Inkwell: Authors and Artists
Topic 394: Carole Berlin, "What You Should Know Before Your Next Mammogram"
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #26 of 141: David Albert (aslan) Fri 15 Oct 10 03:32
permalink #26 of 141: David Albert (aslan) Fri 15 Oct 10 03:32
Is the mortality rate for DCIS much higher than for prostate cancer?
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #27 of 141: Travis Bickle has left the building. (divinea) Fri 15 Oct 10 04:26
permalink #27 of 141: Travis Bickle has left the building. (divinea) Fri 15 Oct 10 04:26
David, a casual lit search suggests that this is kind of an impossible question.
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #28 of 141: David Albert (aslan) Fri 15 Oct 10 09:30
permalink #28 of 141: David Albert (aslan) Fri 15 Oct 10 09:30
Ok, then my original question may have additional answers. My real question is whether at least some of the reason has to do with the fact that one set of tests is for women and the other set is for men, and whether gender issues have anything to do with it. We are not that many decades away from the doctors saying, "Your wife is being admitted for a double mastectomy, but don't tell her until it's all over."
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #29 of 141: For Rosetti, wombats held a peculiar fascination (loris) Fri 15 Oct 10 09:32
permalink #29 of 141: For Rosetti, wombats held a peculiar fascination (loris) Fri 15 Oct 10 09:32
i wonder if folks will look back at the epidemic of overly-aggressive treatment of breast cancers as the equiv of the rush to give women hysterectomies that was so common years ago. and carole, thanx for validating my instinctive refusal of constant mammograms. it just did not make sense to me to constantly expose tissue to radiation
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #30 of 141: Travis Bickle has left the building. (divinea) Fri 15 Oct 10 09:41
permalink #30 of 141: Travis Bickle has left the building. (divinea) Fri 15 Oct 10 09:41
David, if anything, gender differences in surveillance and treatment trend the opposite way. There are risks associated with routine mammograms, to be sure, but at this point,
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #31 of 141: Travis Bickle has left the building. (divinea) Fri 15 Oct 10 09:42
permalink #31 of 141: Travis Bickle has left the building. (divinea) Fri 15 Oct 10 09:42
[oops], I'm quite comfortable that the risks of skipping them are a lot higher.
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #32 of 141: It's all about the margins (gail) Fri 15 Oct 10 11:37
permalink #32 of 141: It's all about the margins (gail) Fri 15 Oct 10 11:37
DCIS is a very odd diagnosis indeed. When I was diagnosed about 15 years ago, the wisdom of the time was that: There were carcinoma cells in the milk ducts, DCIS stands for ductal carcinoma in situ as I recall, but by definition the rebel cells had not formed tumors yet. They might form tumors (since I was young, they might form them fast, and in young dense tissue I might not notice them while they were small, but I was told I could just watch and wait if I wanted to defer treatment. I had been avoiding mammograms for reasons of radiation until the diagnosis, but "just watching" in cooperation with the oncologist at that time involved frequent mammograms, and was scary in it's own way.) Sice it was extensive, when/if they did, there would likely not be a clear margin for a lumpectomy. DCIS is found in autopsies of many older women who die of other causes, as Carole said, having caused no tumors or ill health, but the variations of rate of growth was not then known, so that information was hard to interpret. The DCIS diagnosis was called "stage zero cancer" since there was not any actual tumor. (But insurance company rate setters still interpret that as a regular cancer diagnosis I am told.) Since it was in all quadrants of the breast, and seemed to be advancing according to the hard-to-read experimental MRI, in my case it turned out that clear margins could not be possible without a full mastectomy. Since DCIS is stage zero, surgery without any radiation or chemo often suffices to end the saga, and was suggested to me. By that time -- having taken a full year to research, try other approaches, and think it through, I saw that as lucky. Surgery only - and no lymph nodes taken - such a deal. However, there is always the question of what if anything would have happened without surgical treatment, even with my DCIS known to be spreading. What a weird condition. That was what one DCIS diagnosis was like, in the mid 1990s.
