Evaluation of a suspicious breast should proceed until both the doctor and the patient are convinced there is a reasonable chance no cancer exists.
Early detection of breast cancer involves a progression of steps. A combination of breast self-exam, clinical breast exams and mammography is the first line of defense.
Mammography, which shows the internal structure of the breast, can screen for signs of a problem well before anything can be felt or symptoms expressed. By definition, breast cancers found before they are symptomatic are more likely to be smaller and, in the case of the less aggressive forms, still confined to the breast.
Unfortunately, no technology is perfect and mammograms miss up to 20 percent of the breast cancers that are present at the time of screening. These false negatives occur more often in younger women than in older women because the breast tissue of younger women is denser. Other causes for false-negative results include:
- A tumor's location (it may be in an area that is not easily imaged).
- The presence of shadows that can obscure a mass.
- The size of the tumor.
- The tumor's rate of growth.
- The level of hormones, like estrogen and progesterone, in a woman's body.
- The experience and skill of the radiologist.
On the opposite end of the spectrum is the false positive. If a woman gets 10 or more mammograms, there's about a 50/50 chance that one of them will result in a false positive.
Bottom line: Mammography is not perfect.
But most doctors feel (and our panel of experts agree) that it is improving, and it does make a difference. Many mammography providers have started to provide double reads — meaning mammograms are read by two radiologists. When they do, false-negative and false-positive rates drop considerably. Finally, while there has been controversy about mammography in the medical community and in the press over the years, the American Cancer Society continues to recommend that women get routine mammograms starting at age 40.
What if you get a clean mammogram but develop a suspicious symptom like a breast lump, skin change or unusual nipple discharge? In short, don't delay. Talk to your doctor about further evaluation. There are a number of other diagnostic procedures that can be done to put your mind at rest or to confirm that you need to begin treatment. They include:
- Diagnostic mammography.
- Breast magnetic resonance imaging (MRI).
- Ductal lavage.
How far do you go? Our panelist, Dr. Gretchen Ahrendt, puts it this way: "You should advocate for yourself." She adds: "Doctors go by the rule of threes. The physical exam, breast imaging and pathology all have to agree."
The ultimate answer is a triad:
- Try not to be more apprehensive than you need to be. After all, statistics are on your side, and not all lumps or changes in breast tissue mean you have breast cancer.
- Recognize the inherent shortcomings of today's breast cancer detection procedures, and do not be complacent if your mammogram fails to find a problem. In other words, keep doing your breast self-exams and going to your doctor for a regular clinical breast exam. If you do find a problem, pursue it until you get a definitive answer, even if it means a biopsy.
- Support research efforts to develop better tests to detect breast cancer at its earliest stages.
A Very Personal Choice for Treatment
The powerful prognostic factors that influence the treatment of breast cancer are the size of the tumor, whether it is invasive or not, if it's metastatic at the time of diagnosis, if it's hormonally sensitive and if there is a family history of breast cancer. Regardless of the treatment options, the patient's choice is ultimately a personal one.
Fact: Breast cancer should more accurately be called breast cancers. The disease is not a singular one, but several, and each type is unique. You can think of them in two main categories — invasive breast cancer and in situ breast cancer. The invasive cancers can be further broken down into two categories — those that spread very early in their development and those that spread more slowly as they grow.
Fact: Each woman with breast cancer will receive a diagnosis at a distinct stage of the disease.
Fact: Tumor tissue can be estrogen-receptor or progesterone-receptor positive or negative. A positive result means the cancer uses hormones to stimulate growth and it can be treated by blocking the circulation of that hormone in the body.
Fact: A family history of breast cancer can affect the timing of treatment, treatment response and outcome. A very high-risk woman may start treatment before cancer shows up with a chemoprevention drug or even with prophylactic (preventive) mastectomy. And while studies have shown that the combination of lumpectomy and radiation is equivalent to mastectomy for most women, it is uncertain if women with strong family histories are good candidates for this breast-conserving therapy.
Fact: Cancer treatments all have disadvantages as well as advantages.
Fact: Every woman will react to treatment differently, both physically and emotionally.
Fact (and theory): In many cases, there is no way to predict with absolute certainty whether a cancer has spread. (In the past, breast cancer was thought to grow in an orderly progression from a tiny tumor in the breast tissue to a larger one, sequentially traveling out to the nearby lymph nodes, then distant ones, and finally to other parts of the body. Now, however, it is thought that cancer cells are capable of traveling from the breast through the blood and lymphatic system very early in the course of the disease.)
There is no one treatment plan that is right for every woman. It all boils down to probabilities and weighing risks versus benefits. Breast cancer treatment has to be tailored to each individual woman based on a treatment's probability of success as well as on her preferences. Each woman will have a unique treatment goal that can vary from treating a cancer as aggressively as possible to choosing not to receive treatment at all.
Fortunately, new treatment methods and options are continually presenting better odds with fewer side effects. And doctors and researchers are developing more tools that can help women with the decision-making process. Until we reach an ideal world, though, be prepared to hear, "We don't know." Doctors will tell you there are just too many variables so you do the best you can by calculating odds and doing what our panelists recommend — deciding what degree of uncertainty you can live with then moving forward.
