Dense breasts, contrast-enhanced mammography, and external breast forms after surgery

Kate

Opened the session and introduced both speakers. Otter glued Thomas’s 2016 Fellowship of the Australasian Association of Nuclear Medicine Specialists onto her intro — that credential is his, not hers.

Thomas (Tom)

Senior staff specialist, Gold Coast University Hospital. Medical director of a dedicated cancer imaging practice. Otter: “cancer radiology and therapy, the first dedicated cancer imaging and neurostical practice in Queensland.” Nuclear medicine / radiology. Almost all of the imaging teaching below is his.

Sharon Douglas

Founder of Mind Body Bedroom: surgical garments and external breast-form fitting. Specialist in breast care — Otter said “Indira Private Hospital,” which is almost certainly Pindara Private Hospital on the Gold Coast; this write-up repeats what Otter said rather than asserting the hospital as fact. Nurse counsellor at BreastScreen Queensland (Otter: “Breast Spain”). Gold Coast Breast Centre, Ferry Road. Otter also called her Cheryl / Sheriff in the intro.

Why this talk: common, early, and still mammography

Kate’s intro placed Tom as a senior staff specialist at Gold Coast University Hospital and medical director of a dedicated cancer imaging practice — Otter’s phrase was “cancer radiology and therapy, the first dedicated cancer imaging and neurostical practice in Queensland.” Fellowship of the Australasian Association of Nuclear Medicine Specialists 2016 is his credential. He thanked Kate, joked that it is easier to speak when desserts are out, and said radiologists bring simple slides and a lot of pictures.

The room had mostly been about prosthesis. His topic was adjacent but different: dense breasts, and the utility of what we call contrast-enhanced mammography (CEM) and MRI in that setting.

Breast cancer is common. One in seven women with a lifetime risk. Every day, about 50 women or men together will have a breast cancer diagnosis. That is a critical part of the healthcare they are in.

The most important thing, he said, is that if we catch disease early they are more likely to survive or to do better — whether it is only stage one, or small cancers. Otter then captured him saying they are “approaching 300% survival in these groups.” That figure is garbled. This write-up does not replace it with 99% or any other invented survival number. What he was driving at is the reason we have a breast cancer screening program: early, small, stage-one disease does better.

The foundation imaging modality that we still use in breast screening is the mammogram, which has been around for more than 35–40 years. Some BreastScreen centres, he thought, have started to do some tomosynthesis. When he was a trainee registrar, all they did was more scans. The foundation modality is still mammography. Then they would go through a board of 100 cases and try to pick the cancers out.

BI-RADS density and the dual challenge

BI-RADS (Otter: “the bi-rad is just the beef or breast”) is the nomenclature for breast densities as well as the category of how likely a finding is to be cancer. Density runs from A to D:

• A — predominantly fatty breast
• D — very dense breasts
• B and C sit in between

People often have a misconception that elderly people have more fat-replaced breasts. That is, in some way, mildly true. It is certainly not always the case. He has definitely seen a lot of women in their 70s and 80s who still have very dense breasts. Younger people tend to have denser breasts — again, not an absolute truth across the world.

Categories C and D constitute a very significant number of the population. Usually estimated around 40 to 45% of women are considered to have dense breasts. Nearly half of the patients they see.

Mammography and tomosynthesis are still anatomic

A mammogram is like an x-ray. It uses a lower-energy x-ray to try to give better soft-tissue definition. It gives a radiation dose — Otter captured “marginally harden HS X-ray because of the attenuation for the body” — but basically it is able to show a subtle difference in density, and that is how you see the detail of breast architecture.

That is based on the abnormality having a mass, some kind of structural problem, and distortion. Anatomically based imaging.

About ten years later came tomosynthesis (Otter: torno synthesis / Von Dano). Most imaging centres will probably have tomosynthesis now. It reduces the degree of tissue overlap — you are not having to see all the tissues in one plane; you are able to try and separate them out. But it is still based on the presence of a density, spiculation, distortion, and in DCIS (Otter garbles this) you still need that structural anatomic change detectable on the foundation modalities.