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #33 of 141: It's all about the margins (gail) Fri 15 Oct 10 16:58
permalink #33 of 141: It's all about the margins (gail) Fri 15 Oct 10 16:58
Hope that was not too much, uh, detail. Meanwhile, an article about which research to pay attention to: "Theres error and theres error. Its one thing to be wrong about low-impact treatments: to be wrong, for instance, about how much a low-impact drug like aspirin or glucosamine helps modest knee pain in athletes, or how much benefit you get from walking versus running, or whether coffee makes your smarter or just makes you feel smarter. The stakes run much higher when the treatments cost a lot in money or health. Yet little in our regulatory, medical, or journalistic cultures or practices acknowledges that." <http://www.wired.com/wiredscience/20/10/10/how-to-set-the-bullshit-filter-when -the-bullshit-is-thick/>
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #34 of 141: David Albert (aslan) Fri 15 Oct 10 17:34
permalink #34 of 141: David Albert (aslan) Fri 15 Oct 10 17:34
But here, we don't know whether the error would be in cutting out mammograms -- because they really do save lives, we know that -- or in continuing them, because of the radiation risk or other factors that could cost some number of lives as well. Ultimately, if Carole's main point is that people should be as well informed as possible before making decisions, I'm all for that. But there comes a point where there is information overload as well. I do not want to go back 30 years to the very real scenario I painted above, but I also think that it isn't too much to ask that patients be able to trust an expert in the field, maybe get a second opinion, and then make a decision already so they can move on with their lives.
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #35 of 141: David Albert (aslan) Fri 15 Oct 10 17:36
permalink #35 of 141: David Albert (aslan) Fri 15 Oct 10 17:36
(If that is what they want, of course. For some patients, reading everything ever written on the subject before making decisions is *exactly* the right choice. But not for all.)
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #36 of 141: Carole Berlin (caroleberlin) Fri 15 Oct 10 18:55
permalink #36 of 141: Carole Berlin (caroleberlin) Fri 15 Oct 10 18:55
David, you wrote, "I also think that it isn't too much to ask that patients be able to trust an expert in the field, maybe get a second opinion, and then make a decision already so they can move on with their lives." Aw, it probably is NOT too much to ask. In fact, for most people, that's exactly the way to go. I envy folks for whom things work that smoothly. But me -- if I'd followed that path of "Listen to the doc, see one expert, and get a second opinion"-- I'd've been dead three times over. Because not every physician graduated in the top half of the class. And some experts are 'experts' only because they've had 12 additional course hours. And some of those hours might've been CME's.
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #37 of 141: Carole Berlin (caroleberlin) Fri 15 Oct 10 19:40
permalink #37 of 141: Carole Berlin (caroleberlin) Fri 15 Oct 10 19:40
Gail, Great article ! Thank you! <http://www.wired.com/wiredscience/2010/10/how-to-set-the-bullshit-filter-when- the-bullshit-is-thick/> What the heck CAN you believe? No single research paper on any subject, that's f'sure. But at the moment, since that research is all we've got, I'd rather read it than ignore it. * * * A couple of years ago, we started collecting research that was , um, less than well-done. We meant it to be funny -- "Haha, look how dumb the folks in THIS laboratory were" -- but it stopped being funny very fast.
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #38 of 141: Mark McDonough (mcdee) Sat 16 Oct 10 05:47
permalink #38 of 141: Mark McDonough (mcdee) Sat 16 Oct 10 05:47
Yup. There is an incredible amount of bad science out there in biomedical research. A couple of decades ago, the history field was at least somewhat chastened by a book called "Historians' Logical Fallacies." We badly need a "Biomedical Researchers' Logical Fallacies."
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #39 of 141: David Albert (aslan) Sat 16 Oct 10 07:10
permalink #39 of 141: David Albert (aslan) Sat 16 Oct 10 07:10
Who was it who said that they had determined by a review of the scientific literature that "research causes cancer in laboratory rats"?
