Doctors offer breast care & cancer advice

October is Breast Cancer Awareness Month.

In a story in the Sedona Red Rock News on Aug. 31, “Missed breast cancer leads to loss,” Christine Gallo, a Verde Valley Medical Center employee, shared her story about how two radiologists who worked at Northern Arizona Radiology alleg­edly failed to detect cancer on her mammo­grams in 2017 and 2018. As a result, Gallo had a bilateral mastectomy or the removal of both breasts.

Even though Gallo was diligent in getting her mammograms every year, she became a statistic.

The National Cancer Institute reports that the overall five-year relative survival rate for breast cancer is 90% after being diagnosed. The 10-year breast cancer relative survival rate is 84%.

Early detection of early-stage breast cancer has a survival rate of nearly 100%.

Patients rely on their doctors and radiologists to identify cancer compe­tently and as early as possible to have the best chances of recovery.

Unfortunately, radi­ologists who don’t detect lesions visible on mammography scans or 3D scans can face malpractice lawsuits. According to several law firms, breast cancer misdiagnosis is the leading cause of radiolo­gist malpractice.

Dr. Beth DuPree, a board-certified general surgeon specializing in breast diseases, has been practicing medicine since 1987. She served as vice president of Holy Redeemer Health System in Huntingdon Valley, Penn., and has held an academic appointment as an adjunct assistant professor of surgery at the University of Pennsylvania.

DuPree moved to Sedona in August 2016 and began working for Northern Arizona Healthcare in April 2017. Her goal was to create one of the best breast cancer care centers in the country in Sedona.

DuPree says that early on, she began noticing missed cancer evaluations on mammography reports and demanded NAH have dedicated breast radiolo­gists on staff who would detect abnormalities immediately.

“There are general radi­ologists who can do all aspects of radiology, and then there are physicians who go on to do addi­tional training,” DuPree said. “I followed every appropriate protocol within a health system to provide quality and safety for patients, which I did by getting breast imagers here and making certain things like that mandatory.”

Because of her insis­tence, fellowship-trained breast radiologists were brought on board in 2019 by Northern Arizona Radiology, contracted to work with NAH.

Dr. Michael Ulissey is board-certified in diagnostic radiology and specializes in breast imaging. He was an adjunct professor of radi­ology at the University of Texas Health Sciences Center, former director of breast imaging at the University of Texas Southwestern Medical Center in Dallas and ran the Parkland Hospital Comprehensive Breast Center.

He was hired in December 2019 by NAR along with two other radi­ologists who are board certified and subspe­cialty fellowship trained in breast cancer, breast imaging, and clinically oriented breast radiology. They were hired to do a quality review on 13,675 breast images previously screened from 2016 to 2019 from patients from NAH’s, Verde Valley Medical Center. Their findings of missed cancers on mammograms and 3D imaging were extensive.

“Between 2016-2019, we found significant, severe and sometimes crit­ical, unexplainable errors in judgment and clinical care,” Ulissey stated in reporting the final quality review results to NAH, their Board of Directors and NAR.

To provide women with the best health care recommendations, DuPree and Ulissey offered the following suggestions to help women become proactive in their health care choices.

• “Be the CEO of your health. There’s no one else in the world who is in charge of your health but you,” DuPree said.
• “Women must be honest when they feel something abnormal, and they need to speak up when they go in for their mammogram, DuPree stated. “If they have a family history of breast cancer or a genetic predisposition, they’ve got to be honest about their risk factors because they can essentially instigate a referral from their primary doctor or gynecologist to a breast surgeon for evaluation.
• “High-risk women need more than mammograms. Dense-breasted women need whole breast ultra­sound screening, and women at higher risk need to get MRIs.”
• “We’ve had women go in for mammograms and lie to the technolo­gist,” DuPree said. “When the technologist says, ‘Do you feel a lump in your breasts?’ ‘Have you had any changes in your breasts?’ ‘Do you have any nipple discharge in your breasts?’ ‘Do you have any dimpling in your breasts?’ These are all questions, and these are all signs that you can have cancer.”
• Both DuPree and Ulissey emphasized that women need to be proactive and ask who’s the person reading their mammogram. “Every woman has a right to ask if a dedicated breast imager is reading their breast imaging,” DuPree said. “If so, get the name. Go online, and you can check their credentials. You can see whether they did a fellowship or not.”
• “I would call the center and ask if the person who’s going to read my mammogram is fellow­ship trained in breast imaging and performing breast imaging pretty much 100% of his or her time,” Ulissey said.
• “Annual mammog­raphy is still the gold standard for early detec­tion. Thermography is not something that I recom­mend patients do as a screening tool,” DuPree said. “There are some women that want to get it as an adjunct, but it hasn’t been proven as effective as mammography for early detection, and there’s a lot of women in Sedona who get thermograms, but I’m not a proponent of it because it misses a lot of things.”
• “Currently, tomo­synthesis, called 3D mammography, is multiple short images taken sequentially and allows the breast imager to view the breast in almost a three-dimen­sional pattern,” DuPree noted. “It’s the best thing we have toward three-dimensionality. And it’s that tomosynthesis that allowed us to find things a lot earlier.”

