A pocket sized magnifying glass used to be standard equipment for radiologist and breast health specialist David Green.In those days, radiologists used magnifying glasses to carefully scrutinise analogue mammography X-ray films of breasts for minute traces of cancer.Mammography has since advanced so much that it’s pretty safe for Dr Green to leave the magnifying glass at home.Originally from Liverpool, England, Dr Green became consultant radiologist and clinical director at Bermuda Cancer and Health 18 months ago. He will give a lecture in the coming weeks as part of Breast Cancer Awareness Month, when he will discuss screening advances and new research.Dr Green began his career when screening programmes were first starting in England. He was consultant radiologist at Wirral University Teaching Hospital National Health Service Foundation Trust for more than 21 years and was clinical director for Wirral Breast Screening Unit for more than 20 years.“Radiology techniques have improved dramatically since my career started in 1990,” said Dr Green. “The biggest advancement in mammography has been the introduction of digital mammography. We are very lucky here on a small island to have it. Back in the United Kingdom we are only just beginning to switch over to digital. It is still very much analogue.”Digital mammography exposes the patient to lower radiation levels than analogue does, he explained. It also provides more information because it is better at penetrating dense breast tissue. Digital tests results can also be easily sent electronically.“Another good thing with digital mammography is that you can manipulate the image,” he said. “It is a bit like having a computed tomography scan where you can change the contrast and the brightness, and highlight different areas. That is a very powerful tool in order to look more closely at areas that catch your eye. You can magnify the area very easily.”Digital mammography units usually come with computer aided diagnosis. The computer will highlight areas that might be abnormal. In the past, two radiologists were needed to look at films, one to read and one to double check. CAD eliminates the need for a second pair of human eyes.Dr Green said before screening programmes became the norm, the radiologist’s job was to examine breasts already known to have a lump or abnormality it was relatively easy to see the lump in question. With breast cancer screening you are looking for something that may or may not be there. Sometimes the first signs of breast cancer may be very small or difficult to spot. Often a screener will have four views from a mammogram to look at and they might also look at four from the woman’s previous mammogram as a comparison eight mammograms per person.“In 100 cases we typically read there may only be one cancer or no cancers,” said Dr Green. “So it requires a whole different concept of looking and interpreting the mammogram. It was recognised in the United Kingdom and anywhere there is a national screening programme that you have to be specially trained in that technique. General radiologists cannot take on that role.”He said without training, general radiologists tended to overcompensate, and the patient sometimes had to be called back for further testing when it wasn’t necessary.“That is very devastating for the women because they all think they have cancer,” said Dr Green. “It generates a lot of work in terms of trying to sort those problems out. It is very expensive for the medical fraternity in time and costs.”The most common abnormality found in women before the onset of menopause is cysts in the breasts.“If you are anywhere between the onset of menstruating and the onset of menopause, if you get a breast lump, it is most likely a cyst,” said Dr Green.Ten out of 100 women will encounter an abnormal mammogram. Nine out of ten abnormalities will not be breast cancer.“The problem is by examining the breast externally you can’t tell if it is a cyst or not. By looking at a cyst you can’t tell or not. A mammogram will tell you there is something there but it won’t tell you if it is cystic [ie filled with liquid] or solid. This is where ultrasound comes into its own.”Cysts are filled with liquid and easily spotted on an ultrasound. If it is painful for the patient, Dr Green can drain the cyst right there. However, if the lump is solid, it is not so easy to tell with an ultrasound if it is benign or malignant. This is usually determined with a biopsy.The majority of Dr Green’s patients are female; about one percent of breast cancer patients are male. Despite that he has never found being male to be a disadvantage in his profession.“Patients just want someone who they can talk to and will do a good job for them,” said Dr Green. “They don’t care what sex you are. I have worked with female breast radiologists, and have had female patients saying, ‘I’m never going to her again. I just don’t like her’. It is about personality and your approach with a patient rather than whether you have an XY chromosome. We do treat our patients with great respect. It is a delicate situation to them. They are going to be exposing parts of their anatomy that they wouldn’t normally wish to do so. But, at the end of the day, we do it very discretely and only uncover what is necessary. It is all done very professionally, and I have never, touch wood, had a complaint. The other thing for ladies to be aware of is that we always have female members of staff in the room. So they are never just left alone with just a male member of staff.”He continued: “I have had lots of experiences telling patients bad news, and watching them go through what happens after the diagnosis of breast cancer. You do get attached to patients. Like a general practitioner, you can follow them up for years. It is often the radiologists who will follow them through after breast cancer treatment. Some of them don’t make it and that is not very nice, but you have to harden yourself to that.”The American press revealed recently that breast cancer researchers have discovered that breast cancer can be clearly divided clearly into four different subtypes based on genetic differences. One type was also found to be similar to a treatable type of ovarian cancer. This offers the hope that this breast cancer subtype might one day be eradicated in a way similar to the way ovarian cancer is treated.“I am absolutely excited about new research results coming down the pipeline,” said Dr Green. “If you come to my talk you will find out a bit more about it. The thing about cancer screening is that it doesn’t prevent cancer. The idea is to pick it up early enough so you have more treatment options and it is more likely that you can find a cure. In an ideal world you would be able to prevent it completely. Sadly, I personally don’t think that will happen any time soon.”Since breast cancer screening started in the early 1990s the annual increase in survival rates for breast cancer in the United States has been on average two percent per year. Bermuda has also experienced an increase in survival rates as a result of screening programmes. In 2011, the Bermuda National Tumour Registry recorded 81 diagnoses of breast cancer. The disease that continues to be a life-changing event for patients, their families, and friends. Mammograms and breast exams help find breast cancers early when treatments can be most effective. When that happens, patients with breast cancer have a five year survival rate of 98 percent.Dr Green’s talk will be on October 25 at the Bermuda Underwater Exploration Institute at 6pm. Jane Brock of the Breast Specialist Pathology Team at Brigham and Women’s Hospital in Boston will also speak.To see the range of events organised as part of Breast Cancer Awareness Month visit www.cancer.bm or telephone 236-1001.