William Cockburn, D.C., D.A.B.F.E., F.I.A.C.T
docbill@earthlink.net
Breast cancer and other breast diseases have become a tremendous issue in women's health today, particularly in advanced industrialized nations. Also note that approximately 1,000 men get breast cancer yearly.
A procedure which has gone largely unnoticed is Breast Thermography, also known as Breast Thermal Imaging. Breast thermography promises the opportunity of earlier detection of breast disease than has been possible with breast self examination, physician palpation, or mammography.
The medical community investigated breast thermography quite extensively during the late 1970's and early 1980's. The FDA approved the procedure as an adjunctive tool in breast cancer screening, and many physicians, concerned about the radiation exposure of mammography, began to promote thermography as a replacement for mammography. This was error.
Basics of Thermal Imaging
Thermography is a non invasive test. This means that it sends nothing into your body. In fact, there is no contact with the body of any kind, no radiation and the procedure is painless.
Utilizing very sophisticated infra-red cameras and desk top computers, thermal imaging technicians simply capture a photograph of the breasts. An infra-red photograph, or heat picture. The data is stored in a computer and then can either be printed on high resolution color printers, or sent electronically to a physician with a similar computer for analysis.
The physician, such as a radiologist or thermal imaging specialist, then compares the heat patterns in the left breast to the right breast. Any difference in heat, or any specific blood vessel patterns in one breast that do not appear in another indicate a physiologic abnormality. This may be pathological (a disease) or it might indicate an anatomical variant. When a thermogram is positive, the job of differential diagnosis begins.
This is all that thermal imaging, or thermography provides. A physiologic marker that some abnormality is present in the breast.
Nothing more and nothing less. This is however, an extremely valuable and important finding, but it has historically been the interpretation of these findings that has been the problem, and is now the subject of the "responsible second look"
Competition Paradox with Mammography
Scientists and health care researchers have been looking for many decades at tools that can identify breast cancer reliably and quickly. It takes years for a tumor to grow, and the earliest possible indication of abnormality is needed to allow for the earliest possible treatment and intervention.
Thermography was viewed as a possible early diagnostic tool for cancer. The reason I stated that this was error, is quite obvious, but almost totally overlooked by the clinicians and researchers of the day.
Thermography is a test of PHYSIOLOGY. It does not look at anatomy or structure, and it only reads the infra-red heat radiating from the surface of the body.
Mammography, on the other hand, is a test of ANATOMY. It looks at structure. When a tumor has grown to a size that is large enough, and dense enough to block an x-ray beam, it produces an image on the x-ray or mammographic plate, that can be detected by a trained radiologist. A fine needle biopsy is then generally performed to identify the type of tissue in the mass, to determine if atypical or cancerous cells are present.
We now come to an important point. Neither thermography nor mammography can diagnose breast cancer. They are both diagnostic tests which reveal different aspects of the disease process and allow for further exploration.
The problem has been, that a number of studies were done on patients who had an established diagnosis of breast cancer.
These studies were done with thermal imaging, wherein the patient having known breast cancer acted as their own controls.
In other words, the patients cancerous breast was compared thermographically to the patients healthy breast. In nearly every case the cancerous breasts were hotter and had specific patterns of heat mimicking the appearace of blood vessels that suggested 1) cancerous tumors were hotter than surrounding tissue and 2) blood vessels in the vicinity of the tumor were engorged with blood and this produced hotter thermal images than the normal vessels in the opposite breast.
This made complete sense, until the research proceeded to look at younger, and younger women.. It was at this time thermography was viewed as a failure. In a local newspaper article in my home town paper covering my clinic, the caption read "Thermal Imaging...Useful tool or dinosaur in breast cancer detection".
Here is the problem. Early stage tumors have not grown large enough or dense (thick) enough to be seen by current mammography. When the thermogram picks up the heat from the tumor, a mammogram is performed and often the mass is not detected.
The result of the thermogram is then considered a "False Positive". The more patients of younger age screened with the so-called false positive, the more suspicion was placed on thermography.
Eventually lobbying efforts at the AMA's House of Delegates and at Medicare, brought about the removal of thermographic coverage by insurance companies, and the demise of thermography in large measure. This is most unfortunate.
