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| DR. RACHEL BREM | |
 February 6, 2002  | |
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Dr. Rachel Brem is the director of Breast Imaging and Intervention at George Washington University Medical Center. The full transcript of her interview with Susan Dentzer follows. The NewsHour Health Unit is funded by a grant from The Henry J. Kaiser Family Foundation.
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SUSAN DENTZER: Let's start by talking, Dr. Brem, about your own experience. You're a breast cancer survivor. I know you don't like the word, but let's talk about what happened in your case. DR. RACHEL BREM: I feel very fortunate that I had the opportunity to have an early breast cancer diagnosed, and essentially a cure. And I think that we don't talk about individuals, but certainly I felt the impact of an individual who had the good fortune of having an early diagnosed breast cancer. For me it was an experience that I think is probably, was more straightforward and easier in the terms of having the experience and knowledge of how to deal with this kind of a diagnosis. But I think that any woman who has an early diagnosis of breast cancer is very fortunate in that the odds are still in her favor, that we can really talk about a cure. SUSAN DENTZER: Now, let's talk about the very unusual way you found your own breast cancer. What happened? DR. RACHEL BREM: Well, I mean it--I was just working with some equipment, and--and found the lesion. I don't usually talk about that. SUSAN DENTZER: But you found it yourself? DR. RACHEL BREM: Yeah, I found it myself. And was treated successfully, and it's--you know, it's been quite a number of years now. SUSAN DENTZER: In fact, how long ago was that? DR. RACHEL BREM: Almost six years. SUSAN DENTZER: You were a practicing radiologist then? DR. RACHEL BREM: I was a breast imager, that's right. SUSAN DENTZER: And are that now? DR. RACHEL BREM: That's correct. SUSAN DENTZER: What do you make of this current--the most recent incidence of this entire controversy over mammography? And now the current study is looking at mortality in general, death in general, not from breast cancer. But we're talking about an intervention that impacts mortality from breast cancer. It would be easy to see how, if there was an increase in mortality from a different cause, a different etiology, that that might negate the improvement in survival that woman have from breast cancer. I also think that it's very important to be extremely careful when analyzing data with statistics, because statistics are something that can prove diametrically opposite things depending on how it's presented and how it's analyzed. So I think that with the numerous studies that have shown definitive improvement in survival in women who have mammographic screening, it would be a shame to take that data, have it reanalyzed and come up with the conclusion that mammographic screening does not reduce mortality from breast cancer. SUSAN DENTZER: Olsen and Gotzsche, the two Danish researchers who did the meta-analysis, took a lot of the studies, as you said, and lumped them together, but they didn't take all of them. They threw out a lot of studies that they said were not good. DR. RACHEL BREM: Right. SUSAN DENTZER: Looking at what you know about those studies, did they leave the right ones in; did they take the wrong ones out? DR. RACHEL BREM: That's a very good point. I think if one is going to analyze all the available studies, one should include all the studies. There are laws in design in all the studies. It's a huge population base study. Each and every one of them is. And therefore, it would be impossible to have a perfect design. However, to throw out data and to negate--negate problems in design with some of the studies that were included is really not a strict and accurate way to analyze the data. SUSAN DENTZER: Let's take one of the studies that they actually left in, that they said this is an okay study, to reason forward from it, this Canadian study. DR. RACHEL BREM: Right. SUSAN DENTZER: What was wrong with that study and what was right with that study in your opinion? DR. RACHEL BREM: There were a number--first of all, I think what was right with that study was the effort. I think it's very laudable that people, that the designer--that the people who designed this study wanted to ask a very important question, and that is: what is the impact on mortality from breast cancer with mammographic screening? The problem is that there were statistical problems with the study. There were women included in a screening trial that had a palpable mass. Anyone with a palpable mass is not a candidate for a screening mammogram. They needed diagnostic mammograms. That was clearly a criteria for exclusion from the study. It was not a population-based--it was not a community-based study and-- SUSAN DENTZER: Which means? Explain what that means. DR. RACHEL BREM: Well, it looks at certain segments of the population instead of the entire population. It may look at women who are at high risk of developing breast cancer, or at community--or at hospitals, or in very rural areas, which is where much of the Canadian study was done. And the other problem with the Canadian study is the quality of the mammograms, and in fact, the "Lancet" article discusses many of these problems with the Canadian study and simply negates it. They negate the fact that women have palpable masses. It's discussed they negate the fact that this was not a community-based study, and they discuss the fact that the quality of the mammograms was suboptimal and simply negate the implication for the findings of that trial. SUSAN DENTZER: So they say, in effect, "Yes, we know this study is flawed, but it actually really wasn't all that flawed, and it was still better than all the other ones so we're going to use it." | |||||||||||||||||||
