Herceptin Therapy

• I’ve heard that the drug Herceptin has shown even more promise than originally thought in treating breast cancer.
  
• Will this drug be used to treat more women with breast cancer?
  
• Is the treatment for everyone?
  
• How does Herceptin work?
  
• How does a woman know whether or not she is HER2 positive?
  
• Does Herceptin cure breast cancer?
  
• Are there risks to using Herceptin?
  
• How is the Herceptin therapy administered?
  
• What are the side effects of Herceptin?
  
• Does this mean women with breast cancer don’t need chemotherapy?
  
• How do I know which therapy is right for my treatment?
  
• Where can I learn more about Herceptin?

Q: I’ve heard that the drug Herceptin has shown even more promise than originally thought in treating breast cancer.

A: Yes, a recent editorial in the New England Journal of Medicine reported promising news about Herceptin(trastuzumab), an antibody used with chemotherapy for breast cancer treatment. Major clinical studieshave shown that certain high-risk patients (with stage 2 cancer) who use the drug early in treatmenthave a 52 percent decrease in breast cancer recurrence compared to patients who received chemotherapyalone.

Q: Will this drug be used to treat more women with breast cancer?

A: Yes. It had been recommended only for metastatic cancer (cancer that has spread from its original site). Now, Herceptin is recommended for newly diagnosed breast cancer, too.

Q: Is the treatment for everyone?

A: No. Only about 25 percent of breast cancer patients are eligible for Herceptin therapy. These women have tumors with too much of a cell protein called HER2 (human epidermal growth factor receptor 2). HER2 may play an important role in turning a normal cell into a cancer cell. HER2 is also associated with a more aggressive cancer and higher risk of breast cancer recurrence. Women must test positive for the HER2 protein or gene to be treated with Herceptin.

Q: How does Herceptin work?

A: Herceptin (trastuzumab) is a biologically engineered product that takes advantage of the ability of antibodies to latch on to specific proteins. Herceptin prevents the growth of cancer cells by attaching to and neutralizing the growth effect of HER2, a protein on the surface of breast cancer cells that stimulates their growth. Not only does Herceptin block tumor cell growth, it may even signal the body’s immune system to destroy the cell.

Q: How does a woman know whether or not she is HER2 positive?

A: Doctors should check for HER2 at the time of diagnosis to determine whether or not cells are expressing the protein. Also, they can perform yet another test that detects the HER2 genes inside the cells. Patients who want their tumor’s HER2 status checked should ask their doctor to have testing done at the time of biopsy or surgery, although tests also can be done on a tumor sample that is stored..

Q: Does Herceptin cure breast cancer?

A: It is possible and likely that Herceptin therapy has cured some patients with early stage breast cancer. Over the last 10 to 15 years the breast cancer mortality rate has dropped significantly. But there is no way to know for sure, because not enough time has elapsed since the antibody therapy was first introduced.

Q: Are there risks to using Herceptin?

A: When using Herceptin with chemotherapy, there is a small increase in the risk of congestive heart failure. The risk increases from less than 1 percent with chemotherapy alone to 3 to 4 percent with the combination therapy. Doctors recommend that patients using Herceptin have regular heart function tests. But for HER2-positive women, the risk of congestive heart failure is low compared to the risk of breast cancer reoccurrence.

Always talk with your doctor about the drugs you are currently taking and your risks.

Q: How is the Herceptin therapy administered?

A: Herceptin is a clear liquid administered through an intravenous (IV) infusion at a doctor's office or clinic. The first infusion usually takes about 90 minutes but may be slowed or stopped if patients have discomfort from side effects. Later infusions last only about 30 minutes.

Q: What are the side effects of Herceptin?

A: For the vast majority of patients, there are no major side effects. Antihistamines are provided to prevent any allergic reaction. In clinical trials, some patients experienced flu-like symptoms such as chills, fever and nausea during the first infusion, but symptoms occurred less frequently with subsequent infusions.

Q: Does this mean women with breast cancer don’t need chemotherapy?

A: No, Herceptin is intended for use in conjunction with chemotherapy, not as a replacement. It has been shown that the combination of Herceptin and chemotherapy is more successful in early stage breast cancer than receiving either therapy alone. In the clinical trial, patients continued to receive Herceptin after their planned chemotherapy was stopped for a year of total Herceptin treatment. Patients being treated for metastatic disease may stay on Herceptin longer. Talk to your doctor about how long you should stay on Herceptin therapy.

