The Boutique at KCBC is excited to share information about the launch of “MYFORM” a new innovative personalized fitting full breast form and partial form by ABC. It is instantly customizable and adjustable to your personal fitting needs after any type of breast surgery!
If this sounds like something that you may be interested in please schedule an appointment and join us next month for our special fit event.
We will be hosting this special fit event on Thursday April 21, and Friday April 22 from 9-3.
Call us to schedule an appointment at 865-583-1010. We would need a new prescription from your doctor if you are a new patient or if it has been more than one year since your last visit with us. We look forward to seeing you!
As part of our continuing effort to provide vital information to our patients, we strongly recommend the following article.
Women Should Continue to Begin Annual Mammography Screening at Age 40
January 11, 2016
– If followed, new U.S. Preventive Services Task Force (USPSTF) breast cancer screening recommendations
will result in thousands of unnecessary deaths each year and thousands more women enduring extensive and expensive treatment than if their cancer had been found early by an annual mammogram. To ensure access to mammography, Congress delayed for two years any changes to insurance coverage based on these recommendations, while breast cancer experts vet the recommendations and the process by which they were created. Women ages 40-and-older, and their families, should continue to impress upon lawmakers and their health care providers that they want fully insured access to annual mammograms.
As our shared goal is to save the most lives possible from breast cancer, the American College of Radiology (ACR) and Society of Breast Imaging (SBI) continue to recommend that women get yearly mammograms starting at age 40. New American Cancer Society (ACS) breast cancer screening guidelines, and previous data used by the USPSTF to create its recommendations, state that annual screening in women 40-and-older saves thousands more lives each year than screening at a later age and/or less frequent screening.
“Following these USPSTF recommendations would result in lethal consequences
The US Protective Services Task Force (USPSTF) was created in 1984 as an independent panel of experts in prevention and evidence- based medicine. The members come from the fields of primary care and protective services. The USPSTF is supported by the U.S. Department of health and human services agency. Their purpose is to evaluate scientific evidence to determine whether medical screenings, counseling, and preventative medication works for adults and children who have no symptoms.
The Obama Affordable Care Act was passed in 2009. The USPSTF was engaged to review the screening recommendations previously established for various types of cancer that were already in existence and recommend any changes.
The American Cancer Society (ACS), a grassroots nongovernmental organization was the first organization to recommend mammography screening in 1976. The ACS guidelines were modified several times as increasing evidence worldwide mounted that yearly mammography screening saves lives. This was proven by the decreasing death rates from breast cancer. In 2003, the ACS recommended yearly mammography screening for all women. Breast Cancer was no longer a death sentence due to early detection of smaller cancers. Women also had the opportunity to have conservative breast surgery rather than a mastectomy, and preserve the breast. Mastectomy results in a physical image-altering surgery. Oftentimes, knowing they have physical changes from surgical treatment, women did not seek medical treatment of any other visible changes of her breast, which is generally a sign of an advanced breast cancer. This results in a significant cost of life.
Before 2009, the USPSTF recommended mammography screening every 1-2 years beginning at 40. However, their guidelines changed after the passage of the Affordable Care Act. Now they recommend yearly screening beginning at age 45, and at 55 screen every other year until 74. They considered the anxiety of having an indeterminate screening mammogram report and a resultant call back for further evaluation, or possibly undergoing an in-office needle biopsy with benign results, a harm. To the patient the USPSTF felt that while saving a life is important, there are much fewer lives saved in this age group (40-49) than in the other age groups. Additionally, the task force concluded that there was insufficient evidence to recommend for or against screening women 75 or older.
Keep in mind:
The chances of an “at average risk” woman (a woman with no family history of breast cancer) increases as we get older
1 out of 64 forty year olds is diagnosed with breast cancer
1 out of 50 fifty year olds is diagnosed with breast cancer
1 out of 25 sixty year olds is diagnosed with breast cancer
1 out of 12 seventy year olds is diagnosed with breast cancer
1 out of 8 eighty year olds is diagnosed with breast cancer
What a lot of women and doctors do not know is that 80% of women diagnosed with breast cancer every year do not have a family history of breast cancer; 5-10% of breast cancers are genetically linked! One can also conclude that the average at risk woman is also at high risk.
