Breast health diagnostics: No longer one-size-fits-all

The country’s first hospital-based breast health center integrating mammography, ultrasound and MRI technologies has opened in J'lem.

By JUDY SIEGEL-ITZKOVICH
Mammogram 370 (photo credit: Rebecca Kowalsky)
Mammogram 370
(photo credit: Rebecca Kowalsky)
Just as a woman’s bra cannot be one-size-fits-all, mammography alone – which has for decades been the standard technique for diagnosing breast cancer – is no longer suited to everyone.
Women (and a small number of men) who inherited the BRCA1 or BRCA2 mutation that raises the lifetime risk of breast cancer to a whopping 80 percent, or those who previously contracted a breast tumor (of the “ordinary type” or a more aggressive form involving hormones) need more advanced imaging technologies, which have not to date been available in all hospital settings.
Or at least, they have been lacking until three months ago, when Dr. Shalom Strano opened a one stop multidisciplinary Diagnostic Breast Health Center on the third floor of Jerusalem’s Shaare Zedek Medical Center (SZMC). Strano, a haredi-Zionist surgeon and radiologist who came on aliya from South Africa in 1992– has spent most of his medical career focusing on breast health, an odd choice for a man with a trim white beard and a black kippa on his head.
Having co-founded and directed 14 years ago Israel’s first non-profit, free-standing (non-hospital) mammography center in Jerusalem’s Givat Shaul quarter, he finally decided that the field has gone beyond x-rays of the breast to detect cancer and on to an integrated, holistic approach that includes other “modalities” such as ultra-sound and magnetic resonance instrument (MRI) imaging as well. His team includes not only radiologists but also breast surgeons, oncologists, social workers, plastic surgeons, pathologists, geneticists and more.
The third floor, which accommodated no inpatients but was a “service floor” with only an archive and storerooms, includes more than 1,000 square meters of space, all devoted to breast health. This it follows in the footsteps of two other SZMC special floors – one for heart disease prevention, diagnosis, angioplasty, surgery and rehabilitation and the other for gynecology, obstetrics and pediatrics.
With enthusiastic permission from SZMC director-general Prof.
Jonathan Halevy, Strano saw his center built into a modern and attractive facility in just two months. Halevy, said Strano, was aware that “mammography always pays its way. It offers tremendous added value to a hospital because it’s a high-profile project and brings in patients who need Surgery, oncology, pathology and plastic surgery and all needs a highly regarded imaging center.” Along with Strano, the hospital also absorbed into its staff his colleague at Hala, the Rachel Nash Comprehensive Breast Clinic – breast specialist Dr. David Gechtman, along with three imaging technicians. He has room for one more breast physician in the new center. Strano’s new center is integrated with the other aspects of breast care, including surgery, performed by Dr.
Moshe Carmon and Dr. Oded Olsha. He expects that 100 patients a day – or 20,000 yearly – will visit the center.
STRANO, WHOSE office includes four computer screens – two for ordinary mammography results, one for ultrasound and the other for MRI – studied medicine at the famed University of Witwatersrand in Johannesburg. Then he took fellowship positions at Brigham and Women’s Hospital in Boston and in Rochester, New York. When he returned to South Africa, he established that country’s first dedicated, free-standing mammography center.
“I initially decided to do a full residency in surgery in Johannesburg and Capetown,” Strano told The Jerusalem Post in a long interview.
“Half way through, for family reasons I switched from surgery to radiology. In 1989, I met Prof.
Albert Solomon, ex-head of radiology at Tel Aviv Sourasky Medical Center, who returned to his native country of South Africa for personal reasons about 25 years ago. I worked under him as a junior consultant and and surgical registrar.
He predicted that there would be a new mammography subspecialty and urged me to get into it. I loved the idea, bought equipment and set up a the first private mammography practice in South Africa. Then Prof. Yossi Frost from Kaplan Medical Center in Rehovot invited me to work with him.”
As Strano went to a Jewish day school, spoke Hebrew well, had visited Israel before and was “always a Zionist,” he and his wife (a lawyer) decided to make aliya with their five children, ten aged two to 11 two subsequently born. Upon his arrival, the South African immigrant set up Kaplan’s mammography department and served as its director. He was later introduced to Dr. Yitzhak Peterburg, who was director-general of Beersheba’s Soroka University Medical Center (like Kaplan, owned by Clalit Health Services) and arranged that he also become head of breast imaging there. There his center purchased the first stereotactic table in Israel; such a device, on which a woman lies prone and the breast hangs through an opening hole, became an alternative to excisional biopsies by performing a minimally invasive procedure.
Imaging is used to pinpoint the suspected lesion cells and insert a needle to remove them it for testing without cutting out whole pieces of tissue and causing disfigurement.
Then Rabbi Michoel Sorotzkin, who found funding for a freestanding clinic, invited him to co-found Hala, funded by the late Jack Nash, and Strano remained there as its director for 14 years, becoming Israel’s leading breast diagnostician.
“I was very happy there, but I felt I had reached a ceiling. Breast imaging, especially for more complicated cases, had moved on,” Strano said, explaining his departure.