Functional imaging: leaky new vessels and contrast

What they have moved on to is how to describe image lesions through the cancer’s own characteristics — especially when looking for malignancy. One of the most important things is neovascularisation (Otter: muscleization / media). Cancer cells that try to help themselves grow produce new vessels, which makes them particularly enhancing with contrast, or they can have quite leaky capillaries. That is how contrast helps to find these lesions.

They have moved from more anatomic-based imaging to what he called functional imaging: trying to see what tumour cells are doing rather than just detecting the presence of a mass. That is with contrast, which is a fairly recent thing.

Queensland would be the first state to be introducing this in a major way. He thought it originated more from Western Australia. He now has some centres with contrast mammography capabilities, and his centre as well. MRI has been around for some time and is still considered the gold standard of breast imaging, but there are challenges getting MRI, which he came back to.

How CEM works

Most practices have a mammogram, and women are used to having mammograms — something familiar. If you do not have a machine that is contrast-capable, you cannot do contrast. If you do, the rest is fairly simple.

Most people would have had a CT contrast at some point. The contrast used for contrast mammogram is just like CT contrast — an iodinated (Otter: “nullating”) based contrast medium. You give them contrast and then you take the picture like a mammogram.

The machine has a way of doing this called different-energy acquisition: a high-energy acquisition, which looks a bit funny, and a low-energy acquisition that looks like a normal mammogram (a mammogram is a low-energy x-ray trying to give you detail). The computer then subtracts the two. It knows that anything that is not contrast — a smart little subtraction technique between the black and white — and it leaves you with the lesion of concern, where there is contrast enhancement. That is basically how it works.

Two cases: scar versus a busy breast

71-year-old, surveillance after surgery

A 71-year-old who had previous surgery for breast cancer, on surveillance. A harder case. On the mammogram you could see a white line, a bit of a stellar kind of density. Quite hard. Just on a mammogram he might say: is that early recurrence, or is that just a process called sculpture (Otter; almost certainly scar)? Tricky on mammogram alone.

On contrast mammography, with that subtraction, all that funny density — the lady was close to category C — dropped away. Where you see the state of density, there is no contrast at all. Fairly comfortable, based on the contrast mammogram, that she did not have signs of recurrence. They still did other things. Ultrasound was not the feature of the talk, but they did ultrasound, which had the quite typical appearance of a post-surgical scan. Contrast mammogram alone gave a lot more confidence, and it was fairly easy to diagnose.

If you then couple contrast mammography with AI, he thought you are probably going to get even better, because it becomes an easy means to determine.

56-year-old, nonspecific breast pain

A 56-year-old with some nonspecific breast pain (Otter: “breast tanks”). Her breasts were quite busy. Not clearly a very massive density — it could just be going to the tissue. When they did the contrast enhancement, the nulling of the background tissue was not as good as the case before. The image still looked a little bit busy, but you could make out that something was particularly more obvious in the lateral aspect. She actually did turn out to have a malignancy. He did not have the ultrasound on the slide to prove it, but she did.

Contrast mammography, he said, does make a significant impact on making the diagnosis quickly. All their breast cancers are read by breast radiologists who are very skilled at looking at mammograms — but having contrast mammography does help them get there quicker, analysing areas that are enhancing.

MRI remains the gold standard — with caveats

MRI remains a gold standard for breast imaging. They use the contrast they normally use for other MRI scans, which is gadolinium. They are not looking just about anatomy, the presence of a mass. They are looking at what the tissue does with the contrast: whether it takes a lot, washes it out, keeps taking it up, or does not take it up. Those are the more important features on MRI versus the presence of seeing some kind of mass — and whether you can feel a mass or the patient can feel a mass is not as relevant.