When the USPSTF draft guidelines were released, there was a very important reason for women to be concerned. If the USPSTF draft recommendations were to be finalized as the new guidelines, this could give the private health insurance companies leeway to restrict or deny screening mammography reimbursement. After the new guidelines of the USPSTF were released, there was such an outcry by medical professional organizations and women, that these guidelines were not imposed. However, in the later part of 2015, after allowing time for people to voice their opinion to the task force recommends, the guidelines are likely to be implemented.
Fortunately, through the support of participating organizations such as:
National Consortium of Breast Centers
American Congress of Obstetricians and Gynecologist
American College of Radiology
American Women Unite for Breast Cancer Screening
Black Women’s Health Imperative
Don’t be a Chump! Check for a Lump!
Force (Facing our Risk of Cancer Empowered)
Living beyond Breast Cancer
Men against Breast Cancer
National Association of Nurse Practioners in Women’s Health
National Hispanic Medical Association
National Patient Advocate Foundation
Prevent Cancer Foundation
Society of Breast Imaging
Susan G. Komen
As well as people responding resoundingly to the Change.org petition on the web.
Congress responded to include the Protecting Access to Lifesaving Screenings (PALS) Act in the omnibus spending bill to delay implementation of the USPSTF draft. The act would protect women’s access to mammograms by placing a two-year moratorium on the USPSTF draft recommendation for breast cancer screening. The USPSTF draft recommendations conflict with other key clinical organizations which would result in widespread confusion and put more than 22 million women at risk of losing insurance coverage for mammograms with cost sharing.
By Mary Newell, MD and Peter R. Eby, MD FSBI, and the Breast Screening Leadership Group
While randomized controlled trials (RCT’s) are the most stringent way to assess whether a certain test of treatment decreases death from a disease, there are other data that can be used to further understand the effect of a test as well. Delivering screening mammograms to the community, i.e., service screening, provides an opportunity to evaluate the effect the test has on the general population when widely used by women.
After RCT’s showed that screening mammography saves lives, population-based national screening programs were put in place in the 1980s and 90s throughout the world. Screening mammography is now a routine part of health care in at least 26 countries (1). Data from many of these programs have been analyzed to see if they confirm the RCT results – that invitation to mammography screening, and more directly, exposure to mammography screening, decreases breast cancer deaths.
The results of cohort studies and case-control studies of service screening confirm the results of RCT’s: deaths from breast cancer decrease when widespread screening programs are introduced. In a case-control trial in Western Australia by Nickson and colleagues, death from breast cancer decreased by 52% among women choosing to be screened compared to women who did not (2). A meta-analysis (summary of many different studies) of Australian and European case-control trials showed that breast cancer deaths decreased by 49% in groups of women who used screening mammography compared to those who did not (2). A cohort study published by Coldman and associates reported that groups of women who participated in Canadian service screening programs had a 40% lower death rate from breast cancer than women who did not (3). A different analysis of cohort studies found that breast cancer deaths were reduced by 43% in populations of women who were screened with mammography (4).
Service studies demonstrate that the benefit of screening mammography in terms of lives saved is even higher than RCT’s indicated. This is in part because they measure the effect of screening on women who actually had mammograms, not just those who were invited to have a mammogram. Service screening studies also tend to measure the effect of more recent screening practices that have benefited from improved mammography technology, better breast positioning techniques, and improved interpretive skills. While RCT’s laid the foundation decades ago, data from recent studies of the effects of widespread screening programs confirm that mammograms save lives.
Data from Population Service Screening
Breast Cancer Screening Programs in 26 ICSN Countries, 2012: Organization, Policies, and Program Reach. U.S. National Institutes of Health International Cancer Screening Network website. http://appliedresearch.cancer.gov/icsn/breast/screening.html. Cited March15,2015
Nickson C, Mason KE, English DR, Kavanagh AM. Mammographic screening and breast cancer mortality: a case-control study and meta-analysis. Cancer Epidemiol Biomarkers Prev. 2012 Sep;21 (9):1479-88. PMID:22956730
Coldman A, Phillips N, Wilson C, et al. Pan-Canadian study of mammography screening and mortality from breast cancer. J Natl Cancer Inst. 2014 Oct 1;10(11). Print 2014 Nov. Erratum in: J Natl Cancer Inst. 2015 Jan’107(1). PMID:25274578
Gabe R, Duffy SW. Evaluation of service screening mammography in practice: the impact on breast cancer mortality. Ann Oncol. 2005;16 Suppl 2:153-62. Review. PMID: 15958448
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Debra L. Monticciolo, MD, FACR, shares this list with patients, colleagues, family, and friends.
