morning journal - breast cancer awareness 2013

• morning journal • breast cancer awareness 2013 • october 1, 2013

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morning journal • breast cancer awareness 2013 • october 1, 2013 • page 3

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Approximately 1 in every 7 women in the US will be diagnosed with breast cancer.

• Once a month, make time for a breast self exam. • Be faithful about scheduling an annual mammogram • Each year, thousands of women fight breast cancer and win!

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When people first find outthey have breast cancer, theymay feel overwhelmed, vulner-able, and alone.

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Lie down on your back and place your rightarm behind your head. The exam is done whilelying down, not standing up. This is becausewhen lying down the breast tissue spreadsevenly over the chest wall and is as thin as pos-sible, making it much easier to feel all the breasttissue.

Use the finger pads of the 3 middle fingers onyour left hand to feel for lumps in the rightbreast. Use overlapping dime-sized circularmotions of the finger pads to feel the breast tis-sue.

Use 3 different levels of pressure to feel all thebreast tissue. Light pressure is needed to feelthe tissue closest to the skin; medium pressureto feel a little deeper; and firm pressure to feelthe tissue closest to the chest and ribs. It is nor-mal to feel a firm ridge in the lower curve ofeach breast, but you should tell your doctor ifyou feel anything else out of the ordinary. Ifyou're not sure how hard to press, talk with yourdoctor or nurse. Use each pressure level to feelthe breast tissue before moving on to the nextspot.

Move around the breast in an up and downpattern starting at an imaginary line drawnstraight down your side from the underarm andmoving across the breast to the middle of thechest bone (sternum or breastbone). Be sure tocheck the entire breast area going down untilyou feel only ribs and up to the neck or collar

bone (clavicle).There is some evidence to suggest that the

up-and-down pattern (sometimes called thevertical pattern) is the most effective pattern forcovering the entire breast without missing anybreast tissue.

Repeat the exam on your left breast, puttingyour left arm behind your head and using thefinger pads of your right hand to do the exam.

While standing in front of a mirror with yourhands pressing firmly down on your hips, look atyour breasts for any changes of size, shape, con-tour, or dimpling, or redness or scaliness of thenipple or breast skin. (The pressing down on thehips position contracts the chest wall musclesand enhances any breast changes.)

Examine each underarm while sitting up orstanding and with your arm only slightly raisedso you can easily feel in this area. Raising yourarm straight up tightens the tissue in this areaand makes it harder to examine.

This procedure for doing breast self-exam isdifferent from previous recommendations. Thesechanges represent an extensive review of themedical literature and input from an expert advi-sory group. There is evidence that this position(lying down), the area felt, pattern of coverageof the breast, and use of different amounts ofpressure increase a woman's ability to findabnormal areas.

How to examine your breasts

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Widespread use of screening mammogramshas increased the number of breast cancersfound before they cause any symptoms. Still,some breast cancers are not found by mammo-gram, either because the test was not done orbecause, even under ideal conditions, mammo-grams do not find every breast cancer.

The most common symptom of breast canceris a new lump or mass. A painless, hard massthat has irregular edges is more likely to be can-cerous, but breast cancers can be tender, soft, orrounded. They can even be painful. For this rea-son, it is important to have any new breast massor lump checked by a health care professionalexperienced in diagnosing breast diseases.

Other possible signs of breast cancer include:

• Swelling of all or part of a breast (even if nodistinct lump is felt)

• Skin irritation or dimpling• Breast or nipple pain• Nipple retraction (turning inward)• Redness, scaliness, or thickening of the nip-

ple or breast skin• Nipple discharge (other than breast milk)

Sometimes a breast cancer can spread tolymph nodes under the arm or around the collarbone and cause a lump or swelling there, evenbefore the original tumor in the breast tissue islarge enough to be felt.

Can breast cancer be found early?

Screening refers to tests and exams used tofind a disease, like cancer, in people who do nothave any symptoms. The goal of screeningexams, such as mammograms, is to find cancersbefore they start to cause symptoms. Breast can-cers that are found because they can be felttend to be larger and are more likely to havealready spread beyond the breast. In contrast,breast cancers found during screening examsare more likely to be small and still confined tothe breast. The size of a breast cancer and howfar it has spread are important factors in predict-ing the prognosis (outlook) for a woman withthis disease.

Most doctors feel that early detection tests forbreast cancer save many thousands of lives eachyear, and that many more lives could be saved ifeven more women and their health careproviders took advantage of these tests. Follow-ing the American Cancer Society's guidelines forthe early detection of breast cancer improvesthe chances that breast cancer can be diagnosedat an early stage and treated successfully.

