page 2 • morning journal • breast cancer awareness 2013 • october 1, 2013
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morning journal • breast cancer awareness 2013 • october 1, 2013 • page 3
Reach to recovery
Through face-to-face visits or by phone, Reach to Recovery volunteers give support for:
spread of cancer to another • People facing a possible part of the body) Volunteers are trained to give diagnosis of breast cancer support and up-to-date infor• Those interested in or who mation, including literature for have undergone a lumpectomy spouses, children, friends, and other loved ones. or mastectomy • Those considering breast For more information or to reconstruction locate a Reach to Recovery • Those who have lymphede- program in your area, visit "In Your Area" on our Web ma site at www.cancer.org or call • Those who are undergoing us toll-free at 1-800-227or who have completed treat- 2345. ment such as chemotherapy and radiation therapy
• People recently diagnosed with breast cancer
• People facing breast cancer recurrence or metastasis (the
When people first find out they have breast cancer, they may feel overwhelmed, vulnerable, and alone. Talking with a specially trained Reach to Recovery volunteer at this time can give a measure of comfort and an opportunity for emotional grounding and informed decision-making.
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page 4 • morning journal • breast cancer awareness 2013 • october 1, 2013
How to examine your breasts Lie down on your back and place your right arm behind your head. The exam is done while lying down, not standing up. This is because when lying down the breast tissue spreads evenly over the chest wall and is as thin as possible, making it much easier to feel all the breast tissue.
bone (clavicle). There is some evidence to suggest that the up-and-down pattern (sometimes called the vertical pattern) is the most effective pattern for covering the entire breast without missing any breast tissue.
Repeat the exam on your left breast, putting Use the finger pads of the 3 middle fingers on your left arm behind your head and using the your left hand to feel for lumps in the right finger pads of your right hand to do the exam. breast. Use overlapping dime-sized circular While standing in front of a mirror with your motions of the finger pads to feel the breast tishands pressing firmly down on your hips, look at sue. your breasts for any changes of size, shape, conUse 3 different levels of pressure to feel all the tour, or dimpling, or redness or scaliness of the breast tissue. Light pressure is needed to feel nipple or breast skin. (The pressing down on the the tissue closest to the skin; medium pressure hips position contracts the chest wall muscles to feel a little deeper; and firm pressure to feel and enhances any breast changes.) the tissue closest to the chest and ribs. It is normal to feel a firm ridge in the lower curve of Examine each underarm while sitting up or each breast, but you should tell your doctor if standing and with your arm only slightly raised you feel anything else out of the ordinary. If so you can easily feel in this area. Raising your you're not sure how hard to press, talk with your arm straight up tightens the tissue in this area doctor or nurse. Use each pressure level to feel and makes it harder to examine. the breast tissue before moving on to the next spot. This procedure for doing breast self-exam is different from previous recommendations. These Move around the breast in an up and down changes represent an extensive review of the pattern starting at an imaginary line drawn medical literature and input from an expert advistraight down your side from the underarm and sory group. There is evidence that this position moving across the breast to the middle of the (lying down), the area felt, pattern of coverage chest bone (sternum or breastbone). Be sure to of the breast, and use of different amounts of check the entire breast area going down until pressure increase a woman's ability to find you feel only ribs and up to the neck or collar abnormal areas.
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page 6 • morning journal • breast cancer awareness 2013 • october 1, 2013
Knowing the signs
Can breast cancer be found early? Widespread use of screening mammograms has increased the number of breast cancers found before they cause any symptoms. Still, Screening refers to tests and exams used to some breast cancers are not found by mammo- find a disease, like cancer, in people who do not gram, either because the test was not done or have any symptoms. The goal of screening because, even under ideal conditions, mammo- exams, such as mammograms, is to find cancers grams do not find every breast cancer. before they start to cause symptoms. Breast cancers that are found because they can be felt The most common symptom of breast cancer tend to be larger and are more likely to have is a new lump or mass. A painless, hard mass already spread beyond the breast. In contrast, that has irregular edges is more likely to be can- breast cancers found during screening exams cerous, but breast cancers can be tender, soft, or are more likely to be small and still confined to rounded. They can even be painful. For this rea- the breast. The size of a breast cancer and how son, it is important to have any new breast mass far it has spread are important factors in predictor lump checked by a health care professional ing the prognosis (outlook) for a woman with experienced in diagnosing breast diseases. this disease. Other possible signs of breast cancer include:
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 • Nipple retraction (turning inward) • Redness, scaliness, or thickening of the nip- the 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.