1. The most lives are saved with annual mammography beginning at age 40. Women in their 40’s account for about 40 percent of the years of life lost to breast cancer.
2. Screening saves more years of life for women who get screened every year rather than every other year.
3. The reduction in breast cancer mortality from mammography is significant and has been proven in multiple studies involving millions of women yet it is routinely understated in the press.
4. When presenting research results, being invited to screening is different from being screened. Not all women who are invited to screening actually go through with it. Population-based studies show that breast cancer death decreases by 25–31 percent among women invited to screening, but women who are screened will reduce their chances of dying of breast cancer by 36–48 percent.
5. Entities like the U.S. Preventive Services Task Force underestimate the benefits of mammography and overstate the risks. Radiologists are interested in saving the most lives.
6. Most false positives from mammography are resolved with only additional imaging. Less than 2 percent of women will be recommended to have minimally invasive needle biopsy as a result of screening.
7. Over-diagnosis has been overstated. Studies that properly account for lead time and underlying incidence trends show that the over-diagnosis rate is 1–10 percent, nearly all of which is ductal carcinoma in situ (the presence of abnormal cells inside a milk duct in the breast). The risk of over-diagnosis is small and is outweighed by the mortality benefits of screening.
ACR and SBI Continue to Recommend Regular Mammography Starting at Age 40
Both Agree With ACS That Mammography Screening Saves Lives and That Women Ages 40+ Should Have Access to Mammograms
WASHINGTON, Oct. 20, 2015 /PRNewswire-USNewswire/ — As our shared goal is to save the most lives possible from breast cancer, the American College of Radiology
(ACR) and Society of Breast Imaging
(SBI) continue to recommend that women get yearly mammograms starting at age 40. New American Cancer Society (ACS) breast cancer screening guidelines, and previous data used by the United States Preventive Services Task Force (USPSTF) to create their recommendations, state that starting annual mammography at age 40 saves the most lives.[pl_button type=”primary” link=”http://www.marketwatch.com/story/acr-and-sbi-continue-to-recommend-regular-mammography-starting-at-age-40-2015-10-20?mod=mw_share_facebook” target=”blank”]Read Full Article[/pl_button]
KCBC was proud to be the starting line sponsor at the 2015 Making Strides Against Breast Cancer event at World’s Fair Park on October 4, 2015!
Urgent Call For Action!
Recently you will recall Dr. Kozlowski publishing her thoughts on some very harmful legislation that was being proposed. We would like to thank everyone for their efforts. Last week we at Knoxville Comprehensive Breast Center received the following e-mail from our friends at the National Consortium of Breast Centers Inc. Please take a few moments to read the letter below and if you are so moved, by all means please sign the petition and help the cause.
“Late Wednesday night a two year moratorium proposal was introduced in the House against the USPSTF screening mammogram recommendations!
The bill, HR 3339, was introduced by Reps. Renee Ellmers, (R-NC), Debbie Wasserman Schultz (D-FL), and Marsha Blackburn (R-TN). It is called the Protect Access to Lifesaving Screenings (PALS) Act. We hope you all will help spread the word – we need your networks/membership to contact their members of Congress and ask them to co-
sponsor the bill. The House is in recess until September 8, so we have a little over a month to build sufficient support to improve the chances of prompt action when Congress returns.
We are asking you to act now and forward this petition to your network so we can get even more support. We also wanted to mention that several members of the Senate are also discussing sponsoring the bill, and we may have news about a Senate bill before the Senate departs for the August recess next week.
We are are also getting some great press about our work on this initiative. Here is a story carried in Bloomberg and it includes quotes from the sponsors, attached is the pdf of full bill for you to share.
Thank you for all you have done. It is hard to believe that all of this has happened in the three weeks since the petition was launched. Thank you to all of you who joined our April “call to action” urging you to make a public comment in opposition to the United State Preventative Service Task Force (USPSTF) recommendations on breast screening guidelines and to share your concerns with your congressional representatives. We also thank our 30 Washington Fly-In participants, who met with 90 congress people from 15 states over a very short period of time. Much progress has been made in a very short period of time, so finally and most importantly we must thank Hologic and the staff of Alston and Bird for their support and planning of this initiative.
