Marla R. Lander, M.D. is a Board Certified Diagnostic Radiologist with fellowship/ specialty training in Breast Imaging and Diagnosis. She devotes her professional life to taking care of and educating women in the arena of breast disease, and bone density health. She is one of the founding members of Desert Women's Health center in Indio, CA.Body1: When did you know you wanted to be a doctor?
Dr. Lander: I wanted to be a doctor since I was eight years old.
Body1: What was it that made up your mind so early?
Dr. Lander: When I was growing up our pediatrician was just the most wonderful, caring guy and I always wanted to be like him. I always had a very strong curiosity about how the body works and functions since I was a child.
Body1: How did you come to be interested in this field of breast diagnosis and imaging?
Dr. Lander: I have a very strong family history of breast cancer so I’ve been very aware of it since I was a teenager. Also, when I was going through my training in diagnostic radiology I went to a couple of conferences by Dr. Laszlo Tabar. He’s considered the international father of mammography. He was absolutely brilliant and riveting, and I thought, “This is what I want to do.”
Body1: How did you end up studying with Dr. Tabar in Sweden?
Dr. Lander: I went to one of his conferences when he was keeping them small. People would present their cases in front of everybody and he would be critique them. I was a resident at the time and he called me up to go through my cases. I was very intimidated but still trudged along. Then something came up—I don’t remember what it was—but I asked him a question that he could not answer. His AV guy was hysterical and came running down the hall and said, “Ladies and gentlemen, this is the first time Dr. Tabar has not been able to answer a question.” After that session he came up to me and asked me if I wanted to study with him in Sweden.
Body1: Did he ever answer the question?
Dr. Lander: You know the crazy thing? For the life of us, we can never remember the question.
Body1: You’re using the new technology of SomoVu, a new ultrasound method for screening breasts. Is it going to replace the mammogram?
Dr. Lander: No. The mammogram is essential. The SomoVu cannot replace it. Mammography is still the number one screening tool and it’s going to catch 85 percent of all breast cancers. At this point in our medical history, a mammogram is essential.
Body1: Where does SomoVu and ultrasound fit in then?
Dr. Lander: When you find a mass, ultrasound really helps differentiate whether it’s a tumor or a cyst. Then, if it’s a cyst, is it a simple cyst that we can dismiss or a complex cyst that we may need to follow? While Ultrasound is great at characterizing lesions once found, it typically does not see calcium deposits and about 40 percent of breast cancers are associated with calcium. That doesn’t mean that the ultrasound is going to miss that 40 percent because a lot of those will have tumor masses that the ultrasound will pick up. If it’s strictly a presentation of calcium deposits, you’re going to miss it with ultrasound. The marriage between mammography and ultrasound is going to make a huge difference, particularly for women with dense breasts. Between the two, you’re not going to miss anything.
Body1: So has it become standard procedure for someone with dense breasts to have both a mammogram and ultrasound?
Dr. Lander: It’s not standard. We are hoping to eventually see the day in the not too distant future when it is. It really should be the standard care but it’s not there yet.
Body1: How does the SomoVu differ from a regular handheld ultrasound?
Dr. Lander: The primary difference is how they are used as screening tools. We use ultrasound as a diagnostic tool, meaning if something is found on the mammogram, you can use ultrasound to further characterize it. Ultrasound can also guide you in a needle directed biopsy. With SomoVu you can scan every area of a dense breast and use it as a screening tool. Handheld ultrasound covers maybe 3 centimeters in width whereas the SomoVu is almost 15 centimeters in width. It gives you a nice wide size portion of the breast to look at so you can see details relative to each other. For now, I do all my own ultrasounds because as a radiologist I know what to look for and I don’t trust anyone else. I know what I’m looking for. I can have a tech scan with the SomoVu knowing for certain there is no tissue being missed because there such a broad area being scanned.
Body1: Will it replace the regular ultrasound?
Dr. Lander: No. Handheld ultrasound still has its uses. But the SomoVu does make a difference in screening. It’s digital and automated, so it sets its own standard course every time. To the best of my knowledge, it’s the only product with the ability for three-dimensional pre-construction. A normal handheld ultrasound gives a transverse dimension from skin to chest wall. SomoVu gives transverse but also a longitude, radial and anti-radial view.
Body1: So do you think this will rule out human error?
Dr. Lander: There is always going to be the possibility of human error even with our CAT system on the mammogram. Right now we are working on a CAT system with SomoVu, which will help. It’s still humans using the machines and even if the machine has all the data there, the radiologist doing the interpretation still needs to know what to look for and what they are seeing in front of them.
Body1: What is your patients’ number one concern when they come to you?
Dr. Lander: I think everyone is worried when they come in, even the people who look at this as preventive. There is always that fear of “is it going to be me?” People are afraid to walk into a breast centre because of that fear. I can you that out of a thousand women who come through the clinic for screening, we can tell 997 of them that they are cancer free. Imagine the reassurance when you walk out the door with that diagnosis.
Body1: What is the most frequently asked question from your patients? Are most of them fairly educated or do you also need to do patient education?
Dr. Lander: It’s kind of all over the board. Where I practice there is a large percentage of extremely wealthy women and also a lot of migrant workers who can barely speak English. So we really see a widespread group of women and sometimes you have to do more education with the wealthier ones. They may think they are more educated, but they often have misinterpreted what they’ve read. A large part of my practice is patient education.
Body1: Do you feel your patients are more comfortable because you are a woman?
Dr. Lander: I think so. Also, I’m a people person so I think that helps too. I have patients that have been coming to me for years so I know about their families and their pets. We talk about that and that can put them at ease. If they are in a high anxiety situation, you can talk to them about what interests them and that relaxes them. So I think it’s both. It’s comfortable coming to a woman and also coming to someone who cares.
