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Breast Cancer

Volume 8, Number 6 – August/September, 2004

Editors: Carol A. Rice, Ph.D., RN, Professor and Extension Health Specialist, and Janet M. Pollard, MPH, Extension Associate-Health

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Inside HealthHints....

• HealthHints Brown Bags: A New Approach
• Breast Cancer
• Why Talk About It?
• Are You at Risk?
• What Can I Do?
• What Screenings Do I Need?
• What Should I Expect?
• What About Quality and Cost?
• References

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AGENT ONLY

Breast Cancer: Clarifying Guidelines for Early Detection

There has been considerable, recent controversy over the guidelines for early detection of breast cancer. Some saying that Breast Self Examination (BSE) and Clinical Breast Examination (CBE) are not enough; while others tout the limitations of mammography. This controversy has left many confused about what approach to take or whether to take steps for early detection at all.

As we seek to address the issue of early detection of breast cancer among our clientele and our loved ones, current national guidelines can help us give clear instruction and dispel any myths that surround the issue of early detection of breast cancer.

“SAY”

Why Talk About It? Understanding the Statistics

Breast cancer detection – Why should we talk about breast cancer detection? Unfortunately, today breast cancer is the most common cancer among women in the United States,¹ and the second leading cause of cancer death among North American women – second only to lung cancer.^{2, 3} Though breast cancer can also occur among men, the number of cases is small.³

Unfortunately, many individuals with breast cancer do not know they have it until it is in advanced stages.⁴ In 2001, an estimated 192,200 women were diagnosed with breast cancer, and 40,600 women died from the disease.¹ In her lifetime, approximately 1 in 8 women will receive a diagnosis of breast cancer and 1 in 30 will die of the disease.²

“SAY”

Are You at Risk? Breast Cancer Risk Factors

So, are you at risk for developing breast cancer? If you are a woman, the answer is, to some extent, yes. “Simply being a woman and getting older puts you at risk for breast cancer.⁴” The older you are the greater your chance of developing breast cancer.⁴

The risks for developing and dying of breast cancer are continuous variables that increase with age; the greatest incidence (i.e., occurrence) of breast cancer, however, actually occurs before menopause.²

That said, there are some women who are considered at increased risk for the development of breast cancer. Women who have had a previous breast cancer, or who have a mother, sister, or daughter who has been diagnosed with breast cancer are at increased risk for developing breast cancer themselves.

Some rare alterations in genes (known as BRCA1, BRCA2 and others) are also known to predispose a woman to breast cancer.

Additionally, having had a previous breast biopsy showing atypical hyperplasia – an irregular pattern of cell growth, or lobular carcinoma in situ (LCIS) – abnormal cells found in the lobules of the breast – puts a woman at higher risk.

Having had radiation therapy to the chest before age 30 can also increase a woman’s risk of developing breast cancer throughout life.

Other issues that can increase a woman’s risk are reproductive and menstrual history. Evidence indicates that the older a woman is when she has her first child, the greater her chance of developing breast cancer. Women who start menstruating at an early age (age 11 or younger), experienced menopause late (after age 55), or never had children are also at increase risk. Women who take hormone replacement therapy for a long time may also be at increased risk.

Because breast cancer nearly always forms in the dense tissue (gland and ligaments) of the breast, rather than the fatty tissue, older women who have dense breasts tend to be at increased risk as well.

Additionally, obesity and weight gain in postmenopausal women increases risk, suggesting diet and lifestyle factors are important as well.

Thus,

• age
• breast tissue density
• family history
• menstrual and reproductive history
• genetic alterations
• previously diagnosed atypical
• hyperplasia or LCIS
• previous, early radiation or previous breast cancer, and
• diet and lifestyle factors

can each place one at increased risk for developing breast cancer.^{1, 4, 5}

“SAY”

What Can I Do? Fighting the Statistics on Cancer Deaths

So, what can be done to protect against cancer deaths? Early detection through appropriate health screenings is an important step. What does that mean exactly? Let’s talk about that. “Early detection means applying a strategy that results in an earlier diagnosis of breast cancer than otherwise might have occurred.⁶” Using early detection screening is preferable because breast cancers detected due to symptoms such as pain are usually larger and more likely to have spread beyond the breast to other parts of the body.

