mammography (3-Dm), which is a giant leap forward for the patient, not just their care providers.

With 3-Dm, the mammogram machine creates a series of pictures 1-2mm in thickness from the top to the bottom of the breast and from the inside edge to the outside edge. This information can be fused into a 2-D image (much like a conventional mammogram), or each individual 1-2mm slice can be viewed in the same way you would flip through the pages of a good or e-reader. This allows the radiologist to see inside the breast and to be able to avoid structures in the breast that might be in the way of a lesion. Another way to picture the benefit of 3-Dm is to compare it to a bowl of M&Ms. If you had 100 brown M&Ms and one pink M&M in clear bowl, would you be able to see the pink one? Well, sometimes you would and sometimes you wouldn’t. But if you could cut the bowl up into ten slices and pick each slice up to look at it, you would find the pink one almost every time. This is why 3-Dm finds 30-40% more breast cancers than regular 2-D mammograms. It also explains why the patient is called back for additional imaging far less frequently that with regular mammograms. Patient recalls for additional images decrease by 30-40% when compared to conventional mammography. The patient will hardly notice any difference between her 3-Dm and her old 2-D mammogram. The patient will still be put into the same two positions for the same amount of time. Sorry about that ladies!

So, you may be asking, “Is all this hoopla associated with 3-D mammography really worth it? The best way to answer this is by showing how 3-Dm affected a real patient. The first breast cancer I diagnosed at our Hilton Head office was on “Judy”. Judy was a nurse in her 50’s, who came to our office with a lump she could feel. It has been there for a good deal of time and she had a previous conventional mammogram that showed some dense tissue in the area but nothing that looked like cancer. She also had a prior ultrasound of this area which did not show anything that looked like cancer. When she came to see us, she was perplexed, wondering why she could feel this lump but no one could find anything. We wondered the same thing. While most masses that women feel in their breasts are benign (cysts, fibroadenomas, etc.), doctors must consider these masses suspicious until proven otherwise.

When we performed the 3-Dm, the first images I reviewed were in 2-D and they showed very dense breast tissue in the area where she felt the lump, but nothing that looked like cancer. But when I began to scroll through the 3-D images, it quickly became apparent that something wasn’t right. The area that looked like only dense tissue on the 2-D image showed small finger-like projections around the edges when seen in 3-D. These “fingers” represent the body’s reaction to something that is invading normal tissue. When this occurs in the breast, the diagnosis is usually cancer. I talked to Judy about the findings and we agreed that the mass needed tissue sampling, also called a biopsy. We performed the biopsy the next day and waited for the results.

While I really like what I do for a living, the thing I had to do next is my least favorite part of the job. Some people want to hear it in person, and for others a phone call will do. I called Judy and told her she had breast cancer. It didn’t come as a surprise to either of us. While she did not want the diagnosis of cancer and I certainly did not want to provide that diagnosis, the technology of 3-D mammography did allow me to finally give her a diagnosis for the lump she had been feeling. She has since had surgery, radiation, and chemotherapy and we will be seeing her soon for her follow-up mammograms.

While digital technology has enabled imaging advances like 3- Dm, the real advancement is in how this improves the lives of real people. We all know someone or know of someone who has been diagnosed with breast cancer and we have all heard of the tremendous struggle that they go through. These patients touch the lives of caregivers, such as myself, more than they will ever know.

In Judy’s case, 3-Dm showed us things we wouldn’t have otherwise seen. Finding breast cancer early, using every tool we have is the least I can do for my patients.

SHOPPING PAYS — EVEN FOR HEALTHCARE

When patients get involved, quality improves and costs decrease.

Many women spend hours clipping coupons, going to multiple grocery stores or making sure they get the best price per gallon of gas. They would never fill up the tank of their car not know if they were spending $3 or $30 for a gallon of gas. Yet these same conscientious consumers have no idea what they are spending when one of their family members has a medical procedure, imaging test or surgery - even though the stakes are much higher!

Estimates are that 37% of healthcare costs are now paid by the patient. High deductibles of $1,000 or more are now a part of a third of all private health insurance plans and expected to increase as employers and patients try to control healthcare insurance costs. Many patients, in spite of healthcare reform, are still uninsured or underinsured. Healthcare expenses are the number one cause of bankruptcy, even for patients with health insurance. So how do we employ our skills honed from shopping for  groceries to lowering our healthcare costs???

