Thermal Image Analysis
Dr. William Cockburn, DC, FIACT, FABFE
Fellow in Thermal Imaging
Announcement of Official
Change in Thermal Reporting
Effective Date: July 26, 2005
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There has been much controversy within the thermal imaging community, and
much comment by outside observers concerning two factors related to the
interpretation of thermal imaging of the human breast. In this
regard, I have spent quite some time investigating alternative language
and reporting methodology and I have determined to make changes to my interpretation
reports as follows:
1) The Thermal Rating System is being dropped.
The thermal rating system has proven to be a hindrance to proper communication
and understanding of actual findings with referring physicians and indeed,
with patients. The rating system has not been updated nor revised
since its initial inception and utilization in the mid 1980’s.
There are two significant problems which routinely occur with the utilization
of the reporting system; however there has not been a proposed change that
makes good clinical sense until now. The two key problems with the
thermal reporting or thermal rating system are:
A) Unresolved anxiety for both patient and physician
when TH3 - TH5 class thermograms are not confirmed by so-called conventional
methodologies such as Mammography, Ultrasound or MRI. We all know
that a positive thermogram is often many years ahead of anatomical testing
as confirmed by the scientific research, but this does not help us when we
“label” a breast as suspicious and no other method can confirm or deny the
thermal findings. This creates the medical impression of a false
positive and the resulting loss of confidence by the referring clinician.
B) Inaccuracy of the Rating System itself.
This rating system was designed decades ago to provide for a more accurate
and quantifiable system of reporting risk, however it has inherent errors
which I feel cause tremendous confusion for the primary care physician and
indeed the patient. Many patients with cancer have only one rating
factor, for example a marginal 1.1C delta at the nipple, and are as such,
rated TH-3 Equivocal. Other patients may have three or more low
level rating factors with a completely healthy breast and as such are rated
TH5 Suspicious. Often these patients present in my practice for many
years with absolutely no change in thermal patterning, In other words
- no increase in vascular or heat signature. Very often these patients
have anatomical testing which is clearly within the normal parameters (not
equivocal).
In the world of diagnostic imaging, the premise of any system, be it mammography,
ultrasound or thermography is simply to identify risk factors which may
not be determined in any other way. As such, a heads up is given
to the primary care doctor that there may be pathology requiring further
investigation. That is all.
The attempt of earlier thermographers to create a rating system which is
more objective and meaningful has actually created confusion within and
outside of the thermal imaging community, and as such, this system should
be abandoned.
This does not mean however, that reporting should simply be a series of
circles or squares drawn over areas of clinical concern. Some
rating factors, especially those in the “primary factors” category, still
require description as a methodology to alert the primary care physician to
areas of higher concern. To label these patients as equivocal, abnormal,
suspicious or for that matter, normal is an inappropriate reporting methodology
and as such, is no longer to be utilized.
2. The use of the Thermal Cold Stress Challenge for Breast
Evaluations is being dropped.
This protocol has never been scientifically proven to be reliable and may
indeed; affect the clinical management of a patient in the wrong way, for
the wrong reason.
There are several solid reasons for this decision and these factors are
related to my 20 years of clinical practice in the realm of thermal imaging.
I wish to share these factors with you as a practicum.
A) There is no reliable literature nor blinded
study to validate the use of the procedure for breast thermal imaging studies,
contradictory to many studies on Reflex Sympathetic Dystrophy (RSD) and
Chronic Regional Pain Syndrome (CRPS) (CMPS) Many thermographers have
inappropriately applied the cold stress challenge designed for neurological
conditions to the female breast.
B) The use of the stress challenge does
not, and should not be used as an indicator of “aggressiveness” or “staging”
of breast cancer. Some interp clinicians actually utilize a
(+) or (-) in their reporting methodology to indicate whether for example,
a Suspicious breast (TH5) is more (+) or less (-) suspicious depending on
whether or not the area cooled. This is not a verifiable protocol and
it is to be discouraged. (TH5+ or TH5-) An abnormal breast factor
is ratable as a factor and requires clinical correlation, period.
C) The degree of cooling, or lack thereof, has
also not been scientifically established as an indicator and I feel this has
been an anecdotal use of the procedure. As such the stress challenge can
be very misleading to both physician and patient. Depending on dietary
influences, hormonal levels of the particular day, and the amount of stress
within the patient from a variety of sources, the stress challenge may be
more or less effective. Some days, a patient will cool 0.2C in
a given area, and six months later 1.0 and on the next visit, 1.5. Some
patients will not cool on a particular visit even 0.1C and on a subsequent
visit they may cool 1.2C. Of course there are many instances of
patient’s temperature increasing on the stress challenge and then on subsequent
visits the area cools or stays the same. These variances have
cast great doubt on the reliability of the stress challenge.
D) Some anatomical factors which are benign can
severely compromise the ability of the sympathetics to provoke vasoconstriction.
This would include blood vessels which have been compromised by surgery,
incisional biopsy, lumpectomy, local trauma and even thoracic spine instabilities.
These factors can provide for permanently dilated vessels or capillary networks
which fail to respond to sympathetic stimuli.
E) The patient’s own apprehension of the procedure
may produce sympathetic fight or flight responses prior to the stress challenge,
often seen when patients can view the monitor during exam for example.
This provokes a cooling response and “sets” the sympathetic tone prior to
the actual cold challenge thus producing potential failure reporting when
the fight or flight response actually took place minutes or moments before.
Other examples of this are fear of the exam, an event proximate to the exam
that has upset the patient (phone call) (rude comment) (slip and fall) etc.
Many of these variables simply can not be accounted for.
F) Finally, and most simply, the fight or flight
sympathetic response has never changed the thermal rating nor denies the
need for further testing and correlation. Some clinicians will
make a decision on whether or not to order additional testing based on the
Success or Failure of the stress challenge procedure. The very
fact that we can not with thermography, determine the amount or aggressiveness
of angiogenesis validates this fact. The question must be asked-
At what point of existing cancer development does angio-neo-genesis override
sympathetic input? It is a great concept in theory, but it is not practical
in day to day practice.
These factors (the thermal rating system) and (the cold stress challenge)
contribute greatly to an overall confusion of the basic purpose of breast
thermography and are based largely in Dogma. The purpose of breast
thermal imaging is to view with a complimentary technology, the human breast
and to determine if there are areas of clinical interest that require further
clarification that can not be seen by other methods.
Thermography is a screening procedure. To continue to follow dogma
and unproven methods will further restrain and constrain the advancement
of this noble science.
William Cockburn, DC, FIACT, FABFE
Fellow International Academy of Clinical Thermology
Fellow American Board of Forensic Examiners
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