Screening simply refers to using tests and examinations to look for disease (in this case cancer) before a person has any symptoms.⁷ Screening examinations have the ability to detect breast cancers early, before symptoms occur, and these cancers are more likely to be small and still confined to the breast.⁶ By helping find cancers or abnormal tissue at an early stage, the problems or disease may be more easily treated.⁷

“The size of a breast cancer and how far it has spread are the most important factors in predicting the prognosis – the outlook for chances of survival – of a woman with this disease. Finding a breast cancer as early as possible improves the likelihood that treatment will be successful. Most doctors feel that early detection tests for breast cancer save many thousands of lives each year, and that more lives could be saved if more women and their health care providers took advantage of these tests.⁶”

In fact, it is estimated that if all Americans had early detection testing according to American Cancer Society recommendations for cancers of the breast, colon, rectum, cervix, prostate, testis, oral cavity, and skin, the 5-year survival rate for people with these cancers would increase from about 82% to about 95%.⁸

“SAY”

What Screenings Do I Need? Taking Charge of Your Own Health Care

By knowing what types of screening examinations you need at each stage of your life, you can take charge of your own health care. Though we often leave that responsibility to our health care providers, when we are at an appointment to treat another symptom or illness – for treating bunions or the stomach flu – the doctor may not choose that moment to tell you that you need to go have your annual mammogram done or to go see your gynecologist for a clinical breast exam. Though some medical practices may call or send out reminders, it is still important for you to know your needs so you can express them when required.

So, let’s look at what screenings are important for early detection of breast cancer among women. If you are already familiar with earlier guidelines (established in 1997), you will want to note a few changes in the guidelines updated in 2003.

As you can see, according to the American Cancer Society:

• Yearly mammograms should start at age 40 and continue for as long as a woman is in good health.
• Clinical breast exams (CBE) should be part of a periodic health exam, at least every three years for women in their 20s and 30s and every year for women 40 and over.
• Women should report any breast change promptly to their health care providers. Breast self-exam (BSE) is an option for women starting in their 20s.
• Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (e.g., breast ultrasound or magnetic resonance imaging [MRI]), or having more frequent exams.⁹

“SAY”

What Should I Expect? Understanding Screening Examinations

Now that you know what breast cancer screenings you need on a regular basis, let’s talk about how they are performed, their benefits, and their limitations.

The most effective way to detect breast cancer early is by having a high quality mammogram and a clinical breast exam (an exam done by a health care provider).⁵

Mammography

Like any test, mammograms have both benefits and limitations. For example, some cancers cannot be detected by mammograms, but may be detectable by breast examination, while mammograms can often detect breast cancer that cannot be felt, by either clinical or self breast examination.⁵

There are two types of mammograms: screening mammograms and diagnostic mammograms. Both use an x-ray technique to visualize the internal structure of the breast.¹⁰

A screening mammogram is used to detect breast changes in women who have no signs or symptoms of breast cancer⁵ – we call this being asymptomatic.

A diagnostic mammogram, though performed in the same manner as a screening mammogram, is used to identify unusual breast changes already identified, such as a lump, pain, thickening, change in shape or size, nipple discharge, or other changes such as microcalcifications, which are tiny deposits of calcium in the breast that are sometimes a clue to the presence of breast cancer found in a screening mammogram. A diagnostic mammogram takes longer because it involves taking more x-rays to obtain views of the breast from several angles.⁵

On the other hand, screening mammography usually involves just two views (x-ray pictures) of each breast. For some patients, such as women who have breast implants, additional x-ray pictures may be needed to include as much breast tissue as possible. Note that women who are breast-feeding can still get a mammogram; they will just need to express their breast milk before the mammogram is performed.⁶

Mammography is typically the screening of most concern to women, most often in regards to issues of pain, radiation exposure, or follow-up procedures.

Though the procedure may result in some discomfort, it is usually not lengthy, and is necessary to get a good x-ray picture of the breast.

“For a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. Although this may be uncomfortable for a moment, it is necessary to produce a good, “readable” mammogram. The compression only lasts a few seconds, and the entire procedure for screening mammography takes about 20 minutes. This procedure produces a black and white image of the breast tissue on a large sheet of film that is read, or interpreted, by a radiologist.

The doctor reading the films will look for several types of changes:

• Calcifications, or microcalcifications, are tiny mineral deposits within the breast tissue that appear as small white spots on the film. They may occur singly or in clusters. They are a sign of changes within the breast and can be either carefully watched by additional, periodic mammograms or examined by biopsy (removal of a small amount of breast tissue). They may be caused by benign breast conditions or, less often, by breast cancer.
• A mass, which may occur with or without calcifications, is another important change that can be seen on a mammogram. Masses can be many things, including cysts and fibroadenomas, but they may be cancer and usually should be biopsied if they are not fluid-filled cysts.
• A cyst, is a collection of fluid in a small sac in the breast. It can feel like a lump, usually soft, in the breast. Either a breast ultrasound or removal of the fluid with a needle (aspiration) is used to confirm that a mass, or lump, is a cyst. It is very rare for a cyst to be cancerous. If a cyst has ultrasound features that are suggestive of cancer, fluid removed from the cyst will be examined to look for malignant [cancerous] cells.