He showed a version of a breast lesion, very enhancing, with additional adjacent vessels recruited — the foundation principles they are using. A woman who felt some kind of breast lump. Two images of MRI, fat-saturated (they try to get your eyes to key in on the bright stuff, knowing fat is usually bright with the technique), done about a minute apart. A funny clustered spiculated constellation. After a minute it became a bit more obvious: whatever that is, is taking up more contrast very quickly. Colour images make it even easier for the radiologist in a dark room to see that there is clearly a lot of contrast going to those spots. She actually turned out to have two breast cancers, or a multifocal part of nature.

They can also do curves: put a region around the lesion, map the contrast through that lesion over time. Those kinetics most decisively tell whether that is a malevolent lesion versus something else. Then he said the challenge: not only cancers enhance. Non-cancers also do that part.

Next case: another woman with a funny lump feeling in the right breast (Otter: “white breast”). On the right breast around the 12 o’clock position, a clearly quite uniformly enhancing breast lesion, and a similar one on the contralateral side — well marginated, a little bit lobulated, enhancing, probably a constant curve. On ultrasound they looked the same but also different: one lesion had internal vascularity, which made them much more worried. The other, with colour Doppler, did not have contrast in parts of it. They biopsied the more worrying one first. The other maybe looked like a fibroadenoma (Otter: “fibroid novas,” later “thyroid norms” / “thyroid norma” / “fibromyalgia”) — quite well circumscribed, hybrid vascularity, and they know that fibroadenomas do enhance. Both came back as fibroadenomas. That is the issue with MRI: not all enhancing lesions are malignant. Even though this case had some features that could suggest fibroadenoma, ultrasound was not that reassuring. They still ended up with biopsy.

CEM versus MRI: sensitivity, specificity, time, access

One of the real differences people talk about: yes, the gold standard in terms of diagnostic sensitivity is MRI. Contrast mammography is probably approaching that. In good hands, he would say you can definitely sit in the mid-80s in terms of sensitivity.

What is actually most important: it actually has a higher specificity. If you have seen an enhancing lesion on contrast mammography, it is actually much more likely to be worrying. That does not mean a fibroadenoma may not enhance; the way they do it in some way reduces the likelihood. The MRI case he showed was a bit like a false call — both lesions could have been fibroadenomas; they biopsied the more mass-like one on ultrasound; still a fibroadenoma.

He would like to see BreastScreen in the future have standard contrast-enhanced mammogram for every patient. That would certainly improve their detection rates. As a registrar he looked at boards of films and occasionally they found cases in retrospect that were probably there two years ago. He thinks there is some data: they detect roughly about four to five extra cases per 1,000 using contrast mammography.

His clinic: no extra fee, cannula, who is offered it

Dense breasts are very common — nearly half of people are considered to have dense breasts. The most important thing, especially when they try to improve patients, is trying to find them earlier, and when they are small that makes it harder. Imaging with contrast-enhanced mammogram certainly does improve diagnostic capability and confidence over conventional techniques such as a mammogram. CEM is probably becoming a more adopted modality.

At his clinic, contrast-enhanced mammography is offered for free — no additional charge on top of what they normally charge for a standard mammogram. The woman or the man still needs a cannula, they need to receive contrast, they need to agree. Most women would say yes. Once they have given some factual kind of benefits — yes we need to put a cannula, you need to have this — most women will say of course, I am already here, I have not paid more for it. Uptake about eight out of ten patients they see in the clinic.

This is not population BreastScreen. Any GP or specialist of any subspecialty who refers a case to their service for diagnostic ultrasound — they are talking about high-risk screening or diagnostic cases of breast. Depending on age: if they are too young, maybe no mammogram; if they are at least 35 or above 40, they will probably offer mammogram and ultrasound, and then whatever they would charge them for, the contrast is optional on top of that without any additional charge. It is really for them to gain experience. Their clinic is new; over the last two years they have been doing contrast mammography and have gained a lot of experience. When they first started they were only one or two clinics on the coast with it; now there are a couple more.

Floor: BreastScreen reassurance and out-of-pocket

Someone asked about breast density, then: how can we reassure them that BreastScreen mammograms actually… (the question trailed). Tom: it has been a while since he has been to a BreastScreen. He did not have advice for today. Someone in the room indicated they are making improvements. He said good to know they are making improvements.

