The three approaches to early detection of breast cancer are self-examination, examination by a physician, and mammography No single method alone is sufficient. All women should conscientiously pursue all three.

Monthly self-examination should begin at puberty. You know your breasts and their shape and feel better than anyone else. Although you may not know what a malignant lump feels like, you can detect subtle changes and, if you notice something different, have the change evaluated promptly by a physician.

Once you start to menstruate, you should have a yearly breast exam in conjunction with your regular physical or gynecological exam, preferably by the same person year after year, so that he or she can get to know the character of your breasts and notice if something changes. Such stability can be difficult to achieve in this day and age, when health maintenance organizations make it hard to see the same provider year after year.

The third step is mammography, which can find lesions or lumps that may be too small or too subtle to feel. Even though mammograms do not pick up all lumps, including 7-10 percent of the breast cancers that can be felt, mammograms are far from useless. You must couple them with self-examination and examination by your doctor to get maximum protection.

When should you do your monthly breast exam?

If you do your breast exam at the same time each month, it will be easier for you to identify any changes. The best time is right after your menstrual period, when your breasts are least tender and least lumpy. If you have gone through menopause already or are pregnant, simply pick a convenient day of the month — maybe the first day — and examine yourself then.

How do you do a breast self-exam?

There are five steps to a thorough exam. One of your goals is to familiarize yourself with the geography of your breasts, so that you notice any changes that occur.

What are the symptoms of breast cancer?

The classic symptom of breast cancer is a lump in the breast. You should also report to your caregiver any changes in the contour or shape of the breast, changes in the character of the breast tissue (for example, thickening), a retracted nipple, dimpling of the skin, and bleeding from the nipple or any other drainage, even if it is clear.

Report these signs right away, even though the odds are strongly favorable that the changes you notice are not cancerous.

Breast pain is not usually related to cancer, especially in younger women. Only about 6 percent of women with breast cancer have pain.

What percentage of breast lumps are cancerous?

Fibrocystic breast disease is a very common condition in which the breasts are generally bumpy and lumpy, and it is the cause of the vast majority of lumps in younger women. About half of all persistent breast lumps in women older than 50 (the average age of menopause) are cancerous and about three quarters in women over 70. The odds are much better for younger women.

Is there any way to tell by feel whether a breast lump is benign or cancerous?

There is no sure way to tell by physical examination alone whether a lump is cancerous. Cancerous lumps are often very hard and difficult to move under the skin; some have irregular edges. In medical terminology these lumps are called “discrete,” because they feel very different from the surrounding tissue.

“Vague” lumps are less distinguishable from their surroundings and usually less hard. If someone has a vague lump in her breast and is a heavy caffeine drinker, her physician may take her off caffeine, give her vitamin E and vitamin B, and see whether the lump goes away. If your doctor makes these suggestions, follow them conscientiously for a cycle or two. If the lumps disappear, so much the better. If they remain, see your doctor for a follow-up exam.

Are breast lumps that develop during pregnancy or during breast-feeding more likely to be cancerous than lumps that develop at other times?

It is certainly possible that lumps that develop at these times are related to the hormonal changes that come with pregnancy or nursing, but see your physician right away to make sure they are not cancerous.

If you have previously had breast cancer, is there any danger in becoming pregnant?

This is a controversial area and needs to be addressed individually by each woman who has had breast cancer and is considering becoming pregnant. Age, family history, how advanced the previous cancer was when discovered, and other emotional and personal considerations enter into the decision. Each woman needs careful counseling to review all the factors that have surrounded her breast cancer. Of my own patients, three who had had breast cancer later had children; all did beautifully and are now in good health.

Does breast cancer discovered during pregnancy have a bad prognosis?

People used to think that breast cancer diagnosed during pregnancy was extremely dangerous, but current thinking has softened this view somewhat. If the cancer is found early in the pregnancy, the woman must go seven or eight months without treatment if she wants to preserve the pregnancy. Obviously a pregnant woman cannot have chemotherapy or radiation. The prognosis also depends on how early the cancer is found and how advanced it is at the time of discovery.

How often should you have a mammogram, and when should you start?

I recommend an annual mammogram for women older than 40. We know that for women in their 50s yearly mammograms can improve the cure rate by 30 percent and for women in their 40s by 15 percent. Even 15 percent is a significant improvement.

If some symptom like a lump or discharge has shown up on an earlier examination, or if you have a strong family history of breast cancer or some other risk factor, then your care should be individualized and your age at the first mammogram customized to your personal circumstances. If, for example, your mother had breast cancer while she was in her 30s, you might start having mammograms at that age.

The scheduling of mammograms for women in their 40s is a controversial issue. The American Cancer Society recommends a baseline mammogram at 40 and annual mammograms thereafter. The American College of Obstetricians and Gynecologists, the professional association for these physicians, suggests a mammogram every other year for women in their 40s. The position of the National Cancer Institute is that you do not really need annual mammograms until you are 50. Since breast cancer risk rises with age, yearly mammograms for women over the age of 50 are universally recommended.

Are mammograms painful?