Thermography was viewed as a competitive tool to mammography, a role for which it was never intended. This is a known fact in the community of board certified clinical thermographers. Thermography is complimentary to mammography and an adjunctive tool in the war on breast cancer. We must learn to accept the information these tools bring to us, and use the information to the best management of the patient. You and me.
The Correct Role for Thermal Imaging
This is where the correct utilization of thermographic imaging will demonstrate it's ability. In the correct model, thermography of the human breast can make a profound and positive impact on breast cancer and other breast disease. Here's the correct model.
Thermography is a risk marker for breast pathology. This paper is written for the general public and I am not going to burden the reader with a large base of complex studies that have been published demonstrating the clinical utility and reliability of the procedure. Suffice it to say it is overwhelming.
My purpose is to identify the role of thermography. It is actually quite a simple one.
In performing this procedure, which is non-invasive and non-compressive, we can establish a baseline in women as young as 18. Yearly thermographic evaluations as part of a routine annual physical can be performed inexpensively and quickly.
As soon a suspicious (positive) breast thermal examination is performed, the appropriate follow-up diagnostic and clinical testing can be ordered. This would include mammography and other imaging tests, clinical laboratory procedures, nutritional and lifestyle evaluation and training in breast self examination.
With this protocol, cancer will be detected at its earliest possible occurrence, It has been estimated my a number of my colleagues that thermography is correct 8-10 years before mammography can detect a mass.
This is both exciting and frustrating for the clinician and the patient. It is exciting as it gives us the opportunity to intervene long before cancer can grab hold of the body. Cancer is opportunistic. We must find it, or the suspicious signs of its' presence long before the intervention stage has passed.
On the other hand, it is frightening to uneducated clinicians and patients, and poses quite a dilemma for those rooted in the "wait and see" attitude. It is very difficult to sit in front of a patient and tell them that you have a positive finding with a procedure that suggest the possibility of a terrible disease, and then have no other tools available to confirm or deny the tests correctness.
This is not thermography's failure. Indeed this is where the scientific and research community has failed thermal imaging.
If one can grasp the simple concept that thermography is detecting the fever of a breast pathology, whether it is cancer, fibrocystic disease, an infection or a vascular disease, then one can plan accordingly. One can lay out a careful clinical program to further diagnose and or MONITOR the patient until other standard testing becomes positive, thus allowing for the earliest
possible treatment.
Two other positive benefits of breast thermal imaging have also been proposed by the author at scientific symposia. As a non-invasive low cost procedure, thermography can be made available to two distinct subpopulations:
1) Patients who are economically deprived and can not afford the cost of mammography.
2) Patients who are afraid of mammography due to fear of x-ray or breast compression, and thus do not get their recommended mammogram.
The Paradigm Shift
It is my position that the role of thermography is vastly different than it originally was determined to be. We must begin to look at this tool for what it really is. A highly accurate, high yield thermometer, much like the one every physician uses daily to determine the presence of fever.
Numerous studies have been published in the United States, England and France demonstrating that patients in the false positive thermographic group I mentioned earlier, those patients with positive thermograms and negative mammograms who were told the thermography was wrong, were determined by long term follow-up to have developed breast cancer in exactly the location
thermography had demonstrated its positive finding 5-10 years earlier.
Thermography's only error is that it is too right ~ too early. It is our job as scientists, physicians and concerned patients, to identify the appropriate protocols once a thermogram is positive. It is in this capacity that the paradigm must shift.
We have a wonderful and exciting opportunity to at last change the incidence of this horrible disease, by screening younger women utilizing high resolution thermal imaging technology and then placing those women with positive findings into the appropriate lifestyle modification and treatment model which may be able to prevent or minimize not only cancer, but all breast disease.
This is our task.
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Basis of Thermography in Breast Imaging
There is great hope for the future in the diagnosis and management of breast cancer. Genetic and clinical researchers are hard at work attempting to unlock the secrets that continue to delay a cure for this terrible disease.
It is our belief that a vital step in this process has been overlooked because of politics, flawed research and reporting of thermal imaging. Until such time as a cure has been found, the approach must be made in the fields of early detection and risk evaluation coupled with sound clinical decision making.
