|DR. SHAWNA WILLEY|
February 6, 2002
Dr. Shawna Willey is the chief breast surgeon 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.
SUSAN DENTZER: We're looking at a mammogram here I gather. What are we actually seeing?
DR. SHAWNA WILLEY: Well, this is a series of films that would have been brought in by a patient for a new patient consultation, and the standard mammogram is a four-view mammogram, and the appropriate labeling with left and right. And this is the view called the CC view where the breast is compressed flat on the plate. And this is the view when the arm is up and the breast is compressed.
So that this is a bit of muscle that you see, the pectoralis muscle. This is all breast tissue, and the breast tissue is interlaced with fatty tissue so that you get this nice lacy appearance. And the nipple is here. You can just see the muscle stripe in the back.
These are some variations of that view to evaluate some of the obvious abnormalities on this mammogram, which this is one of these. This patient also has some calcifications that happen to be vascular calcifications, which are not worrisome.
SUSAN DENTZER: Which means what?
DR. SHAWNA WILLEY: Calcifications are calcium deposits, in this case that are deposited in the blood vessel, and that can happen commonly in the breast and is not a cause for concern necessarily.
SUSAN DENTZER: They're not in the milk ducts?
DR. SHAWNA WILLEY: Those are not. Calcifications many times are in the milk ducts, and that's one of the things that we look at, is the character and the shape, the distribution of the calcifications to see whether we can say those calcifications, indeterminate or malignant appearing.
SUSAN DENTZER: So you said a moment ago this lacy effect is created by--it's fat tissue--
DR. SHAWNA WILLEY: Interlaced with the breast tissue. The breast tissue shows up as whiter tissue. So in this instance you see that there's a whiter area of tissue underneath the nipple, and that's certainly an area that has a higher concentration of breast tissue.
SUSAN DENTZER: And breast tissue as distinct from fat?
DR. SHAWNA WILLEY: Fat. Fat shows up dark on a mammogram.
SUSAN DENTZER: Okay.
DR. SHAWNA WILLEY: So in this case this layer here--under the skin in a breast, there's a layer of fat, and then there's the breast tissue which is interlaced with fat. In this instance you can see a skin line and you can see a darker area, and that's the fatty layer of the breast. And then this is the actual glandular breast tissue.
SUSAN DENTZER: Which is milk ducts and--
DR. SHAWNA WILLEY: Milk ducts and lobules which are the milk producing units of the breast. Milk is--breasts, first of all, are made to produce milk. Lobules produce the milk. The ducts drain the milk onto the surface of the nipple. That's why you have more breast tissue underneath the nipple because that's where it all converges to exit onto the several milk ducts that are present on the [inaudible] of the nipple.
SUSAN DENTZER: So you or anybody, a radiologist looking at this, the first thing you are looking for, as you're examining a mammogram, is you want to look for, as you said, obvious areas of that could potentially be malignancies, and you pointed to that one earlier.
DR. SHAWNA WILLEY: There's an obvious white spot. We call it a density. And, yes, that's an obvious abnormality that would need to be worked up, which indeed it was in several ways, because the possibilities exist that this could be a lymph node, which is common in breast tissue. This could be a malignancy. And this could be a cyst. This could be--even something on the skin could have an appearance like this. So you have to really evaluate that further, and you can do that mammographically, you can do that sonographically. Certainly you do that with physical exam.
Ultimately this lesion may need to be biopsied, which could be done either with surgery or with a needle biopsy.
SUSAN DENTZER: So in effect this mammogram just flags areas that you want to pay more attention to.
DR. SHAWNA WILLEY: Absolutely. In a mammogram that starts off as normal appearing from this distance, you look for many different things. You want to look at the breast pattern. You want to look for calcifications. You want to look at the symmetry between the two sides. You want to look at quality control. You want to make sure that there's enough breast tissue on the film so that you are imaging most of the breast tissue. You want to make sure that the entire breast is on the film. Some people have very large breasts and--and you might need to do two mammograms of that breast for that view.
When you're reading mammograms to--for diagnosis, most radiologists sit in a dark room, have a bright light that they can look at with this mammogram, and also have magnifying glasses. They have special magnifying devices so that they can look at the big picture as they step back, but also look at all these fine details of these calcifications to see if there's anything there that they would identify as possibly being a malignancy.
SUSAN DENTZER: In this particular set of mammograms, are there other things that immediately jump out as areas that need further exploration?