| The Malmo study | ||||||||||||||||||||
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SUSAN DENTZER: The other study that they said was okay to include, not perfect, was the--one of the Swedish studies known as the Malmo Study. DR. RACHEL BREM: Correct. SUSAN DENTZER: In your view, was that appropriate to do? DR. RACHEL BREM: Yes, I think the Malmo Study is one of the better screening trials, and I think the Swedish studies--there are three Swedish studies looking at screenings. And I think that the analysis of the Swedish screening trials has shown definitive improvement in mor--in survival and decreased mortality from breast cancer as a result of mammographic screening. SUSAN DENTZER: Is it useful to have done this exercise that the Danish researchers engaged in? DR. RACHEL BREM: I think it's a dangerous exercise. What they've done is they've--resulted in enormous amount of confusion on the part of patients. I think that women are really unsure as to what to do. They are no longer convinced of the efficacy of mammography, that those of--many of us who are in this field are convinced of and have repeatedly both seen the data and seen individual cases which have been impacted as a result of mammographic screening. So I think the exercise is a very dangerous exercise, that the conclusion is extremely questionable at best. There are numerous studies that directly contradict the results of a re-analysis of old data, and I think that it is not a service to the medical community. I think it's--it's a disservice to the community and to women in general. SUSAN DENTZER: Is it--is it at all useful to do, as you just said, a re-analysis of old data, or should we be doing new analyses with new technology and so on to really get a grasp--a grip on this issue? DR. RACHEL BREM: Well, optimally, the best thing to do would be to do a perfectly designed study with the newest technology. And it's important to realize that the mammography today only vaguely resembles the mammography of the 1960s and '70s. And so our ability to diagnose and to visualize cancers is very different than it was in some of the studies that were included in the Danish study that was recently published in "Lancet." I think that it would be, obviously, optimal to do the perfect study with the current technology and with a well-designed study. However, it's extremely expensive, extremely difficult because it takes a large population of women over a long period of time to demonstrate the impact of any screening intervention. SUSAN DENTZER: And some people have a grasp of the obvious, which is that mammography, having become the standard of care, you couldn't possibly now conduct a trial which you randomly-- DR. RACHEL BREM: Right. SUSAN DENTZER: --didn't give half the women in the trial mammograms. DR. RACHEL BREM: Right. I think it's important to look at the survival curves of women from breast cancer and the utilization of mammography, and as mammography has increased in the United States, the mortality from breast cancer has clearly decreased, and there is no doubt that there is an impact and an implication from increased utilization of mammography and decreased mortality from breast cancer. And it's very important for people to realize that the study that was presented discusses overall mortality, overall death, not death from breast cancer. When you're looking at an intervention, it has to be an intervention that impacts what you're looking at and not overall with regard to everything. SUSAN DENTZER: So you're saying they're essentially raising the wrong standard to judge the effectiveness of mammographic screening by? DR. RACHEL BREM: They're looking at the wrong outcome. If you're looking at mammographic screening, then you have to look at mortality from breast cancer or the impact of mammographic screening and breast cancer survival, not on survival in general. SUSAN DENTZER: And let's just say a word about why they said total mortality is the better end point to look at. SUSAN DENTZER: Weren't they also raising the specter that in some cases treatment would lead directly to mortality, would somehow aggravate mortality? There is no data to support the fact that the treatment of breast cancer results in a significant number of additional cancers which would negate the improved survival from mammographic screening? SUSAN DENTZER: And what about data to suggest that treatment of breast cancer could effectively lead to mortality itself as opposed to the death from the actual breast cancer itself? DR. RACHEL BREM: Again, there's no data to support the fact that--that treatment from breast cancer, with the exception of some extreme interventions for extremely advanced breast cancer, which are not curable, there is no increased incidence of mortality from chemotherapy or other interventions in early-stage breast cancer. SUSAN DENTZER: What about your patients who have been coming in the last several weeks? The New York Times--this most recent "Lancet" study was published in October. The