Thermography has been clearly demonstrated to be the earliest and safest risk marker of breast pathology, and in the opinion of our founder, the best case management tool available today in the ongoing monitoring and treatment of breast disease.
Thermal imaging, as a test of physiology, can detect subtle changes in breast temperature that indicate a variety of breast diseases and abnormalities. Unlike mammography, the current gold standard for breast cancer detection, thermography looks at the functional component of breast abnormality, not the anatomical.
In simple terms, thermography is capable of detecting and measuring the body's physiologic response to abnormality and mammography is capable of detecting and measuring the structural or anatomical lesions present.
It has been estimated that thermal imaging is 8-10 years ahead of mammography as a risk indicator.
By utilizing thermographic imaging under carefully controlled clinical protocols developed by Dr. Cockburn, the most complete diagnosis can be made by combining the physiologic status of the patient with other assessment tools and effective treatment.
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Breast Thermal Imaging, the paradigm shift
William Cockburn, D.C., B.C.F.E., F.I.A.C.T.
(f) Associate Professor of Clinical Sciences
Department Chairman Thermographic Sciences
CCC-LA
(reprint) original published in Thermologie Oesterreich, ISSN-1021-4356
April 95'
inquiries should be directed to docbill@earthlink.net
note: reprint on the internet and forwarding of this article is granted by the author without further
notification.
SUMMARY
Infrared thermal imaging of the breast, a non-invasive adjunctive diagnostic methodology has become all but non-existent in the United States. This is in large part due to extensive debate concerning thermography in the trial courts, related to spinal injury cases and also due to the model or basis used for breast thermal imaging. This paper attempts to identify possible factors which will bring thermal breast imaging back into serious mainstream consideration as a valid adjunct to overall breast pathology diagnosis.
KEY WORDS:
Breast thermal imaging, protocol, technology, quantification, paradigm shift, prevention, risk assessment.
INTRODUCTION:
For purposes of this paper, I define the word "paradigm" to mean "model". The paradigm, or model for breast thermal imaging must change.
The initial use of thermography was for breast cancer screening and diagnosis. This was error. Thermography as a test of physiology is not capable of, and will never be capable of detecting breast cancer.
Anatomical testing such as mammography can also not detect breast cancer. This is a paradox. Both procedures, thermography and mammography, demonstrate abnormalities indicating the possibility of the presence of cancer, as well as a host of other breast conditions. These clinical findings require differential diagnosis.
ONLY laboratory confirmation of abnormal cell morphology can make the correct diagnosis of cancer.
Thermography's role in breast cancer and other breast disorders is one of early detection and monitoring of aberrant (abnormal) physiology and the establishment of risk factors for the development or existence of cancer. This is breast thermography's only role at the current time in history.
After large scale clinical trial under appropriate protocols and further development of the procedure, equipment, protocol and certification it is hoped that certain thermal "markers" may become more generally accepted and pathognomonic of various breast disorders, including types and location of cancer.
APPROPRIATE TRAINING
Since thermography is a non-invasive (no radiation) procedure there is no specific legislation or regulatory act under which thermography can be scrutinized in the United States. Early thermographic pioneers created entrepreneurial training and certification programs for both physicians and technicians.
These programs cultivated a host of new course instructors and a variety of organizations and certifications became available.
Some courses offered thermographic certification to people with no medical background or formal medical education. For example, injured workers in California could under vocational rehabilitation laws to become certified as thermographic technicians and open their own labs.
These individuals needed an interpreting physician, so they found doctors who were willing to review and "read" the
examinations performed, although few of those physicians themselves had training or certification in the field of thermography.
To avoid a deluge of poor quality and inadequate thermographic study as well as faulty interpretation of the studies, university
based training programs must be established. With the electronic super highway in existence, a global network can be aimed at
creating such standards and uniformity of study, worldwide.
APPROPRIATE EQUIPMENT
There are essentially two types of thermographic equipment utilized in medical practice.
One is LCT (liquid crystal thermography). These are essentially latex plates embedded with liquid crystals which react to
surface heat of the body by giving off visible color. The mix of crystals used in the detector determines the detectors ability to
differentiate heat ranges.
The other is Electronic Thermography also known as telethermography. The latter are camera\computer based systems which
are highly accurate and function in real time with no contact to the subjects skin.