Q: How do I know which therapy is right for my treatment?

A: Cancer treatments are becoming more individual and targeted , so each person’s treatment may vary. You should educate yourself about the latest methods so that you can discuss them with your doctor. For example, anti-estrogen therapy is indicated for women with estrogen sensitive breast cancer (cancers that test positive for the estrogen receptor. In addition, another antibody called Avastin (bevacizumab) is used with the chemotherapy agent Taxol for patients with metastatic breast cancer. While Herceptin will be recommended for treatment of newly diagnosed breast cancers that express the HER2 protein, Avastin is recommended now only for women with advanced breast cancer.

Q: Where can I learn more about Herceptin?

A: www.herceptin.com

Antibiotic Use and Breast Cancer

Q: Are antibiotics another risk factor for breast cancer?

A: Not necessarily! The Journal of the American Medical Association has reported a study linking high use of antibiotics with increased risk of breast cancer.

The use of antibiotics, which can change the bacterial environment of the intestinal tract, has been theorized to affect cancer risk by disrupting the protective effect of bacteria on food products that could potentially be cancer causing. Reported in the February 18th issue of JAMA is a study from the University of Washington, Seattle, which describes an association between use of antibiotics and increased risk of breast cancer. The risk increased with increasing use of antibiotics, up to a doubling of risk for women who had more than 25 antibiotic prescriptions or who took antibiotics for at least 501 days over an average of about 17 years.

Before women stop taking antibiotics appropriate to the infection being treated, it is important to understand the limitations of this study. First, the group with increased numbers of breast cancer also had an increase in the number of women at risk for developing breast cancer in the first place. These risk factors include:

• higher education status
• use of oral contraceptives
• early first menstrual periods
• having first child over 30 years of age
• positive family history of breast cancer
• obesity

Second, the study reported lower mammography rates among the control group, which could have underestimated the number of breast cancers because they were not detected prior to the study. Third, the study reports an association, not a cause and effect.

Studies of this type are important because they raise questions that will be tested in the future. However, additional research will be required to confirm the results found in this observation.

Luther Rhodes, M.D., Lehigh Valley Health Network's chief of infectious diseases, has also carefully reviewed the studies just published on antibiotics and possible risk for breast cancer. He is very concerned that people who have breast cancer or are worried about a reoccurrence of cancer might assume that a recent or past course of antibiotics will put them at risk of cancer. The medical science on this topic if far from conclusive . The studies just published are an important avenue for further study, but are not intended to be the final word. Just a few years ago, there were articles trumpeting an association of coffee consumption and various cancers which caused cancer patients ( and coffee drinkers) allot of anxiety and guilt. Those articles have subsequently been proven false. The message for patients today is not to use a fear of cancer as a reason not to take a necessary antibiotic. Discuss your concerns with your physician or nurse practitioner.

Making Decisions About Breast Cancer Treatment

When my mother-in-law had breast cancer 36 years ago, she had a mastectomy and removal of all lymph nodes under her arm. Chemotherapy, radiation and follow-up hormone therapy weren’t options then. Her only choice was whether or not to have surgery.

How things have changed! When I was diagnosed with breast cancer last year, I was faced with a lot of decision-making. “Now, surgery is just the first step,” says oncologist Gregory Harper, M.D., of Lehigh Valley Hospital and Health Network. “Our main focus is not simply to remove the cancer but to prevent it from recurring.”

Thanks to better detection methods, cancers are found much earlier (and smaller) now than when my mother-in-law was diagnosed. That means most women—including me—only need a lumpectomy and radiation. I didn’t have to deal with losing a breast. But my doctors and I did have a lot of choices to make.

Cancers vary widely, and treatment choices depend on the stage and characteristics of your particular cancer. Besides surgery, the options today include: chemotherapy, before the surgery to shrink the tumor and/or afterward to eliminate any stray cancer cells; radiation after surgery, to kill any cancer cells left in the breast; hormone therapy (for estrogen-sensitive cancer) to reduce the chances of the cancer recurring.

Because there were microscopic cancer cells in my lymph node, the doctors recommended chemotherapy. My heart sank; I was prepared for five weeks of radiation after surgery, but not for 12 weeks of chemo. Ultimately, I did decide to go ahead with it.

