One of the country’s foremost breast surgeons shares her thoughts on digital mammography, breast cancer mortality reduction, and the country’s shortage of breast imagers
In 1989, Nancy Elliott, MD, FACS, started the Montclair Breast Center (Montclair, NJ). A breast surgeon hailing from Mount Sinai Medical Center and St Vincent’s Hospital (both of New York), Elliott is passionate about women’s health and the fight against breast cancer. Her facility is a multidisciplinary and comprehensive breast center offering screening, diagnosis, and treatment under one roof with the help of two breast imagers, two breast surgeons, and a wealth of other highly trained staff. Elliott knows the statistics from the American Cancer Society: An estimated 215,990 new breast cancer cases will be reported this year, with an estimated 40,110 breast cancer deaths. As a member of the President’s Council of the National Breast Cancer Coalition, the Metropolitan Breast Cancer Group, and the American Society of Breast Surgeons, Elliott is working diligently to decrease the breast cancer mortality rate, one patient at a time.
One of your goals is to create a state-of-the-art medical facility that incorporates elements to make a woman’s life easier. What exactly are these elements, and how have they been implemented at your practice?
We’re unique in that we have the breast imaging part of the center—the mammography and breast ultrasound, which is the screening and diagnosis part. But we also have the surgical part. The fact that we have both in one center is unique, and very few places in the country have that ability. Today, I operated on a woman on whom we had done the biopsy on the same day that we found the lesion. And we get the results in 24 hours. She said, “I had my mammogram, ultrasound, and biopsy, and I was out of there in 2 hours.” Typically, it’s about 5 to 6 weeks from noticing the problem to the time of the surgical procedure. So we’ve streamlined all of that. Unfor-tunately, in order to do that, we cannot get the reimbursement from the managed care industries. We’re a fee-for-service breast center, and we do not participate with managed care companies or insurance plans. Health insurance is a contract between the insurance company and the patient; we prefer to stay out of the middle. In other words, we accept payment for services at the time they are rendered. The patient then files to her insurance company for reimbursement. Most of our patients accept this policy and truly appreciate the care that they receive.
Mammography requires some of the highest malpractice insurance in healthcare. Yet, to be a full-service provider, a facility needs to offer mammography. What advice would you give to facilities facing this financial dilemma?
If you can’t offer the highest quality mammography, then you shouldn’t offer it, because you’re just setting yourself up for a malpractice case. And that’s true of anything: If you can’t do it really well, then you shouldn’t be doing it.
And to perform a mammography really well, you believe a facility must have a breast imager—one who is dedicated solely to radiological procedures that image the breast—rather than a general radiologist?
Absolutely. And unfortunately in the United States, there aren’t enough breast imagers to go around. I would say that 90% of women have their mammograms read by a general radiologist.
What are the dangers of having a general radiologist read a mammogram?
Obviously, the general radiologist isn’t going to say it’s dangerous. But it’s like anything else: If this is what you do all day long, and you’ve had special training in it, then you’re going to be better at it. I think there aren’t more breast imagers, because it’s a very poorly reimbursed study. Medicare pays $100 for a screening mammogram. You can’t give quality service for $100 a mammogram, so you have to cut corners. Most places that do mammograms are general radiology groups that lose money from their mammography program. Do you think they’re going to invest in the highest quality unit? Do you think they’re going to spend money to hire a good mammo technician? And they’re certainly not going to hire a breast imager. And if they do, they’re not going to pay him much because that part of their practice doesn’t make any money.
That’s why it’s even more important for women to be their own advocates. Here’s an example. A new patient of ours, “Karen,” is 44 years old. Her mother was 48 when she died of breast cancer. Karen has dense breasts, and she asked her gynecologist if there was anything else she could do besides getting a mammogram, specifically ultrasound, which she had read about. The gynecologist said no, but Karen felt uncomfortable and thought she should have an ultrasound. She came to us, and, believe it or not, we found a breast cancer on her ultrasound. Her tumor was 9 mm, and she had same-day surgery. She’s not going to need chemotherapy. Karen is a smart woman who did her homework. She knew there was more available to high-risk women than just mammography. She persisted even after being misled by her own doctor. Bravo, Karen!
With the cost of breast cancer—in terms of disability and the trauma that women go through—we deserve breast imagers reading our mammograms and talking to us afterward, explaining any abnormalities and recommending additional studies. And we could decrease the mortality rate from breast cancer significantly if a law or regulation mandated that only dedicated breast imagers were allowed to read mammograms. A lot of radiologists’ jaws will drop, but I believe this policy will save thousands of lives.
Other than passing that kind of law, what improvements or advancements need to be made on both the diagnostic and treatment sides to help reduce the number of deaths?
Having only breast imagers read mammograms is certainly the most important thing. And, we could enforce that every woman with dense breasts should have a whole-breast ultrasound. But unless someone who’s very qualified does it, it could generate a lot of unnecessary biopsies, because, again, people don’t want to be sued. They see something, they don’t know what to do about it, so they recommend biopsy. So really, we need a cadre of breast imagers who are passionate about reducing the mortality rate from breast cancer. And women have to smarten up also. I’m amazed at how many educated women don’t know who is reading their mammograms. They investigate their hairdresser more than they investigate who’s reading their mammogram.
