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Information on breast cancer that may help save your life.

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Page 1: Morning Journal - Breast Cancer Awareness 2014
Page 2: Morning Journal - Breast Cancer Awareness 2014

page 2 • morning journal • breast cancer awareness 2014 • october 1, 2014

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Page 3: Morning Journal - Breast Cancer Awareness 2014

morning journal • breast cancer awareness 2014 • october 1, 2014 • page 3

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Page 4: Morning Journal - Breast Cancer Awareness 2014

page 4 • morning journal • breast cancer awareness 2014 • october 1, 2014

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Page 5: Morning Journal - Breast Cancer Awareness 2014

morning journal • breast cancer awareness 2014 • october 1, 2014 • page 5

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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 felt tendto be larger and are more likely to have alreadyspread beyond the breast. In contrast, breastcancers found during screening exams are morelikely to be small and still confined to the breast.The size of a breast cancer and how far it hasspread are important factors in predicting theprognosis (outlook) for a woman with this dis-ease.

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 improves thechances that breast cancer can be diagnosed atan early stage and treated successfully.

American Cancer Society recommenda-tions for early breast cancer detectionWomen age 40 and older should have a

screening mammogram every year and shouldcontinue to do so for as long as they are in goodhealth.

Continued on page 7

Knowing the signs

Page 6: Morning Journal - Breast Cancer Awareness 2014

page 6 • morning journal • breast cancer awareness 2014 • october 1, 2014

Page 7: Morning Journal - Breast Cancer Awareness 2014

morning journal • breast cancer awareness 2014 • october 1, 2014 • page 7

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Current evidence supporting mammograms iseven 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, including biop-sies.

Women should be told about the benefits,limitations, and potential harms linked with reg-ular screening. Mammograms can miss somecancers. But despite their limitations, they remaina very effective and valuable tool for decreasingsuffering and death from breast cancer.

Mammograms for older women should bebased on the individual, her health, and otherserious illnesses, such as congestive heart failure,end-stage renal disease, chronic obstructive pul-monary 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, atleast every 3 years. After age 40, women shouldhave a breast exam by a health professionalevery year.

CBE is a complement to mammograms and

an opportunity for women and their doctor ornurse to discuss changes in their breasts, earlydetection testing, and factors in the woman's his-tory 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 of get-ting 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. Oth-er women are more comfortable simply lookingand feeling their breasts in a less systematicapproach, such as while showering or gettingdressed or doing an occasional thorough exam.Sometimes, women are so concerned about"doing it right" that they become stressed over

Page 8: Morning Journal - Breast Cancer Awareness 2014

page 8 • morning journal • breast cancer awareness 2014 • october 1, 2014

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about "doing it right" that they becomestressed over the technique. Doing BSE regularlyis one way for women to know how theirbreasts normally look and feel and to notice anychanges. The goal, with or without BSE, is toreport any breast changes to a doctor or nurseright 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 and feeland you can more readily detect any signs orsymptoms if a change occurs, such as develop-ment of a lump or swelling, skin irritation or dim-pling, nipple pain or retraction (turning inward),redness or scaliness of the nipple or breast skin,or a discharge other than breast milk. Shouldyou notice any changes you should see yourhealth care provider as soon as possible for eval-uation. Remember that most of the time, howev-er, these breast changes are not cancer.

Women at high risk (greater than 20% lifetimerisk) based on certain risk factors should get anMRI and a mammogram every year. Women atmoderately increased risk (15% to 20% lifetimerisk) should talk with their doctors about thebenefits and limitations of adding MRI screeningto their yearly mammogram. Yearly MRI screen-ing is not recommended for women whose life-time risk of breast cancer is less than 15%.

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 testing them-selves

• 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 when theywere between the ages of 10 and 30 years

Page 9: Morning Journal - Breast Cancer Awareness 2014

morning journal • breast cancer awareness 2014 • october 1, 2014 • page 9

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• 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 isbecause 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 cancer risk.These tools give approximate, rather than pre-cise, estimates of breast cancer risk based on dif-ferent combinations of risk factors and differentdata 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.

Page 10: Morning Journal - Breast Cancer Awareness 2014

page 10 • morning journal • breast cancer awareness 2014 • october 1, 2014

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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 canbe seen on mammograms. Although mammo-grams are a sensitive screening method, a smallpercentage of breast cancers do not show up on

mammograms 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 withbreast 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 has onlyexisted since 1969. That was the first year x-rayunits specifically for breast imaging were avail-able. Modern mammogram equipmentdesigned for breast x-rays uses very low levels ofradiation, usually a dose of about 0.1 to 0.2 radsper picture (a rad is a measure of radiationdose). OH Lic. #23635

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Page 11: Morning Journal - Breast Cancer Awareness 2014

morning journal • breast cancer awareness 2014 • october 1, 2014 • page 11

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Strict guidelines ensure that mammogramequipment 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.

Continued on page 14

Page 12: Morning Journal - Breast Cancer Awareness 2014

page 12 • morning journal • breast cancer awareness 2014 • october 1, 2014

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Page 13: Morning Journal - Breast Cancer Awareness 2014

morning journal • breast cancer awareness 2014 • october 1, 2014 • page 13

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Page 14: Morning Journal - Breast Cancer Awareness 2014

page 14 • morning journal • breast cancer awareness 2014 • october 1, 2014

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Although digital mammograms have someadvantages, 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 arerelated 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 ona 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 are benign anddon’t need to be biopsied. Any other type ofmass (such as a complex cyst or a solid tumor)might need to be biopsied to be sure it isn’t can-cer.

A cyst and a tumor can feel alike on a physicalexam. They can also look the same on a mam-mogram. To confirm that a mass is really a cyst, abreast ultrasound is often done. Another optionis to remove (aspirate) the fluid from the cystwith 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.

Page 15: Morning Journal - Breast Cancer Awareness 2014

morning journal • breast cancer awareness 2014 • october 1, 2014 • page 15

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Page 16: Morning Journal - Breast Cancer Awareness 2014

page 16 • morning journal • breast cancer awareness 2014 • october 1, 2014