Thermogram of a woman with significant foci of hyperthermia and inflammation in her left breast. State of the art thermography captures 26 qualitative and quantitative parameters, from which are derived a risk score, and an aggregate “TH” grade indicating the patient’s overall likelihood of developing breast cancer. In this case, the woman’s left breast showed a score of 165 (out of 250) and a TH grade of 5 (1=minimal risk; 5=worrisome risk). Her right breast score was 70, with a TH grade of 2. The good news is that inflammation, and consequently cancer risk, is reversible with nutritional and lifestyle changes. Thermogram courtesy of Breast Health & Wellness Centers (www.breasthealthandwellness.com).

It’s radiation-free, non-invasive, FDA-approved, relatively inexpensive, and detects early, potentially reversible physiological changes associated with later development of breast cancer. So, why isn’t breast thermography a routine part of women’s health practice?

It really ought to be, say a growing number of physicians who are re-discovering this long-overlooked imaging method. Advocates say it’s a technology whose time has come, not so much as a substitute for mammography, but as a method of identifying tissue in which tumors are more likely to emerge.

Thermography emits no radiation. Rather, it picks up infrared emission from the surface of the skin and displays detailed temperature patterns. Areas of hyperthermia are reflective of increased microcirculation and hypermetabolic states in the underlying tissue. Thermography has many potential clinical applications; it has been studied in the breast cancer context since the early 1960s.

Research over the last 40 years has shown a consistent relationship between abnormally high breast tissue temperature and increased vascularity suggestive of angiogenesis (Sterns EE, et al. Cancer. 1996; 77: 1324–1328; Head JF, et al. Ann NY Acad Sci. 1993; 698: 153–158). This, in turn, correlates with cancer.

In a study funded by France’s National Institute for Health & Medical Research, investigators followed 1,527 asymptomatic women with abnormal thermograms for 12 years, and found that 40% had breast malignancies within 5 years (Gros C, Gautherie M. Cancer. 1980; 45: 51–56). In 1996, Guidi and Schnitt hypothesized that thermographically detectable hyperthermia is reflective of early stage neoplastic activity, arising well before neoplastic cells have the ability to invade surrounding stroma (Guidi AJ, Schnitt SJ. The Breast J. 1996; 2: 364–369).

Early Tumor Detection ≠ Prevention

The potential to detect pre-cancerous changes is the real value of thermography, says Joel Evans, MD, founder-director of the Center for Women’s Health, Stamford, CT. Dr. Evans began offering thermography one year ago.

“We really need to shift away from the idea that early detection is synonymous with prevention. Conventional medicine continually argues that mammography is the answer to the problem of breast cancer. But early detection of tumors is not really prevention. True prevention is about identifying women, or more specifically breasts, that are at risk for developing tumors. This is what thermography allows us to do.”

Abnormally increased bloodflow in a specific area usually signifies inflammation, and breast tumors typically emerge in areas of inflammation. Whether prolonged inflammation “causes” neoplasia or neoplasia induces inflammation remains to be determined. But foci of inflammation are usually detectable long before actual tumors. Thermography, said Dr. Evans, detects this “fertile soil for tumor development.”

According to Neil Hirschenbein, MD, a La Jolla, CA, internist who has been using the technique for 2 years, “The most powerful argument for thermography is that with thermography, you are looking at physiology, whereas mammography looks at anatomy. And physiology almost always changes before anatomy changes. So this is extremely helpful for prevention,” he told Holistic Primary Care.

Thermography vs. Mammography: The Great Debate

The role of thermography in breast tumor detection and its value relative to mammography have been the subject of intense debate since the 1960s. Early thermography advocates believed it to be a valuable cancer detection tool, comparable to mammography. A number of studies through the ’70s and early ’80s showed that thermography could indeed find cancers.