New York Times picked this up and made an issue of it in December. DR. RACHEL BREM: Right. SUSAN DENTZER: From that point forward, have people been coming in with a different attitude about mammography? Have you seen any sign that things have changed? DR. RACHEL BREM: No. We have not seen--women have not been asking me. Patients have not been asking me about the efficacy of mammography or the importance of mammographic screening. But I think it's a self-selection process. The women who are here are believers, if you will, and the question is, what's happening to all those other confused women at home, the ones who don't--who are truly questioning what the impact of mammography is and what the importance of mammography is on coming to the breast center for their mammograms or might not be coming to the breast center as readily as they had before. |
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| The shortcomings of mammography | ||||||||||||||||||||
| SUSAN DENTZER: Everyone agrees apparently that mammography is not a perfect tool. Let's talk about that. Do you in fact share that view? Would you say that in effect, that it's not perfect? DR. RACHEL BREM: Absolutely. Mammography is not a perfect tool but it's the best tool we have, and the intervention of mammographic screening results in decreased mortality from breast cancer. So it is an effective tool, but it is an imperfect tool. SUSAN DENTZER: And if I said to you, "Okay, you're the mammography czar, you get to make it a perfect tool." What would--what would it--how would it be different? DR. RACHEL BREM: Well, it would be different in that every breast cancer would be diagnosed with a mammogram, and we know that 10 to 15 percent of breast cancers are not identifiable, visualized with mammography. So they are clearly a subset of breast cancers that we don't see with mammography. We're developing newer technologies to help improve our diagnostic capabilities with mammography, as well as numerous adjunct modalities, including ultrasound, digital mammography, computer-aided detection, MRI, nuclear medicine imaging, a huge gamut of other approaches towards improving breast cancer diagnosis. However, even though mammography is an imperfect examination, it remains a very powerful examination for the early diagnosis of breast cancer. And, obviously, the perfect examination would allow for diagnosis of every early breast cancer. In fact, it would be better if we could diagnosis abnormal cells before they become cancerous, when they first become abnormal. There are molecular approaches to that. Clearly, there's research being investigated, approaches that are being investigated to achieve exactly that. Let's see if we can find the cells before they become malignant, before they have the potential to metastasize and kill. But right now, in this year, this is the best we have. And it's important to remember that it is very effective. Imperfect, yes, but very effective. SUSAN DENTZER: And in addition to the false negative rates, we have the problem of false positive rates. How big a problem is that in your view as a radiologist? DR. RACHEL BREM: That's a very significant problem, and we know that only about 20 to 25 percent or up to 30 percent of breast biopsies for findings that are suspicious enough to biopsy result in a diagnosis of malignancy. And so the vast majority of biopsies are done for suspicious findings that fortunately turn out to be not malignant. As a result of that, understanding this problem, we have had a paradigm shift in treatment or--I'm sorry--we have had a paradigm shift in biopsy of breast cancer. In the previous decade women would go to the operating room and have a surgical procedure with full anesthesia. Now a breast biopsy is a procedure that's done with image guidance, it takes about 20 minutes. There is no preparation. There's no sutures, no stitches. It's, you know, scarlessly. And so we've really moved it to a minimally invasive approach to breast cancer diagnosis. Probably, the best would be if we could differentiate the non from malignant findings without biopsy. SUSAN DENTZER: So the fact that we've been able to move to these more advanced forms of biopsy that are less invasive--I think everything is invasive at a certain level--is essentially reducing that part of the problem, that false positive part of the problem? DR. RACHEL BREM: No, it hasn't reduced the false positive--false positive problem, but what it's done is it's made the consequence of the high false positives a less invasive procedure. And there's enormous amount of work being done to try to differentiate the non from malignant lesions on a number of levels. One is computer analysis of mammograms. Is there something different about calcifications which are benign and calcifications which are malignant? Calcifications can be one of the signs of early breast cancer. The vast majority of calcifications are benign, but some of them are the indication of an early breast cancer. And so is there something that a computer can objectively analyze that we can't as humans and tell us, well, these are benign and these are malignant? And so there's work being done on that. We're not there yet, but there's certainly significant amount of movement forward in that regard. Even with MRI with nuclear medicine imaging, here we see something on the mammogram. Can we differentiate whether it's benign or malignant with other technologies? And so this is the approach