DR. SHAWNA WILLEY: Well, as I mentioned, these calcifications, if I was--if I was working this patient up, I would want to magnify possibly some of these areas of calcifications, and that's--I can magnify it with a magnifying glass that I use with my eyes, but that can also be done with a mammographic technique so that those calcifications are kind of isolated, so you're not asking to see the whole breast, you're asking to see a specific spot, and it's what we call a spot magnification.
So that specific spot is compressed a little bit more so that we can see more fine detail, and also it's magnified so that you can--you can really see what shape those calcifications are in.
SUSAN DENTZER: And what would that tell you, a certain shape versus another?
DR. SHAWNA WILLEY: Well, there's a shape of calcifications that will--that we would say are typical of cancerous calcifications. We use the term pleiomorphic or lineal or branching calcifications. Those are the kinds of calcifications you might see that are within the ducts themselves that would have the shape of the duct itself.
There are sometimes calcifications that we see that we call rounded or punctate. Those kind of put this--this more into a benign category, and those tend to be calcifications that are in little tiny cysts or in fluid in the breast.
In this case we look at these, and we can say that those are vascular calcifications, and we don't really feel the need to work those up further.
If there's a question about the calcifications, however, if they are indeterminate, which is a broad category, or certainly if they're malignant appearing, those calcifications should be biopsied.
SUSAN DENTZER: And we--I think we mentioned this earlier, but just to make sure we have this on the record--calcification is actually what?
DR. SHAWNA WILLEY: Calcification is a calcium deposit. They can be--calcium can be deposited for many reasons, but the reason that we look at is they can be a sign of rapidly-dividing cells, and of course, cancer is rapidly-dividing cells, and so that's one of the things that we're looking for, is kind of a byproduct of that rapid division.
And there's many, many reasons for calcifications, and the vast majority are benign.
SUSAN DENTZER: And is this calcium as in related to the production of milk, or is it independent of the fact that milk is produced?
DR. SHAWNA WILLEY: Well, some of it is related to what we call milk with calcium, which is the kind of calcium that's in fluid in the cysts. But the calcifications that are associated with malignancy tend not to be associated with fluid or with milk. They tend to be associated with solid tissue and the ductal tissue.
SUSAN DENTZER: Another condition we hear a great deal about is ductal carcinoma in situ, DCIS. How would that manifest itself on a mammogram?
DR. SHAWNA WILLEY: That commonly is seen on a mammogram with calcifications, and it could be a tiny little spot of calcifications. It could be an area where there's a very diffuse distribution of calcifications, often in what we call a ductal distribution so that you see a segment that you could imagine is the tubular system leading up to the nipple itself.
Most commonly, we see a small cluster, or desirous to see small cluster of calcifications without this whole diffuse area of calcifications. You can see denser areas that wouldn't look necessarily like this, but you can see denser areas that can be ductal carcinoma in situ. Often, however, there are still calcifications associated with that dense area or that whiter area.
SUSAN DENTZER: And to define DCIS, what is it actually?
DR. SHAWNA WILLEY: Ductal carcinoma in situ is the presence of cancer cells that are confined within the duct on a microscopic level. So these are cells that have undergone malignant transformation but have not yet spread outside of the duct, so that they're still contained within the duct. A synonymous term would be "non-invasive cancer." And these are the kinds of--or the kind of malignancy that is what we would term early stage. Some people would even argue that we shouldn't call ductal carcinoma in situ a malignancy.
But nonetheless, we do know that in a percentage of cases that can proceed to invasive carcinoma, which is the type of cancer that we classically think of as breast cancer, and as the kind that can spread outside of the breast.
SUSAN DENTZER: Now, in terms of what we are seeing here in these mammograms--these are obviously new mammograms--and most of the current controversy pertains to studies of--older studies with older technology. Would we be talking about images that led people 10 and 15, 20 years ago, to do different things or see different things because the technology was inferior, because this image was inferior? I mean how different is what we're looking at today versus all of the mammography that is essentially under review in these studies?
DR. SHAWNA WILLEY: Well, mammograms--first of all, these are film screen mammograms which are very different than an older technique called a zero mammogram. Our technique now is that we get much more fine detail, and we see much more on a mammogram now than we did even 6, 8, 10 years ago.
Every time a new machine is bought by a mammography unit, you get better quality films. And of course that improves our detection of any abnormality. It may also increase the number of findings that we have to follow up or we have to biopsy or that patients worry about. But certainly our detection is better with the better techniques. And this clearly is different than films that were done 10 years ago or 15 years ago. If I had a patient that I had followed for 15 years, if I had her chart in front of me, you could see the progression and difference in the quality of the mammography.
You also have to realize, however, that as a woman ages, her breast quality changes. The degree of fatty tissue in the breast versus the breast tissue changes, so you do get some changes that are age related.