American Cancer Society recommenda-tions for early breast cancer detection

Women age 40 and older should have ascreening mammogram every year and shouldcontinue to do so for as long as they are in goodhealth.

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morning journal • breast cancer awareness 2013 • october 1, 2013 • page 7Current evidence supporting mammograms is

even stronger than in the past. In particular,recent evidence has confirmed that mammo-grams offer substantial benefit for women intheir 40s. Women can feel confident about thebenefits associated with regular mammogramsfor finding cancer early. However, mammogramsalso have limitations. A mammogram will misssome cancers, and it sometimes leads to followup of findings that are not cancer, includingbiopsies.

Women should be told about the benefits,limitations, and potential harms linked with reg-ular screening. Mammograms can miss somecancers. But despite their limitations, theyremain a very effective and valuable tool fordecreasing suffering and death from breast can-cer.

Mammograms for older women should bebased on the individual, her health, and otherserious illnesses, such as congestive heart fail-ure, end-stage renal disease, chronic obstructivepulmonary disease, and moderate-to-severedementia. Age alone should not be the reasonto stop having regular mammograms. As long asa woman is in good health and would be a can-didate for treatment, she should continue to bescreened with a mammogram.

Women in their 20s and 30s should have aclinical breast exam (CBE) as part of a periodic(regular) health exam by a health professional,at least every 3 years. After age 40, womenshould have a breast exam by a health profes-sional every year.

CBE is a complement to mammograms andan opportunity for women and their doctor ornurse to discuss changes in their breasts, earlydetection testing, and factors in the woman'shistory that might make her more likely to havebreast cancer.

There may be some benefit in having the CBEshortly before the mammogram. The examshould include instruction for the purpose ofgetting more familiar with your own breasts.Women should also be given information aboutthe benefits and limitations of CBE and breastself exam (BSE). Breast cancer risk is very low forwomen in their 20s and gradually increases withage. Women should be told to promptly reportany new breast symptoms to a health profes-sional.

Breast self-exam (BSE) is an option forwomen starting in their 20s. Women should betold about the benefits and limitations of BSE.Women should report any breast changes totheir health professional right away.

Research has shown that BSE plays a smallrole in finding breast cancer compared with find-ing a breast lump by chance or simply beingaware of what is normal for each woman. Somewomen feel very comfortable doing BSE regular-ly (usually monthly after their period) whichinvolves a systematic step-by-step approach toexamining the look and feel of their breasts.Other women are more comfortable simplylooking and feeling their breasts in a less sys-tematic approach, such as while showering orgetting dressed or doing an occasional thoroughexam. Sometimes, women are so concerned

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• morning journal • breast cancer awareness 2013 • october 1, 2013about "doing it right" that they become stressedover the technique. Doing BSE regularly is oneway for women to know how their breasts nor-mally look and feel and to notice any changes.The goal, with or without BSE, is to report anybreast changes to a doctor or nurse right away.

Women who choose to do BSE should havetheir BSE technique reviewed during their physi-cal exam by a health professional. It is okay forwomen to choose not to do BSE or not to do iton a regular schedule.

However, by doing the exam regularly, you getto know how your breasts normally look andfeel and you can more readily detect any signsor symptoms if a change occurs, such as devel-opment of a lump or swelling, skin irritation ordimpling, nipple pain or retraction (turninginward), redness or scaliness of the nipple orbreast skin, or a discharge other than breastmilk. Should you notice any changes you shouldsee your health care provider as soon as possi-ble for evaluation. Remember that most of thetime, however, these breast changes are notcancer.

Women at high risk (greater than 20% life-time risk) based on certain risk factors shouldget an MRI and a mammogram every year.Women at moderately increased risk (15% to20% lifetime risk) should talk with their doctorsabout the benefits and limitations of adding MRIscreening to their yearly mammogram. YearlyMRI screening is not recommended for womenwhose lifetime risk of breast cancer is less than15%.

