For SBI Awardee: Face-to-Face Collaborations, a Challenge; New Modalities, Exciting Possibilities

April 14, 2021
Whitney J. Palmer

MD Anderson Cancer Center medical director shares her thoughts the priorities and challenges facing breast cancer detection and screening.

When it comes to breast cancer, imaging and preventive efforts go hand-in-hand. This year, through its Honorary Fellow Award, the Society of Breast Imaging recognized a provider who collaborates closely with imaging colleagues to bring the best level of care to women facing or receiving a breast cancer diagnosis.

Therese Bevers, M.D., is professor of clinical cancer prevention and medical director of the Cancer Prevention Center and prevention outreach programs at MD Anderson Cancer Center. In addition to overseeing the first comprehensive clinical cancer prevention service program that opened in 1996, she concentrates her efforts of breast cancer prevention, screening, and diagnosis.

For additional Society of Breast Imaging conference coverage, click here.

Diagnostic Imaging spoke with Bevers about what she sees as the main priorities in the fields surrounding breast cancer, as well as the main challenges that exist and what the future brings with imaging.

Diagnostic Imaging: How did you become interested in breast cancer prevention and screening? What was in your background or your education that led you to want that to be your focus?

Bevers: Interestingly, my background and my board certification is in family medicine. Prevention is a big component of primary care, and I eventually went into preventive medicine as a field of practice. Then, I was hired by MD Anderson to run the newly opened Cancer Prevention Center in 1996. That's when I really focused my career on cancer prevention, screening, and diagnosis. The natural area for me was breast cancer prevention and screening and diagnosis. I quickly became involved in the breast cancer prevention trial, which was the trial of tamoxifen versus placebo, that showed that tamoxifen reduced the risk of developing breast cancer by one-half. That just naturally led to expanding my career in the field of breast cancer prevention, screening, and diagnosis. I don't do any treatment – my background is primary care. Although, I have become a specialist in the field of preventive medicine and cancer diagnosis.

Diagnostic Imaging: What do you consider to be your most significant contributions to the field surrounding breast cancer?

Bevers: I think my biggest contribution has been in a leadership role largely through the National Comprehensive Cancer Network (NCCN), but through other entities, as well. That's my biggest area where I have led the breast cancer screening and diagnosis guideline panel that talks about how we should screen women at average and increased risk, and how we make the right diagnosis. Then, I also chaired the breast cancer risk reduction guideline panel, which talks about how to reduce a woman's risk of developing breast cancer, not only through tamoxifen and Raloxifene and aromatase inhibitors, but also through healthy lifestyle changes and for very high-risk women through prophylactic mastectomy.

I feel that my biggest contribution has been through that arena because I feel that as far as breast cancer risk reduction, I have helped to lead practice-changing guidelines there in the field of breast cancer screening. I, along with SBI and the American College of Radiology, have really endorsed, strongly supported, and being very vocal about the importance of beginning annual mammograms at age 40. The U.S. Preventive Services Task Force really recommends biennial or every other year mammograms beginning at age 50. I think if COVID-19 does nothing else, it shows us the error of going to every other year. Many women have not gotten their screening during COVID-19. So, some of their intervals have stretched out two years, and we are seeing more advanced diagnosis of breast cancer. I feel very strongly that the data supports getting an annual mammogram beginning at age 40.

So, the SBI and ACR are very vocal about that, along with my co-chair of the NCCN panel. Having said that, I would like to note that I think it is the members, many members of SBI, who have really taught me all that I know about screening mammography and the data supporting annual beginning at age 40.

Diagnostic Imaging: What are the most significant challenges you see facing efforts for breast cancer prevention, screening, and detection?

Bevers: For screening, it's that there are a number of different recommendations out there that just simply confuse women. Women don't know what to do, and when you don't know what to do, many people take the action of not doing anything. That concerns me, and I wish that we had a more unified voice for breast cancer screening, unfortunately, we don't.

I am very blessed in the institution that I work in that I get to work literally across the hallway from our breast imagers. I get to have daily one-on-one interactions with them about the symptoms a woman presents with the clinical findings that I identify and what their imaging findings are. We get to approach it collaboratively. Unfortunately, in the real world, out in the community, that doesn't get to happen often. That’s the biggest challenges for many clinicians who are trying to do the best that they can for women in making appropriate recommendations and making an accurate diagnosis. They just don't have that one-on-one collaboration with their breast imager.

Diagnostic Imaging: What do you see as the main priorities in the field today or 5-to-10 years out?

Bevers: Looking at new ways of screening for breast cancer, we have seen huge advances. I remember when I started at MD Anderson, there was a huge film library dedicated just to mammograms and breast imaging studies. Now, that film library has gone to the wayside and we have digital images. We now have expanded into tomosynthesis – in street lingo called 3D mammography – where we're actually getting images of the breast in slices like a CT scan would do. One other modality that has come since I started practicing 25 years ago is being able to offer women breast MRI if they're at high risk of developing breast cancer. That wasn't something we offered when I started in the field in 1996. But, now, it's codified in the NCCN and American Cancer Society recommendations for women at increased risk of breast cancer.

We’ve already made great strides that helped us to improve imaging. But, there are so many new modalities out there that are coming down the pipe. Areas I think that we will see continue to grow, at least in the field of imaging, would be contrast enhanced mammography where not only do we get the images, but we get functional information if contrast is injected. Is there a role for molecular breast imaging in screening? Maybe, maybe not. It has a higher dose of radiation. So, that's a bit of a concern. Certainly, it is an opportunity in the diagnosis of breast cancer because it gives functional information, especially for women that can't do MRI whether due to claustrophobia or body habitus. we're seeing more and more imaging modalities.

There's a lot of interest in identifying the Holy Grail of tumor markers in the blood that would identify women at risk for developing breast cancer or women that actually have breast cancer. If we had a tumor marker in the blood or saliva or whatever body fluid that we use, that allows us to move away from mobile mammography vans and brick-and-mortar buildings out to maybe a mall or a health fair where we could draw blood or get the saliva specimen. Then, we could circle back to that woman and say, “Hey, you're okay,” or the next woman and say, “We're a little concerned with what we saw. We need to get you in now for the imaging and do a workup to see if there is actually something going on.”

Diagnostic Imaging: For you, in your career, what’s on the horizon? What is your next endeavor or area of focus?

Bevers: I intend to continue with NCCN and leading those two guideline panels. I think there's a lot of opportunity. I have seen our NCCN and breast cancer screening and diagnosis guideline panel grow from a few pages to now close to 30 pages, We encompass not just the straightforward screening of average risk women and the diagnosis of just breast masses and nipple discharge, etc., but to encompassing more rare conditions like anaplastic large cell lymphoma (LCL), breast implant associated LCL, as well as breast cancer in men and breast pain imaging in the pregnant and lactating woman. That’s a big interest for me – being able to take what experts know and what the data has shown and being able to put it in a recommendation or a guideline such that community physicians can easily access it and say, “Ah, I should do that. I didn't think of that.”

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