Talking to Patients about Breast Cancer Screening: Radiation Risks & Other Concerns

Introduction

Hello, my name is Isabel Newton, and I'm from the University of California at San Diego and the VA in San Diego Healthcare System.

Opening Objectives

Today my talk will concentrate on how to counsel patients about breast cancer screening focusing on radiation risks and other concerns.

These are my disclosures. None of them are relevant for today's talk.

Our aims are to discuss the value of Compassionate Counseling which can be very important and quite powerful when talking to a patient about breast cancer screening.

We'll explore the common fears and misconceptions that go into a patient's perception of breast cancer screening with a specific review on photon physics and radiation biology so that you're armed to answer the questions that they may have and to understand the real risk rather than the imagined ones.

We'll review the data regarding these misconceptions. And then finally, we'll talk about strategies to address patient concerns.

Topics

Compassionate Counseling

We will start with Compassionate Counseling because this is an opportunity to connect with a patient, ensure that they are comfortable with the screening process, and ensure that they understand their risk to make informed decisions about how to mitigate that risk.

Establishing rapport is essential, and there are some simple techniques you can use:

Sit down and get on the same level as your patient.
Pause, make eye contact, and ask open-ended questions such as, "What worries you?" and "Do you understand why your doctor has referred you to come here today?"
Listen without interrupting, acknowledge their experience, and validate their concerns.
Respond to disinformation calmly and factually without being dismissive.
Respect the patient's decision, even if they choose against your recommendation, but ensure they understand the information provided.

Common Misconceptions

It's important to recognize that when a patient objects or has concerns regarding breast cancer screening, it often reflects misconceptions, and these misconceptions are common.

Some common misconceptions include:

I am too young to worry about breast cancer.
No one in my family has ever had breast cancer.
Mammograms overdiagnose breast cancer.
Mammograms are too much radiation.
Compression spreads cancer.
Mammograms hurt too much and they never find anything.
Other tests are just as good or better than mammograms for detecting breast cancer.
Every time I get a mammogram they make me come back and it turns out to be nothing. So what's the point?
Mammograms are just done so doctors can make more money.

Before delving into these common misconceptions, let's talk about the actual risk of breast cancer. Breast cancer risk drives screening, and one in eight women will be diagnosed with invasive breast cancer in her lifetime, which is 13%.

Radiation Risks

A screening mammogram delivers less radiation than we all get from about two months of exposure to normal sources of radiation, such as radon. The benefits of a mammogram far outweigh the tiny potential risk of radiation.

For example, a screening mammogram's radiation dose is less than what we get from living on Earth for two months or flying cross-country. Even dental radiographs expose us to higher levels of radiation.

To understand the radiation involved in mammography, we must review the concepts of attenuation and penetration:

Attenuation: Photons absorbed by the subject, contributing to patient dose.
Penetration: Photons that reach the detector and contribute to the image.

Factors affecting radiation dose include:

Photon energy (KV or kvp): Higher voltage means greater penetration and lower contrast.
Number of photons (ma): More photons mean a higher chance of penetrating tissue and increasing dose.
Tissue properties: Higher density tissues and thicker body parts attenuate more photons, requiring higher doses.

Radiation effects can be stochastic (dependent on chance, with no safe threshold) or deterministic (occurring above a certain dose threshold, with severity increasing with dose). Women, newborns, and babies are more radiosensitive than men.

Compression in Mammography

Compression remains a powerful tool for better diagnostic exams, as it reduces scatter radiation, lowers dose, reduces motion blurring, and decreases overlapping fibroglangular densities.

However, compression can be painful, discouraging patients from future mammograms. Addressing concerns about compression spreading cancer cells is important, as there is no evidence to support this claim.

Alternatives to Mammography

When patients inquire about alternatives to mammography, it's essential to compare other breast cancer screening modalities:

Traditional and 3D mammography: Most sensitive methods.
Contrast-enhanced mammography: Increased sensitivity in some settings, but not widely available.
Ultrasound: Used to investigate areas of interest revealed by other imaging.
MRI: Used for patients with very dense breasts, breast cancer history, or high risk (e.g., BRCA mutation).
Thermography: Not shown to be helpful and is not a substitute for mammography.

Conclusion

In summary, Compassionate Counseling promotes greater trust between the clinician and the patient and encourages adherence to recommendations. Protests to breast cancer screening reflect common fears and misconceptions. When we discuss the risk of breast cancer being one in eight women, it's important to acknowledge and address these fears.

Mammograms are a low radiation exam and have not been shown to increase cancer risk. They remain the best breast cancer screening exam available. Listening to patients authentically and openly can help address their fears and concerns.

Thank you for your attention, and I hope that this will help you in your next difficult conversation with your patients about breast cancer screening. As a result, we may increase the number of women getting breast cancer screening to as close to 100% as we can. Take care.

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