Women at high risk include those who:

• Have a known BRCA1 or BRCA2 gene muta-tion

• Have a first-degree relative (parent, brother,sister, or child) with a BRCA1 or BRCA2 genemutation, but have not had genetic testingthemselves

• Have a lifetime risk of breast cancer of 20%to 25% or greater, according to risk assessmenttools that are based mainly on family history

• Had radiation therapy to the chest whenthey were between the ages of 10 and 30 years

• Have Li-Fraumeni syndrome, Cowden syn-drome, or Bannayan-Riley-Ruvalcaba syndrome,or have first-degree relatives with one of thesesyndromes

Women at moderately increased riskinclude those who:

• Have a lifetime risk of breast cancer of 15%to 20%, according to risk assessment tools thatare based mainly on family history

• Have a personal history of breast cancer,ductal carcinoma in situ (DCIS), lobular carcino-ma in situ (LCIS), atypical ductal hyperplasia(ADH), or atypical lobular hyperplasia (ALH)

• Have extremely dense breasts or unevenlydense breasts when viewed by mammograms

If MRI is used, it should be in addition to, notinstead of, a screening mammogram. This is

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morning journal • breast cancer awareness 2013 • october 1, 2013 • page 9because while an MRI is a more sensitive test(it's more likely to detect cancer than a mammo-gram), it may still miss some cancers that amammogram would detect.

For most women at high risk, screening withMRI and mammograms should begin at age 30years and continue for as long as a woman is ingood health. But because the evidence is limitedabout the best age at which to start screening,this decision should be based on shared deci-sion making between patients and their healthcare providers, taking into account personal cir-cumstances and preferences.

Several risk assessment tools, with names likethe Gail model, the Claus model, and the Tyrer-Cuzick model, are available to help health pro-fessionals estimate a woman's breast cancerrisk. These tools give approximate, rather thanprecise, estimates of breast cancer risk based ondifferent combinations of risk factors and differ-ent data sets.

Because the different tools use different riskfactors to estimate risk, they may give differentrisk estimates for the same woman. For exam-ple, the Gail model bases its risk estimates oncertain personal risk factors, like current age, ageat menarche (first menstrual period) and historyof prior breast biopsies, along with any history ofbreast cancer in first-degree relatives. In contrast,the Claus model estimates risk based only onfamily history of breast cancer in both first andsecond-degree relatives. These 2 models couldeasily give different estimates for the same per-son.

Risk assessment tools (like the Gail model, forexample) that are not based mainly on familyhistory are not appropriate to use with the ACSguidelines to decide if a woman should haveMRI screening. The use of any of the risk assess-ment tool and its results should be discussed bya woman and her doctor.

It is recommended that women who getscreening MRI do so at a facility that can do anMRI-guided breast biopsy at the same time ifneeded. Otherwise, the woman will have tohave a second MRI exam at another facility atthe time of biopsy.

There is no evidence right now that MRI is aneffective screening tool for women at averagerisk. MRI is more sensitive than mammograms,but it also has a higher false-positive rate (it ismore likely to find something that turns out notto be cancer). This would lead to unneededbiopsies and other tests in many of thesewomen, which can lead to a lot of worry andanxiety.

The American Cancer Society believes the useof mammograms, MRI (in women at high risk),clinical breast exams, and finding and reportingbreast changes early, according to the recom-mendations outlined above, offers women thebest chance to reduce their risk of dying frombreast cancer. This combined approach is clearlybetter than any one exam or test alone.

Without question, a breast physical examwithout a mammogram would miss the oppor-tunity to detect many breast cancers that are toosmall for a woman or her doctor to feel but can

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be seen on mammograms. Although mammo-grams are a sensitive screening method, a smallpercentage of breast cancers do not show up onmammograms but can be felt by a woman orher doctors. For women at high risk of breastcancer, like those with BRCA gene mutations ora strong family history, both MRI and mammo-gram exams of the breast are recommended.

Mammograms

A mammogram is an x-ray of the breast. Adiagnostic mammogram is used to diagnosebreast disease in women who have breastsymptoms or an abnormal result on a screeningmammogram. Screening mammograms areused to look for breast disease in women whoare asymptomatic; that is, they appear to haveno breast problems. Screening mammogramsusually take 2 views (x-ray pictures taken fromdifferent angles) of each breast, while diagnosticmammograms may take more views of thebreast. For some patients, such as women with

breast implants, more pictures may be neededto include as much breast tissue as possible.Women who are breastfeeding can still getmammograms, but these are probably not quiteas accurate because the breast tissue tends tobe dense.

Breast x-rays have been done for more than70 years, but the modern mammogram hasonly existed since 1969. That was the first year x-ray units specifically for breast imaging wereavailable. Modern mammogram equipmentdesigned for breast x-rays uses very low levels of

radiation, usually a dose of about 0.1 to 0.2 radsper picture (a rad is a measure of radiationdose).

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morning journal • breast cancer awareness 2013 • october 1, 2013 • page 11Strict guidelines ensure that mammogram

equipment is safe and uses the lowest dose ofradiation possible. Many people are concernedabout the exposure to x-rays, but the level ofradiation used in modern mammograms doesnot significantly increase the risk for breast can-cer.