Body1: Do you think we are making progress in preventive breast care?
Dr. Lander: I’m extremely disappointed in what’s going on now. Breast cancer mortality is down in the first time in medical history and the main reason for that is screening. The medication, the chemotherapy and radiation therapy out there has not changed significantly. Women being found with late stage disease after a mammogram are dying at the same rate as their grandmothers who never had screening. I feel that a lot of credit is erroneously going to the therapies instead of to the early detection.
Body1: What is the best way to cure cancer?
Dr. Lander: To find it early. Early detection we can cure sometimes with simple surgery, without chemotherapy and radiation. We are making wonderful strides but at the same time we go back a notch. The New York Times just talked about the mortality rate being down for the first time and now women are getting a relaxed attitude thinking, “Well breast cancer rates are down. Why should I go in for my mammogram?” The rates for mammograms are dropping and I want to bang my head against the wall!
Body1: What do you find the most challenging when treating your patients?
Dr. Lander: One of my frustrations is when after a really good screening, I find some “baby cancers” – these tiny, tiny, little cancers that probably wouldn’t be felt for a few years. I’m excited about finding it but then the woman gets over-treated with chemo and radiation. The treatments have to catch up with the new screening and they need to be tailored so we don’t over treat. There are times that you have to throw everything at it but not with these tiny cancers.
Body1: What is the most effective method we have for treating breast cancer?
Dr. Lander: The key thing for breast cancer is surgery. If you could only pick one treatment that would be it, 100 percent, especially with screen detected cancers. Radiation is always an additional treatment when indicated and that would be with a very select portion of eligible patients based on where the cancer is located and how large the breasts are.
Body1: We have a lot of emotional attachment to our breasts. What kind of coping techniques do you use to help women facing a mastectomy?
Dr. Lander: Some ladies are really tough and really wise. A lot of time it’s the elderly ladies who say “I’ve already had my kids. I’ve breastfed. My husband knows what I looked like in my youth and now it’s more important to stay alive.” They are right on the key. I find it much harder with the younger women. The most tragic cases for me are the advanced cancers in young moms. These cancers tend to be more aggressive in younger women. In those cases there are no easy answers and there are no right answers.
Body1: How do you help keep things in perspective?
Dr. Lander: What I try to present is that the most important thing is to save your life. No ifs, ands or buts. Usually I encourage them to have their husbands or significant others, their families, friends and whoever they can get because that’s their support system and we go over it in front of everyone if they are comfortable with it. I tell them that this is a fight for your life. You have to do what is going to give you the best options. It’s not every time you need a mastectomy. It’s only in specific instances. I tell them whatever emotion you feel – angry, distraught – you are entitled to feel any emotion.
Body1: Is this hard on families?
Dr. Lander: A lot of the time this is very hard on relationships. I’ve seen many marriages hit the rocks on breast cancer. Sometimes you have young women and they never expected to be staring death in the face at this age. All kinds of things happen between the couple. Disfigurement just makes things worse. The wife may feel the husband is not being sensitive to her. The husband may feel like he can’t even relate and he doesn’t know the first thing to say to her. Or, he may say the wrong thing and she jumps all over him. Lots of stuff happens in that direction. So one of the things I talk to them about is how difficult it is and I let the wife know that even though it’s her breast, her husband is suffering too. I try to get them hooked up or at least let them know there is counseling and therapy available. I bring it right up at the beginning.
Body1: How else do you help a woman to prepare?
Dr. Lander: We often talk about reconstruction. Depending on the type of cancer, sometimes they can have reconstruction immediately after their breast(s) are removed so they can still wake up with breasts. Sometimes we have to wait to make sure the cancer isn’t going to come back or because they need more radiation therapy right into the chest wall. So if it’s delayed we may talk about medical prosthetic places where they can be fitted. It’s not an easy subject and it all depends on who you’re talking to.
Body1: Does our cultural obsession with breasts every come into play?
Dr. Lander: Yes. I have some women who are now dying of their breast cancer because they refused to have a mastectomy which is one of the saddest things for me. They need to hold onto their breast so much that they would rather die with their breasts than give them up and live. It’s unbelievable.
Body1: There is so much information and so many theories about what causes breast cancer. Do you think there is a connection between our environment and breast cancer?
Dr. Lander: I honestly do. Not that anything has been scientifically proven but something’s going on because worldwide breast cancer is rising. It’s not just because screening is better and more things are detected. It’s on the rise with the population not being screened. Perhaps there is something in the environment that triggers a mutation that is passed on, at which point it becomes genetic. There has got to be some major environmental factors.
Body1: Why isn’t there more research being done about this possible connection?
Dr. Lander: Unfortunately, most of the money for breast cancer research is going into the pharmaceutical end of things. I think this is tragic. There is only a limited need for it. I wish we could redirect funding into educating doctors. There are people who are trained in breast imaging but we don’t have enough of them. The field hardly pays anything. It’s the highest area of medical malpractice so nobody wants to go into it. Yet, there is so much breast cancer.
Body1: Where do you think we should be focusing on breast cancer?
Dr. Lander: We need to approach breast cancer from a wellness model. We need to put more funding into the screening and prevention side of this. People out there ask me what they can do, particularly if they have a strong family history of breast cancer. It’s basic common sense stuff. There is information out there in the nutritional literature but it’s not necessarily large studies. The money just isn’t there. A vitamin company can’t patent a vitamin because they’re not FDA controlled. They are not going to get the big money for trials because it is so plentiful. I come from a family with breast cancer on both sides so I need to follow this. You need to get enough sleep, exercise without going overboard and eat smartly. Cut out refined carbohydrates, increase your fiber, and try some of the non-meat proteins.