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morning journal • breast cancer awareness 2013 • october 1, 2013 • 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. Women should be told about the benefits, limitations, and potential harms linked with regular screening. Mammograms can miss some cancers. But despite their limitations, they remain a very effective and valuable tool for decreasing suffering and death from breast cancer. Mammograms for older women should be based on the individual, her health, and other serious illnesses, such as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, and moderate-to-severe dementia. Age alone should not be the reason to stop having regular mammograms. As long as a woman is in good health and would be a candidate for treatment, she should continue to be screened with a mammogram. Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional, at least every 3 years. After age 40, women should have a breast exam by a health professional every year.
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CBE is a complement to mammograms and 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 self exam (BSE). Breast cancer risk is very low for women in their 20s and gradually increases with age. Women should be told to promptly report any new breast symptoms to a health professional. Breast self-exam (BSE) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away. Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. Some women feel very comfortable doing BSE regularly (usually monthly after their period) which involves a systematic step-by-step approach to examining the look and feel of their breasts. Other women are more comfortable simply looking and feeling their breasts in a less systematic approach, such as while showering or getting dressed or doing an occasional thorough exam. Sometimes, women are so concerned
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page 8 • morning journal • breast cancer awareness 2013 • october 1, 2013 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. Women who choose to do BSE should have their BSE technique reviewed during their physical exam by a health professional. It is okay for women to choose not to do BSE or not to do it on a regular schedule.
Women at high risk include those who: • Have a known BRCA1 or BRCA2 gene mutation • Have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, but have not had genetic testing themselves • Have a lifetime risk of breast cancer of 20% to 25% or greater, according to risk assessment tools that are based mainly on family history
• Had radiation therapy to the chest when However, by doing the exam regularly, you get to know how your breasts normally look and they were between the ages of 10 and 30 years feel and you can more readily detect any signs or symptoms if a change occurs, such as devel• Have Li-Fraumeni syndrome, Cowden synopment of a lump or swelling, skin irritation or drome, or Bannayan-Riley-Ruvalcaba syndrome, dimpling, nipple pain or retraction (turning or have first-degree relatives with one of these inward), redness or scaliness of the nipple or syndromes breast skin, or a discharge other than breast milk. Should you notice any changes you should Women at moderately increased risk see your health care provider as soon as possi- include those who: ble for evaluation. Remember that most of the time, however, these breast changes are not • Have a lifetime risk of breast cancer of 15% cancer. to 20%, according to risk assessment tools that are based mainly on family history Women at high risk (greater than 20% lifetime risk) based on certain risk factors should • Have a personal history of breast cancer, get an MRI and a mammogram every year. ductal carcinoma in situ (DCIS), lobular carcinoWomen at moderately increased risk (15% to ma in situ (LCIS), atypical ductal hyperplasia 20% lifetime risk) should talk with their doctors (ADH), or atypical lobular hyperplasia (ALH) about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly • Have extremely dense breasts or unevenly MRI screening is not recommended for women dense breasts when viewed by mammograms whose lifetime risk of breast cancer is less than 15%. If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is
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morning journal • breast cancer awareness 2013 • october 1, 2013 • page 9 Risk assessment tools (like the Gail model, for because while an MRI is a more sensitive test (it's more likely to detect cancer than a mammo- example) that are not based mainly on family gram), it may still miss some cancers that a history are not appropriate to use with the ACS mammogram would detect. guidelines to decide if a woman should have MRI screening. The use of any of the risk assessFor most women at high risk, screening with ment tool and its results should be discussed by MRI and mammograms should begin at age 30 a woman and her doctor. years and continue for as long as a woman is in good health. But because the evidence is limited It is recommended that women who get about the best age at which to start screening, screening MRI do so at a facility that can do an this decision should be based on shared deci- MRI-guided breast biopsy at the same time if sion making between patients and their health needed. Otherwise, the woman will have to care providers, taking into account personal cir- have a second MRI exam at another facility at cumstances and preferences. the time of biopsy. Several risk assessment tools, with names like There is no evidence right now that MRI is an the Gail model, the Claus model, and the Tyrer- effective screening tool for women at average Cuzick model, are available to help health pro- risk. MRI is more sensitive than mammograms, fessionals estimate a woman's breast cancer but it also has a higher false-positive rate (it is risk. These tools give approximate, rather than more likely to find something that turns out not precise, estimates of breast cancer risk based on to be cancer). This would lead to unneeded different combinations of risk factors and differ- biopsies and other tests in many of these women, which can lead to a lot of worry and ent data sets. anxiety. Because the different tools use different risk factors to estimate risk, they may give different The American Cancer Society believes the use risk estimates for the same woman. For exam- of mammograms, MRI (in women at high risk), ple, the Gail model bases its risk estimates on clinical breast exams, and finding and reporting certain personal risk factors, like current age, age breast changes early, according to the recomat menarche (first menstrual period) and history mendations outlined above, offers women the of prior breast biopsies, along with any history of best chance to reduce their risk of dying from breast cancer in first-degree relatives. In contrast, breast cancer. This combined approach is clearly the Claus model estimates risk based only on better than any one exam or test alone. family history of breast cancer in both first and second-degree relatives. These 2 models could Without question, a breast physical exam easily give different estimates for the same per- without a mammogram would miss the opporson. tunity to detect many breast cancers that are too small for a woman or her doctor to feel but can
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page 10 • morning journal • breast cancer awareness 2013 • october 1, 2013 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 xray units specifically for breast imaging were available. Modern mammogram equipment designed for breast x-rays uses very low levels of be seen on mammograms. Although mammograms are a sensitive screening method, a small percentage of breast cancers do not show up on 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 radiation, usually a dose of about 0.1 to 0.2 rads different angles) of each breast, while diagnostic per picture (a rad is a measure of radiation mammograms may take more views of the dose). breast. For some patients, such as women with
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morning journal • breast cancer awareness 2013 • october 1, 2013 • 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.