A mammogram cannot prove that an abnormal area is cancer. To confirm whether cancer is present, a small amount of tissue must be removed and examined under a microscope. This procedure is called a biopsy.

You should also be aware that mammography is imperfect at finding breast cancer. If you have a breast lump, you should have it checked by your doctor, even if your mammogram is normal.

[Additionally], mammography is less effective in younger women, usually because their breasts are dense, which can obscure a tumor. Since most breast cancers occur in older women, this is not a major problem. But it is for young women who have a genetic risk factor for breast cancer. Breast cancer often develops at a younger age in these women. For this reason, some doctors are now suggesting MRI [magnetic resonance imaging] for screening in this situation.⁶

Note: Although imaging tests like MRI and ultrasound have the advantage of showing more dimensions of the breast and the benefit of not using radiation, these procedures also have limitations. MRI, as well as ultrasound, is limited in the ability to accurately distinguish between cancerous and non-cancerous breast conditions, and cannot detect micro-calcifications within the breast tissue.¹⁰

“Modern mammography equipment designed for breast x-rays uses very low levels of radiation, usually a dose of about 0.1 to 0.2 rads per picture. [Although breast x-rays have been performed for more than 70 years, modern mammography has only existed since 1969. That was the first year x-ray units specifically for breast imaging were available].

Strict guidelines are in place to ensure that mammography equipment is safe and uses the lowest dose of radiation possible. Many people are concerned about the exposure to x-rays, but the level of radiation in modern mammography does not significantly increase the risk for breast cancer.

To put dose into perspective, if a woman with breast cancer is treated with radiation, she will receive several thousands rads. If she had yearly mammograms beginning at age 40 and continuing until she was 90, she will have received 20 to 40 rads. As another example, one mammogram exposes a woman to roughly the same amount of radiation as flying from New York to California on a commercial jet.⁶”

Clinical Breast Examination (CBE)

Because mammography cannot identify all breast cancers, it is still critical to have a clinical breast exam and to consider breast self exam as an option for early detection.

A clinical breast examination (CBE) can be done by a health care professional, such as a doctor, nurse practitioner, nurse, or doctor’s assistant. For this examination, you undress from the waist up. The health care professional will first look at your breasts for changes in size or shape. Then, using the pads of the fingers, the examiner will gently feel (palpate) your breasts.

Special attention will be given to the shape and texture of the breasts, location of any lumps, and whether such lumps are attached to the skin or to deeper tissues. The area under both arms will also be examined.

Breast Self Examination (BSE)

During the CBE is a good time for the health care professional to teach breast self-examination to the woman who does not already know how to examine her breasts or wants to make sure she is performing the breast exam correctly. You can ask your doctor or nurse to teach you and watch your technique.

Women should be told about the benefits and limitations of breast self examination beginning at age 20. Checking one’s own breasts for lumps or other unusual changes alone, without mammography or clinical breast examination, so far has not been shown to reduce the numbers of deaths from breast cancer.⁵ Thus, breast self examination should not take the place of clinical breast examination and mammography; however, it may be useful for self awareness as to how the breast feels and appears normally.

Women should be aware of how their breasts normally feel and report any new breast changes to a health professional as soon as they are found. Finding a breast change does not mean that a cancer is present.

The best time for a woman to examine her breasts is when the breasts are not tender or swollen. Women who are pregnant, breast-feeding, or have breast implants can also choose to examine their breasts regularly. It is acceptable for women to choose not to do breast self exams or simply to do them on an occasional basis. If you choose not to do breast self exam, you should still be aware of your breasts and report any changes without delay to your doctor.⁶

“SAY”

What About Quality and Cost? FDA Standards and Financial Assistance

Whether you are just beginning the process of screening for early detection of breast cancer, or whether you have been having screenings regularly for years, you can be sure you are receiving the best quality services by following a few simple tips:

• The U.S. Food and Drug Administration (FDA) ensures that facilities around the country meet the standards of the law under the Mammography Quality Standards Act (MQSA). Therefore, you can begin by looking for or asking to see the FDA certificate that is issued to all facilities that meet high professional standards of safety and quality. You can also search for a certified facility at the FDA website http://www.fda.gov/cdrh/mammography/certified.html.
• Use a facility that either specializes in mammography or performs at least 3 to 5 mammograms a day. Ask how many mammograms your facility performs on a regular basis.
• If you are satisfied that the facility is of high quality, continue to go there on a regular basis so that your mammograms can be compared from year to year.
• If you change facilities, ask for your old mammograms to bring with you to the new facility so that they can be compared to the new ones. Your facility is required by law to transfer your original mammograms upon your request to you or to a facility or doctor you specify – be sure your “original” mammogram pictures are sent, not copies which can be distorted– a copy of the medical report is fine.¹¹
• If you have sensitive breasts, try having your mammogram at a time of the month when your breasts will be least tender. Try to avoid the week right before your period. This will help to lessen discomfort.
• Don’t wear deodorant, powder or cream, under your arms – it may interfere with the quality of the mammogram.
• Bring a list of the places, dates of mammograms, biopsies, or other breast treatments you have had before.
• You should be contacted within 5 working days if there is a problem with the mammogram. If you do not hear from your physician within 10 days, however, do not assume that your mammogram was normal – confirm this by calling your physician or the facility. All mammography facilities are now required to send your results to you within 30 days.