Out-of-pocket for contrast-enhanced mammography: at his clinic, none on top of the standard charge, as above. Cannula, consent, eight-out-of-ten uptake, diagnostic and high-risk — not the screening population.

Sharon Douglas: external breast forms after surgery

Kate introduced Sharon Douglas, founder of Mind Body Bedroom, a company that specialises in surgical garments, external breast-form fitting, and oncology counselling (Otter: “oncologist counsellor” / “surgical guards”). Specialist in breast care at Indira Private Hospital — Otter’s wording; on the Gold Coast that is almost certainly Pindara, but this page does not treat the hospital name as confirmed. Nurse counsellor at BreastScreen Queensland. Previous roles in gynaecology and sexual health, GCP qualifications through corporate clinical trials, advanced diploma in laboratory technology, Bachelor of Nursing, postgraduate nursing technology, postgraduate counselling. Her goal, in the intro: remove financial toxicity of accessing mental health support for patients with a cancer diagnosis, and normalise having mental health support from diagnosis. Member of the (Otter-garbled) Breast Disease Society, the Cancer Nursing Society, the Australian Counselling Association, and the Psychotherapy Counselling Federation.

Sharon’s talk: the role of external breast forms post breast cancer surgery. Breast forms can be used for benign conditions as well as breast cancer surgery; she would talk about the breast cancer surgery part.

External breast forms are external prostheses. They sit outside the chest. They sit in pocketed garments. There was a table of them outside. They are generally used post mastectomy. They can also be used in between surgeries — if somebody has had an implant that has not quite gone to plan and they will not have symmetry for a few months, they can fit an external breast form.

• Variety of shapes and sizes, matched to what is important to the client.
• Aqua breast forms for clients who swim a lot.
• Clients who do lots of yoga, running, or who are on hormone blockers: breast forms that will withdraw the heat from the chest and will not interrupt healing or skin integrity on the chest wall.
• She would not usually fit silicon breast forms until six weeks post surgery.
• There is a form you can stick onto the chest wall — particularly here on the Gold Coast if you want to wear strappy garments — but she would not do that for six months after breast surgery.
• They can put nipples on top of breast forms.
• Breast forms you can pump up with air, so if there are cavities within a chest wall post surgery they can achieve symmetry based on how much air they put in. Partials for lumpectomies as well — they can still create symmetry.

Medicare, DVA, and a one-hour fitting

Medicare rebates can be achieved for breast forms post breast cancer surgery. The Medicare rebate is up to $400 per external breast form per breast. DVA Gold Card holders (Otter: DBA) are eligible for whatever they like — as many breast forms as they like, as many bras as they like — providing it is signed off by a GP, or she can do it as a clinical nurse specialist at the Gold Coast Breast Centre. They will do all of the paperwork for the clients when it comes to the Medicare rebate forms.

What an appointment looks like: allow at least an hour for a breast-form fitting. Bring in clothes that you want to wear. See what a breast form looks like under the clothes. Match the form to their style. Completely secure room. Optional mirror — she wants people to go by how they feel first, as opposed to how they look. She will often have a cuppa with everyone, sit, explain the difference in forms, sip them first, meet them where they are at. What is their goal of the breast form today?

Some people, particularly in the sexual health space, who are struggling to find intimacy with a partner post breast cancer surgery, will often do different counselling sessions: it is okay to leave your bra on, have your external breast form in, utilise some olive oil (Otter: “olive and be”) and get to know your body again. Everyone’s needs are different in this space.

Mastectomy garments do not always look like surgical garments. Initially post surgery it is really important to have thicker straps, so that you have really good lymphatic flow, particularly post sentinel node biopsy (Otter: “center molybdenum biopsy”). You do not want underwire — none of her garments have underwire. You may want thicker sides depending on how the scar looks, or how comfortable a person is feeling with their body habitus — a woman post mastectomy will often notice a stomach she did not notice when she had breasts. Sit and listen. Match garments. If you do not have the right garment, it does not matter what breast form you have got — they are not going to sit well.