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #40 of 141: Chris (cooljazz) Sat 16 Oct 10 09:01
permalink #40 of 141: Chris (cooljazz) Sat 16 Oct 10 09:01
Hi Carol, - an interesting discussion, I hadn't known about Thermograms until this topic. My question is how about testing these devices, the thermogram for example, in clinical trials? I know something about clinical trials - and let me explain what might be needed, below And An aside, to #39, ...research causes cancer in laboratory rats".. Don't know the answer to that, but maybe the same person who said if you don't want to find any problems with <fill in the procedure> stop looking at the data. And to the background for clinical trials. As to the future for thermograms and testing in clinical trials, - if all the promises from Obama's new health care legislation are kept - then Thermograms, and many other devices, drugs etc. will get evaluated in "Comparative Effectiveness Research" (or CER) It can be very complicated, and here's an example why. About a month ago I spent several days at a research symposium with the Society of Nuclear Medicine talking about Molecular imaging. (That's PET scans, CT, MRI's etc). I'm a Pharmaceutical (drugs and devices) statistician and three of us were there, with about 50 prominent M.D.'s, to give advice on issues of statistical methods, clinical trial designs, and so forth for Molecular Imaging clinical trials. We all understood that was hard, because basically there have been few or no clinical trials for Molecular imaging devices. However, we were there because the future is comparative evaluation of treatments, devices, procedures in Medical care. And, the Obama plan has a "cost saving" component of CER for determining which drugs/devices work so we can use them and which don't work, and we stop using them and stop wasting money on them. The lessons from that symposium are germane to thermograms. Unlike prescription drugs, which must meet the "two adequate and well controlled randomized clinical trials" standard to be approved, devices (e.g. stents, MRI's, x-rays, etc.) need not meet that standard. There is a different standard for devices. That's likely to change and there is a lot of press out there for it. e.g. this has an example of a platelet therapy that was apparently never tested in clinical trials http://www.jsonline.com/business/103800949.html The huge dilemna it causes is, in the absence of randomized trials how does one assess if one technology is better than any other? For molecular imaging, the problem is more complex because of the stakeholders involved. HOw could one do a "comparative study". The problem is challenging because first, there is the person who takes/reads the scan (say an MRI or a thermogram). He sends that report back to the doctor, possibly with a recommedation for treatment. The doctor makes a decision as to how to treat. Now suppose one does find a tumor and the doctor treats. The challenge is, how or whether one can design a cliniical trial that considers both decisions (the thermogram erader), the doctor who treats, then, follows the patients for say 20 years to determine if the woman lived longer, than -not- having that done. The gold standard is to randomize, and how might that be done? Well one could consider randomizing women, one-half to have a thermogram, the other half to an MRI, then to some particular treatment based on what was found. Then follow for survival for 10-20 years. Gets pretty complex fast, and the studies take years, because they involve survival. As to whether or not, this is the future http://www.minnesotamedicine.com/CurrentIssue/CommentaryPlotnikoffDec2009/tabi d/3272/Default.aspx http://tinyurl.com/2ea5bal The link spells out the consequences of Bad screening decisions ... The authors noted that for every breast cancer death averted, even in the age group for which screening is least controversial (ages 50 to 70 years), 838 women must undergo screening for six years, generating thousands of screens, hundreds of biopsies, and many cancers treated as if they were life-threatening when they are not..... IN the U.S. FDA is reconsidering the need for clinical trials for devices http://news.morningstar.com/articlenet/article.aspx?id=355465 .... We think it is unlikely that medical device companies will conduct 10,000 patient trials on each product, and we believe going forward we will have to rely more heavily on postmarketing registries to track the performance of devices over the longer term... I think thermograms will get used, once they get tested and demonstrated that they do save lives.
