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morning journal • breast cancer awareness 2014 • october 1, 2014 • page 3
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Knowing the signs Widespread use of screening mammograms has increased the number of breast cancers found before they cause any symptoms. Still, some breast cancers are not found by mammogram, either because the test was not done or because, even under ideal conditions, mammograms do not find every breast cancer.
Can breast cancer be found early?
Screening refers to tests and exams used to find a disease, like cancer, in people who do not have any symptoms. The goal of screening exams, such as mammograms, is to find cancers before they start to cause symptoms. Breast cancers that are found because they can be felt tend The most common symptom of breast cancer to be larger and are more likely to have already is a new lump or mass. A painless, hard mass spread beyond the breast. In contrast, breast that has irregular edges is more likely to be can- cancers found during screening exams are more cerous, but breast cancers can be tender, soft, or likely to be small and still confined to the breast. rounded. They can even be painful. For this rea- The size of a breast cancer and how far it has son, it is important to have any new breast mass spread are important factors in predicting the or lump checked by a health care professional prognosis (outlook) for a woman with this disease. experienced in diagnosing breast diseases. Most doctors feel that early detection tests for breast cancer save many thousands of lives each • Swelling of all or part of a breast (even if no year, and that many more lives could be saved if even more women and their health care distinct lump is felt) providers took advantage of these tests. Follow• Skin irritation or dimpling ing the American Cancer Society's guidelines for • Breast or nipple pain the early detection of breast cancer improves the • Nipple retraction (turning inward) • Redness, scaliness, or thickening of the nip- chances that breast cancer can be diagnosed at an early stage and treated successfully. ple or breast skin • Nipple discharge (other than breast milk) American Cancer Society recommendaSometimes a breast cancer can spread to tions for early breast cancer detection Women age 40 and older should have a lymph nodes under the arm or around the collar bone and cause a lump or swelling there, even screening mammogram every year and should before the original tumor in the breast tissue is continue to do so for as long as they are in good health. large enough to be felt. Continued on page 7 Other possible signs of breast cancer include:
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morning journal • breast cancer awareness 2014 • october 1, 2014 • page 7 Current evidence supporting mammograms is even stronger than in the past. In particular, recent evidence has confirmed that mammograms offer substantial benefit for women in their 40s. Women can feel confident about the benefits associated with regular mammograms for finding cancer early. However, mammograms also have limitations. A mammogram will miss some cancers, and it sometimes leads to follow up of findings that are not cancer, including biopsies.
an opportunity for women and their doctor or nurse to discuss changes in their breasts, early detection testing, and factors in the woman's history that might make her more likely to have breast cancer.
There may be some benefit in having the CBE shortly before the mammogram. The exam should include instruction for the purpose of getting more familiar with your own breasts. Women should also be given information about the benefits and limitations of CBE and breast Women should be told about the benefits, self exam (BSE). Breast cancer risk is very low for limitations, and potential harms linked with reg- women in their 20s and gradually increases with ular screening. Mammograms can miss some age. Women should be told to promptly report cancers. But despite their limitations, they remain any new breast symptoms to a health profesa very effective and valuable tool for decreasing sional. suffering and death from breast cancer. Breast self-exam (BSE) is an option for Mammograms for older women should be women starting in their 20s. Women should be based on the individual, her health, and other told about the benefits and limitations of BSE. serious illnesses, such as congestive heart failure, Women should report any breast changes to end-stage renal disease, chronic obstructive pul- their health professional right away. monary disease, and moderate-to-severe Research has shown that BSE plays a small dementia. Age alone should not be the reason to stop having regular mammograms. As long as role in finding breast cancer compared with finda woman is in good health and would be a can- ing a breast lump by chance or simply being didate for treatment, she should continue to be aware of what is normal for each woman. Some women feel very comfortable doing BSE regularscreened with a mammogram. ly (usually monthly after their period) which Women in their 20s and 30s should have a involves a systematic step-by-step approach to clinical breast exam (CBE) as part of a periodic examining the look and feel of their breasts. Oth(regular) health exam by a health professional, at er women are more comfortable simply looking least every 3 years. After age 40, women should and feeling their breasts in a less systematic have a breast exam by a health professional approach, such as while showering or getting dressed or doing an occasional thorough exam. every year. Sometimes, women are so concerned about CBE is a complement to mammograms and "doing it right" that they become stressed over
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page 8 • morning journal • breast cancer awareness 2014 • october 1, 2014 Women at high risk (greater than 20% lifetime risk) based on certain risk factors should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifeWomen who choose to do BSE should have time risk of breast cancer is less than 15%. their BSE technique reviewed during their physiWomen at high risk include those who: cal exam by a health professional. It is okay for women to choose not to do BSE or not to do it • Have a known BRCA1 or BRCA2 gene mutaon a regular schedule. tion • Have a first-degree relative (parent, brother, However, by doing the exam regularly, you get to know how your breasts normally look and feel sister, or child) with a BRCA1 or BRCA2 gene and you can more readily detect any signs or mutation, but have not had genetic testing themsymptoms if a change occurs, such as develop- selves ment of a lump or swelling, skin irritation or dim• Have a lifetime risk of breast cancer of 20% pling, nipple pain or retraction (turning inward), redness or scaliness of the nipple or breast skin, to 25% or greater, according to risk assessment or a discharge other than breast milk. Should tools that are based mainly on family history you notice any changes you should see your • Had radiation therapy to the chest when they health care provider as soon as possible for evaluation. Remember that most of the time, howev- were between the ages of 10 and 30 years er, these breast changes are not cancer. about "doing it right" that they become stressed over the technique. Doing BSE regularly is one way for women to know how their breasts normally look and feel and to notice any changes. The goal, with or without BSE, is to report any breast changes to a doctor or nurse right away.