Many manufacturers modified thermographic equipment utilized for night vision or military applications. Some of these detectors
were not of adequate quality to read heat patterns emitted from human skin. For example, a system with a sensitivity above 0.5
degrees C, did not provide consistent quantification (numeric measurement).
Systems which sensitivity of 1.0 degrees centigrade provide for errors ranging between 0.1 and 1.9 degrees. With pathology
found at the .4 to 1.0 C range, it is obvious that such equipment is not appropriate for utilization, but none the less, these
inappropriate systems were heavily utilized in the 70's and 80's for this purpose.
Early electronic thermographic systems utilized optics (mirrors) made from indium antimonide which had a spectral range of 2-5
millimicrons. As heat patterns detectable from breast tissue fall into the 8-13 millimicron range the 2-5 millimicron detectors
were not adequate and the more expensive mercury cadmium telluride detectors should have been used.(1). These detectors
were much more costly to the average clinician or research facility and so they were not used.
Unaware physicians, who desired to use thermography in their practices purchased the less expensive systems and thus the
basis for many of the false positive findings reported in the literature. Had they used the appropriate systems with the correct
optical wave band, these false positives would have been eliminated or significantly reduced.
Many of the manufacturers of computer based systems designed software that caused the images to look fantastic, but these
images were displaying information that was not necessarily complete and thus, the unwary physician found inconsistency in his
studies as well as a high false positive rate which would not have occurred had the appropriate systems been utilized in breast
cancer screening.
As with any medical device the appropriate technology, performed according to a consistent and established protocol by board
certified individuals will result in more accurate studies and satisfactory scientific yields.
REGULATION:
Though medicine as a whole cries out for less governmental control, the lack of regulation within the field of thermography is a
significant problem. For example, in the United States, medical, chiropractic and podiatric licensing boards have adopted
position statements regarding clinical utility of thermography and some have "accepted" various protocols for implementation,
but that is all.
However, anyone can own and operate thermographic equipment. Only a licensed health care providers with portal of entry
status, (MD, DC, DPM, etc.) can interpret or render a diagnostic opinion of the examination.
In addition, this also relates to the ability to bill an insurance carrier and receive payment for services. Thus entrepreneurs with
no formal medical training often submitted studies to insurance companies which were of very poor quality. This resulted in not
only denial of payment, but a doubt was rightfully cast on the legitimacy and quality of thermographic studies as they were being performed by inadequate personnel.
With this lack of regulation, a great many poorly performed studies found their way into the medical literature and the court
system. (see personal injury model below).
PROPER PROTOCOL
A major factor related to the inconsistency of published works in the thermographic imaging field is the various protocols under
which the procedures is performed. Although not difficult, the protocol of the examination, a with x-ray or any other diagnostic
device, is essential to accurate and reliable outcome.
Some examples of thermographic protocols would be :
Factors Affecting Examination
the ambient room temperature at
which the examination is performed
the length of time allowed for patient
equilibration to the ambient temperature
the type of equipment utilized
the type of floor covering
the presence or absence of windows which
can alter room temperature
the type of heating or air conditioning
for thermal regulation of the room.
the usage of lotions, deodorants and
cosmetics on the skin
the ingestion of vasodilator and
vasoconstrictor substances (ie:caffeine)
the medications taken by the patient
While the scope of this paper can not devote a great deal of space to protocol, it is important to note that most
non-thermographic clinicians that the author has had opportunity to oppose in the legal system, have had no idea that such
protocol exists or is important.
When I taught the diplomate course for thermography in California, physicians were asked to submit thermographic studies as
part of their completion requirements. The vast majority of unacceptable studies (which incidentally, were used for diagnosis of
patients in these clinicians practices) were found to contain errors created simply by poor protocol which would have been very
easy and inexpensive to correct. For example, performing the procedure on tile flooring which by its cold temperature, caused
abnormal sympathetic heating responses in the subject under evaluation. A carpeted floor is required.
Protocol is everything. Without an internationally accepted protocol, no comparison of accuracy, double blinded study, or
evaluation of the technology and its effectiveness can be made. With the wide ranging opinion of thermographers and
pseudo-thermographers concerning appropriate protocol, it is no wonder that many studies performed worldwide do not
correlate, while other studies performed to a stringent protocol are so very consistent.
