Letting Your Guard Down

Such imaging, known as surveillance mammography, is important because women who have developed cancer in one breast are at a higher risk of developing cancer in the other breast, notes Terry Field, DSc, associate director of the Meyers Primary Care Institute and associate professor of medicine at the University of Massachusetts Medical School. Breast cancer survivors also face a risk of recurrence at the site of the first cancer.

“This risk is greater among women who have a higher-stage or larger tumor, and women who receive breast-conserving surgery and do not receive radiation therapy,” Field explains. “Surveillance mammography is recommended in the expectation that it will capture second cancers or recurrences early enough that they can be treated easily and with a very high cure rate.”

Field says that women who were not initially diagnosed through mammography may not be getting the screening because they never established a pattern of annual mammography.

“These women may not have been diagnosed until their cancer was at stage 2 or 3, which might produce a tendency not to continue receiving mammograms after they were diagnosed. Funding is needed to support research that will produce a better understanding of that issue,” Field says.

Another potential explanation is that breast cancer survivors often stop visiting their oncologists or cancer surgeons four or five years after their treatment. “At that point, they may feel that they have survived and can ease up on surveillance mammograms, but it doesn’t appear [from our studies] that most primary care providers are picking up on that,” notes Field. “They may not be up to speed on what cancer survivors require over time.”

Recent studies have also confirmed inadequate use of surveillance mammography among older breast cancer survivors.

It’s possible that health concerns other than cancer are directing older women away from routine mammograms, says Rebecca Silliman, MD, PhD, professor of medicine and epidemiology at the Boston University Schools of Medicine and Public Health, and chief of the geriatrics section at Boston University Medical Center.

“Older women are more likely to have multiple things wrong with them and also to have multiple doctors,” she explains. “If the systems aren’t in place to emphasize to women that surveillance mammograms are important and provide reminders, it may be one of those things that just falls through the cracks because other conditions take a higher priority.”

For breast cancer survivors who may be reluctant to get a surveillance mammogram because the treatment of their first cancer was so debilitating, it’s important to know that treatment options have improved dramatically in recent years.

“One woman told us that her treatment experience was so bad that she would rather die than go through it again. But treatment today really is much better,” says Field. “The world of oncology has become much more assertive about managing symptoms associated with chemotherapy and other treatment options, and in ensuring that patients don’t go through misery during the treatment process.”

Meanwhile, new research suggests that some women who have had a total mastectomy and breast reconstruction may also benefit from surveillance mammography of the reconstructed breast. Philip Barnsley, MD, of Dalhousie University in Halifax, Nova Scotia, notes that a substantial proportion of mastectomy sites have residual breast tissue. He led an analysis of literature describing surveillance mammography in breast cancer survivors with reconstructions using implants or their own tissue and found that mammography in the reconstructed breast could detect local recurrences.

Studies have shown varying rates of local cancer recurrence among women treated with mastectomy and breast reconstruction. Taken together, these studies show the rate of local recurrence to be between 2.3 and 7.5 percent — comparable to rates reported for women who have had mastectomy without reconstruction, Barnsley says.

“Women with breast reconstruction on one side and a native breast on the other side are encouraged to undergo yearly surveillance mammography of the unaffected side,” Barnsley says, “but there is no recommendation of what to do with the reconstructed side. It’s clear that variation of practice exists, and that we as physicians do not have a consistent way of following these women for local recurrence in their reconstructed breast.”

The most likely reason for this, he says, is that women who undergo breast reconstruction are still the minority, and therefore tend to be overlooked. “The rate of breast reconstruction is increasing,” he notes, “and I think that they will get more attention in coming years.”

Annual post-treatment mammography has been shown to detect local recurrent and new primary breast cancers in the early, treatable stages. The screening is recommended by the American Society of Clinical Oncology for women who undergo lumpectomy — or breast-conserving surgery — and for women who undergo mastectomy for the remaining healthy breast. Yet a surprising number of breast cancer survivors fail to get the potentially lifesaving procedure on an annual basis.

Women with brest reconstruction on one side and a native breast on the other side are encouraged to undergo yearly surveillance mammography of the unaffected side, but there is no recommendation of waht to do with the reconstructed side.