“But the bottom line is, it needs to be read by someone who’s actually going to read the images, go back and compare those breast images to prior years, and who under­stands breast pathology extensively, which is why people do breast imaging fellowships or additional training,” DuPree said. “Breast imagers go into breast imaging because they want to identify cancers as early as possible so that patients have the best opportunity to treat cancer … we have better technology, but the better technology still requires a better-trained doctor to read it.”

Ulissey says reading a mammogram is what he calls “the 1,000 faces of normal.”

“If I show you an MRI of the brain — I can show you 100 brain MRIs,” he said. “If they are all normal, they all look the same. There might be a very tiny, normal variant difference in one or two of them, but essentially 100 brain MRIs that are all normal all look the same. One-hundred CAT scans of the abdomen that are all normal, all look the same; 100 CAT scans of the chest that are on the lungs and are all normal, all look the same. I can show you 1,000 mammograms — every one of them is normal. And every one of them looks different. That’s why I call it 1,000 faces of normal,” Ulissey stated.

DuPree and Ulissey agree that most OB-GYNs are not certified in reading mammography scans. “If you go in for a diagnostic mammogram, your [OB-GYN] will get a letter and you will get a letter [reporting the results of your mammo­gram],” Dupree said. “If a woman has something that feels abnormal, if they have a significant family history, if they have a genetic predisposi­tion, they should go to a breast surgeon for a clin­ical evaluation to ensure that they’re not missing something.”

• “Breast imaging mammography is a completely different animal than all the other areas of radiology,” Ulissey said.
• “I would ask if they do 3D mammograms and if they don’t do 3D, I would go somewhere else,” he stated.
• “Fear should never stop someone from getting a biopsy or an evaluation. If you get your mammo­gram and everyone says, ‘Oh, everything is fine,’ you can always ask to go see a breast specialist. You can always see a breast surgeon and get their opinion,” DuPree stated.
• “A mammogram only images about 80% of the [breast] tissue because you can’t pull your whole chest wall into the machine. So, you can miss about 20% of cancers because of the geography of where they are in the breast,” DuPree said.
• “I would ask the radiologist who read it to sit down with me and go through it,” Ulissey noted. “Because I don’t think an OBGYN doctor really would know how to read a mammogram. He or she might have some basic exposure to it and residency, but not to the detail you need to know what’s going on in mammograms.”
• Ulissey suggested that diet and exercise are key. “Maintaining ideal body weight and having a low-fat diet — the Mediterranean diet has been shown to reduce the risk of breast cancer. It doesn’t eliminate it,” he said.
• He also suggested going to a facility specializing in women’s imaging, mammograms, ultrasounds, MRIs and bone densitometry.

“A lot of people go to a hospital that does a little bit of everything,” Ulissey said. “So, you get a jack of all trades, but a master of none. In this day and age, you can send images to specialty centers with the beam of the internet. I don’t think there’s an excuse for women not being able to have their mammogram read by someone who specializes in only breast, radiology breast imaging and clin­ical breast radiology. We don’t yet have a specialty center in Sedona, the Verde Valley, or Flagstaff. But there are those types of centers in Phoenix.

“One of the best things women can do is to trust their intuition,” Ulissey said.