The usual course of events is mammogram, ultrasound, and then MRI. Do you perform breast MRI in your center?
Yes. MRI is also going to improve the early detection of breast cancer. A mammogram takes two pictures of each breast: One picture is the up/down view, and one is the side-to-side view. But all of the breast tissue from one side to the other side gets squished into one picture, creating a lot of overlapping tissue. But an MRI takes hundreds of images every 3 mm, so there’s no overlap. Then on the computer, you can look at hundreds of images in two dimensions, from all directions, so you’re going to see those 2 to 3 mm cancers, which would be very difficult to pick up on a mammogram. Some studies have shown that if you do MR on everyone who’s diagnosed with breast cancer, there’s a 20% chance you’re going to find a second cancer in that breast or the other breast, which didn’t show up on any other imaging study. So we perform breast MRI on women who have been recently diagnosed with breast cancer. We also screen high-risk women—those whose mothers and sisters had breast cancer. In studies of high-risk women, I would say they’re finding about a 4% to 5% incidence of breast cancer. That’s a lot! And we’ve actually gotten some insurance approval for doing MRIs on high-risk women. I think the reluctance to go to MRI is because of the cost. It’s so expensive—anywhere from $1,000 to $2,000. Imagine everyone going for a screening MRI at $1,000. That would bankrupt Medicare.
What do you think of digital mammography?
We love it. If you look at a digital image and compare it to a film screen, it’s a more beautiful picture. It is crisper and clearer. It hasn’t been proven to pick up more breast cancers, but it certainly doesn’t pick up less. I tell my patients that I prefer digital, but I can’t tell them that I’m going to pick up more breast cancers because the mammogram is digital.
Other than image quality, what do you think are other advantages to digital?
We found a big advantage in doing interventional procedures. In the past, we used to have to keep the woman in compression until her film was developed to see if the needle was in the right place. With digital, the image comes up immediately, we can see that the needle is in the right place, and we can proceed with the localization procedure. We can do a procedure in 5 minutes; in the past, it would take 20–25 minutes. That’s a big plus. But really, if you talk to anyone who’s done both, any breast imager will prefer digital images. There is less radiation dose, less additional views, and no lost films, because they are archived and stored in the computer.
What are some of the innovative surgical techniques that you use for detecting and treating breast cancer?
I’ve worked with a group of plastic surgeons in our building since I started my practice 15 years ago. This experience has enabled us at the Montclair Breast Center to perform breast-conserving surgery in more and more women. Even though a patient might have a large breast cancer and I have to take a lot of breast tissue, I know how to reconfigure the breast with the help of the plastic surgeons so that she still has a breast. It’s going to be smaller, but it will have a nice shape and won’t be indented on the side. What we do is a breast reduction and a lumpectomy at the same time. Women love that, and it’s also very helpful for radiation therapy, because smaller breasts do better with radiation therapy.
Also, working with the plastic surgeons has enabled me to do skin-sparing mastectomies. You’re able to keep all the skin of the breast and “scoop out” all the breast tissue from one surgical incision around the nipple and areola complex. The plastic surgeon then replaces that breast with abdominal fat and muscle. It’s called a TRAM [transverse rectus abdominus myocutaneous] flap. It looks beautiful, and you couldn’t tell the difference between that and your own breast because the whole skin envelope is there. And since the breast is mostly fat, it’s replaced by fat, so it feels the same. And the patient gets a tummy tuck to boot. We try to make the best of a bad situation.
We’ve also quit using the term “mastectomy” and now use the phrase “glandular replacement therapy,” or GRT. I heard Dr Melvin Silverstein use this term at a conference, and I think it is much improved terminology.
Besides having a mammogram every year, what else can high-risk women do for early detection?
First, she should have a history and physical exam by a breast specialist. Get the mammogram and ultrasound. Then discuss with her doctor whether she’s a candidate for genetic testing. Ask to see a genetic counselor for further discussion. Chemoprevention, or the prevention of breast cancer, with a medication called tamoxifen is now available. Tamoxifen has been proven to decrease a woman’s risk for breast cancer by 50%. Tamoxifen is an estrogen receptor blocker that was and still is currently used to treat breast cancer. I let my patients know what the advantages are and that it’s available to them. Also, having an MR is an option. If a woman has a negative MR, it’s a 99% assurance that she doesn’t have breast cancer. It’s as close to a guarantee as we can get with any study, which is as good as it gets in 2004.
We’re getting somewhere in this fight against breast cancer. If you look at statistics from the past 5 years, mortality has gone down for the first time ever. We’re making strides. It’s just that this information is not being disseminated enough throughout the country. Certainly, I have a chorus of women in whom I’ve found breast cancer through ultrasound only, and they’re going out into their communities and letting everyone know. For example, one of my patients was interviewed on NBC. She had a normal mammogram, but we found a 6 mm cancer on ultrasound. We were able to treat her without chemotherapy. And now, she’s doing great and feels great, which is why she wanted to go on television. She wants everyone to know that an ultrasound saved her life, with a little help from Dr Elliott.