that is being taken. And clearly there are other approaches which is to try to prevent breast cancer. We're on the threshold of that with tamoxifen. We know that women who are at high risk for breast cancer, who take tamoxifen as a prophylactic approach have a significant reduction in the incidence of breast cancer. Can we move forward and achieve 100 percent prophylaxis? Well, obviously that would be optimal, but we're not there yet. SUSAN DENTZER: One of observations made by Richard Horton, who's the editor of the "Lancet", in his most recent commentary, is that women have far too high expectations of mammography. Do you think that's true? DR. RACHEL BREM: That's probably true. I think women who have a mammogram and walk out of here with a normal report feel that they should be guaranteed, or many of them feel that they should be guaranteed that they don't have breast cancer. And what they need to understand is, yes, they don't have breast cancer to the best of our ability to obtain that information from a mammogram, but just because a woman has a normal mammogram does not assure, it's not a guarantee that they do not have breast cancer. It's overwhelmingly likely that they don't have breast cancer, but it's not a guarantee. Well, I think a woman should be diligent about having her screening mammograph examination, but not negate anything that she might feel that's different, and I think it's very important for women to do monthly self-examination as well, because that way they'll know their own bodies, and if there is a change which is one of the signs of cancer, they should seek medical attention. And women should also know that every change is not cancer, that the vast majority of findings that they'll feel with their monthly self-examination is generally a benign finding. |
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| Analyzing a mammogram | ||||||||||||||||||||
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SUSAN DENTZER: Now, let's talk a bit about what one actually sees on a mammogram film, let's actually start up here with this one. What are we actually looking at? What view are we looking at? What are we seeing? And what we see here is a woman who has predominantly breast--fatty breast tissue. These are mammograms which are relatively easy to interpret. And here you can see normal--this white patchy area is normal breast tissue. On the other side she's got some white patchy area, but here you begin to see a subtle star-burst appearance to this area of the breast. When you look at the other view, that is, the view where the x-ray tube is from above, again you see the scattered normal white glandular tissues, and here again, alongside of the normal breast tissues, you see what we call a spiculated mass, again the star-burst appearance of this small breast cancer. SUSAN DENTZER: And when you saw this--because I presume you read this-- DR. RACHEL BREM: Right. SUSAN DENTZER: What did you say? And at the time of her diagnostic examination, we saw a--we confirmed the presence of the spiculated mass, and then we went on to recommend a minimally invasive biopsy, which showed invasive ductal carcinoma. She had negative nodes. This is an early breast cancer. SUSAN DENTZER: And negative nodes in this case means it had not spread to any lymph nodes. DR. RACHEL BREM: That's correct, that's correct, and her prognosis is excellent. SUSAN DENTZER: But this was in effect an early cancer in the ducts of the breast. DR. RACHEL BREM: That's right, an invasive ductal carcinoma, the most common kind of breast cancer. And again, even when we knew where it was, it was not something that she could feel. It was not something that we could feel. It was something that could only be detected on the mammogram. So this was the--this additional view that was obtained after the patient came back for her diagnostic mammogram, confirmed the presence of this star-burst mass, which was an invasive ductal carcinoma. SUSAN DENTZER: Now, is this a type of cancer that could have been picked up, say, with the screening technology of 15 or 20 years ago, or is this something that can be picked up only today as a consequence of the advances in the technology? DR. RACHEL BREM: It's hard for me to say for sure, but clearly we see it better with the technology that we have today. SUSAN DENTZER: Now, in the case of this woman, if she had not had this screening exam, what would have been the likely progression of this cancer, and when is it likely she would have picked it up? DR. RACHEL BREM: It may have been years. It's really unclear. It depends on what the--what the biology of the tumor itself is, how fast is it replicating, how fast is it growing? But it may not have been years until she felt it, or it may have been a month. It's really very hard to predict. SUSAN DENTZER: But in any case, it's safe to assume that it would have been later? DR. RACHEL BREM: Oh, it was later. I mean she came in for a--a screening examination, and in fact, even knowing where it was, it was not something that we could feel. SUSAN DENTZER: Let's look at some of these other films. DR. RACHEL BREM: One of the things to appreciate with this examination is how light the breast is, how different it is from the breast that we looked at before, which was predominantly fat and somewhat easier to interpret. And here, even with this very white breast, which hinders, which decreases the sensitivity of mammography, makes it more difficult to