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morning journal • breast cancer awareness 2014 • october 1, 2014 • page 9 Several risk assessment tools, with names like • Have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, the Gail model, the Claus model, and the Tyreror have first-degree relatives with one of these Cuzick model, are available to help health professionals estimate a woman's breast cancer risk. syndromes These tools give approximate, rather than preWomen at moderately increased risk cise, estimates of breast cancer risk based on different combinations of risk factors and different include those who: data sets. • Have a lifetime risk of breast cancer of 15% Because the different tools use different risk to 20%, according to risk assessment tools that factors to estimate risk, they may give different are based mainly on family history risk estimates for the same woman. For exam• Have a personal history of breast cancer, ple, the Gail model bases its risk estimates on ductal carcinoma in situ (DCIS), lobular carcino- certain personal risk factors, like current age, age ma in situ (LCIS), atypical ductal hyperplasia at menarche (first menstrual period) and history of prior breast biopsies, along with any history of (ADH), or atypical lobular hyperplasia (ALH) breast cancer in first-degree relatives. In contrast, • Have extremely dense breasts or unevenly the Claus model estimates risk based only on family history of breast cancer in both first and dense breasts when viewed by mammograms second-degree relatives. These 2 models could If MRI is used, it should be in addition to, not easily give different estimates for the same perinstead of, a screening mammogram. This is son. because while an MRI is a more sensitive test Risk assessment tools (like the Gail model, for (it's more likely to detect cancer than a mammogram), it may still miss some cancers that a example) that are not based mainly on family history are not appropriate to use with the ACS mammogram would detect. guidelines to decide if a woman should have For most women at high risk, screening with MRI screening. The use of any of the risk assessMRI and mammograms should begin at age 30 ment tool and its results should be discussed by years and continue for as long as a woman is in a woman and her doctor. good health. But because the evidence is limited It is recommended that women who get about the best age at which to start screening, this decision should be based on shared deci- screening MRI do so at a facility that can do an sion making between patients and their health MRI-guided breast biopsy at the same time if care providers, taking into account personal cir- needed. Otherwise, the woman will have to have a second MRI exam at another facility at cumstances and preferences. the time of biopsy.
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page 10 • morning journal • breast cancer awareness 2014 • october 1, 2014 There is no evidence right now that MRI is an effective screening tool for women at average risk. MRI is more sensitive than mammograms, but it also has a higher false-positive rate (it is more likely to find something that turns out not to be cancer). This would lead to unneeded biopsies and other tests in many of these women, which can lead to a lot of worry and anxiety. The American Cancer Society believes the use of mammograms, MRI (in women at high risk), clinical breast exams, and finding and reporting breast changes early, according to the recommendations outlined above, offers women the best chance to reduce their risk of dying from breast cancer. This combined approach is clearly better than any one exam or test alone. Without question, a breast physical exam without a mammogram would miss the opportunity to detect many breast cancers that are too small for a woman or her doctor to feel but can be seen on mammograms. Although mammograms are a sensitive screening method, a small percentage of breast cancers do not show up on
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mammograms but can be felt by a woman or her doctors. For women at high risk of breast cancer, like those with BRCA gene mutations or a strong family history, both MRI and mammogram exams of the breast are recommended. Mammograms A mammogram is an x-ray of the breast. A diagnostic mammogram is used to diagnose breast disease in women who have breast symptoms or an abnormal result on a screening mammogram. Screening mammograms are used to look for breast disease in women who are asymptomatic; that is, they appear to have no breast problems. Screening mammograms usually take 2 views (x-ray pictures taken from different angles) of each breast, while diagnostic mammograms may take more views of the breast. For some patients, such as women with breast implants, more pictures may be needed to include as much breast tissue as possible. Women who are breastfeeding can still get mammograms, but these are probably not quite as accurate because the breast tissue tends to be dense. Breast x-rays have been done for more than 70 years, but the modern mammogram has only existed since 1969. That was the first year x-ray units specifically for breast imaging were available. Modern mammogram 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 (a rad is a measure of radiation dose).
