Breast cancer is the second most diagnosed cancer among females. During their adult lives, about 50% of women will have some type of breast related problem (Perry, Hockenberry, Lowdermilk, & Wilson, 2010). This is where breast cancer screening comes into play. It has been a standard to undergo annual mammography to screen for breast cancer but in a technologically growing society we are always searching for the next best thing. Magnetic resonance imaging (MRI) is a promising alternative to mammography. Though there are pros and cons to both types of testing I feel that one method stands above the other. The purpose of this paper is to discuss both the benefits and drawbacks to both types of screening processes.
When making important decisions in regards to something as vital as ones health it is a smart practice to get the facts before making decisions. To begin it is very important that women have a good understanding about breast cancer. Breast cancer, like any other cancer, occurs because of genetic alterations in the DNA of cells. These changes can be inherited or spontaneous and can be found in lobular tissue, ductal tissue, or epithelial cells (Perry, Hockenberry, Lowdermilk, & Wilson, 2010). Because changes can occur in different tissues there are many different types of breast cancer. Breast cancer can be either invasive (infiltrating) or noninvasive (in situ). In the breast, cancer begins in the epithelial cells lining the mammary ducts. When breast cancer is invasive it grows from the walls of the mammary ducts into the surrounding tissues. Ductal carcinoma, which originates in the lactiferous ducts and then invades surrounding tissues, is the most frequently occurring breast cancer. Ductal carcinoma tumors are usually solid, non-tender, non-mobile, unilateral, and not well delineated. When a cancer originates in the lobules of the breasts it is called lobular carcinoma. This type of tumor is usually non-palpable and bilateral. When a cancer originates in the nipple it is called a nipple carcinoma or Paget's disease. Nipple carcinoma usually occurs with invasive ductal carcinoma. When these cancers occur together they can cause oozing, bleeding, and crusting of the nipple (Perry, Hockenberry, Lowdermilk, & Wilson, 2010). The way breast cancer invades surrounding tissues is by growing tentacle-like projects. During palpation these tentacles make the tumor border feel irregular. Cooper's ligaments can be affected by the tentacle-like projections as they develop fibrosis. The fibrosis shortens Cooper's ligaments causing peau d'orange (orange peel-like) skin and edema which can be associated with some types of breast cancer. The tumor can continue to grow into the outer layers of the skin creating ulcerations or into the surrounding lymph channels causing tumors to grow in lymph nodes. Once the cancer is in the lymph nodes it can metastasize by "seeding" breast cancer cells into the system. This can also occur in the blood stream. Once in one of these systems, tumors can develop in different parts of the body (Perry, Hockenberry, Lowdermilk, & Wilson, 2010). Along with peau d'orange skin, ulcerations of the skin, edema, oozing, bleeding, and crusting of the nipple women need to look for thickening of the breast, dimpling skin, nipple discharge, itching, and the cardinal lump. If a woman has any of these symptoms she needs to see her doctor to find out the cause. Before a lump is felt it can usually be detected on a mammogram but 90% of lumps are found by the woman during a breast self exam (Perry, Hockenberry, Lowdermilk, & Wilson, 2010).
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Screening for breast cancer can be a very stressful time for women, especially if they have a family history. That is why it is so important to know your options when it comes to your health. The different breast cancer screening technologies available include screen-film mammography, full-field digital mammography, computer-aided detection and diagnosis (CAD), ultrasound, and MRI. The gold standard for breast cancer screening is screen-film mammography. Full-field digital mammography can catch breast cancer that has been missed by screen-film mammography. CAD digitizes and analyzes screen-film mammography for abnormalities. Ultrasound and MRI are considered adjuncts to mammography. Table 6-5 on page 119 in Maternal Child Nursing Care (2010) states the American Cancer Society's guidelines for breast cancer detection in asymptomatic women. It states that women between the ages of 20 and 39 should have a clinical breast examination every three years. Women who are 40 years old or older should do a breast self exam monthly and a clinical breast examination and mammography annually. When it comes to women who are at increased risk for breast cancer, they need to discuss other screening options with their doctor like breast ultrasound and MRI and starting mammography screenings earlier (Perry, Hockenberry, Lowdermilk, & Wilson, 2010). "Major obstacles to breast cancer screening include older age; fiscal barriers (e.g., expense, lack of health insurance); knowledge, attitudinal, and behavioral barriers (e.g., fear, ignorance, lack of motivation); and organizational barriers (e.g., scheduling problems, lack of availability of mammography services, lack of physician referral)" (Perry, Hockenberry, Lowdermilk, & Wilson, 2010, p.119).
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MRIs have not been widely used to screen for breast cancer but mammography has. There is hope thou, because there are different studies being conducted to test breast MRIs and how well they can ultimately decrease mortality rate. To date, mammography is the only screening tool shown to reduce breast cancer mortality. Many studies believe that screening with both MRI and mammography is better than just screening with mammography (Warner, Messersmith, Causer, Eisen, Shumak, & Plewes, 2008). One study stated that, "the relatively small increase in cancer detection observed with the addition of mammography to MRI raises the possibility that MRI alone could be a reasonable screening strategy" (Warner, Messersmith, Causer, Eisen, Shumack, & Plewes, 2008, p. 678). Even thou there are many studies looking into the efficiency of breast MRI there is no conclusive evidence to date that states breast MRI reduces breast cancer mortalities (Eggertson, 2004). Since mammography has been around longer it has a proven track record in helping to prevent breast cancer mortality, where as MRI breast cancer screening has not gathered enough data to prove its effectiveness just yet.