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #41 of 141: Pat Adams (scarlet) Sat 16 Oct 10 11:16
permalink #41 of 141: Pat Adams (scarlet) Sat 16 Oct 10 11:16
Perhaps this technology will be developed further: <http://gizmodo.com/5665071/what-is-this>
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #42 of 141: Carole Berlin (caroleberlin) Sat 16 Oct 10 13:09
permalink #42 of 141: Carole Berlin (caroleberlin) Sat 16 Oct 10 13:09
To #40 A valuable post, Chris. Thanks for taking the time to put it together. Comparing two procedures to identify the 'best' one might be an idea whose time has come, but it does open some of those twisty little passages of questions that lead only to more questions. 1. Who determines which questions should be answered? (I mean, you'll get different answers to "Which machine identifies early bc better?" and "Which tells us sooner that something's going wrong in that breast?" "Sooner" is easier to answer than "better," because what does "better" mean, anyhow? Which machine sees bc more often? more clearly? with fewer false positives? false negatives? less patient pain? less expense?) 2. Who's defining "breast cancer" ? In some circles , there's still a controversy about whether DCIS even COUNTS as cancer. And five pathologists are not necessarily going to see one type of cancer in a given slide. You're talking about a discipline that's as much art as science. 3. FInally, maybe I missed something, but would you explain why treatment is even part of the 'comparative' mix? You're talking about machines to help diagnose breast cancer. Why, then, is the pathologist's report not sufficient proof that the machine did or did not identify cancer? Isn't it enough to say "This machine pointed to an abnormal breast-spot which, when biopsied, turned out to be invasive lobular bc"? What more can any machine offer?
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #43 of 141: David Albert (aslan) Sat 16 Oct 10 13:19
permalink #43 of 141: David Albert (aslan) Sat 16 Oct 10 13:19
> Who's defining "breast cancer" ? I have always assumed that the reason DCIS is treated as cancer (for the purposes of treatment) is that it DOES usualy turn into regular cancer eventually -- and that one is more likely to develop cancer if one has untreated DCIS than if one does not. If it is true, as I have read, that DCIS usually progresses to invasive cancer, then it seems as if discovering and treating DCIS at an early stage will save you from the effects of treating invasive cancer (chemotherapy, radiation, axillary dissection, lymphedema, etc.) later on. So then the tradeoff is between watchful waiting, with the possibility of needing more radical treatment to avoid early mortality, or early treatment with the possibility of having had surgery for a condition that might not have progressed rapidly enough to matter.
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #44 of 141: Travis Bickle has left the building. (divinea) Sat 16 Oct 10 13:41
permalink #44 of 141: Travis Bickle has left the building. (divinea) Sat 16 Oct 10 13:41
I think it's fair to say that there is some art, and perhaps even experientally-developed instinct (cf: deBecker and Gladwell), to the discipline of pathology, but saying that pathology is "as much art as science" is pushing beyond accuracy.
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #45 of 141: Carole Berlin (caroleberlin) Sat 16 Oct 10 14:17
permalink #45 of 141: Carole Berlin (caroleberlin) Sat 16 Oct 10 14:17
I'm not pushing thermograms, but-- Y'know who might benefit most from yearly thermograms? Men and late-teenaged boys with breast cancer. Male breast cancer is real, if uncommon. (In the US, about 200,000 women are diagnosed each year, in contrast with fewer than 2,000 men/year). They get mastectomies, just like women, and -- based on what I know about female breast cancer and the use of mammograms for follow-up--- I'd guess that men are sent for mammograms too. If you guys have ever seen how a mammogram machine works, you'd understand why I vote thermograms for males with breast cancer. * * * Speaking of male breasts, I don't know how often y'all get to see a lot of young people, but I saw them all the time in New Orleans when I lived there, especially at Carnival parades. At any given parade, I'd notice at least one, sometimes two or three pudgy pre-teen or barely-teenaged boys with not-just-fat-chests, but with, well, small breasts. I've since learned that, as these boys grow into their late teens, some plastic surgeons have begun to do on them what would, in a woman, be called a mastectomy. I hadn't realized it might be a nationwide thing until I learnedd that the same surgery is now being done on boys here in Asheville, too. I bring it up because I have some guesses as to the causes of breast development in young males, and they tie in with Julie's question about preventing breast cancer. First, though, let me ask if anybody else has noticed this phenomenon.