To put dose into perspective, if a woman withbreast cancer is treated with radiation, she willreceive around 5,000 rads. If she had yearlymammograms beginning at age 40 and contin-uing until she was 90, she will have received 20to 40 rads.

For a mammogram, the breast is pressedbetween 2 plates to flatten and spread the tis-sue. This may be uncomfortable for a moment,but it is necessary to produce a good, readablemammogram. The compression only lasts a fewseconds. The entire procedure for a screeningmammogram takes about 20 minutes. This pro-cedure produces a black and white image of thebreast tissue either on a large sheet of film or asa digital computer image that is read, or inter-preted, by a radiologist (a doctor trained to inter-pret images from x-rays, ultrasound, MRI, andrelated tests).

Digital mammograms: A digital mammogram(also known as a full-field digital mammogram,or FFDM) is like a standard mammogram in thatx-rays are used to produce an image of yourbreast. The differences are in the way the imageis recorded, viewed by the doctor, and stored.

Standard mammograms are recorded onlarge sheets of photographic film. Digital mam-mograms are recorded and stored on a comput-er. After the exam, the doctor can look at themon a computer screen and adjust the image size,brightness, or contrast to see certain areas moreclearly. Digital images can also be sent electroni-cally to another site for a remote consultationwith breast specialists. Most centers offer thedigital option, but it may not be available every-where.

Although digital mammograms have some

advantages, it is important to remember that astandard film mammogram also is effective.Nobody should miss having a regular mammo-gram because a digital mammogram is notavailable.

What the doctor looks for on your mam-mogram

The doctor reading your mammogram willlook for several types of changes:

Calcifications are tiny mineral deposits withinthe breast tissue, which look like small whitespots on the films. They may or may not becaused by cancer. There are 2 types of calcifica-tions:

Macrocalcifications are coarse (larger) calciumdeposits that are most likely changes in thebreasts caused by aging of the breast arteries,old injuries, or inflammation. These deposits are

related to non-cancerous conditions and do notrequire a biopsy. About half the women over 50,and in about 1 of 10 women under 50 havemacrocalcifications.

Microcalcifications are tiny specks of calciumin the breast. They may appear alone or in clus-ters. Microcalcifications seen on a mammogramare of more concern, but still usually do notmean that cancer is present. The shape and lay-out of microcalcifications help the radiologistjudge how likely it is cancer is present. If the cal-cifications look suspicious for cancer, a biopsywill be done.

A mass, which may occur with or without cal-cifications, is another important change seen on

• morning journal • breast cancer awareness 2013 • october 1, 2013a mammogram. Masses can be many things,including cysts (non-cancerous, fluid-filled sacs)and non-cancerous solid tumors (such asfibroadenomas), but they could also be cancer.

Cysts can be simple fluid-filled sacs (known assimple cysts) or can be partially solid (known ascomplex cysts).Simple cysts arebenign and don’tneed to be biop-sied. Any othertype of mass(such as a com-plex cyst or a sol-id tumor) mightneed to be biop-sied to be sure itisn’t cancer.

A cyst and atumor can feelalike on a physi-cal exam. Theycan also look thesame on a mam-mogram. To confirm that a mass is really a cyst,a breast ultrasound is often done. Anotheroption is to remove (aspirate) the fluid from thecyst with a thin, hollow needle.

If a mass is not a simple cyst (that is, if it is atleast partly solid), then you may need to havemore imaging tests. Some masses can bewatched with periodic mammograms, whileothers may need to be biopsied. The size, shape,and margins (edges) of the mass help the radi-ologist determine if cancer is likely to be present.

Having your previous mammograms availablefor the radiologist is very important. They canshow that a mass or calcification has notchanged for many years. This would mean that itis probably a benign condition and a biopsy isnot needed.

Your mammogram report may also containan assessment of breast density or state that youhave “dense breasts.” Breast density is based on

how much of your breast is made up fatty tissuevs. how much is fibrous and glandular tissue.

Dense breasts are not abnormal and abouthalf of women have dense breasts on a mam-mogram. Although dense breast tissue canmake it harder to find cancers on a mammo-

gram, at thistime, experts donot agree whatother tests, ifany, should bedone in additionto mammo-grams in womenwith densebreasts.

Limitationsof mammo-grams

A mammo-gram cannotprove that anabnormal area is

cancer. To confirm cancer is present, a smallamount of tissue must be removed and lookedat under a microscope. This procedure, called abiopsy, is described in the section, "How isbreast cancer diagnosed?"