Initially, when someone gets a breast form, they are a certain weight. As treatment finishes and life settles — “when the snow globe’s been shook” — people can lose weight, but the remaining breast is not going to change size. People may not be able to wait. Whilst the rebate can occur every two years, people do not need to wait two years; it just means they cannot get the rebate if they replace sooner.

Location: Gold Coast Breast Centre, Ferry Road. Free parking. Free appointments. A really supportive environment to help people navigate life post breast cancer surgery. Floor question at the end was partly inaudible (Otter: “where city” / “which may be under”). She said she would not charge that into friction in place; you can get at the Gold Coast Breast Centre 100% rebate for some personals; they can fit for all benign conditions as well; some developments can also be included.

Appointments are free; the clinic does the Medicare paperwork. GP or CNS sign-off for DVA Gold Card. Not a sales-assistant experience.

Take-home messages for clinic

1. One in seven lifetime; about 50 women or men diagnosed daily. Early / small / stage-one disease does better. Otter said “approaching 300% survival” — that is garbled; do not quote a made-up survival percentage from this page.
2. Mammography remains the 35–40 year foundation of screening. Some centres have tomosynthesis. Both are still anatomic: mass, distortion, density. Tomosynthesis reduces overlap; it does not see function.
3. BI-RADS density A (fatty) to D (very dense). Not just a young-woman story — 70s and 80s can still be dense. C and D ≈ 40–45% of women.
4. Dual challenge: density hides small cancers and about 3–4× risk.
5. Functional imaging uses neovascularisation and leaky capillaries plus contrast. Queensland introducing CEM in a major way; originated more from WA. MRI still gold standard but access, cost, claustrophobia, prone position, and often no rebate.
6. CEM: iodinated CT-type contrast, then mammogram; dual-energy acquisition and subtraction → enhancing lesion. Cannot inject contrast on a standard machine. About 3–4 Gold Coast clinics with capability.
7. Cases: 71-year-old post-surgical stellar density, CEM no enhancement, ultrasound typical scar. 56-year-old nonspecific pain, busy breast, CEM found malignancy. CEM plus AI mentioned as a future step.
8. Sensitivity approaching MRI, mid-80s in good hands. Higher specificity than MRI — enhancing on CEM more likely worrying. MRI: gadolinium, kinetics/curves, fat-sat. Not everything that enhances is cancer (fibroadenomas; Otter said fibroid novas / thyroid norms).
9. His clinic: CEM no extra charge on top of the usual mammogram fee for diagnostic / high-risk (not population BreastScreen). Cannula + consent. Uptake ~8/10. Typically offer mammo + ultrasound from about 35–40. Extra detection about 4–5 cases per 1,000. He would like BreastScreen to use CEM routinely.
10. BreastScreen dense-breast reassurance: he had not been to BreastScreen recently; someone in the room said they are making improvements. He did not give a script for that conversation.
11. Sharon Douglas / Mind Body Bedroom at Gold Coast Breast Centre, Ferry Road: free appointments and parking. External forms in pocketed garments after mastectomy, after implant problems, lumpectomy partials, aqua, heat-withdrawing, air-pump, optional nipples. Silicon from 6 weeks; adhesive-on-skin not for 6 months. Also benign indications.
12. Medicare up to $400 per breast for external forms post breast-cancer surgery; rebate every 2 years, but people can replace sooner without rebate. DVA Gold Card more generous with GP or CNS sign-off. Clinic does the paperwork. Fitting ~1 hour, own clothes, secure room, optional mirror, cuppa, no underwire, thicker straps for lymphatics post sentinel node. Sexual health counselling; she mentioned olive oil. Not a David Jones change-room. Otter named the hospital Indira; Pindara is the likely local hospital, not asserted here as fact.

Dr Kotha · Gold Coast · breast-imaging.drkotha.com