  1. Preventive care: certain prevention services are now mandated by the Accountable Care Act to be in your health insurance plan and are not charged to you, do not fall under your deductible. (https://www.healthcare.gov/what-are-my-preventive-care-benefits/).
  2. Medications: Generics save. Many older medications are as effective as newer ones. Ask your physician if there are generic alternatives to your expensive medications.
  3. Outpatient services - procedures such as colonoscopy, imaging such as CT and MRI and surgeries are almost always less expensive with the same or better quality when performed in an outpatient facility or imaging center ( http://www.consumerreports.org/cro/magazine/2012/07/that-ct-scan-costs-how-much/index.htm).
  4. Costs may vary even between in-network providers. For example, the price of a surgery procedure may vary between in network hospitals. This can vary with location, urban vs rural, inpatient vs outpatient. An outpatient service billed under a hospital tax ID may cost more than an independent facility. A short drive may save you big bucks.
  5. Make sure all services are included when requesting prices. A facility may be in-network but the physician rendering the service may not. For example, a hospital is in-network but the anesthesiologist is not.
  6. To compare apples and apples, know the difference between technical/professional and global billing. When an MRI is performed at a hospital, the hospital bills for the test being performed, the radiologist bills to interpret the study and you receive two bills. You need to know both fees. A single, global bill is the norm in an outpatient center and includes both the cost of the procedure and the radiologist’s interpretation.
  7. Compare prices, it is ok to ask! You are the consumer! The simplest is to request the self pay fee schedule. Price transparency is becoming more available with sites such as Healthcare Bluebook (https//www.healthcarebluebook.com/<http://www.healthcarebluebook.com/>).
  8. Choose a Healthy Lifestyle - families who eat healthy foods focusing on daily fruits and vegetables, exercise regularly, and do not smoke have lower healthcare costs.
  9. Open a Health Savings Account (HSA) - decrease your taxes and be prepared to cover your healthcare expenses.
  10. Educate and empower yourself. Patients involved in their own healthcare will improve the outcome, raise quality and lower costs.

http://www.modernhealthcare.com/article/20140816/magazine/308169968
http://www.tampabay.com/news/health/as-health-costs-soar-more-consumers-shop-by-price/2115129
http://www.cnbc.com/id/100840148
http://time.com/198/bitter-pill-why-medical-bills-are-killing-us

Early detection and a Chance to Survive Lung Cancer

By Patricia Shapiro

I am nine years old and, for the third time this week, Mom is taking me and my three brothers to our cousins’ home all the way in town. I adore my cousins; we share everything with them. Thanksgiving is at their home; Christmas is at ours. We take swim lessons together in the summer, and vacation together in the cabins at Goldhead Branch State Park—but three trips to town in one week? My Uncle Frank is Mom’s only brother. He loves to read, which is a good thing, because my aunt and my mother are librarians! I know he has been sick. We visited him in the hospital when he had surgery, and he has to wear a patch over one eye because he has double vision. When we arrive at their home, I run in to give him a hug. He is in bed. It is summer, and a white sheet is draped loosely over his legs. I can see one leg, all the way up to his hip, and it is very, very thin. An IV pole is in the room, and my aunt in putting medicine in the line. I stop, and suddenly I know that Uncle Frank is going to die. My six-, four- and one-year old-cousins will not have a father. He is only 42 years old.

I am in high school. Juniors and seniors on honor roll have the privilege of leaving campus for the lunch hour. It is cool to smoke, and the lunch hour is frequently not just eating a sandwich but walking along the river bank with friends, bonding over cigarettes, plans for the weekend, and sports teams. I am not in this “in crowd” and, years later, reflect that I am grateful that my father threatened torture if he ever caught us smoking.

I finish reading a CT scan of the chest and go to share the results with the patient. He is 38 years old, looks young for his age, trim and obviously works out. His wife is with him, beautiful with long auburn hair. They are a striking couple. I review the findings of the scan and my fear that he has lung cancer. They return many times over the next two years, often bringing their young daughter. They are so hopeful—so kind and so appreciative of all our efforts. But we cannot save him.

A 55-year old-woman is referred for a screening chest CT. She has no symptoms. I find a small tumor in the left lung and a tiny dot in the right lung. The left lung mass is removed and is a stage 1 lung cancer. Six months later, the dot in the other lung has doubled in size, is removed and is also a stage 1 lung cancer. I see her annually, and after seven years, she is disease free and we joyfully hug. I am as thrilled as she!