In a cohort of 4,621 asymptomatic women, one third of whom were under 35, thermography was able to detect breast cancers with a sensitivity of 98.3% and a specificity of 93.5% (Stark A, Way S. Cancer. 1974; 33: 1671–1679). Among 61,000 women screened over a 10-year period, thermography had a sensitivity and specificity of 89% for detecting cancers, and it picked up 91% of all non-palpable tumors. In 61% of the cancer cases thermography alone was the “first alarm” (Spitalier H, Giraud D. Biomedical Thermology. 1982, AR Liss).

According to Gamagami, thermography detected hypervascularity and hyperthermia in 86% of non-palpable breast lesions; 15% of those lesions were not detectable with mammography (Gamagami P. Indirect Signs of Breast Cancer, in Atlas of Mammography.1996, Blackwell).

Up until the early ’70s, many US breast cancer experts saw thermography as a less invasive (i.e., radiation-free) screening tool that could determine which women truly needed mammography, itself still evolving at that time.

Wider acceptance of thermography in the US was largely derailed as a result of the Breast Cancer Detection Demonstration Project (BCDDP), a massive, federally-funded multicenter trial from 1973–1979. The study initially compared physical exam, thermography and mammography for the detection of breast cancers. But in 1977, trial leaders opted to exclude thermography, deeming it insufficiently accurate compared with mammography and palpation.

In 1982, Sterns and colleagues published a high-profile study of 502 women showing a large number of equivocal or abnormal thermograms in women with normal breasts or benign disease (i.e., false positives), while at the same time missing half of all actual cancers (i.e., false negatives). Sterns, who had previously written on the connection between surface hyperthermia and angiogenesis, concluded that, “Clinical diagnosis of breast cancer was not enhanced,” and that “Thermography is not a sufficiently precise modality for use in routine breast diagnosis” (Sterns EE, et al. Cancer. 1982. 50 (2): 323–325).

The combined impact of the BCDDP, the Sterns paper, and the lack of well-defined procedural and interpretive standards, effectively side-lined thermography, and mammography emerged as the standard for tumor detection. Though FDA approved thermography as an adjunct to mammography in 1982, few mainstream physicians embraced it.

A False Premise

Modern thermography advocates like Dr. Hirschenbein say both BCDDP and the Sterns study were flawed. BCDDP’s methodology was highly questionable in that it lacked standards for the actual thermographic procedures, the training of scan interpreters, or the manner in which findings were reported.

The Sterns paper, though more solid methodologically, suffered from misinterpretation. Dr. Hirschenbein contends that had investigators followed the women with so-called false positive thermograms for several years, they would likely have seen many of them develop malignancies. The point is, the thermograms were revealing early pre-lesional states. They were likely truly positive for elevated cancer risk, though not necessarily for extant tumors.

He, Dr. Evans and other recent fans of thermography say the “mammography versus thermography” argument is misguided to begin with, and predicated on a false premise that thermography could be used in place of mammography.

“They give very different types of information,” Dr. Evans said. “I see thermography as an adjunct to mammography, not a substitute. Thermography plus mammography is definitely better and gives more information than either alone. However, there are a lot of women who are dead-set against mammography either because they find it painful or they’re concerned about radiation exposure—a legitimate concern in my mind. For these women, thermography is definitely better than nothing.”

Amanda Ward, ND, a San Diego-area naturopath who has made thermography a significant part of her practice, says she will advise a patient with an abnormal thermogram to get a mammogram immediately. “I always ask if they’ve had one, and if they say no I strongly suggest they get one. A lot of women come to see me because they’re rejecting mammography, and if they choose not to have a mammogram, I get that in writing. It is important to get a signed informed consent statement.” (For more on informed consent, see “What to Do—And What Not to Do—When Your State Medical Board Comes A’Calling,” another article from the current issue, on our website, www.holisticprimarycare.net.)

Struggling with Standards

Both the technology for capturing thermographic information, and the computer-based protocols for interpreting, displaying, and reporting that information have evolved greatly since the 1970s. There are a number of thermographic imaging systems on the market, and an equal number of digital interpretation systems, thermography franchises, and training courses.