ANECDOTAL Vs SCIENTIFIC EVIDENCE
It is very important to differentiate scientific fact from anecdotal evidence. For purposes of this paper I define anecdotal to
mean a myth or a fable not supported by fact, but accepted because of a common belief or usage.
Many physicians and investigative journalists use anecdotal data to support their point of view. An example of this is the often
published article in a medical journal that uses 20-30 references by other authors who all have just rewritten an original thesis or
premise in order to get published without contributing any new data.
Now the materia medica has a number of consistent articles or studies which appear to be powerful when used as an argument
for or against a given procedure or point of view. In reality, anecdotal evidence is disastrous when not recognized.
Thermal imaging is pure science. While prone to misinterpretation by "untrained" clinicians, its diagnostic accuracy and yield are unparalleled. With respect to breast thermal imaging, a great number of studies by researchers in different parts of the world,
utilizing different technology have still demonstrated the usefulness and clinical utility of the procedure. (when utilized
appropriately).
In the United States, William Hobbins, MD(2) demonstrated in a sample of 37,050 patients, a yield of 56 cancers per 1,000
abnormal thermograms as compared to the 5.6 per 1,000 in the BCDDP studies utilizing mammography. In France, Gauthrie et
al(3) utilizing thermography determined 73% correct diagnosis in 486 breast cancer patients.
In worldwide retrospective studies, thermograms were positive in a minimum of 71% to a maximum of 93% in patients with
breast cancer as reported by Nyirjesy (4).
There are literally thousands of pages of discussion in print regarding the benefits of thermography as it relates to breast cancer.
The interesting observation to this author is the wide variety of protocols and equipment utilized and yet a tremendously high
statistical correlation of accuracy prevails. Think of what might happen if the technology and training were more standardized.
COMPARISON OF THERMAL IMAGING TO OTHER DIAGNOSTIC PROCEDURES
Comparing anatomic (mammography) to physiologic (thermography) is a great irony and source of confusion in medicine. Many radiologists I have spoken to fear that their investment in mammographic equipment will be wasted because they view
thermography as competitive with mammography or that stereo-tactic biopsy is better than thermography.
This is a classic example of the lack of training and anecdotal arguments I have previously described. Mammography is
anatomical. So are other beneficial procedures such as ultrasound, diaphenoscopy and CT scanning.
Thermography is a test of physiology (function), and not of anatomy. One can not compare apples to oranges. The procedures
are most definitely correlative and complimentary and not competitive. The view that thermography is competitive is error, and
one of the most significant detractors from its effective utilization today.
When used adjunctively with other laboratory and outcome assessment tools, the best possible evaluation of breast health is
made.
Radiologists need to understand the tremendous potential of thermography to detect the physiologic manifestation of disease
that so often predate the anatomical analysis of the condition. In my first paper on this subject (5) I point out the danger in "over
reading" thermograms and state that we should utilize the data obtained from thermal imaging from a "screening" standpoint
only, not from a diagnostic one. (1987)
This "complimentary" nature of thermal imaging is of unparalleled significance to this issue.
QUANTIFICATION
Technology, especially in light of the desk top PC and the Pentium processor, has at last reached a stage of development and
cost effectiveness that makes the availability of dynamic quantitative and reliable thermography a definitive reality.
In the past, the quantitative (or numbers) measurement of actual spot temperatures was difficult. Many thermographer s' used
liquid crystal imaging (much like the temperature strips we use on our children's foreheads). While bright, colorful and reliable
images could be obtained, no precise measurement could be made. This is called qualitative imaging. (quality of image)
While the quality of a properly performed thermogram can provide immediate thermal imaging information to the unaided eye,
(excluding the estimated 15% of the population who are color blind), errors can be made in the interpretation by assuming that
a color change is significant when in fact it may not be.
(authors note: due to the email capabilities of this type of correspondence, the original text and illustration presented below have
been modified to meet the standards available for download)
Qualitative thermography uses color or gray scale images for comparison of left to right, as in the right nipple as compared to
the left, or the full breast, right compared to left. With qualitative imaging, a color scale is presented as a crude marker for
comparison to the patients actual temperatures. It was assumed that a color change indicated a pathology as illustrated below.
