A second mammogram required; questions answered

Pleased to have this task completed in less than 15 minutes after arrival; I was feeling pretty cheeky as I left the clinic this year after my annual mammogram. Unfortunately, I would receive a call later that day informing me additional images were needed. I would undergo a second mammogram and ultimately a biopsy. To my relief, I ended up having a benign breast calcification, not cancer. As I look back on this experience, which was pretty surreal, I realize I had quite a few questions throughout the process. I will now attempt to answer those questions with the intention of helping others in a similar situation.

How common is it to be called back for a second image?
About one in ten mammogram screenings result in a patient being called back for further testing. Most likely this call back is not due to a bad image, but because the radiologist saw something that looked suspicious and wants a better view. The second screening is a magnification or a compression view where they zone in on a specific area or an ultrasound that will give information like is it a solid area or just a more dense area of tissue or if it's a cyst.

What was seen on my second diagnostic image?
The radiologist saw a calcification on my left breast that had not been present on prior images.

What are breast calcifications?
They are deposits of calcium in some areas of the breast tissue that show up as white spots on a mammogram. They cannot be felt, and are only detected on a breast mammogram. They are very common and in most cases harmless.

There are two types:
Macro-calcifications are usually larger, fewer in number, widely dispersed, and round. They are harmless and need no treatment or monitoring.

Micro-calcifications are specks of calcium that may be found in an area of rapidly dividing cells. When many are seen in a cluster, they may indicate a small cancer. About half the cancers detected appear as these clusters.

What causes breast calcifications?
Calcium can be deposited in breast tissue for a variety of reasons, many of which are not related to cancer. Some benign causes of breast calcifications include inflammation from a breast infection, and injury or trauma to the breast. Calcium deposits may also be included in a benign breast cyst or a benign breast growth like a fibroadenoma. Taking calcium pills does not cause them. Also, there is no known link between calcium intake in diet and the formation of breast calcifications. Nor has a correlation been found between post-menopausal hormone replacement therapy and the development of breast calcifications. Calcifications in breast tissue occur most commonly as a natural process of aging. As we age, there is some degeneration of tissues and this can cause calcifications. Hence most women develop calcifications as they grow older. The cause which worries women the most is of course cancer. But cancer as a cause of breast calcification is quite uncommon compared to the high proportion of calcifications seen due to other causes. Cancer is suspected only in some specific patterns of calcification.

Why a biopsy?
The way these calcifications are positioned within the breast and their number and shape can provide the radiologist with an idea of whether these should be left alone or further examined for invasive or preinvasive disease.

My radiologist explained there are three possible determinations he makes based on the shape of the calcification:
1. A mass that is star-shaped or irregular is serious.
2. A round or smooth-edged mass is more likely to be a fluid-filled cyst and not serious.
3. Calcifications that are hard-to-tell he deems indeterminate. Of course, mine was indeterminate.

There are two approaches to dealing with indeterminate calcifications:

A wait and see approach ~ I would return in six months for a follow-up mammogram to see if the calcifications have changed - a sign that a cancer could be growing.

Perform a biopsy ~ This is the only way to be absolutely certain the calcification is benign. Whether or not to do a biopsy depends on the radiologist's level of suspicion. When suspicious micro-calcifications appear on a mammogram, but no lump is felt, a needle localization biopsy is recommended, so that breast tissue can be removed and examined under a microscope by a pathologist. Some radiologists recommend the aggressive approach when dealing with indeterminate calcifications, recommending a needle-localization biopsy to see whether malignancy is present.

Because the deposit had not been present on prior mammograms along with the indeterminate positioning of the calcifications my radiologist strongly recommended a biopsy.

What actually takes place during the biopsy which is called a stereotactic core needle biopsy?
The radiologist removes small slivers of tissue containing the “suspicious” calcifications through a thin, hollow needle. This procedure is done using a special table and computer guidance device. A stereotactic core needle biopsy requires only local anesthesia (the patient is awake and alert) and the tissue can be sent to the laboratory for analysis without surgery.

My biopsy went well; the radiologist was able to remove the entire mass of calcifications. Afterward, he indicated he would be surprised if the biopsy results did not come back benign. Also, he was pleased to have been able to remove the entire deposit.

What percentages of biopsies are benign?
Around 85%. Calcifications themselves are not cancer but may be present in the midst of a cancer. Clustered small calcifications alone are associated with about a 25 percent risk of cancer.

Final thoughts on the ordeal:
~I didn’t get rattled, but I was anxious. To help ease the anxiety, I rescheduled both appointments to earlier dates as cancelled appointments became available. If something was seriously wrong I wanted to know as soon as possible.

~ I asked as many questions as I could of family and friends who had undergone the same procedure to give myself some idea of what to expect.

~ My sister, who is a radiologic technologist, gave me the following advice which did wonders to reassure me everything was going to be fine even if the calcs were malignant:
Calcium deposits also called micro-calcifications can be a very early sign of a cancer called ductal carcinoma in situ. If this is the case, would be easily treatable since it is so early.

~ Now that the bills are coming in (this procedure cost close to $5,000, of which my insurance company will pay 90% after I meet my deductible), I can't help wonder if I should have gone with the wait-and-see approach. My sister strongly disagrees with this statement insisting I did the right thing following the radiologist's recommendation.

~ You can’t take aspirin seven days prior to the biopsy and for three days following, but you can take Tylenol. I wasn't informed of the Tylenol option until after I developed an incredible migraine and pleaded with my breast care coordinator to allow me to take some type of pain reliever.

~What do you wear to a biopsy?
As I prepared for my biopsy, I couldn’t help think what does one wear to a biopsy; do you go for style or cheering up? I ended up going with worn and comfortable. I thought this was kind of weird thing to think about until I read in his book Chasing Daylight;Eugene O’Kelly wore golf clothes to his radiation appointments to get in a good mood as if he were going to play a round.

~During the procedure, the breast care coordinator stood next to me talking me through the procedure. I appreciated this diversion.

~The biopsy itself hurt. My back and neck got stiff. Also, the recovery wasn’t pleasant for the first couple of days. I had to ice the area every four hours and could lift nothing heavier than a jug of milk. Even moderate activity produced bleeding. Plus, I am still black and blue and the procedure was three weeks ago.

~Despite all of the favorable assurances I received, it was an incredible relief to know for sure it wasn't cancer.

~ And lastly, if you need to let a patient know their lab results are going to take longer than anticipated do not start the conversation with: “I HAVE BAD NEWS.”