While no one thinks that mammograms are fun or comfortable, the peace of mind a favorable mammogram report can bring is certainly worth the momentary discomfort. Some women with very small breasts find mammograms painful; so do some women with very large breasts. To minimize the discomfort, you can cut down on caffeine for a few days before the exam, which will also make the x-ray easier to read.

How reliable are mammograms?

Everyone has heard stories of women whose mammograms gave false negatives (did not find existing breast cancer). Research has shown that mammography has a sensitivity (ability to detect existing cancer) of up to 94 percent, which means that about 6 percent of cancers will not be found. On the other hand, mammograms have a specificity (ability to find an absence of cancer when the woman being screened does not have the disease) of greater than 90 percent. Mammography can detect a cancerous growth as much as two years before it can be felt by a manual exam. However, mammography may not be able to detect a growth in dense breast tissue, the type of tissue often seen in young women’s breasts.

Are mammograms safe?

Since 1992, when the Food and Drug Administration required hospitals, breast clinics, and other facilities to meet specific standards in order to offer mammography, the quality and the safety of mammography has improved. The guidelines assure that the mammography equipment is safe and uses the lowest possible dose of radiation.

Many people are concerned about exposure to x-rays, but the level of radiation in up-to-date mammograms does not significantly increase the risk for breast cancer. A woman who receives radiation therapy for breast cancer will receive several thousand rads (a measure of the energy absorbed from radiation). A woman getting yearly mammograms from age 40 until age 90 will receive 10 rads total. The amount of radiation to which you are exposed during a single mammogram equals the radiation you get flying from New York to Los Angeles.

 

When Your Mammogram Gives the Wrong Answer

False negatives (missed diagnoses) occur when mammograms appear normal even though breast cancer is actually present. False negatives are more common in younger women than in older women. The dense breasts of younger women contain many glands and ligaments, which make breast cancers more difficult to detect in mammograms. As women age, breast tissues become more fatty and breast cancers are more easily “seen” on the mammograms. Screening mammograms miss up to 25 percent of breast cancers in women in their 40s, but only 10 percent in older women.

False positives occur when mammograms are read as abnormal but no cancer is actually present. For women of all ages, between 5 and 10 percent of mammograms are abnormal. Most abnormalities are not confirmed as cancer. Like false negatives, false positives are more common in younger women than in older women. About 97 percent of women aged 40-49 who have abnormal mammograms turn out not to have cancer, as compared with about 86 percent for women 50 and older. But all women who have an abnormal mammogram need to undergo follow-up procedures such as repeat mammograms or biopsies.

 

Do you need a mammogram even if you have no family history of breast cancer?

Absolutely. Most women who develop breast cancer do not have a known family member who has had the disease.

Do breast implants interfere with the accuracy of your mammogram’?

Women with breast implants must be particularly vigilant about breast self-examination, yearly exams, and mammograms. The implants can obscure portions of the breast tissue that need to be examined.

The capsule of the implant holds either a silicone gel (no longer on the market, but still present in implants done before 1992) or a saline (salt water) solution. Over time the capsule can leak, and the leakage can appear as a lump in the breast. Even though you suspect that your implant has sprung a leak, have the lump evaluated by your doctor. Do not assume that the implants have caused any changes you notice in your breasts.

Can you have a mammogram if you are breast-feeding?

Yes, although the breast tissue is very dense at this time and the density might hide a lump or other lesion. There are other ways to evaluate the situation using ultrasound or perhaps even a biopsy. I usually recommend waiting three to six months after your baby is weaned before having a routine mammogram; however, if you notice a lump or some other change, be certain to notify your doctor.

What tests other than mammograms can be used to detect breast cancer?

Mammograms are still the most accurate way to detect breast cancer, though some newer techniques can be used to supplement them. If we want to know whether a breast lump is filled with solid matter or fluid, ultrasound can help. Sound waves can outline the area whose texture differs from the surrounding tissue, but ultrasound does not detect the kind of small calcium deposits that often appear on a mammogram, sometimes triggering a diagnosis of breast cancer.

Magnetic resonance imaging is another new technique, touted by the press as marvelous and less painful than mammography technology. Magnetic resonance imaging is useful for finding out whether a breast implant has developed a leak, which can help determine whether a breast lump is caused by leakage or something more worrisome. In terms of evaluating breast tissues, pointing out areas in the breast that may be suspect, or suggesting whether suspicious tissues are actually cancerous, Magnetic resonance imaging is still an experimental technique.

Thermograms, which measure heat production by tissues, were popular for a while on the premise that cancer produces heat. However, the sensitivity of these tests did not ultimately prove helpful in screening for breast cancer.

So mammograms remain the principal test for breast diagnosis. No replacements appear on the immediate horizon. However, one radiologist at the University of Arkansas is using Magnetic resonance imaging for diagnosis. While this technology is still in the research stage, it holds out the promise that women might not need surgical biopsy to diagnose or rule out cancer. At present, Magnetic resonance imagings are too costly to be used as a screening tool for the general population: a single study costs more than a thousand dollars. If they can be made more cost effective, Magnetic resonance imagings could be a satisfactory tool for diagnosing lumps that are too small to be felt.

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