SUSAN DENTZER: And what does that--what does that do in terms of making a mammogram easier to read versus harder to read?
DR. SHAWNA WILLEY: If you have a patient who has a more fatty breast, more contrast, your detection is easier. So a fatty breast is much easier to see the fine detail. Like I say the difference is if you're trying--if you're in a forest and you're trying to see a shadow. You need contrast. And that's what we're looking for is contrast. If you have the dark of the fat to contrast against the white of the breast tissue, your detection rate is better. This area in this breast tends to be more dense. It's whiter. There's a higher concentration of breast tissue there, whereas on this side we get a little more the lacy appearance. And this--this breast is not quite as dense.
SUSAN DENTZER: And do breasts on the whole get fattier or less fat as women age?
DR. SHAWNA WILLEY: As women age, they tend to get fattier, although that can certainly be influenced by many factors, probably the most significant of which is their hormonal status, whether they're menopausal, whether they're on hormone replacement therapy.
SUSAN DENTZER: So on the whole does that make on balance a mammogram easier to read as a woman ages versus not?
DR. SHAWNA WILLEY: Yes, it does. And that's part of the reason that mammograms in young women, other than the fact that breast cancer in younger women is not as common, but younger women have denser breast tissue, and it goes back to that whole contrast issue. You have to have a contrast between what you're looking for and the normal. And if there's no difference in the density of those tissues, you won't be able to detect a malignancy if it's there.
And that's why young women's mammogram are so challenging because their tissue is quite dense.
SUSAN DENTZER: Over the course of your career, if you could contrast for me what a mammogram used to look like and how useful a tool it was to you as a surgeon versus today, how different is it?
DR. SHAWNA WILLEY: Well, for me--I have been in practice 20 years, and when I first started in practice we were still getting some patients come in with zero mammograms, which were--I don't know if you've ever seen one, but they are on photographic paper rather than on an actual film.
We could see many things then. I mean, mammography even then was testing things that were cancer. But over the years has been improvement in the quality and--and I would say, to play both sides of that, that's beneficial because I think we're detecting more things that--that might have been missed in the past.
On the other side of that is we see things now that perhaps were there 3 or 4 or 5 years ago, but because we seen them better now, comparing the new films to the old films becomes an issue. And is there really a change?
If we have something that's been stable for 5 years and it absolutely has not changed, we can tell that patient with good certainty or pretty good certainty that she doesn't have a malignancy in that area, whereas if now she comes in and somebody sees a cluster of calcifications, and this is the first time she's heard about it, and when we go back and retrieve our old films and we look at our old films, we say, "Well, you know, these were probably there before." There's a level of anxiety that's been raised as to, "Well, why didn't they tell me about it before and why--what are we going to do about it now?"
So the comparison between newer and older mammograms may be difficult, but that's still a very valuable tool, to really see if something is changing.
SUSAN DENTZER: As some have said, you know, you look at this image and you see all kinds of things, and it may set off too many alarm bells. We may end up exploring too many things that don't really need attention. Is that the case?
DR. SHAWNA WILLEY: Well, I think there certainly are situations where we do biopsies on women that with probably an 80 to 90 percent certainty have something that is benign. I think there's a lot of issue here though as to what women want and how much of a guarantee they need or want.
And I would say that in our country women are very aware of breast cancer, and they are very aware that they don't want a diagnosis of breast cancer missed. Mammography certainly will help you make a diagnosis of breast cancer. The question is: at what cost and at what risk to the patient? Are they going to go through a lot of needless procedures? Are they going to go through a lot of anxiety?
I would say, judging from my experience with my patients, that most patients err on the side of being aggressive about following up a mammographic abnormality, for instance. There's many times when I can say to them, just like these vascular calcifications, "This is absolutely okay. You don't need to worry about that."
But if there is something there that I think is okay but I can't guarantee it, then those are--those are the situations where we may be doing biopsies that likely would be okay, likely could have a follow-up visit, but patients need a guarantee that it's okay.
So there may be a certain number of procedures that because we are doing screening mammography, we are doing biopsies of benign lesions that might need to be done, but the question is: who defines whether it needs to be done?
As I always tell my patients, "If you know it's benign to begin with, of course you don't need to do a biopsy, but if you don't know what it is, the only way to find out is to do a biopsy."
|Statistics and patients|
SUSAN DENTZER: Let's start actually with that anecdote. Who was this patient who you had this conversation with?