All of these patients had lung cancer. Lung cancer is the leading cause of cancer deaths in men and women, more than prostate or breast cancer. Eighty-five percent of smokers begin smoking before their sixteenth birthday. They are addicted before they know it is happening, and as adults, they are scared. They want to quit, but it is so hard. Even if they quit, they are still scared of the consequences of smoking, especially lung cancer. They fight the stigma of society viewing lung cancer as their fault for smoking. They should have known better; they should never have smoked. There is finally hope.

The difference between dying and the possibility of surviving lung cancer is early detection. Since Uncle Frank died in 1965, there was little hope for early detection until now. A large multicenter study has shown a 20 percent reduction in mortality from lung cancer for patients having an annual low dose screening chest CT. This means that four out of five patients diagnosed with a Low Dose Screening Chest CT will be alive in five years. It is the only way currently that stage 1 disease can be routinely detected. Prior studies with chest X-ray and sputum samples every six months did not detect lung cancer early enough to make a difference. The CT scan takes less than a minute, there is no injection, and private insurance plans as of January 1, 2015 must provide the scan as part of preventative services for patients ages 50-80 years with a 30-plus pack per year history of smoking. Medicare is expected to begin coverage within months, and every chest society in the United States has encouraged Medicare to do so. Even for patients not covered by insurance, the price has decreased and, in most centers, is less than $200. Low Dose Screening Chest CT—early detection—a chance to survive lung cancer.

Patricia Shapiro is a practicing diagnostic radiology doctor at Island Imaging Center in Savannah, Georgia.

After this article was published, MediCare approved screening chest CT for reimbursement.

The 3D Mammography is the most significant advancement in mammography in decades

As a radiologist, I want to be able to offer the most advanced technology available to help my patients. With 2D screening mammograms it is like I am looking at a closed book, all the breast tissue is layered upon itself and it can be impossible to tell when an early breast cancer is present.

With 3D mammography, 1mm thick slices are imaged through the breast. The book is now open and I can turn the pages to see through the breast tissue.

Women know they have a 1 in 8 chance of developing breast cancer in their lifetime. Most of us have a mother, sister or friend who has been diagnosed with breast cancer. The only consistent risk factors for breast cancer are being a woman and getting older. Most women diagnosed have no family history of breast cancer.

You can decrease your chances of getting breast cancer by healthy lifestyle choices. These include regular physical activity, maintaining a healthy weight and limiting the amount of alcohol to no more than the equivalent of a glass of wine per day. Women should be aware of the look and feel of their breasts. Many breast cancers are first detected by the patient performing a breast self exam. Any change should be promptly reported to the woman’s physician.

Regular screening mammograms do not prevent breast cancer but offer the best opportunity currently available to detect breast cancer at an early stage.The American Cancer Society and the American College of Radiology recommend a  baseline screening mammogram at age 35 and annual mammograms beginning at age 40. An exception is for women whose mothers had premenopausal breast cancer. These women should begin screening 10 years earlier than the age their mother was diagnosed. So if the mother had breast cancer at age 40, the daughter should begin screening exams at age 30.

A small group of women and men have an increased chance of developing breast cancer because they inherited a mutation in the BRCA1 or BRCA2 gene. The gene can be inherited from the mother or the father. The incidence of breast cancer in the general population is 12%, the incidence increases to 55-65% when a woman inherits the BRCA1 mutation. Women are also at increased risk for ovarian cancer. Men are at increased risk for prostate cancer. Fortunately the gene mutation is not common and can be detected with genetic testing. Families with multiple cases of breast and/or ovarian cancer, a family member with breast and ovarian cancer or a case of male breast cancer should consider genetic testing and counseling.

A recent study examined over 7,000 women and found that the mean age at diagnosis of patients with fatal breast cancers was 49 years. Of those who died from breast cancer, 65% had never been screened and 6% had not been screened in over 2 years. The younger women are, the more fibroglandular, dense breast tissue they have and 3D mammography becomes even more important.

We want the most effective screening we can get so that if we do have breast cancer, it is diagnosed early. A woman with stage 1 breast cancer has a 90 % 5 year survival rate; with stage 4 breast cancer 5 year survival decreases to 15%. This is why 3D mammography is so important. In published studies, 3D mammography has shown      

  • a 53% increase in invasive cancer detection
  • a 35 % increase in cancer detection
  • a 37 % decrease in callbacks and
  • an 11% decrease in biopsies.

What a winning combination - a screening exam with fewer callbacks, a screening exam with fewer biopsies, a screening exam that detects more breast cancers at an earlier stage. 3D mammography, is the new PINK standard.

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