Here’s how I worked through my decision-making process:

I took time to absorb it all, resisting my usual impulse to decide quickly and “get on with it.” I wrote in my journal, acknowledging my initial anger and budding hopefulness. I meditated to calm my mind and spirit. I prayed.

I involved my family and friends. They were all willing to listen as I talked things through. “Even women with supportive partners often need someone else to help them process everything,” says Diane Brong, clinical social worker for the cancer support team at Lehigh Valley Hospital and Health Network.

I called women I knew who are survivors. They all shared their experiences and gave me hope.

I chose to be positive and hopeful. That helped me be an active member of the team that would see me through treatment.

I began considering myself a survivor soon after I was diagnosed. Today—healthy and energetic and with a new covering of thick, but very short hair—I feel empowered to handle any future crisis. I’m looking forward to my mother-in-law’s 84th birthday, when we’ll celebrate her many years as a survivor.

Besides those named, we thank the other professionals who served as resources for this story: Lorraine Gyauch, R.N., Support of Survivors Helpline; Neddy Mack, R.N., program director, Breast Health Services; Dorothy Morrone, R.N., Breast Cancer Consultative Service coordinator.

Who’s Interpreting Your Mammogram?

You know you need to schedule a yearly mammogram beginning at age 40* for early detection of breast cancer. But that’s only the beginning. It’s also important to consider the skill of the radiologist who reads your mammogram.

Your radiologist should have the experience and eye to recognize subtle signs, says oncologist Gregory Harper, M.D., of Lehigh Valley Health Network. “The most serious changes can be the most difficult to find,” says Kenneth Harris, M.D., a breast radiologist at the hospital. “We look for masses, distortions, irregular patterns and pin-sized calcifications, comparing current and previous studies to find even the smallest changes early.”

To ensure you’re getting an expert reader, ask these questions when scheduling your mammogram:

Is the radiologist certified by the American College of Radiology and the U.S. government’s Mammography Quality Standards Act?

Is the radiologist a breast specialist? “Some radiologists evaluate brain scans one day, breast scans the next,” Harris says. “Look for someone who specializes in breast imaging.”

Is the radiologist highly experienced? National standards require radiologists to read at least 470 scans a year. Harper advises looking for a radiologist who evaluates at least 1,000 a year.

Will the radiologist use the latest technology? If your mammography center is equipped with digital mammography, the radiologist can read sharper images and manipulate them more easily. “Digital images also detect changes earlier in the dense tissue of women younger than 50,” Harris says. In mammography centers with computer-aided detection, the radiologist takes advantage of an additional computer-aided reading to ensure all areas of concern have been identified and addressed.

Is there a team of breast health specialists? Radiologists benefit from collaborating with other radiologists, breast oncologists, surgeons, genetic counselors and nurse specialists to ensure you’ll get the best results.

*You may need earlier mammograms if you’re at high risk for breast cancer; ask your doctor.

Breast MRI

• I read that the American Cancer Society (ACS) is now recommending breast MRIs as well as mammograms for women at high risk for breast cancer. How do I know if I need a MRI?
• If a woman has been recently diagnosed with breast cancer after a mammogram, why would she need a MRI?
• So why not just do MRIs on everyone?
• Will insurance pay for a MRI?
• Do MRIs have a high rate of false positives?
• Are there other uses for breast MRI?

Q: I read that the American Cancer Society (ACS) is now recommending breast MRIs as well as mammograms for women at high risk for breast cancer. How do I know if I need a MRI?

A: An annual mammogram remains the best screening method for most women, but if you are at high risk, or if you have been recently diagnosed with breast cancer, MRI is an effective addition to your evaluation.

If your lifetime risk for developing breast cancer is more than 20 percent, the ACS recommends an annual MRI. If genetic testing determines you have certain mutations (BRCA), you also are a candidate. If your family has a high rate of ovarian and breast cancer, you should have annual MRIs, even if genetic testing is negative. If you had radiation to your chest area between ages 10-30 for treatment of other disorders, such as Hodgkin's Lymphoma, you are a candidate. Also, if you have other rare high-risk syndromes (Cowden or Li-Fraumeni) you should have annual MRIs. Our Cancer Risk Assessment Program can help you with risk assessment using models that are based on the health history of you and your family.