Very few physicians who do thermography read their own scans, a process that is quite complex, time-consuming and requires considerable training. Most companies marketing thermographic technology also provide processing and interpretation services, typically with a turn-around time of 7–10 days.

The biggest challenge to the further evolution of clinical thermography is the lack of agreed-upon, independently validated, national standards for the technology, interpretation, and education of practitioners and readers.

“It’s the Wild West out there,” said Dr. Ward. “Some companies are selling very sub-par imaging systems. I’ve looked at reports from a number of different companies and it’s scary the way the findings are being interpreted. Some are only doing the qualitative part (i.e., color-coded images alone), and not giving quantitative measures. You really need to have the quantitative part.”

Dr. Ward said that after reviewing the available options, she chose to go with the system developed by Breast Health and Wellness Centers (www.breasthealthandwellness.com), a California-based company with thermography clinics in several states. After working with the system, she decided to become one of the company’s physician representatives.

BHWC’s “Green Screen” protocol uses state-of-the-art infrared and radiometric equipment to look at 26 distinct parameters. It assigns a specific score for each one. These individual scores are then compiled into an overall aggregate “TH” score ranging from 1 (completely normal) to 5 (worrisome).

The information is presented with the objective of identifying risk, not of diagnosing tumors, per se. The Green Screen provides precise instructions on how to conduct the actual scan, as well as patient guidelines (i.e., no exercise 6 hours prior to the exam, no food or drink 2 hours prior, etc.), to minimize variables that might affect the readings.

The Green Screen also utilizes dynamic file transfer protocols so that the entire-real time scan, with full 3-dimensional images, is sent to the lab for interpretation, not just static images, as is the case with some other systems. The scans are read by sophisticated image analysis software adapted from technology developed by the US military.

Chris Cozzie, BHWC’s president, acknowledged that the lack of national standards is a problem for the field. He told Holistic Primary Care that a number of thermography companies, including his own, are working hard to develop and promote scientifically sound guidelines for both the capture and interpretation of breast thermograms.

BHWC has worked closely with George Chapman, DC, and Barbara Britt, CTT, RTT, both 30+ year veterans of clinical and research thermography, to establish the International College of Clinical Thermography (ICCT), a non-profit organization committed to creation and promotion of thermography standards. Several other similar groups exist, such as the International Academy of Clinical Thermology (IACT).

The difficulty, Mr. Cozzie admitted, is that all of these groups are affiliated with thermography companies, and as yet, there is no national consensus or third-party oversight. “ICCT is a club, and IACT is no different. We are trying to work with Scripps to develop a truly independent organization that could ultimately lead to nationally recognized standards. In the mean time, though, we have to take the first steps.”

Who Should Have a Thermogram?

Fortunately, there are no safety risks associated with thermography, and no real downsides, so long as it is used appropriately. Even the cost is fairly low. Most practitioners charge $200–$300 per exam. Since it is not covered by insurance plans, it is an out of pocket cost to patients, but not an onerous one.

Dr. Evans recommends it to almost all of his patients, especially those who are too young for mammography. Because it is radiation-free, it can be safely used in women in their late teens and early 20s. Dr. Hirschenbein agreed. “We all know that mammography is not very good for younger women because their breasts are usually too dense. There’s real concern about the radiation because younger breast tissue is more sensitive to the effects than older tissue.”

Dr. Hirschenbein finds thermography extremely valuable in clarifying what’s going on in women who have ambiguous or equivocal mammographic findings. Since there is no radiation exposure, thermography can be done with far greater frequency than mammography, a big plus in terms of tracking pre-malignant changes, and also in monitoring therapeutic interventions. He added that it also has a role in evaluating women who test positive for the BRCA 1 or 2 genes. “I’ve had a few women in my practice who had prophylactic mastectomies. It’s very sad because I think a lot of those surgeries could have been prevented.”