DR. SHAWNA WILLEY: Okay. I was seeing a patient yesterday, and she is a recent breast cancer diagnosis. She just finished her radiation therapy. She had had breast-conserving surgery and a sentinel node mapping. And she asked me about the whole mammography concern controversy. And my comment to her was that there still seems to be value of mammography, and I pointed her out as an example because she had a rather large breast cancer. It was about a 2 centimeter breast cancer that she had not felt, her physician had not felt, and I could feel only in retrospect of knowing where it was on the mammogram. So we've treated her, and she obviously is doing well at this point.
But her issue was that she was--she was quite annoyed with all this controversy because she said that they're looking at the wrong end point. She says, "I don't care about survival. I just want to live now. I don't--I don't care about what's going down the road. I don't care about the statistics. This worked for me."
And this is what I always tell patients, is statistics fall apart when you apply them to an individual. So if you have a patient who mammography worked for, they're big advocates of it.
There's the other patients who had a malignancy that didn't show up in mammography. They often feel betrayed by mammography. They feel that it doesn't work. And of course there's women that have malignancies that have never shown up on a mammogram, and that's a limitation of mammography.
So I think it's really important that we educate women that mammography is not 100 percent. It's simply another tool that we add to trying to detect this disease.
SUSAN DENTZER: So this one particular patient would have argued that the appropriate end point is, does it catch anything ever, and get you into treatment sooner and improve your quality of life regardless of what your eventual outcome is going to be.
DR. SHAWNA WILLEY: That's exactly right. Her point was that without that mammogram identifying that malignancy, she doesn't know when she would have been diagnosed. She doesn't know when it would have become palpable so that somebody noticed it, either her or her physician. And--and so she doesn't know what was in the future for her. She doesn't know how long that would have sat there, whether it would have metastasized.
We know in her, her nodes are negative, and I think that's an important thing. We know that if we can catch breast cancer at the earliest stage possible, not only are we improving a patient's survival, we may also be limiting the kind of treatment or the aggressiveness of treatment that they need.
And that's another end point that isn't necessarily related to the survival benefit, but might be related to a quality of life issue right now. If you have a malignancy picked up at an early enough stage that you, for instance, don't need chemotherapy, regardless of what your longevity is, most women would opt not for chemotherapy. So I think that--that you have to look at that on an individual basis when you're speaking of patients.
SUSAN DENTZER: You've been in practice you've said 20 years. One point that has been made to us, as you were saying a moment ago, that one of the great benefits of current mammography is that it does enable cancers, when they can be identified, to be identified when they're smaller, more easily excised, et cetera, and more conducive to being treated in a breast-conserving fashion. Is that true in your experience? Have you sort of lived that empirically, that benefit of mammography over the years?
DR. SHAWNA WILLEY: I absolutely have lived that over the years, but I would also--I've also practiced in a few other countries where they have a very different philosophy towards mammography. I spent some time practicing in Saudi Arabia and some time practicing in Poland. And in those countries screening mammography programs were not available when I was there.
And what I saw in those countries was women coming in with breast cancers that were large, that sometimes weren't even operable, certainly were high-stage disease. In fact I worked at a hospital one time where the interesting case was the patient who came in with the mammographic detection of a breast cancer, and that's the case they wanted presented at Tumor Board because it was so unusual.
Here it's the norm. And I would say that treating a patient with a very small breast cancer is much easier than treating a patient with a large breast cancer. It's easier for the physician certainly, but it's much easier for the patient. And of course the results are better.
So I have seen that in my own practice here, but I think that was really pointed out to me when I saw other countries that have different philosophies about screening mammography, where screening mammography does not exist, and women only come in when they have an obvious breast cancer.
SUSAN DENTZER: And as a surgeon, literally, what's the difference to you of having a tumor that's half a millimeter versus 2 or 3?
DR. SHAWNA WILLEY: Well, certainly to take out a small lump is an easier proposition. It--it requires that you remove less breast tissue surrounding the lump. You can have a smaller incision. You have a better chance of getting clear margins which is so incredibly important for reducing recurrence rates.
SUSAN DENTZER: Which means?
DR. SHAWNA WILLEY: Which means that if we have a big margin, the chances are much better that that cancer will never come back in the breast.
If you have a tumor that's twice that size or three times that size, you have to take out much more tissue. It may mean that you have to do a mastectomy rather than breast-conserving surgery where you can leave part of the breast tissue behind, and of course that is a much bigger proposition.
From a surgeon's standpoint, I can do both operations, but certainly from the patient's standpoint and recuperation, and body image, I think it's much better if we can detect a small cancer. The breast can look essentially normal other than the fact they have a small scar. And psychologically I think for patients that's much better. But not just psychologically, they do better long term. Their survival is better.