When annual screening is recommended in these situations, we will advise you to stagger the imaging so you will have mammography in one month and the MRI six months later. You would then have a screening every six months.

As of now, there is not sufficient evidence to recommend a yearly MRI if you have a personal history of breast cancer or dense breast tissue, as long as your risk for developing cancer is less than 20 percent. If you have breast cancer, talk to your cancer physician to determine if you are a candidate for MRI evaluation.

Q: If a woman has been recently diagnosed with breast cancer after a mammogram, why would she need a MRI?

A: MRI is useful in determining the extent of disease in a breast where cancer is suspected or diagnosed. In addition, in a recently published study, MRIs found cancer (undetected by a mammogram) in the opposite breast of 3 percent of women already diagnosed with breast cancer. Detecting cancer in the other breast enables women to have definitive treatment of both cancers at the same time. In addition, a woman who knows the opposite breast is cancer-free by MRI can be reassured that a preventive mastectomy for the healthy breast is not necessary.

Q: So why not just do MRIs on everyone?

A: MRI evaluation is useful in newly diagnosed breast cancer to determine the extent of disease in the involved breast and evaluate for the presence of disease in the opposite breast. MRI is useful to screen selected women at high risk for developing breast cancer. MRI is not useful for screening women at average risk for breast cancer, or women with mostly fatty tissue in the breast. In addition, insurance companies will not pay for screening MRIs unless specifically indicated.

Q: Will insurance pay for a MRI?

A: A MRI costs 10 times as much as a mammogram, but most insurance companies will pay for it when your doctor shows it is necessary for the reasons listed.

Q: Do MRIs have a high rate of false positives?

A: MRIs can have a high rate of false positives. However, in centers like Breast Health Services at Lehigh Valley Hospital, where radiologists are experienced in reading MRI studies, false positives are fewer. If your doctor recommends a breast MRI, it is important to have it done by an experienced, on-site professional staff that can correlate your physical examination, your digital mammogram, and perhaps an ultrasound with your MRI.

Q: Are there other uses for breast MRI?

A: Yes. For the past few years at Lehigh Health Networkl, we have been using breast MRI for staging newly diagnosed cancer to see if it has spread within the breast or to the opposite breast, and to determine the extent of cancer within the breast. MRIs also are helpful in looking for ruptured silicone breast implants, differentiating scar tissue from recurrent cancer or determining if chemotherapy is working. We also use MRIs in difficult situations when mammography and/or ultrasound does not explain the clinical findings.

Evista for Prevention

• I heard the drug, Evista may reduce the risk for breast cancer—is that true? Who can benefit from this medication?
• Who is considered at high risk?
• Is Evista as effective as tamoxifen in reducing breast cancer risk?

Q: I heard the drug, Evista may reduce the risk for breast cancer—is that true? Who can benefit from this medication?

A: U.S. Food and Drug Administration (FDA) approved Evista (the brand name for raloxifene previously used to treat osteoporosis) to help prevent breast cancer in postmenopausal women who are at high-risk for the disease. If you think you’re at increased risk for breast cancer, you should talk with your doctor about whether or not this medication—if any—is right for you.

Q: Who is considered at high risk?

A: Risk factors for women at high risk include those who are age 50 or over, have a family history of breast or ovarian cancer on mother’s or father’s side (especially first-degree relatives like mother, sister or daughter), previous breast biopsies (especially if the biopsy revealed any precancerous changes) and certain reproductive factors such as menstruation before age 12 or menopause after age 55, and no children or first child after age 30. Additional risk factors may include several years of hormone replacement therapy (especially combined estrogen/progesterone), alcohol use (risk rises with daily amount consumed), obesity, high-fat diet and lack of exercise (especially after menopause).

Q: Is Evista as effective as tamoxifen in reducing breast cancer risk?

A: Results from the Study of Tamoxifen and Raloxifene, or STAR, which included participation of 19,000 postmenopausal women who are at increased risk for breast cancer, showed that raloxifene was just as effective as tamoxifen in reducing the number of invasive breast cancers. Even better, raloxifene didn’t appear to cause as many serious side effects, such as uterine cancer or blood clots. And for women with osteopenia or osteoporosis, Evista also will help to improve bone density.

To Your Health

Protect Yourself and Your Family From MRSA

You’ve likely heard news reports about MRSA (methicillin resistant staphylococcus aureus), a type of bacterial infection resistant to some antibiotics. Cases have been reported in our region, including among school athletes.