Only 1 or 2 mammograms out of every 1,000 lead to a diagnosis of cancer. Approximately 10% of women will require additional mammograms. Don’t be alarmed if this happens to you. Only 8% to 10% of those women will need a biopsy, and 80% of those biopsies will not be cancer.⁶

If you are a woman and age 40 or over, you should get a mammogram every year. You can schedule the next one while you’re there at the facility and/or request a reminder. You can also set up a mammogram reminder that will send you an e-mail message reminding you or your loved ones to schedule a mammogram – go to the American Cancer Society website at http://www.cancer.org and search “mammogram reminder” or type in the link http://www.cancer.org/docroot/PED/content/PED_2_3x_Mammogram_Reminder.asp.

If you are concerned about the cost of a mammogram, assistance can generally be found. Screening mammograms generally cost between $100 and $150. Most states now have laws requiring health insurance companies to reimburse all or part of the cost. Medicare pays 80% of the cost for screening mammograms for beneficiaries age 40 and older and one baseline mammogram for beneficiaries age 35 to 39. There is no deductible for this benefit, but Medicare beneficiaries are responsible for a 20% copayment of the Medicare approved amount.

Some state and local health programs and employers also provide free or low cost mammograms and clinical breast exams. One such program, the Centers for Disease Control’s National Breast and Cervical Cancer Early Detection Program, provides these screening services to women throughout the U.S. and in several U.S. territories. For more information you can contact CDC at 1-888-842-6355 (select option 7) or go to their website at http://www.cdc.gov/cancer/nbccedp/contacts.htm. Other information on low cost or free mammography screening programs is available through the National Cancer Institute’s Cancer Information Service (CIS) at 1-800-4-CANCER (1-800-422-6237).⁵

Remember, early detection is worth the cost. Breast cancer screening examinations can lead to earlier, more successful treatment and prognosis. Though all screening procedures come with some limitations, they have the potential to save lives.

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References

1. United States Department of Health and Human Services (2002). HHS affirms value of mammography for detecting breast cancer. Retrieved August 10, 2004. From http://www.hhs.gov/news/press/2002pres/20020221.html.
2. Humphrey LL, Helfand M, Chan BKS, Woolf SH. Breast cancer screening: Summary of the evidence. Annals of Internal Medicine 2002;137:344-6.
3. National Cancer Institute (2003). Breast cancer: Prevention, patient version. Retrieved August 10, 2004. From http://www.cancer.gov/cancertopics/pdq/prevention/breast/Patient.
4. National Cancer Institute (2004). Get a mammogram: Do it yourself, do it for your family. Retrieved August 10, 2004. From http://www.cancer.gov/cancertopics/breasthealth.
5. National Cancer Institute (2002). Screening mammograms: Question and answer. Retrieved August 10, 2004. From http://cis.nci.nih.gov/fact/5_28.htm.
6. American Cancer Society (2003). Can breast cancer be found early? Retrieved August 10, 2004. From http://www.cancer.org/docroot/CRI/content/ CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp.
7. National Cancer Institute (2004). What is screening? Retrieved August 10, 2004. From http://cancer.gov/cancertopics/pdq/screening/breast/patient.
8. American Cancer Society (2004). Early detection. Retrieved August 10, 2004. From http://www.cancer.org/docroot/PED/content/PED_2_3X_Early_Detection.asp.
9. American Cancer Society (2004). ACS cancer detection guidelines. Retrieved August 10, 2004. From http://www.cancer.org/docroot/PED/content/ PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp.
10. National Cancer Institute (2002). Improving methods for breast cancer detection and diagnosis. Retrieved August 10, 2004. From http:// cis.nci.nih.gov.fact/5_14.htm.
11. United States Food and Drug Administration (2004). Mammography today: Questions and answers for patients on being informed consumers. Retrieved August 10, 2004. From http://www.fda.gov/cdrh/mammography/mmwebbro/ mambrochure.html.

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  • (Handout 1) What’s My Profile
  • (Handout 2) Guidelines and Information for Breast Cancer Screenings
  • (Handout 3) Resources
  • (Handout 4) My Personal Plan for Early Detection
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