Mammograms can be a very painful process for woman, which is what makes the less invasive MRI seem more attractive and becoming more sought after. The overall practice of mammograms and the way in which they are administered is one of the leading flaws of this test. This can be a factor in women not testing at all which according to research, any delay in treatment can adversely affect the woman's subsequent prognosis and treatment options (Perry, Hockenberry, Lowdermilk, & Wilson, 2010). Mammograms work by compressing the breast, this can distort the tumor and depending on the size of the breast and how far away the tumor is from the film can cause it to be under measured (Wasif, Garreau, Terando, Kirsch, Mund, & Giuliano, 2009). On the other hand the process of the MRI screening is substantially less invasive and in most cases less painful. This testing process is used widely throughout the medical community and has proved to be irreplaceable in the detection of other health related issues. During a breast MRI the patient will have a small IV inserted in her arm and injected with a contrast agent that will highlight areas of abnormal vascularity, she will then be positioned on the MRI table in a prone position, she will put her arms around a pillow supporting her head, both breasts are in a cushioned recess, the table is then moved into the magnet, the patient will need to lay there for about 15 minutes, and then the procedure is over (MRI's emerging role, 2007). As with any test the MRI does have its own set of drawbacks, according to the article in Harvard Women's Health Watch MRIs can be stressful, and the article goes on to say, "The procedure requires a substantial investment of time and fortitudeâ€¦some women feel claustrophobic" (MRIs emerging role, 2007, p. 3). Anxiety appears to be the common factor in both tests so it ultimately comes down to what you feel comfortable with. It seems to me that if you do not have issues with tight spaces than the MRI becomes the lesser of two evils.
Another consideration is the cost of the procedure and if insurance will cover it. Breast MRIs can cost over $1,000 and most insurance will not cover the procedure for women who are at an average risk for breast cancer (MRI's emerging role, 2007). Because mammograms are less accurate than MRIs they may require further testing which can add to the overall cost (Eggertson, 2004). MRIs can have false-positive results because of different interpretations from the technology, which can also lead to further testing (Bremner & Recabaren, 2007).
MRIs have also been found to be more sensitive than traditional mammograms. A MRI uses both morphology and enhancement kinetics when it evaluates breast lesions, by doing this it can differentiate between benign and malignant lesions and is more accurate at measuring the size of the lesion (Wasif, Garreau, Terando, Kirsch, Mund, & Giuliano, 2009). MRI can provide an excellent picture of soft tissue and it can do this without injecting an iodine contrast medium. It is able to capture images in multiple planes and skeletal and fatty structures do not interfere with the image (Perry, Hockenberry, Lowdermilk, & Wilson, 2010). Mammography only measures the size of the lesion across its widest part (Wasif, Garreau, Terando, Kirsch, Mund, & Giuliano, 2009). Mammograms are less sensitive in denser breast (Choi, 2005). MRIs are not affected by breast density and can detect breast cancers that have invaded surrounding tissues with 90-95% accuracy (Dang, Zaghiyan, Karlan, & Phillips, 2009). Cancers that occur in high risk women can develop and grow rapidly in between regular mammogram screenings, so the need for more sensitive equipment is extremely important. If more sensitive equipment is used it can catch the smaller cancers that a mammography can miss. One study showed breast cancers that had not been found by mammogram but later found by MRI had already become invasive (Choi, 2005).
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With my age being what it is I have no firsthand experience in dealing with any type of breast cancer testing. I have to form my opinion based solely on what I have read throughout my research and from what I have heard from different women who do have experience. When discussing this topic with women the major concern has always been the pain associated with the mammography. The process of "smooshing" the breast is a common fear and ultimately the deciding factor on whether or not the women gets her test done at all. I feel that if women had the option of the MRI given to them that they would gladly take it for no other reason than the comfort factor.
If there is ever a time to spend money it is on one's own health or the health of a loved one. The cost of mammography is usually covered by insurance which makes it a more suitable and a more logical choice. Along with the cost being lower mammography is also more widely available. The majority of people have access to mammography set up where as not everyone has the ability to get to a MRI machine.
If my decision rested solely on the comfort and cost factor than I would have to call it a draw but to me there is a factor that outweighs both of these. The MRI has proven to be much more sensitive in picking up structures that the mammography cannot see. This clarity not only could prove to be beneficial for the doctor but also give the patient a better understanding of what it is the doctor is looking for.
There are both pros and cons to both forms of breast cancer screenings. The pros of the MRI revolve around it being less invasive which leads to less pain as well as being more sensitive to the structure of the breast tissue. The cons to MRI include being more expensive, not widely used, and more false-positive test results. Mammography has its pros as well which include the cost effectiveness of the screening, the wide accessibility, and proven results over an extended period of time. The cons of mammography consist of its general pain and invasiveness of the procedure. While both methods show their merit it is my conclusion that the MRI serves as the better test. Ultimately I feel that a combination of the two treatments would be the best possible scenario but given the research at hand I can see that this will not always be available. Having said that I believe that a woman should do whatever is in her power to detect and help prevent breast cancer by whatever means possible.