MRSA is preventable with good hygiene, says infectious disease specialist Luther Rhodes, M.D., of Lehigh Valley Health Network. “Regular hand-washing and alcohol-based hand sanitizers are a proven defense,” he says. “Also, clean any wounds with hot, soapy water and apply a bandage immediately.” Another tip: wash your clothes regularly. (Clothing is a potential carrier of bacteria.) For more details, call 610-402-CARE.

New Insights on Colon Rectal Cancer

Researchers at Lehigh Valley Health Network are collaborating with other members of the Penn State Cancer Institute to determine if a combination of genetics and lifestyle factors—including smoking tobacco and consuming overgrilled red meats—can lead to colon rectal cancer. The incidence and death rates from this cancer in a six-county region are high compared to the rest of Pennsylvania and the nation. “We’re trying to figure out why,” says oncologist Gregory Harper, M.D., the study’s medical director. The goal: preventing colon cancer in the future.

Health Risks for Shift Workers

Can working the night shift raise your risk for breast or prostate cancer, as suggested in a report from the World Health Organization? It might, says occupational medicine physician Carmine Pellosie, D.O., of Lehigh Valley Health Network: “People who work rotating or night shifts or often travel across time zones may suffer circadian (sleep) rhythm disturbances that affect the body’s production of the hormone melatonin. This can lower immunity and raise cancer risk.” Reduce the detrimental effects by:

• Getting bright light exposure at work.
• Getting at least eight hours of sleep in a darkened room.
• Avoiding caffeine and alcohol for 4-6 hours before bedtime.
• Getting regular exercise and eating a healthy diet.
• Asking your doctor about melatonin supplements.

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Published from Healthy You Magazine, March-April 2008

Chemotherapy Before Breast Cancer Surgery?

When your doctor tells you you have breast cancer, your first impulse is to get rid of that tumor. Hold on! As Jill Kardos discovered, an immediate surgery isn’t always the best treatment.

The 36-year-old Hellertown woman was diagnosed in October 2006. She used Lehigh Valley Hospital-Cedar Crest’s Breast Cancer Consultative Service to help her decide on a treatment course that began with eight rounds of chemotherapy to shrink her tumor. By the time of her lumpectomy the following May, the tumor had disappeared. Just to be sure, her surgeon removed some nearby tissue and lymph nodes—and it all tested negative.

“I felt the tumor begin to shrink after the third round of chemotherapy,” Kardos says. “I was thrilled, because it confirmed that the treatment was working.”

Traditionally, breast cancer patients receive chemotherapy after their surgery, to kill any remaining cancer cells. “The main advantage to doing chemotherapy first is that it gives more women the option of a breast-saving lumpectomy rather than a full mastectomy,” says Gregory Harper, M.D., oncologist at Lehigh Valley Health Network.

For women whose biopsy reveals cancer in the lymph nodes or whose cancer has spread, starting chemotherapy immediately (instead of waiting until a month after surgery) is a definite advantage. The chemotherapy targets both the breast tumor and any microscopic cancer cells that may have escaped the breast.

“Research over the past several decades has helped us analyze various types of breast cancer,” Harper says. “We now can tailor the treatment to the individual patient based on her heredity, menopausal status, the stage of her tumor and whether it’s receptive to hormones or proteins that promote cancer growth.”

In tumors that are “estrogen- or progesteronereceptor- positive,” those hormones stimulate the tumor’s growth, and anti-estrogen therapy (with tamoxifen, for example) is effective. In tumors coated with a specific tumor-stimulating protein, treatment involves neutralizing that protein.

Kardos’ tumor was of a type called “triple negative”— not hormone-receptive and not coated with the protein. Chemotherapy is especially effective in cases like hers.

Before her diagnosis, Kardos was unaware that there are many different ways of being treated for breast cancer. “Knowing what type of tumor you have and following the advice of your physicians can really help you through this difficult time,” she says. “I feel fantastic now, and I’m looking forward to the rest of my life cancer free.”

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Published from Healthy You Magazine, May-June 2008

To Your Health

Young Women and Epilepsy

Adolescence is a trying time for girls and their parents, and it becomes even more so when the teen is coping with epilepsy, or seizure disorder. For example, young women may have more seizures during the menstrual cycle, or when they don’t get enough sleep. Epilepsy can affect bone health and complicate decisions on oral contraceptives. Get an indepth look at how epilepsy affects women throughout life at an educational conference Sept. 13. Call 610-402-CARE.

