Featured Expert

Nagi Khouri, M.D., on Breast Cancer Diagnosis

Accounting for 1 out of 3 cancers diagnosed in women, breast cancer is still a devastating killer.  In the United States, among cancers, only lung cancer kills more women every year. In the fight against breast cancer, early detection can still make the difference between life and death.  To discuss the latest diagnostic tools available for early detention, we interviewed Dr. Nagi Khouri, Director of Breast Imaging in the Johns Hopkins Breast Center.  A graduate of the American University in Beirut, Lebanon, Dr. Khouri has dedicated his efforts since 1986 to researching new breast imaging techniques and to educating other professionals in the latest imaging techniques.

What are the risk factors for breast cancer?

Dr. Khouri:  At least 70% of breast cancers develop in women who have no known risk factor other than being a woman of advancing age. The occurrence of breast cancer starts becoming significant after the age of 40.  Higher risk factors for the development of breast cancer include family history such as breast cancer in a first degree relative. A personal history of breast cancer or a biopsy proven high risk tissue from a prior surgical biopsy are other risk factors. Hormonal factors, postmenopausal hormonal therapy and diet may also play a role.

Why are mammograms so important?

Dr. Khouri: Mammograms allow early detection of breast cancer long before a woman or her physician can feel it. Using high quality mammography, expert interpretation and with the proper screening frequency, the mortality of breast cancer may decrease by as much as 50%.  A number of studies carried out over the past 40 years, frequently with less than optimal mammography and with variable compliance by women, have shown a drop in mortality by factors ranging from 25 to 30%.

When and how often should women have mammograms?

Dr. Khouri:  For the general population, several professional organizations in the United States recommend annual screening with mammography every year after age 40.  The screening should consist of 2 views of each breast.  High-risk individuals may need to start screening at a younger age. In addition, every woman should have an annual clinical examination of the breast by a health care professional and should be familiar with her breasts (breast self-examination). She should report any changes to her physician.

How reliable are mammograms?

Dr. Khouri:  While mammography (traditional or digital) is the fundamental breast cancer screening tools it is important to remember that it is not perfect and that up to 15% of cancers may not be seen on a mammogram.  Other imaging modalities are available to supplement screening in high risk individuals or complement mammography in certain situations, such as the detection of a mass felt on examination or seen on a mammogram, or to evaluate the extent of a suspected malignancy to better plan the optimal surgical procedures.

What are those supplemental imaging modalities for the breast?

Dr. Khouri:  They include high resolution Breast Ultrasound (which is a fundamental part of breast imaging along with mammography), Breast MRI and Sestamibi Scintimammography for evaluation of the breasts. Also Positron Emission Tomography (PET scan) is used to evaluate possible regional lymph node involvement  in patients with a known primary breast cancer as well as for evaluation of possible distant metastases. We also use the PET scan to monitor treatment response in patients with locally advanced breast cancer being treated with chemotherapy.

Can you tell us about the research your Division of Breast Imaging at Johns Hopkins is involved in?

Dr. Khouri:  We are participating in a multi-institutional study to compare digital mammography to standard film mammography. We also are engaged in a study to evaluate the use of MRI in screening the contralateral breast in women recently diagnosed with breast cancer. Hopkins is also conducting a study to compare MRI and Whole Breast Ultrasound in breast cancer screening of very high-risk individuals.

What are the challenges to an effective breast cancer-screening program?

Dr. Khouri:  These challenges are numerous. First at all, it is key that we inform and educate women about breast cancer and about the benefits of mammographic screening. Part of that education also involved updating and training physicians. Many nations lack a national policy for breast cancer screenings and there is a huge need for more screening and diagnostic centers.

Specialized training is also needed in order for technologists, radiologists and surgeons to perform their tasks well. The fight against breast cancer requires learning how to image the breasts, detect abnormalities, diagnose them and perfect the surgical techniques for the treatment of breast cancer.

What lessons can be learned from the Hopkins and American approach to the diagnosis of breast cancer?

Dr. Khouri:  Breast cancer is a complex condition that requires the work of a team that includes the surgeon, the radiation therapist and the medical oncologist. But there are other members of that team who are also key and must be professionally trained and developed.  I am referring to the social workers, the physical therapists and the psychologists who play a very important role in educating and supporting comprehensive care for our patients.