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #46 of 141: Chris (cooljazz) Sat 16 Oct 10 14:30
permalink #46 of 141: Chris (cooljazz) Sat 16 Oct 10 14:30
Carole, thanks for #42 above. AS to diagnosis and treatment for cancer, CER is to evaluate the long term outcomes for people. In Breast cancer, it is in looking over the long term outcomes that decisions are made whether all women should get a mammogram or only some woman. And those decisions include whether women may, by "false negative" or "false positive" get treated when they don't need it or, don't get treated when they do need it. The outcome that matters, later, is whether they live or die. Thats' really the ultimate test. (I"m not suggesting that every device or drug will be evaluated based on survival, cancer nearly always kills, or kills sooner than not having cancer, so how long you live after a diagnosis is very important) It took a long time to get cancer treatments evaluated in clinical trials. There was a time, when doctors would refer say, to the last 50 patients they treated, to judge whether a treatment worked or not. The notion of comparing one treatment to another, with randomization was new, similarly for devices. For many devices, which may differ in small ways from a predecessor (e.g. this new device has a titanium screw instead of stainless steel) there has been no requirement to send those to randomized trials. That may change. As to who determines, it happens all the time in cancer. For cancer (I spend a lot of my time in cancer clinical trials), its the National Cancer Institute, and, many times the Pharma companies who are doing research into new treatments. ... Why, then, is the pathologist's report not sufficient proof that the machine did or did not identify cancer?... Yes, it matters whether the machine did or didn't and it matters what happens next, especially to those who were false positive or negative. And whether the machine correctly determined the cancer and as well the pathologist reading the machine output. Pathologists have their own sensitivity and specificity. From time to time studies are done, say, sending the same pathology slide to, say, 6 different pathologists for a diagnosis and checking their "agreement". Not surprisingly, pathologists can disagree. And for the machines, even with a high sensitivity and specificity (which will never be 100%), there are people who will be treated, who shouldn't have been treated (the machine said "cancer" when it was benign), and people not treated when they should have. Multiply up to tens or hundreds of thousands of people being screened, diagnosed, and treated and it adds up.
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #47 of 141: Carole Berlin (caroleberlin) Sat 16 Oct 10 15:38
permalink #47 of 141: Carole Berlin (caroleberlin) Sat 16 Oct 10 15:38
#44: Divinea, You wrote: " I think it's fair to say that there is some art, and perhaps even experientally-developed instinct (cf: deBecker and Gladwell), to the discipline of pathology, but saying that pathology is "as much art as science" is pushing beyond accuracy. " Thanks for putting it so delicately. (grin) Nevertheless, though I'd consider amending the statement to "ALMOST as much art as it is science," I'll stand by what I said. The UNamended statement came straight from a pathologist who teaches pathology at a medical school, with the bulk of his students being pathology residents. He encouraged me to get a THIRD path opinion after the first two were so different that I thought my slides had gotten mixed up with someone else's. I WANT to believe that all pathologists know exactly what they're looking at all the time. It's just not true, though. My own experience has validated his statement more than once. The women on my listserv who've had their own "HUH?" path-report-moments have also seen the truth of it. MY EXPERIENCE: BREAST TISSUE: I sent my breast cancer slides to three different pathologists at three different institutions in three different regions of the country. Though I no longer have the path reports themselves, I remember how puzzled I was that they seemed to have been based on three separate sets of slides. The three agreed only in that there was invasive lobular on the slides. As to the other components, one said there was an area of DCIS while the other two labeled this non-lobular part as two different types of bc (It's been fourteen years and the reports drowned in the flood following Hurricane Katrina, so I can't be more precise than that.) I know now that it's not as unusual as I thought it was at first. Let me point out that there's almost always uniform agreement when tissue is benign. That IS generally clear-cut. It's when the tissue is not or might not be benign that these questions of "Well, what IS it?" arise, and the answers are not as uniform as one would expect. MY EXPERIENCE THYROID SLIDES Six months ago, because there was a growing cyst on each lobe of my thyroid, I went for a fine needle aspiration of one of the cysts. FIRST PATHOLOGIST: Possible neoplasm (looks like it could be cancerous) ENDOCRINOLOGIST: Have it removed. ME: Second path opinion, please. SECOND PATHOLOGIST, same slides as the first one: Are you kidding? There's not even enough solid tissue on these slides to make an assessment. Get another biopsy. ENDODOC: Get it removed. ME: Another biopsy, please. SECOND BIOPSY: FIRST PATHOLOGIST: Benign. SECOND PATHOLOGIST: Benign. I could have lost my thyroid altogether if I'd listened only to the first pathologist. He called it as he saw it. But so did the other guy. Mind you, this is not a secret, Divinea. It might not be widely publicized, but pathologists are fully aware of these differences in opinion. Pathologists at U.S. med schools and teaching hospitals are being asked to work out clear-cut guidelines for their discipline, but it's a work in progress. It's not that easy to delineate exactly what an invasive lobular cell looks like. In GENERAL, yes. But for a specific cell? Eep. It's not just in this country, either. The call for better regulations, clearer guidelines is happening in the UK, too.