The Risk Factors
There are risk factors for breast cancer. The ones you cannot control are getting your period early in life, your age and a family history of breast cancer. The risk factors you can control are hormone replacement therapy, not smoking and not using alcohol excessively.
Left out of the statement above is the most obvious of risk factors — gender. Men do get breast cancer, but the likelihood of women getting breast cancer compared to men is 100 to 1.
That said, no one knows the exact causes of breast cancer and doctors cannot really explain why one woman gets breast cancer and another does not.
Risk factors you can't control
Getting your period early in life is one of the big three uncontrollable risk factors and it all boils down to estrogen. The longer a woman is exposed to estrogen (whether it is made by the body, taken as a drug or delivered by a patch), the more likely she is to develop breast cancer. Women who began menstruation at an early age (before age 12), went through menopause late (after age 55), never had children or who took hormone replacement therapy for an extended period of time are at an increased risk for developing breast cancer.
Age is by far the greatest risk factor. Breast cancer is extremely rare under the age of 30, and is unusual up to 40. The risk of getting breast cancer goes up to about 18 percent among women in their 40s, while about 77 percent of women with breast cancer are older than 50 when their cancer is diagnosed.
A family history of breast cancer is a predictor for about 5 to 10 percent of breast cancers. Having one first-degree relative (mother, sister or daughter) with breast cancer approximately doubles a woman's risk, and having two first-degree relatives increases her risk five-fold. Risk is also higher among women whose close blood relatives have this disease. Blood relatives can be from either the mother's or father's side of the family. The National Cancer Institute states that risk is higher if the relative(s) developed breast cancer in both breasts, or developed breast cancer before menopause. Also, a family history of ovarian cancer, increases the risk of breast cancer.
Risk factors you can control
Hormone replacement therapy was once thought to improve a woman's odds of not getting breast cancer. However, in 1999, a study in The Journal of the American Medical Association (JAMA) linked hormone replacement therapy after menopause to increased risk of uncommon forms of breast cancer that have good prognoses. HRT was not associated with the more common types of breast cancer, invasive lobular or ductal breast cancer and ductal carcinoma in situ.
Research is being done to determine the link between cigarette smoking and breast cancer, and we do know that smoking affects overall health and increases the risk for many other cancers, as well as heart disease.
Use of alcohol is clearly linked to increased risk of developing breast cancer. Women who have 2 to 5 drinks daily, have about 1.5 times the risk of women who drink no alcohol. Alcohol is also known to increase the risk of developing cancers of the mouth, throat and esophagus.
Remember that all risk factors are based on probabilities, and even someone without any risk factors can still get breast cancer. Proper screening and early detection are the best weapons in reducing the mortality associated with this disease.
Ask Your Doctor
This list of questions is a good starting point for discussion with your doctor, but it is not a comprehensive list.
General questions about breast health and breast cancer detection:
- Can you or someone in your office work with me to make sure I'm doing my breast self exams correctly?
- Are there changes in my breasts I should expect when I'm close to my menstrual period?
- What does it mean if I have breast pain?
- What does it mean if I have nipple discharge or inflammation?
- If I feel something during my self-exam, have breast pain or nipple discharge/inflammation, should I see you immediately or should I wait for a time to see if it resolves? If so, how long?
- Are any medications I am taking likely to cause breast problems?
- What are the pros and cons of having a mammogram at my age?
- What is your recommendation on mammograms?
If you believe you're at high risk to get breast cancer:
- Is there anything in my background that indicates I should have mammograms more often than your usual recommendations? Should I see a specialist?
- Where should I have my mammogram?
- What do you recommend to women to prevent breast cancer?
If you have found a lump in your breast:
- What tests should I have?
- How likely is it that the lump is cancerous
If a biopsy is recommended:
- What type of biopsy are you recommending and why?
- What is involved in the type of biopsy you are recommending?
If you have been diagnosed with cancer
- What is the stage of my cancer?
- Has my cancer spread to lymph nodes or internal organs?
- What are the results of my estrogen and progesterone tests?
- What were the results of other tests (flow cytometry and other markers for tumor aggressiveness)?
- What treatments are appropriate for me? What do you recommend? Why?
- How often will I receive treatment?
- How long will the treatment last?
- How well has this option worked for others?
- What are the potential benefits of this treatment?
- What are the risks or side effects that I should expect?
- If I experience side effects, how long will they last and how can they be managed?
- Are the possible side effects of this treatment serious enough to interfere with continuing therapy?
- How effective will breast reconstruction surgery be in my case if I need it or want it?
- What should I do to get ready for treatment?
- Should I follow a special diet?
- Will I be able to have children after my treatment?
- Will I go through menopause as a result of the treatment?
- What are the chances of recurrence of my cancer with the treatment programs we have outlined?
- What is my prognosis?
This article reprinted with permission from Second Opinion, a public television health program hosted by Dr. Peter Salgo and produced by WXXI (Rochester, N.Y.), West 175 and the University of Rochester Medical Center.
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