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morning journal • breast cancer awareness 2014 • october 1, 2014 • page 11 Strict guidelines ensure that mammogram 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 used in modern mammograms does not significantly increase the risk for breast cancer.
preted, by a radiologist (a doctor trained to interpret images from x-rays, ultrasound, MRI, and related tests).
Digital mammograms: A digital mammogram (also known as a full-field digital mammogram, or FFDM) is like a standard mammogram in that x-rays are used to produce an image of your To put dose into perspective, if a woman with breast. The differences are in the way the image breast cancer is treated with radiation, she will is recorded, viewed by the doctor, and stored. receive around 5,000 rads. If she had yearly Standard mammograms are recorded on mammograms beginning at age 40 and continuing until she was 90, she will have received 20 large sheets of photographic film. Digital mammograms are recorded and stored on a computto 40 rads. er. After the exam, the doctor can look at them For a mammogram, the breast is pressed on a computer screen and adjust the image size, between 2 plates to flatten and spread the tis- brightness, or contrast to see certain areas more sue. This may be uncomfortable for a moment, clearly. Digital images can also be sent electronibut it is necessary to produce a good, readable cally to another site for a remote consultation mammogram. The compression only lasts a few with breast specialists. Most centers offer the seconds. The entire procedure for a screening digital option, but it may not be available everymammogram takes about 20 minutes. This pro- where. cedure produces a black and white image of the Continued on page 14 breast tissue either on a large sheet of film or as a digital computer image that is read, or inter-
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morning journal • breast cancer awareness 2014 • october 1, 2014 • page 13
D.M.X.I. Digital Screening Mammograms Is proud to participate in the promotion of early detection and diagnosis of breast cancer for National Breast Cancer Awareness Month. We will be offering our patients digital screening mammograms at the special rate of $75.00 payable at the time of exam, throughout the month of October. ** These rates are offered to help patients that have either no insurance or very high deductibles; therefore no insurance will be billed.
According to the American Cancer Society, it is recommended that woman age 40 and over have an annual mammogram, as current statistics reveal Breast Cancer will affect 1 in 8 women throughout their lifetime. Please call 330-726-6010 to schedule an appointment at your earliest convenience.
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page 14 • morning journal • breast cancer awareness 2014 • october 1, 2014 Although digital mammograms have some advantages, it is important to remember that a standard film mammogram also is effective. Nobody should miss having a regular mammogram because a digital mammogram is not available.
A mass, which may occur with or without calcifications, is another important change seen on a mammogram. Masses can be many things, including cysts (non-cancerous, fluid-filled sacs) and non-cancerous solid tumors (such as fibroadenomas), but they could also be cancer.
What the doctor looks for on your mammogram
Cysts can be simple fluid-filled sacs (known as simple cysts) or can be partially solid (known as complex cysts). Simple cysts are benign and don’t need to be biopsied. Any other type of mass (such as a complex cyst or a solid tumor) might need to be biopsied to be sure it isn’t cancer.
The doctor reading your mammogram will look for several types of changes:
Calcifications are tiny mineral deposits within the breast tissue, which look like small white A cyst and a tumor can feel alike on a physical spots on the films. They may or may not be caused by cancer. There are 2 types of calcifica- exam. They can also look the same on a mammogram. To confirm that a mass is really a cyst, a tions: breast ultrasound is often done. Another option Macrocalcifications are coarse (larger) calcium is to remove (aspirate) the fluid from the cyst deposits that are most likely changes in the with a thin, hollow needle. breasts caused by aging of the breast arteries, If a mass is not a simple cyst (that is, if it is at old injuries, or inflammation. These deposits are related to non-cancerous conditions and do not least partly solid), then you may need to have require a biopsy. About half the women over 50, more imaging tests. Some masses can be and in about 1 of 10 women under 50 have watched with periodic mammograms, while others may need to be biopsied. The size, shape, macrocalcifications. and margins (edges) of the mass help the radiMicrocalcifications are tiny specks of calcium ologist determine if cancer is likely to be present. in the breast. They may appear alone or in clusHaving your previous mammograms available ters. Microcalcifications seen on a mammogram are of more concern, but still usually do not for the radiologist is very important. They can mean that cancer is present. The shape and lay- show that a mass or calcification has not out of microcalcifications help the radiologist changed for many years. This would mean that it judge how likely it is cancer is present. If the cal- is probably a benign condition and a biopsy is cifications look suspicious for cancer, a biopsy not needed. will be done.
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page 16 • morning journal • breast cancer awareness 2014 • october 1, 2014