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. What the doctor looks for on your mammogram
To put dose into perspective, if a woman with breast cancer is treated with radiation, she will The doctor reading your mammogram will receive around 5,000 rads. If she had yearly look for several types of changes: mammograms beginning at age 40 and continCalcifications are tiny mineral deposits within uing until she was 90, she will have received 20 the breast tissue, which look like small white to 40 rads. spots on the films. They may or may not be For a mammogram, the breast is pressed caused by cancer. There are 2 types of calcificabetween 2 plates to flatten and spread the tis- tions: sue. This may be uncomfortable for a moment, but it is necessary to produce a good, readable Macrocalcifications are coarse (larger) calcium mammogram. The compression only lasts a few deposits that are most likely changes in the seconds. The entire procedure for a screening breasts caused by aging of the breast arteries, mammogram takes about 20 minutes. This pro- old injuries, or inflammation. These deposits are cedure produces a black and white image of the breast tissue either on a large sheet of film or as a digital computer image that is read, or interpreted, 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 related to non-cancerous conditions and do not breast. The differences are in the way the image require a biopsy. About half the women over 50, and in about 1 of 10 women under 50 have is recorded, viewed by the doctor, and stored. macrocalcifications. Standard mammograms are recorded on Microcalcifications are tiny specks of calcium large sheets of photographic film. Digital mammograms are recorded and stored on a comput- in the breast. They may appear alone or in cluser. After the exam, the doctor can look at them ters. Microcalcifications seen on a mammogram on a computer screen and adjust the image size, are of more concern, but still usually do not brightness, or contrast to see certain areas more mean that cancer is present. The shape and layclearly. Digital images can also be sent electroni- out of microcalcifications help the radiologist cally to another site for a remote consultation judge how likely it is cancer is present. If the calwith breast specialists. Most centers offer the cifications look suspicious for cancer, a biopsy digital option, but it may not be available every- will be done. where. A mass, which may occur with or without calAlthough digital mammograms have some cifications, is another important change seen on
page 12 • morning journal • breast cancer awareness 2013 • october 1, 2013 a mammogram. Masses can be many things, how much of your breast is made up fatty tissue including cysts (non-cancerous, fluid-filled sacs) vs. how much is fibrous and glandular tissue. and non-cancerous solid tumors (such as Dense breasts are not abnormal and about fibroadenomas), but they could also be cancer. half of women have dense breasts on a mamCysts can be simple fluid-filled sacs (known as mogram. Although dense breast tissue can simple cysts) or can be partially solid (known as make it harder to find cancers on a mammogram, at this complex cysts). time, experts do Simple cysts are not agree what benign and don’t other tests, if need to be biopany, should be sied. Any other done in addition type of mass to mammo(such as a comgrams in women plex cyst or a solwith dense id tumor) might breasts. need to be biopsied to be sure it Limitations isn’t cancer. of mammograms A cyst and a tumor can feel A mammoalike on a physigram cannot cal exam. They prove that an can also look the abnormal area is same on a mammogram. To confirm that a mass is really a cyst, cancer. To confirm cancer is present, a small a breast ultrasound is often done. Another amount of tissue must be removed and looked option is to remove (aspirate) the fluid from the at under a microscope. This procedure, called a cyst with a thin, hollow needle. biopsy, is described in the section, "How is breast cancer diagnosed?" If a mass is not a simple cyst (that is, if it is at You should also be aware that mammograms least partly solid), then you may need to have more imaging tests. Some masses can be are done to find breast cancers that cannot be watched with periodic mammograms, while felt. If you have a breast lump, you should have others may need to be biopsied. The size, shape, it checked by your doctor and consider having it and margins (edges) of the mass help the radi- biopsied even if your mammogram result is norologist determine if cancer is likely to be present. mal. Having your previous mammograms available for the radiologist is very important. They can show that a mass or calcification has not changed for many years. This would mean that it is probably a benign condition and a biopsy is not needed.