You should also be aware that mammogramsare done to find breast cancers that cannot befelt. If you have a breast lump, you should haveit checked by your doctor and consider having itbiopsied even if your mammogram result is nor-mal.

For some women, such as those with breastimplants, additional pictures may be needed.Breast implants make it harder to see breast tis-sue on standard mammograms, but additionalx-ray pictures with implant displacement andcompression views can be used to more com-pletely examine the breast tissue.

Mammograms are not perfect at findingbreast cancer. They do not work as well in


women with dense breasts, since dense breastscan hide a tumor. Dense breasts are more com-mon in younger women, pregnant women andwomen who are breastfeeding , but any womancan have dense breasts.

This can be a problem for younger womenwho need breast screening because they are athigh risk forbreast cancer(because ofgene mutations,a strong familyhistory of breastcancer, or otherfactors). This isone of the rea-sons that theAmerican CancerSociety recom-mends MRIscans in additionto mammo-grams forscreening inthese women.

At this time, American Cancer Society guide-lines do not have recommendations for addi-tional testing to screen women with densebreasts who aren’t at high risk of breast cancerfrom other factors.

What to expect when you have a screen-ing mammogram

To have a mammogram you must undressabove the waist. The facility will give you a wrapto wear.

A technologist will be there to position yourbreasts for the mammogram. Most technologistsare women. You and the technologist are theonly ones in the room during the mammogram.

To get a high-quality mammogram picturewith excellent image quality, it is necessary toflatten the breast slightly. The technologist placesthe breast on the mammogram machine's lowerplate, which is made of metal and has a drawerto hold the x-ray film or the camera to produce a

digital image. The upper plate, made of plastic,is lowered to compress the breast for a few sec-onds while the technician takes a picture.

The whole procedure takes about 20 minutes.The actual breast compression only lasts a fewseconds.

You will feelsome discomfortwhen yourbreasts are com-pressed, and forsome womencompression canbe painful. Trynot to schedulea mammogramwhen yourbreasts are likelyto be tender, asthey can be justbefore or duringyour period.

All mammo-gram facilities are now required to send yourresults to you within 30 days. Generally, you willbe contacted within 5 working days if there is aproblem with the mammogram.

Being called back for more testing does notmean that you have cancer. In fact, less than10% of women who are called back for moretests are found to have breast cancer. Beingcalled back occurs fairly often, and it usually justmeans an additional image or an ultrasoundneeds to be done to look at an area more clear-ly. This is more common for first mammograms(or when there is no previous mammogram tolook at) and in mammograms done in womenbefore menopause. It may be slightly less com-mon for digital mammograms.

Of every 1,000 mammograms, only 2 to 4lead to a diagnosis of cancer.

If you are a woman aged 40 or over, youshould get a mammogram every year. You can


schedule the next one while you're at the facilityand/or request a reminder.

Tips for having a mammogram

Here are some useful suggestions for makingsure that you will receive a quality mammo-gram:

• If it is not posted visibly near the reception-ist's desk, ask to see the US Food and DrugAdministration (FDA) certificate that is issued toall facilities that offer mammography. The FDArequires all facilities to meet high professionalstandards of safety and quality in order to be aprovider of mammography services. A facilitymay not provide mammography without certifi-cation.

• Use a facility that either specializes in mam-mography or does many mammograms a day.

• If you are satisfied that the facility is of highquality, continue to go there on a regular basisso that your mammograms can be comparedfrom year to year.

• If you are going to a facility for the first time,bring a list of the places, dates of mammograms,biopsies, or other breast treatments you havehad before.

• If you have had mammograms at anotherfacility, you should make every attempt to getthose mammograms to bring with you to thenew facility (or have them sent there) so thatthey can be compared to the new ones.

• On the day of the exam don't wear deodor-ant or antiperspirant. Some of these containsubstances that can interfere with the reading ofthe mammogram by appearing on the x-ray filmas white spots.

• You may find it easier to wear a skirt orpants, so that you'll only need to remove yourblouse for the exam.

• Schedule your mammogram when yourbreasts are not tender or swollen to help reducediscomfort and to ensure a good picture. Try toavoid the week just before your period.

• Always describe any breast symptoms orproblems that you are having to the technologistwho is doing the mammogram. Be prepared todescribe any medical history that could affectyour breast cancer risk — such as surgery, hor-mone use, or family or personal history of breastcancer.

• Discuss any new findings or problems inyour breasts with your doctor or nurse beforehaving a mammogram.

• If you do not hear from your doctor within10 days, do not assume that your mammogramwas normal—call your doctor or the facility.

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