Dr. Ward says she has started getting referrals from gynecologists and other MDs specializing in women’s health, who send patients with equivocal mammograms for thermography. “They’re trying to figure out whether to biopsy or not, and sometimes the thermogram can help.”

Many women are not waiting around for referrals, she added. “Roughly 40% of my patients come in asking for thermography. If they’ve heard of it, they’re seeking it out.” The interest is driven in part by advocacy from celebrities like singer/actress Olivia Newton-John, a breast cancer survivor and champion of thermography. The star power, combined with the promise of actual prevention, and the perception that thermography is safe and more comfortable than mammography makes it a big draw for many women.

Reversing Breast Cancer Risk

Thermography advocates say the technique opens a true window for breast cancer prevention because the abnormalities it detects (hyperthermia suggestive of inflammation and angiogensis; metabolic changes suggestive of hormone imbalances) are correctable through nutritional and lifestyle interventions.

Many of these physicians base their recommendations on protocols developed by Sherry Tenpenny, DO, an osteopathic physician in Middleburgh Heights, OH, and a pioneer in natural therapeutics for disorders affecting women and children. Dr. Tenpenny’s approach makes use of anti-inflammatory nutrients like omega-3 fatty acids, flax lignans and herbs like hops and rosemary to quell breast inflammation, while at the same time, using bioidentical hormones (if necessary) to restore a healthier estrogen-progesterone balance.

Patients at high risk of breast cancer will also benefit from taking indole-3-carbinol (I3C) or diindolylmethane (DIM), phytonutrients derived from cruciferous vegetables, that shift the metabolism of estrogen to favor 2-hydroxyestrogen (2OHE), which is anti-proliferative and promotes apoptosis, as opposed to 16-alpha hydroxyestrogen (16OHE), which promotes breast cell proliferation. Many American women, especially those at risk for breast cancer, underproduce 2OHE and overproduce 16OHE (for more on this subject, visit www.holisticprimarycare.net, and read “Cruciferous Indole at the Crossroad of Estrogen Metabolism” from our April 2002 edition).

Dr. Evans says he offers his at-risk women a “buffet table” of therapies, including conventional drug therapies like tamoxifen and raloxifene, as well as a host of nutraceuticals and botanicals that can reduce inflammation and shift the estrogen 2/16 ratio to a more favorable balance. Vitamin D and Iodine are also important nutrients for breast cancer prevention.

With diligent engagement in a treatment protocol, women will often show normalization of thermographic findings within 3 months, if the initial abnormality was mild. More significant abnormalities with higher degrees of inflammation and hormone imbalance take more time to resolve.

The big question, still unanswered, is whether the reversal of thermographic abnormalities actually translates into reduced breast cancer incidence. It makes physiological, as well as intuitive sense that it would, but this has not been definitively proven. Like any primary prevention question, this one would require a lot of time and money to answer. Unless the federal government or a very wealthy philanthropy becomes interested, a definitive trial is unlikely.

A Strong Health Motivator

The physicians interviewed for this article stress that there is little potential harm in thermography, or in the interventions an abnormal finding would prompt. In fact, the protocols recommended to reduce breast inflammation have many collateral health benefits like reducing risk of heart disease, stroke, diabetes, endocrine/metabolic dysfunction, and autoimmune/inflammatory conditions.

Thermography can be a huge health motivator for women, says Dr. Ward. “The visuals are very, very powerful, and patients can see changes over time. It helps them to stay on the treatment plan, and it is worth it just for that!”

Because it is a visualizable early warning signal, an abnormal thermogram acts as a wake-up call, providing a genuine opportunity for prevention. “When women have an abnormal mammography and they’re diagnosed with breast cancer, everything happens so fast. They’re suddenly rushed into mastectomies, radiation, chemotherapy. It’s such a crazy vortex, and it’s really too late to do anything else,” said Dr. Ward. “But with thermography, we can find the risky states early on. It gives us time to make dietary and lifestyle changes, and true preventive steps. This is really empowering to a lot of women.”