New Drug for Breast Cancer

A recent study suggests that for breast cancers that carry a protein (HER2) promoting cancer cell growth, the new drug lapatinib may be a wise choice. “Chemotherapy alone may leave ‘chemo-resistant’ cells that can lead to cancer regrowth,” says oncologist Gregory Harper, M.D., of Lehigh Valley Health Network. “But lapatinib combined with chemotherapy appears to inhibit the growth of the stem cells which produce the cancer.” That lowers the risk for recurrence. Harper and his colleagues are using lapatinib to treat women whose cancers would benefit from it.

Recognizing its overall commitment to cancer care, Lehigh Valley Health Network was recently designated a Blue Distinction Center for the treatment of complex and rare cancers.

Breast Self-Exams

• I heard recently that breast self-exams don't do any good. Is that true?
• What benefit do breast self-exams have?
• I think I felt a lump in my breast during a self-exam. What should I do?
• When should I do a breast self-exam?
• How should I perform a breast self-exam?
• What can I do to lower my breast cancer risk?

Q: I heard recently that breast self-exams don't do any good. Is that true?

A: There was a study recently that generated a lot of media attention surrounding the usefulness of breast self-exams. The bottom line is the study showed breast self-exams in the absence of other screenings like mammograms don't make a difference in mortality rates. More than 80 percent of breast lumps discovered by women are not cancerous. While it's important to be aware of how your breasts feel, getting regular mammograms is much more important than doing breast self-exams. This study shows you cannot rely on breast self-exams alone.

Q: What benefit do breast self-exams have?

A: Breast self-exams are useful as a tool for awareness. You should be aware of any changes that occur in your breasts and report persistent changes to your physician.

Q: I think I felt a lump in my breast during a self-exam. What should I do?

A: You should report persistent changes to your physician. He or she can then advise you on next steps. It's better to be examined and given a clean bill of health than to wait too long before seeing your physician.

Q: When should I do a breast self-exam?

A: If you use breast self-exams for a self-awareness tool, there are some general guidelines you can follow. For menstruating women, a breast self-exam should be done at the same time each month after the menstrual cycle. Post-menopausal women can perform the exam whenever they want. Please remember that even with a normal breast self-exam, you still need a mammogram. All women age 40 and older need to stay vigilant about getting their annual mammograms.

Q: How should I perform a breast self-exam?

A: The technique ("circular" vs. "rows") isn’t as important as consistency (doing it the same way each time). You need to know how your breasts feel so you can detect changes. If you are unsure of where to start, Breast Health Services can teach you how to perform a breast self-exam.

Q: What can I do to lower my breast cancer risk?

A: Breast self-exam is a useful tool, but you should not rely solely on it. Mammography is absolutely essential. If you believe you're high risk for developing breast cancer you can take advantage of the health network's cancer risk assessment program to help you learn more about hereditary risk factors.

Key Decisions in Cancer Treatment

Cancer is a scary reality that more than six in 10 people over age 65 eventually face. If you’re diagnosed, you’ll face tough treatment decisions. You should know age is not the primary decision-making factor. “But age-related issues do add to the complexity,” says oncologist Gregory Harper, M.D., of Lehigh Valley Health Network.

When faced with a cancer diagnosis, ask yourself: How do I want to spend the next part of my life? Then talk to your family and doctors. You may want aggressive treatment to gain enough time to attend a granddaughter’s wedding. Or you may choose to receive hospice care at home with your loved ones.

Know Who is Reading Your Mammogram

If you’re approaching 40, you know you need to schedule a yearly mammogram for early detection of breast cancer. It’s also important to consider the skill of the radiologist reading your mammogram. Your radiologist should have the experience and eye to recognize subtle signs of breast cancer, says medical oncologist Gregory Harper, M.D., of Lehigh Valley Health Network.

To make sure you’re getting a qualified radiologist, ask these questions:

• Is the radiologist certified by the American College of Radiology and the U.S. government’s Mammography Quality Standards Act?
• Is the radiologist a breast specialist?
• Is the radiologist highly experienced?
• Will the radiologist use the latest technology?
• Is there a team of breast health specialists?