This was based on a ten color scale, 1 degree centigrade between colors. So as represented in the diagram, a shift from yellow
to orange was assumed to be a 1 degree centigrade increase in heat, left compared to right.
Sample Color Scale Representation .1 degree increments
Pink Red Orange Yellow Olive Lime k Blue Blue Lavender Black
31.0* 30.0* 29.0* 28* 27* 26* 25 24* 23* 22*
X X X-X = 1.0 degree centigrade difference
Y Y Y-Y = 1.9 degree centigrade difference
Z Z Z-Z = 0.1 degree centigrade difference
* degrees centigrade
So, if the right breast were orange on the qualitative image, and the left breast were red, a pathology was assumed to exist as a
1 degree centigrade increase in heat had occurred thus shifting the color scale..
WRONG! Please notice that the beginning of each color block has a temperature selected. They increase in 1 degree
centigrade increments. Also notice that there is a "0" in the tenths position. This means the system is measuring unit values of
1/10th degree centigrade. Because the color "scale" is assigning only one color to a block of temperature, all temperatures
falling within that "block" are assigned by the computer, the same color.
Therefore, a difference as little as .1 degree centigrade or as much as 1.9 degrees centigrade could shift the color assignment.
Obviously a .1 degree centigrade shift is minimal and non diagnostic. A 1.9 degree centigrade shift is quite severe and indicative
of pathology. Both however, would assign with these outdated systems, the same relative color shift and thus the reason for
misdiagnosis and the reporting of the so-called false positives.
In my thermography lecture series, I devote one hour with graphic slides explaining this phenomenon, which is so easily
corrected once the "concept" is grasped
I have now designed software that differentially measures the actual spot temperatures in the contralateral tissues so that this
error can no longer occur, yet many clinicians still utilize, and rely upon the outdated and dangerous qualitative imaging
techniques.
CONCLUSION: I would like to restate, that thermography of the human breast is not a stand alone tool as some have
suggested in the screening and diagnosis of breast cancer. It is adjunctive. We can not ignore thermographys' tremendous role
as an early risk indicator or as a monitor for treatment.
When a thermogram is positive, a closer look at the patient's diet, exposure to environmental toxins and pollution and lifestyle is
in order. Clinical blood work in addition to mammography is essential.
When mammography and blood work are negative or equivocal, thermographic monitoring on a quarterly to semi-annual basis
should be performed in those patients with suspicious thermograms.
In this way changes in tumor angiogenesis can be evaluated and other procedures can be ordered to aid in the earliest possible
diagnosis. The procedure is non-ionizing and safe and there is no reason to simply "wait and see" any longer.
It is here that the paradigm needs to shift. We can no longer accept the "wait and see" attitude just because a mammogram is
negative. Perhaps some day with a more universal and a-political approach, thermal imaging markers can be even further
classified into more effective and even pathognomonic categories. This will require a team approach, worldwide.
Until that time, one thing is certain. In the presence of cancer or not, an abnormal thermogram is indicative of abnormal
physiology, and this can not be ignored any longer.
Link to Sample Thermograms of the Human Breast
REFERENCES
1. Hardy, JD: The Radiation of Heat from the Human Body, J. Clinical Investigation, 13:539-615
2. Hobbins, Wm, Abplanalp. K., Barnes, C., Moner, B.: Analysis of Thermal Class TH-V Examinations in 37,050 Breast
Thermograms, Thermal Assessment of Breast Health MTP Press Limited, 25: 249-255, 1984
3. Gross, C., Gauthries, M, Archer, F. et al: Classification Thermogaphique des Cancers Mammaires, Bull Cancer (Paris),
58:351-362, 1971
4. Nyirijesy, J., Abernathy, MB., Billingsley, FS., Bruns, P.,: Thermography and Detection of Breast Cancer, a review and
comments, J. Reproductive Medicine, 18/4 165-175
5. Cockburn, Wm., Breast Thermography, to screen or not to screen: J International Academy of Clinical Thermology, Vol1
No2, 17-44 1989
This article was first submitted for publication 24, October 1994
Accepted December 1994
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