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #48 of 141: Travis Bickle has left the building. (divinea) Sat 16 Oct 10 17:09
permalink #48 of 141: Travis Bickle has left the building. (divinea) Sat 16 Oct 10 17:09
I have to admit that I find it a bit confusing that you seem to be maintaining that pathology is an inexact science, or "art", while you also seem to be advocating thermography over mammograpy, while thermography is, at least at this point, an unproven technology with no established clinical standards. Can you clarify your reasoning?
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #49 of 141: Carole Berlin (caroleberlin) Sat 16 Oct 10 19:39
permalink #49 of 141: Carole Berlin (caroleberlin) Sat 16 Oct 10 19:39
#41 Pat Adams wrote, Perhaps this technology will be developed further: <http://gizmodo.com/5665071/what-is-this> Y'know, you bring up a good point, Pat. If computers could be brought in to enhance mammograms as beautifully as this NASA-enhanced pic, AND if they became part of the pathologist's arsenal, we'd see vast improvements in diagnosis. I don't know how feasible that is, but that NASA-enhanced image is awfully impressive. If their enhancement technique involves picking up what passes for heat in a mammogram, it might be the best of thermography and mammography combined. Thanks for bringing that in, Pat. I won't hold my breath waiting for it to happen, but if it does, I'll be very interested to see it in action.
inkwell.vue.394
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Carole Berlin, "What You Should Know Before Your Next Mammogram"
permalink #50 of 141: paralyzed by a question like that (debunix) Sat 16 Oct 10 20:35
permalink #50 of 141: paralyzed by a question like that (debunix) Sat 16 Oct 10 20:35
The tricky part of pathology of cancer is trying to predict when the cells look enough like cancer cells that they're behaving like cancer cells--ready to break out of their home tissue, invade the blood stream, and set up metastases elsewhere. If it looks like breast tissue and it's someplace outside the breast, that's pretty clear. And healthy normal cells are pretty clear. But just from looking at them determining what is and what isn't cancerous can be very tough, even if you have a few special stains available to look for extra things that can't be seen in a regular H&E stained slide. I'm not a pathologist but I've looked at enough tissue samples to know that the kind of signals they're looking for can be pretty subtle. Their cytoplasm that does most of the tissue-specific work of the cell shrinks, their nuclei get more irregular, and they start to look a little more like a generic dividing machine than like a breast or a thyroid cell. They pile up irregularly instead of forming nice structured ducts or glands or membranes. Sometimes they outstrip their blood supply and bits of them die and new irregular blood vessels start to form. By then it's obvious. But the grey area between the obviously cancerous and obviously benign is large and potentially contentious, because cells don't come labelled 'cancer' or 'not cancer'. I see a good deal of art within the science of pathology. And thermography, if it can be standardized and consistently effective, may be especially good for men who don't have breasts large enough to squish in a mammography machine. But as noted above, there are a heck of a lot of fat guys of all ages out there who have breasts of sufficiently generous size to fit the mammography machine. I've yet to see one actually join us in the mammogram waiting area, however.
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