With a history of breast cancer in her family, Andrea Cronin has been careful to get annual mammograms since she was in her early 30s.
Like a lot of women, though, she skipped the test in 2020 due to the pandemic. She was relieved when her 2021 test came back negative, but she wanted more reassurance. Cronin’s mother was diagnosed with breast cancer 28 years ago, and the cancer has since metastasized to her stomach and bones. Cronin also has dense breasts, which can make reading a mammogram more difficult.
“With my mother’s history, I just wanted to be proactive,” recalled Cronin, 47, who is from Haddonfield. “My doctor suggested alternating mammograms and MRIs every six months.”
This past January, Cronin’s MRI showed a tumor, which was confirmed by an ultrasound. She was diagnosed with stage II invasive ductal carcinoma.
Cronin’s hunch that she needed further testing paid off. Not waiting another year to find the cancer means her prognosis is good, said Zonera Ali, Cronin’s oncologist at the Lankenau Institute for Medical Research.
But her situation is unusual, her doctor and experts stressed.
“Most patients’ cancers are picked up on the mammogram, but about twice a year I see a patient whose cancer is found through the MRI,” said Ali. “When cancers are detected earlier, chances of cure are much higher.”
For Cronin, getting additional testing made sense, given her mother’s bouts with breast cancer. But that is not advised for women without a family history of cancer. The increased sensitivity that MRIs offer can show something that looks like a problem but may not actually be a problem, said Richard Bleicher, leader of the Breast Cancer Program and professor of surgical oncology at Fox Chase Cancer Center.
MRIs can result in three times more unnecessary biopsies than mammograms, he noted.
“We end up doing a lot of biopsies, more testing and interval testing, and sometimes unnecessary surgeries that cause pain and discomfort for women, not to mention costs and anxiety,” he said.
When Cronin’s cancer was detected, she was given the option of having a lumpectomy, in which just the lump and surrounding tissue would be removed, but opted to have both breasts removed in a double mastectomy, given her mother’s history of recurrence.
“This would require only one surgery and get me back into my life of dentistry quicker,” Cronin said.
Her mother, Joyce Makarczyk, was first diagnosed with breast cancer through a routine mammogram in 1993, at the age of 46.
“I was going to go for a second opinion but the doctor said it was an aggressive cancer so I shouldn’t waste any time,” recalled Makarczyk, who lives in Mays Landing. Cancer was also discovered in her lymph nodes, so she had one breast removed, followed by chemotherapy and radiation.
About 10 years later, the cancer returned in her right breast. She had a lumpectomy and radiation and was cancer-free for five years. But then she started having stomach problems. The cancer had metastasized into her stomach and bones.
Makarczyk, now 75, has taken the targeted therapy Ibrance ever since and has PET scans every six months. A couple of times, the scan showed cancer cells in her stomach, which were surgically removed.
“I’m feeling OK,” she said. “The cancer doesn’t cause me any trouble at all.”
During Cronin’s double mastectomy in March, cancer was found in one of the 11 lymph nodes tested. In late April, she started eight sessions of chemotherapy over four months, which will be followed by one month of radiation.
“Once cancer escapes into the lymph nodes, the chance of that cancer going somewhere else is higher,” said Ali. “Especially in women below the age of 50, we recommend chemotherapy and post-mastectomy radiation.”
After Cronin’s cancer diagnosis, her older sister Erica Toffenetti also is seeking additional screening.
“The fact that my sister showed no symptoms, it wouldn’t hurt to have these tests done for a baseline,” said Toffenetti, 51, from Buena, N.J. “I’m feeling a little nervous but also more relieved. With my mother I’ve been dealing with breast cancer more than half my life.”
Toffenetti, who has two children, had genetic testing done in 2012 and again in 2019 as the testing became more advanced. Like her sister, she doesn’t have the BRCA gene associated with higher risks of cancer.
Both sisters have dense breasts, as do nearly half of all women age 40 and older who get mammograms, according to the NIH. Dense breasts have relatively high amounts of glandular tissue and fibrous connective tissue, which make it more difficult to see potential tumors.
The American Cancer Society recommends mammograms as a choice for women aged 40 to 44. Women aged 45 to 54 should get a mammogram every year; and women 55 and older should switch to a mammogram every two years, or can continue yearly screening.
At this time, experts do not agree what other tests, if any, should be conducted in addition to mammograms in women with dense breasts, according to the American Cancer Society website.
“ACS recommends mammograms for dense breasts without any other high-risk factors,” said Karen E. Knudsen, chief executive officer of the American Cancer Society and former enterprise director of the Sidney Kimmel Cancer Center at Jefferson Health.
When Renee Anderson, Cronin’s ob/gyn at Pennsylvania Hospital, sends mammogram results to patients with dense breasts, she includes an explanation of what it means.
In those cases, Anderson gives her patients the option for more testing, and about half, most often those with a family history of cancer, choose to have an MRI or ultrasound.
“When you get a discrepancy like what you have with Andrea, it could have been missed because of dense breasts,” she said. “Or what’s more worrisome is that you could have a very aggressive form of cancer that started quickly and is growing quickly.”
Cronin, whose cancer is slow growing, was fortunate that her insurance covered the MRI. That’s not the case for every woman. In 2020, Pennsylvania Gov. Tom Wolf signed into law legislation requiring insurers to cover breast MRIs or ultrasounds for women at increased risk of breast cancer. But the patient still may be responsible for co-pays and deductibles, which can be costly.
Anderson stressed that the most important form of self-care is seeing your gynecologist and having a mammogram annually, especially for older women. The ACS guidelines say screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.
“For some women as they get older, 50 and above, they don’t think they need to come to a gynecologist, so nobody is doing an exam,” she said.
Breast cancer is associated with the BRCA1 and BRCA2 genes, but just 0.25% of the general population who have breast cancer have the BRCA gene, said Ali, Cronin’s oncologist. That number jumps to 2.5% among Ashkenazi Jewish women.
With an 11-year-old daughter, Cronin was eager to have genetic testing. She was tested for 35 different genes related to an increased risk for certain cancers and was negative for all of them, including the BRCA genes.
“Unfortunately, I feel that I still have to worry about her, because I don’t have the gene but still got cancer,” she said.
Cronin shared her experience in an email to her dental patients, alerting them to the fine print disclaimer at the bottom of some mammogram reports that says “extreme breast density decreases the sensitivity of mammograms. Please discuss family history and any concerns with your provider.”
“So many patients have thanked me directly for being so transparent with them,” Cronin said. “Specifically, two patients told me that after sharing my emails, their mothers demanded more testing after first being told no. It’s so important to be your own patient advocate.”