SUSAN DENTZER: Is that another area that ought to be an end point in some of these mammography studies?
DR. SHAWNA WILLEY: The cosmetic appearance, the psychologic evaluation? I think the women I've spoken to would like to have other parameters introduced into it. Of course that makes the studies much more difficult to do. Survival is a very definite end point, and it's hard to argue with survival as an end point. And if there's controversy about these studies, even when you use a very definite end point such as survival or death, then there's going to be more controversy I think about the quality of life issues, the psychologic impact, the cosmetic impact, because that becomes much more subjective.
I think it's important. I think patients would like that looked at. I think even as physicians we have our own sense of whether patients do better with one treatment versus another, diagnosis at one stage versus another, psychologically or cosmetically, or just socially. But I think to use that as an end point is going to be more difficult to evaluate the studies.
My perception is patients would like to have quality of life, treatment modalities, the need for aggressive treatment to be part of those end points.
SUSAN DENTZER: What do you think, based on--I assume you've read the "Lancet" studies or at least--
DR. SHAWNA WILLEY: Yes.
SUSAN DENTZER: --coverage of the "Lancet" studies, this response from the researchers at Weill Cornell critiquing those studies in the context of this ongoing controversy now dating back probably three decades, about the value of mammography? What's the bottom line for you?
DR. SHAWNA WILLEY: Well, I was going to point out this is not a new controversy. We've been struggling with this issue for a long time, and the data is reviewed, and we, as clinicians, have to apply this data that's available. It becomes very difficult because I don't have the resources, I don't have the ability to make these incredible analyses that these researchers have made. I have to interpret this information for the patients.
My take home message is that I am still recommending to patients that they have mammograms. On an individual basis mammography does make a difference. As to a broad base of population, I can't answer that. I can't tell my patient that, "Well, because it hasn't been shown to improve survival, you don't need a mammogram." To me, I can't, in good conscience tell a patient that, because I do know that if that patient's breast cancer is detected mammographically, they have a better chance of survival than if we wait until I feel it, or they detect it, or it erupts through the skin.
SUSAN DENTZER: What about some of your other patients? You mentioned the one instance. Are other patients generally now confused, ambivalent, angry? What's the reaction?
DR. SHAWNA WILLEY: I think many patients have talked to me about how they should interpret this. Certainly after the Danish study came out, I had many questions. "Well, I hear mammograms aren't worthwhile. I hear I shouldn't be getting my mammograms. What should I do?"
Women want to have a way to screen for breast cancer. Women feel very vulnerable about breast cancer, and so to take away something that has been kind of a lifeline for a lot of women, to say, "Okay, at least if I'm doing my mammograms and I'm doing my breast self-exam, and I'm doing my clinical exams, and I'm paying attention, I have a better chance of finding this disease than if I don't." I think it's hard to take that away from a women.
There is--most women have been continuing with what they've been doing. They've somewhat disregarded this information. They listened to it. They listened to the controversy. And yet, I don't see it as significantly impacting what they had already decided about mammography for themselves.
I have some women that I follow who refuse to have mammograms for various reasons. And they'll use this information to say, "Okay. See, I'm right. I shouldn't have a mammogram."
So I think women are basically--have already made their decision. They'll listen to this controversy and they find it interesting.
I don't think patients are angry about this. I think that they really would like an answer, but realize that they're probably not going to get a clear-cut answer. They understand there's controversy. Most women had made up their mind before this came along how they were going to have breast surveillance, and for most women that involved annual mammography. So I don't see this as affecting that decision.
They'd like me to tell them what I think. They're very interested in--in what I would recommend if I'm going to change my recommendations based on this information. But overall, women still want some kind of screening and surveillance for breast cancer.
SUSAN DENTZER: You said a moment ago you do have some patients who won't give mammograms. What's the issue for them?
DR. SHAWNA WILLEY: Women--it's a very small percentage of women who absolutely refuse to give mammograms. In their particular cases, they usually have most concerns, I would say, about radiation. And some of them have concerns that they've had radiation in the past. They don't want to add to the radiation that they're getting now. Some people just philosophically are opposed to radiation. I would say that's probably the number one concern.
Most women who say that mammograms are painful still get mammograms. They--they'll complain that they're painful, but they still will get them. I have a few patients who have kind of a real psychological issue with going to get mammograms, mostly because they had their breast cancer diagnosed with mammography, and they're fearful of going back in for a mammogram. Generally, in that setting I try to hand pick technicians who will really help the patient get through that.
But it's really a small percentage of women that absolutely refuse to have a mammogram. And I have not met any who have refused on the basis of this data.