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Oct 6, 2020 09:23AM
Oct 6, 2020 09:30AM
I agree with Ingerp. Your follow-up sounds typical.
Is your breast density heterogeneously dense (Cat. 3 density) or extremely dense (Cat. 4 density)? If it's Cat 4 density, then you should be able to get a supplemental ultrasound, if not an MRI, in addition to your mammogram. But with Cat. 3 density, that's not usually done because at your age, Cat. 3 density is normal - it's what most women have.
I certainly agree that with your history of breast cancer, additional screening would seem reasonable, even though it's not standard to do it. But here's the problem. Neither a mammogram nor an MRI nor an ultrasound is likely to find anything smaller than 4mm or 5mm. No method of screening regularly finds tumors that are that small. Sometimes a lesion can cause a reaction in the breast tissue - distortion, for example, or the development of calcifications - and that might show up, but tumors that small often won't be seen. The reason for using different screening modalities is that not that one will catch something that is smaller, but because each 'sees' the breast tissue differently, and highlights different things. Therefore even larger lesions might not be seen on one modality but may be seen on another. I had 7+ cm of high grade DCIS along with a 1mm microinvasion of IDC - some of it showed up on my mammogram, more if it showed up on my MRI, nothing at all showed up on my ultrasound. Similarly, there are women here who have had larger solid IDC tumors that haven't shown up on mammograms but have been seen on ultrasounds. I'm sure that doesn't make you feel any better about only having one modality of screening, but it's important to know that small lesions may not be seen by any type of screening.
Lastly, I'm very surprised at the risk figures you were given. For your cancer diagnosis, yes, a 1% risk of mets seems reasonable for a 2.5 mm grade 1 tumor - I was told about 1% for my 1mm tumor. And a 4% local recurrence risk, with a small grade 1 tumor and good surgical margins (I'm assuming that), is also reasonable. But a 3% risk in your right breast? No. You are a woman. Just because you've had breast cancer before doesn't make you immune to develop breast cancer again. In fact because you've had breast cancer before, your risk to develop a second breast cancer, a new primary in either breast, unrelated to your previous diagnosis, is likely higher than the risk of the average woman. I had just turned 49 when I was diagnosed. The average 49 year old has an 11% lifetime risk to be diagnosed with breast cancer. S0 your risk has to be at least 11%. But my MO told me that my risk to be diagnosed again, at some point of my life (with approx. 40 years ahead of me) was about double that of the average woman my age. So that meant that my risk was about 22%. The only good news with that risk figure is that it goes down as we get older. This is simply because the 22% (for me) is the addition of the risk for every year of life. So as the years pass, we have fewer years ahead of us, and therefore our lifetime risk to be diagnosed goes down. What's important to understand, however, is that for all women, the highest risk age to be diagnosed with breast cancer is when we are in our 60s and 70s. So while cumulative lifetime risk goes down, annual risk - the risk level associated with just that one year - is highest when we are in our 60s and 70s. And that's another reason to push for supplement screening.
Lastly, this risk is not additive. Each risk is a separate and distinct risk. Your local recurrence risk of 4% could have been reduced by approx. 50% if you were taking Tamoxifen. Your distant recurrence risk of 1% could have been reduced by approx. 33% with Tamoxifen. And your risk of a new cancer - as I said, based on my understanding, I think it's significantly higher than the 3% you were told - could be reduced by at least 50% by taking Tamoxifen - but not for the entire rest of your lifetime. Tamoxifen will reduce your risk for the period during which you take it. And it provides an extended benefit, at a reduced level, for many years afterwards. But 5 years of Tamoxifen would not reduce your new primary risk by 50% for the next 40 years. That's important to know too.
All that to say that while your screening protocol is normal, given your breast cancer history, I think it's reasonable to make a fuss and push for a supplemental ultrasound, in addition to your annual mammogram.
Dx 9/15/2005 Right, 7cm+, DCIS-Mi, Stage IA, Gr 3, 0/3 nodes, ER+/PR- ** Dx 01/16/2019 Left, 8mm, IDC, Stage IA, Gr 2, 0/3 nodes, ER+/PR-, HER2- (FISH) ** Surgery 11/30/2005 MX Right, 03/06/2019 MX Left ** Hormonal Therapy 05/2019 Letrozole