For some women, such as those with breast implants, additional pictures may be needed. Breast implants make it harder to see breast tissue on standard mammograms, but additional x-ray pictures with implant displacement and compression views can be used to more completely examine the breast tissue.
Your mammogram report may also contain Mammograms are not perfect at finding an assessment of breast density or state that you have “dense breasts.” Breast density is based on breast cancer. They do not work as well in
morning journal • breast cancer awareness 2013 • october 1, 2013 • page 13 women with dense breasts, since dense breasts can hide a tumor. Dense breasts are more common in younger women, pregnant women and women who are breastfeeding , but any woman can have dense breasts. This can be a problem for younger women who need breast screening because they are at high risk for breast cancer (because of gene mutations, a strong family history of breast cancer, or other factors). This is one of the reasons that the American Cancer Society recommends MRI scans in addition to mammograms for screening in these women. At this time, American Cancer Society guidelines do not have recommendations for additional testing to screen women with dense breasts who aren’t at high risk of breast cancer from other factors. What to expect when you have a screening mammogram To have a mammogram you must undress above the waist. The facility will give you a wrap to wear.
digital image. The upper plate, made of plastic, is lowered to compress the breast for a few seconds while the technician takes a picture. The whole procedure takes about 20 minutes. The actual breast compression only lasts a few seconds. You will feel some discomfort when your breasts are compressed, and for some women compression can be painful. Try not to schedule a mammogram when your breasts are likely to be tender, as they can be just before or during your period. All mammogram facilities are now required to send your results to you within 30 days. Generally, you will be contacted within 5 working days if there is a problem with the mammogram. Being called back for more testing does not mean that you have cancer. In fact, less than 10% of women who are called back for more tests are found to have breast cancer. Being called back occurs fairly often, and it usually just means an additional image or an ultrasound needs to be done to look at an area more clearly. This is more common for first mammograms (or when there is no previous mammogram to look at) and in mammograms done in women before menopause. It may be slightly less common for digital mammograms.
A technologist will be there to position your breasts for the mammogram. Most technologists are women. You and the technologist are the only ones in the room during the mammogram. To get a high-quality mammogram picture with excellent image quality, it is necessary to Of every 1,000 mammograms, only 2 to 4 flatten the breast slightly. The technologist places lead to a diagnosis of cancer. the breast on the mammogram machine's lower If you are a woman aged 40 or over, you plate, which is made of metal and has a drawer to hold the x-ray film or the camera to produce a should get a mammogram every year. You can
page 14 • morning journal • breast cancer awareness 2013 • october 1, 2013 schedule the next one while you're at the facility and/or request a reminder.
• If you have had mammograms at another facility, you should make every attempt to get those mammograms to bring with you to the Tips for having a mammogram new facility (or have them sent there) so that Here are some useful suggestions for making they can be compared to the new ones. sure that you will receive a quality mammogram: • On the day of the exam don't wear deodorant or antiperspirant. Some of these contain • If it is not posted visibly near the reception- substances that can interfere with the reading of ist's desk, ask to see the US Food and Drug the mammogram by appearing on the x-ray film Administration (FDA) certificate that is issued to as white spots. all facilities that offer mammography. The FDA • You may find it easier to wear a skirt or requires all facilities to meet high professional standards of safety and quality in order to be a pants, so that you'll only need to remove your provider of mammography services. A facility blouse for the exam. may not provide mammography without certification. • Schedule your mammogram when your breasts are not tender or swollen to help reduce • Use a facility that either specializes in mam- discomfort and to ensure a good picture. Try to mography or does many mammograms a day. avoid the week just before your period. • If you are satisfied that the facility is of high • Always describe any breast symptoms or quality, continue to go there on a regular basis problems that you are having to the technologist so that your mammograms can be compared who is doing the mammogram. Be prepared to describe any medical history that could affect from year to year. your breast cancer risk — such as surgery, hor• If you are going to a facility for the first time, mone use, or family or personal history of breast bring a list of the places, dates of mammograms, cancer. biopsies, or other breast treatments you have had before. • Discuss any new findings or problems in your breasts with your doctor or nurse before having a mammogram.
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page 16 • morning journal • breast cancer awareness 2013 • october 1, 2013