While a mammogram is still the standard for breast cancer diagnosis, a screening breast ultrasound may be used in certain circumstances, either alone or in combination with a mammogram. Read on to learn more about when a screening breast ultrasound may be necessary and what you can expect when you undergo this procedure.
What Can I Expect During This Procedure?
An ultrasound, which you may have already experienced if you’ve ever been pregnant, is a quick and painless procedure. The technician will lubricate your skin with ultrasound gel before moving a microphone like instrument (called a transducer) on the breast tissue. The transducer emits sound waves that bounce off the tissue and produces images of the inside of the area on an attached screen. Our doctors use these images to diagnose potential breast masses and other issues. The test usually takes about 30 minutes to complete.
When Do I Need a Screening Ultrasound?
Most often, a screening breast ultrasound is ordered after abnormal findings are detected on a mammogram. This imaging test can help distinguish cysts or fatty deposits that are benign from masses that may need biopsy (an invasive procedure) in order to determine whether they are cancerous. In addition, while screening ultrasound may produce false positives and false negatives when used alone, it is often used in combination with a mammogram in women who have very dense breast tissue or who have silicone breast implants, as well as for those who are considered at high risk for developing breast cancer.
If you already have a cyst, you may need regular ultrasounds to ensure that it doesn’t grow or spread. If you’re experiencing strange symptoms in your breast, such as swelling or redness, your doctor may order an ultrasound to diagnose the cause. This modality is also sometimes used in combination with other procedures; for example, to guide the needle into a mass if you’re having a biopsy done.
When Do I Need Breast Cancer Screening?
Most experts recommend that women begin to have yearly mammograms starting at age 40. If you are at high risk for breast cancer, however, you may need to begin screening sooner. Our doctors can consult with you to recommend the frequency of screening as well as the type of screening test that works best for you. In addition to mammogram and ultrasound, doctors sometimes request a breast MRI.
Schedule Your Consultation
At Knoxville Comprehensive Breast Center, it is our mission to save lives from the disease of breast cancer. As such, we offer a number of different services for prevention, early detection, and treatment of breast cancer. Our medical team will work with you to determine the most effective treatment plan for you and your needs. Contact Knoxville Comprehensive Breast Center today to schedule your consultation and we can answer any questions you may have.
Experts recommend that most women begin receiving annual screening mammograms for breast cancer at the age of 40, or earlier for those at high risk for developing the disease. If you’ve never had a mammogram before, you may feel apprehensive about undergoing this procedure. Read on to learn more about what to expect.
What Is a Mammogram?
Simply put, a mammogram is an X-ray image of the breast tissue. It’s used to identify potential areas of concern, such as lumps or abnormal tissue. If a cyst or other mass is identified during the mammogram, your doctor will order follow up tests to determine whether the mass is cancerous.
What Is Involved in a Mammogram?
For this procedure, your breast will be compressed between two surfaces so that the breast tissue is spread out and evenly distributed. During the compression, the technician will take X-ray images of the breast. A thinner layer of breast tissue allows for more clarity in the images. These pictures are then examined by one of our doctors, who will identify any abnormalities and recommend a further course of action if necessary. The test tends to last about 15 or 30 minutes and is done on an outpatient basis, without anesthesia.
Although the compression may cause some discomfort, technicians try to minimize this as much as possible. If you are in pain, let her know so that she can try to reposition you to alleviate the discomfort. The actual compression lasts about 10 to 15 seconds on each breast. You may want to take ibuprofen or another pain reliever prior to your mammogram appointment. Also, try to schedule your test for just after your period, when your breasts tend to be less sensitive.
How Should I Prepare for This Test?
Do not wear any deodorant, lotions, powders, or creams on or around your chest the day of your mammogram. These substances can interfere with the imaging. You should also let the technician know if there’s a chance you may be pregnant. Plan to wear a two-piece outfit, since you’ll have to remove all clothing above the waist during the test.
Are There Risks to This Procedure?
Though you will be exposed to radiation during a mammogram, it’s a very small amount. The benefits of this procedure far outweigh the risks. While a mammogram can be slightly uncomfortable, it is an important part of early detection of breast cancer. This disease is much more treatable when found early.