“At Hala, we had a very strong relationship with SZMC, which sent us all their breast imaging work. When I left, it was served by 16,000 women a year – up to 80 patients a day.”
IT’S GOING to be unique,” Strano continued. “In the 1980s and 1990s, mammography was the only breast imaging modality.
Then high-quality breast ultrasound was added – and the field hit a plateau. What changed the whole playing field was MRI and genetics. MRI always existed as a possible modality, but genetics was a precipitating factor. Fortunately, world-renowned SZMC medical geneticist Prof. Ephrat Levy-Lahad has long been working there with patients who carry breast cancer genes. “She set up the Noga clinic for BRCA patients from around the country. It is run by Dr. Pnina Mor, a nurse with a doctorate who runs the clinic for BRCA carriers that offers ultrasound of ovaries, a search for tumor markers, referral for mastectomy and reconstruction and prophylactic oophorectomy [surgical removal of the ovaries]. They are all there, and they are included in the basket of health services.”
The incidence of breast cancer in Israel is relatively high. Between the ages of 40 and 50, 50% of women have dense breasts and little fatty tissue. As they get older, dense breast tissue gradually turns to fat.
“Fatty tissue appears black on a mammogram, and dense breast tissue and tumors are white. If everything is white, you’ll miss a certain percentage of cancers in a dense breast. One can’t see a white piece of paper on a white wall in a white room,” Strano explained. As we moved to risk-assessed imaging, we saw that women are not all the same. One who is over 50, has average fat density and no family history will do fine being screened only with mammography. in a center like Hala.
But if there’s a 40-year-old woman with dense tissue and a higher risk of cancer, she will also need an ultrasound, which catches things a mammogram doesn’t find. So there are fewer false negative -positive results. And then MRIs were also introduced for breast cancer diagnosis. Ultrasound cannot be used alone as a screening tool; Mammography MRI is needed as a road map,” he added. And then MRIs were also introduced for breast cancer diagnosis.
At least some of the health funds don’t want to deal with this new development. The problem is that “statistical models for risk are poor; each one lacks factors critical for reasonable lifetime risk assessment.
But we can’t perform an MRI on everybody. There’s a high falsepositive rate in inexperienced hands and also a fairly high falsenegative rate. It is not 100%. MRI has to be used with caution and skill and always in context of mammography and perhaps ultrasound.
There is high, intermediate and low risk, and women at higher risk should not be screened with ultrasound or MRI alone. I realized 20 years ago that it’s ridiculous to take a woman with a very high lifetime risk and use only mammography.
Different women with different risks need different imaging.”
Overdiagnosis of breast cancer is not the real problem, but “underdiagnosis is. If there is no appropriate imaging or or assessment of risk, we will not get better survival statistics. The issue is not how many cancers you detect but which cancers – slow growing or aggressive ones.”
He said he was “worried about commercial abuse of breast imaging; some private centers may offer automatic whole breast, 3-D ultrasound without obligatory mammography and not integrated in breast imaging departments.”
Strano is also concerned that as a result of interest spurred by the case of actress Angelina Jolie – who recently announced she underwent a double prophylactic mastectomy to head off breast cancer resulting from her inherited BRCA gene – there will public demand for more MRIs for breast imaging.
“There is no need for more at present,” he asserted. “Jolie was very brave to go public – but her decision was not mandatory for every woman in her situation. There is a new study from Toronto with encouraging survival figures of BRCA patients.”
Mammography screening, with the encouragement of the Israel Cancer Association, has high compliance today, except for some sectors liked haredi and Arab women – although their willingness to go now is improved. The different modalities have to be integrated.
Bad breast imaging is worse than no imaging.
What does the future hold? “There is will be isotope imaging,” said Strano. “There’s already a US company that’s but we have to reduce working on a whole-body dose. Whatever the modality, But it has to become cheap, fast and available. People are also working on PET [positron emission tomography].
Other possibilities are CT [computerized tomography] and even fMRI [functional MRI}. Laserlight- mediated imaging, which can be merged with ultrasound, is very promising. Another possible modality is digital tomosynthesis, an add-on of tomography to existing mammography units.” However, he said, it takes a long time to develop for new technologies to mature– an average of 40 years from laboratory bench to bedside use with the patient.”
TO MARK the opening of the new center, SZMC will host a Breast Cancer Symposium this morning (Sunday, July 21), with three world-renowned guest speakers and a panel discussion.
They are Dr. Armando Giuliano, executive vice-chairman of surgery in the department of surgery at Cedars-Sinai Medical Center in Los Angeles; Prof. Hadassah Degani, a member of the faculty of the Weizmann Institute of Science in Rehovot and an Israel Cancer Association funded researcher who developed a non-invasive method to differentiate between cancerous tumors of the breast and benign lumps; and Dr.
Pavel Crystal, assistant professor at the University of Toronto and staff radiologist of breast imaging for the University Health Network and Mount Sinai Hospital, Princess Margaret Cancer Center in Toronto.