identify breast cancers, we can still, in this very breast--very dense breast, see a very small breast cancer. SUSAN DENTZER: And again, with--this is one where we don't know what the course would have been. We don't know if the patient ever would have felt anything. DR. RACHEL BREM: That's correct. We know that a third of ductal carcinoma in situ go on to become the invasive form of the disease, the form that has the potential to spread to the nodes and metastasize. But we don't know which third will go on to become an invasive cancer, and therefore it's important, it's critical to treat each and every one as if it has the potential to become that invasive form of the disease so that we can essentially achieve a cure in this type of--in ductal carcinoma in situ. SUSAN DENTZER: And what happened in the case of this patient? DR. RACHEL BREM: This patient had a lumpectomy and radiation therapy, and is doing fine. SUSAN DENTZER: And what are the likely odds that she'll have a recurrence? DR. RACHEL BREM: Oh, a recurrence? It's virtually 100 percent cure rate. There is a small chance of recurrence in a woman who's had a lumpectomy. I don't know that we should really get into that. I mean if you want me to, I'll be happy to. SUSAN DENTZER: Just all I really want to do is get an overall sense of-- DR. RACHEL BREM: Right. I mean her survival--her prognosis is excellent, virtually 100 percent. In woman who have a lumpectomy as opposed to a mastectomy, there's always a small, 1 percent per year chance of a recurrence, but we know that lumpectomy and mastectomy are equivalent in terms of survival, in that women who have a recurrence go on to have a mastectomy subsequently and have no difference in survival. SUSAN DENTZER: What do you think--these women obviously aren't here to tell us how they feel, but in general I'm sure over the years you've spoken with patients who have been in exactly the same shoes as these women. What do they think about mammography? DR. RACHEL BREM: It's a very interesting question actually, and it's something that never ceases to amaze me. When a woman has a diagnosis of breast cancer, the reaction runs the gamut from being very fortunate to having an early cancer diagnosed to, you know, feeling extraordinarily victimized, you know, "why me?" And I think the latter type of woman sort of doesn't think about what the impact of mammography is, just sort of dealing with the very difficult issue of having their own breast cancer. But I think the women who do think about it in a global sense or in the sense of how this examination impacted them, they feel fortunate, if you will, that it was diagnosed early in a curable form. SUSAN DENTZER: So they say, in effect, "Thank God. Thank God the screening picked it up." DR. RACHEL BREM: May women do. Many women do. There's one other cancer here, again, very much a microcalcification in a fattier breast, and here you can see a somewhat larger, more extensive cancer. Again, a very early breast cancer, but it's these white dots in a line distribution which is the mammographic sign of an early breast cancer, ductal carcinoma in situ again. Here you can see white dots in a configuration of a line, and what you're actually seeing is the microcalcification in the duct system of the breast, that are actually branching, which is why it looks like a "Y." And this is again a sign of an early breast cancer or ductal carcinoma in situ. So this is a very small cluster of what we call pleiomorphic microcalcifications. They're suspicious microcalcifications in that they're different in size and shape, and they're tightly clustered, and you can see that there isn't any other evidence of white dots or microcalcifications in the vicinity. So this is a cluster of suspicious microcalcifications which on minimally-invasive biopsy was found to be ductal carcinoma in situ. These red lines. I'm sorry. This is again a very dense breast, which decreases the sensitivity of mammography, and yet even in this very dense breast, you can see a very small cluster of suspicious pleiomorphic microcalcifications, which on biopsy was found to be the earliest form of breast cancer, ductal carcinoma in situ. SUSAN DENTZER: Your analysis here is bringing out an important point, which is that women could have the best screening technology in the world, but a key part of this use of the technology is the analysis by trained professionals such as yourself. How much has that been a factor in any of the disputes over the effectiveness of mammography in your view? How much are we talking about that's obviously--as you suggested earlier, was the case in the Canadian study? DR. RACHEL BREM: Right. DR. RACHEL BREM: Much of the Canadian study was done in rural parts of Canada, and interpreted by physicians, radiologists who are not specifically trained in mammography. And I think that training in mammography is critical for the proper interpretation, the proper analysis of the mammogram. And I think it's an important thing for women to consider when they decide where they're going for their mammogram. There are places that do everything and there are places that do mammography. Like anything else, the more you do of something the better you are at it, and that's true of mammographic interpretation as well in general. | ||||||||||||||||||||
| Practices in other countries | ||||||||||||||||||||