Schedule Your Appointment
If it’s time for your first mammogram, our team at Knoxville Comprehensive Breast Centerwill work with you to ensure you are comfortable throughout the process. During your consultation, we’ll review the entire process with you and make sure you are prepared for your mammogram. Contact Knoxville Comprehensive Breast Center today to schedule your consultation.
If you’ve been diagnosed with cancer, your doctor may recommend a surgical procedure known as a sentinel node biopsy. The purpose of this biopsy is to determine whether cancer cells have spread into the lymphatic system, a phenomenon most commonly associated with breast cancer as well as melanoma. Read on to learn more about what to expect if you’ve been scheduled for a sentinel node biopsy.
The sentinel lymph node is the one to which cancer cells from a primary mass are most likely to spread. Before performing breast cancer surgery, the surgeon will inject a special type of dye that helps indicate the presence of cancer cells into the lymph node. This node is then removed as a standard part of the mastectomy or lumpectomy procedure and the path of the dye analyzed to determine whether and how far the cancer cells have spread. If cancer is not present in the sentinel node, it means that the cancer has not yet spread. Where cancerous cells are present, more testing may be required to determine the extent to which it has spread and develop a treatment plan.
A sentinel lymph node biopsy is typically done under general anesthesia. After the use of dye to identify the sentinel node, doctors make a small incision in the armpit area to remove the node so that it can be tested for the presence of cancerous cells. This procedure typically requires a hospital stay, especially if you are having your cancer removed or other surgery at the same time as the biopsy. Return to normal activities largely depends on your individual health situation; your doctor will advise about what’s best for you.
This procedure is important since it lets doctors target and remove only those lymph nodes that need to be removed, lessening the likelihood of complications such as pain and swelling. According to research published by the American Society of Clinical Oncology, sentinel lymph node biopsy is as effective in preventing the spread of cancer as more extensive lymph node surgery.
The most common complications of this procedure are short term pain, swelling, and redness at the surgical site. You may also experience an allergic reaction to the dye used in the procedure.
If you have been diagnosed with breast cancer, talk with your doctor about whether a sentinel node biopsy may be right for you, as well as about any concerns you may have prior to having this procedure.
At Knoxville Comprehensive Breast Center, it is our mission to save lives from the disease of breast cancer. We’ll work with you every step of the way to ensure you get the safest, most effective care possible. Our medical team is comprised of dedicated breast cancer specialists, who will work with you to provide the individualized care you deserve. Contact Knoxville Comprehensive Breast Center today to schedule appointment.
It’s important for every woman to feel comfortable in her own skin. If you have had a mastectomy, lumpectomy, reconstruction or Poland Syndrome, you deserve to feel at peace with your body. Virage Breast Forms are custom-fitted and lightweight, which will allow you to return to the everyday activities you love and will help you feel like yourself again – confident and comfortable. Virage Breast Forms are custom-fitted, lightweight breast forms that allow you to return to the everyday activities you love. They are custom-made and personalized to ensure a perfect fit despite healing patterns and surgical depth. We support you and all breast cancer survivors by providing the support and products you need to adapt to life after cancer. Virage Breast Forms give you peace of mind after your recovery and help you get back to your normal self and routines effortlessly.
When it comes to the technology involved in creating breast forms that are meant to restore your self-confidence, we have implemented the safest and most advanced measures to ensure comfort and good fit. Virage Breast Forms creates the most life-like custom breast prostheses in the world by harnessing state-of-the-art laser scanning and 3-D CAD/CAM technology with our patented handcrafted processes. The chest wall contour is captured through laser scanning so the breast form fits like a puzzle piece and hugs the chest wall. It is our opinion that breast cancer survivors deserve the best, most life-like breast prostheses created with unparalleled technology. Our purpose is to use this technology to help women who have gone through a mastectomy or related procedure and help them transition back to their normal body and routine.
Custom Breast Forms
Virage Breast Forms custom products include complete and partial breast prostheses in various styles and colors individually handcrafted giving each woman a natural, custom fit. The back of the breast form wicks away moisture and lifts it above the skin, creating a mold free environment. With different colors and sizes to choose from, you have the ability to help create the right breast form for yourself. Your custom breast form will feel and look natural, allowing you to return to your daily activities without pause. Whether you’ve undergone a mastectomy or lumpectomy, our mission is to provide you with high quality breast prostheses that allow you to live life to the fullest.