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SUSAN DENTZER: And finally, I just want to talk about your experience in Poland, because you had said you had gone over recently and seen sort of the evidence of what happens in the situation where screening mammography is not the standard of care. DR. RACHEL BREM: Correct. SUSAN DENTZER: What did you see when you were there? DR. RACHEL BREM: Well, what happens, not infrequently in many emerging countries, is that women present with breast cancer when they have a huge mass in their breast. Oftentimes it's fungating, it's open, it's bleeding, it's really a stage of breast cancer that we rarely see here in the United States. These women require extensive surgery, often with skin graft. It requires--they're often sent away for weeks to recuperate, and it's a very different approach than the same-day surgery that we have here, where women come in and go home within hours of their definitive breast cancer surgery. So I think one of the other implications of not having mammograms and diagnosing later breast cancer, is the more extensive surgical procedure that that will require. SUSAN DENTZER: Do you think it's at all conceivable that we're in danger of falling back to that era, or do you think that screening has so much become the standard of care that that's not an issue? DR. RACHEL BREM: Well, I think many women have screening mammography as part of their annual physical examination, and are well indoctrinated in its importance and continue to have that. But I think if the media continues to bombard women about the questions of the efficacy of mammography, clearly women will begin to question it. We know that the media was an incredibly important advocate for improved mammographic screening compliance, and it can do just the opposite as well. When women pick up every magazine every month and see an article about the importance of screening it will--it will entice them or inspire them to come for their mammogram. On the contrary, if women pick up the media and see that they are being bombarded with the ineffectiveness of mammography, then with time I think it will have an impact to our detriment. SUSAN DENTZER: Side effects. How many women, in your experience, are concerned about radiation, and are worried about mammograms because of that issue? DR. RACHEL BREM: I think there is quite a number of women who worry about mammograms as a result of the radiation exposure, but women get more radiation exposure flying across the country than they do in a mammogram simply by virtue of the fact that they are closer to the ozone layer. And so we have come to a level of sophistication with our equipment and federal regulation that requires us to have the most minimal of dose for a mammographic examination. In fact, in most states it does not require a leaded wall. Simply sheetrock is sufficient for the radiation which is generated during a mammograph examination. So that--that speaks volumes. In any other radiographic examination you're required to have leaded walls. Not so with mammography in most states. | ||||||||||||||||||||
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DR.
RACHEL BREM: I think that it's--it's such a shame that after all the strides forward
that we've taken, we're now moving backwards with the re-analysis of the data.
And it's very important to realize that there is no new data in this analysis.
It's simply a reevaluation of previous data that had definitively shown an improved
survival from breast cancer in women, who had mammographic screening, who had
early diagnosis.
DR.
RACHEL BREM: Well, they're saying more than that. They're saying, "Yes, we
know that's flawed, but we're going to--we're going to ignore the fact that it's
flawed instead of dealing with what the impact of the flaws in the study might
have on--on the findings.
DR.
RACHEL BREM: Because when one is looking at survival, one is looking at overall
mortality as they presented. However, it's easy to see how another cause of death
could negate the impact of mammography. That is, if there's an increase in death
from a different disease or another system, organ system, then that would negate
the very significant and very real impact of decreased mortality from breast cancer
with mammographic screening.
DR.
RACHEL BREM: So this is actually a screening examination. This was a woman who
came in for her annual examination, who had no signs or symptoms of breast cancer.
And this is two views. A mammogram is two views of each breast, one where the
x-ray tube is from above, and that's what this view is; and one is when the x-ray
tube is from the side, and that's this view.
DR.
RACHEL BREM: Well, she's not here. So we actually called her and asked her to
come back for additional evaluation which is what we see here. This film was taken
several days later. And a screening examination is generally an examination where
the woman comes in for two views of each breast, and she doesn't stay for her
results, unlike a diagnostic examination, where she will get her results at the
end of the examination.
And
here between these red marks--and again, in a magnification view, you can see
these very small white specks, which is what we call microcalcification, and these
are specifically the microcalcifications as we discussed earlier. The vast majority
of microcalcifications are benign, but this is a suspicious cluster of microcalcification,
which was again biopsied with a minimally-invasive technique, turned out to be
a focus of ductal carcinoma in situ, the earliest form of breast cancer.