Available for purchase in the complementary boutique located in the lobby of the Breast Center
Breast cancer is a disease that affects many people – both men and women – in the United States. It is estimated that about 12 percent of women in the United States – or 1 in 8 – will develop invasive breast cancer over the course of her life. Second only to skin cancer, breast cancer is one of the most commonly diagnosed cancers among American women. At Knoxville Comprehensive Breast Center, it is our mission to save lives from the disease of breast cancer. For many, that can start with at our High Risk Assessment Clinic.
Getting your breast cancer risk assessment with us is a great step for the future of your health. We employ some of the best doctors and surgeons in the medical field, and our breast cancer risk assessment considers all factors to give you the best prognosis for your future health.
What Are the Risk Factors for Breast Cancer?
There are several risk factors that our medical team looks for when assessing a patient for breast cancer. First, our doctors will look at your family history. The truth is that women who have breast cancer in the family have a higher likelihood of contracting the disease. In addition, those women who are most at risk may have breast cancer within one generation. In other words, their mothers or sisters might have the disease, and this will put them at greater risk.
There are other factors at play here as well. For example, overall health will be assessed. Women who might be at risk are always encouraged to take care of their health by eating well, exercising on a regular basis and avoiding excess alcohol and smoking.
Get Your Breast Cancer Risk Assessment at KCBC
KCBC is one of few facilities in the country that offers the Myriad myRisk™ Hereditary Cancer panel. This panel is comprised of 25 genes and analyzes elevated risk for eight important cancers. It also identifies up to 50 percent more mutation carriers than the panels developed for hereditary uterine and colorectal cancers.
Schedule Your Consultation
If breast cancer runs in your family, contact Knoxville Comprehensive Breast Center to schedule your high risk assessment. We’ll work with you to determine your risk factors for breast cancer. Our calm, spa-like facility provides a safe and comfortable atmosphere for all of our patients. Together we can take preventative measures to keep you safe from breast cancer.
A breast MRI, or magnetic resonance imaging, takes pictures of the breast with radio waves and a magnetic field. It does not use X-rays, and it can catch problems within the breast that mammograms, CT scans and ultrasound cannot.
A breast MRI typically takes 45-60 minutes, but the patient should plan on spending 1 1/2 hours on the procedure and associated preparations. Several dozen pictures will be taken during the breast MRI.
Beforehand, the patient will be asked to remove any personal items like watches, jewelry, and money. Hearing aids, piercings and credit cards with magnetic strips especially must also be removed, as the MRI will damage them. A hospital gown will be provided for the patient to change into.
During the breast MRI, patients typically lie on their stomachs on a table that is part of the scanner. The technician may use straps to keep the patient’s body in the desired position. They may also put a device called a coil over the breast area. The patient will then be slid into the part of the machine containing the magnet.
Once inside the scanner, the patient will hear the sounds of a fan plus thumping or tapping noises as the pictures are taken. Earplugs or headphones may be provided to help cope with the noise. The patient must stay completely still during the scans, or repeat scans may have to be taken. The patient may be alone in the scanner room, but the technologist will be watching from a window, communicating through a speaker.
Does a Breast MRI Hurt?
The MRI itself does not hurt, although lying on a hard table in one position may get uncomfortable. Claustrophobic patients may have the option of a sedative to help them relax. Patients with metal fillings may feel a tingling sensation in their mouth, and others may feel their breasts heat up. This is normal, and any discomfort experienced with these sensations is temporary.
A patient undergoing a breast MRI should discuss the following symptoms during their appointment:
- Breathing problems
- Burning sensation
Other things to bring to the attention of the technician prior to the breast MRI are:
- Pacemakers or other medical devices containing iron
Metal fragments in the eyes
- Gadolinium may cause serious problems in people with kidney failure.
- Extreme obesity. A very large patient simply won’t be able to fit in the machine.
- Metal anywhere will interfere with the scanners.
After the MRI, the patient will be able to return to normal activities. The period of getting the results will be discussed prior to the breast MRI. Contact Knoxville Comprehensive Breast Center today to talk to one of our breast cancer specialists or schedule your breast MRI. We offer services dedicated to screening, diagnosing and treating breast cancer, and your comfort is our top priority.