October isn't just for Halloween, costumes, parties, and candy. October is also Breast Cancer Awareness Month. Following are some interesting facts about breast cancer. Remember: please do a self exam every month, and have regular mammograms as directed by your doctor. If you feel anything unusual, don't hesitate to get it checked out; early detection can save lives!
Breast cancer is the most common cancer in women in the United States, aside from skin cancer. According to the American Cancer Society (ACS), an estimated 192,370 new cases of invasive breast cancer are expected to be diagnosed among women in the United States this year. An estimated 40,170 women are expected to die from the disease in 2009 alone. Today, there are about 2.5 million breast cancer survivors living in the United States.
If you're worried about developing breast cancer, or if you know someone who has been diagnosed with the disease, one way to deal with your concerns is to get as much information as possible. In this section you'll find important background information about what breast cancer is and how it develops.
Breast cancer is a malignant tumor that grows in one or both of the breasts. Breast cancer usually develops in the ducts or lobules, also known as the milk-producing areas of the breast.
Breast cancer is the second leading cause of cancer death in women (after lung cancer). Although African-American women have a slightly lower incidence of breast cancer after age 40 than Caucasian women, they have a slightly higher incidence rate of breast cancer before age 40. However, African-American women are more likely to die from breast cancer at every age. Breast cancer is much less common in males; by comparison, the disease is about 100 times more common among women. According to the American Cancer Society, an estimated 1,910 new cases of invasive breast cancer are expected to be diagnosed among men in the United States in 2009.
Types of breast cancer
There are several different types of breast cancer that can be divided into two main categories - noninvasive cancers and invasive cancers. Noninvasive cancer may also be called "carcinoma in situ." Noninvasive breast cancers are confined to the ducts or lobules and they do not spread to surrounding tissues. The two types of noninvasive breast cancers are ductal carcinoma in situ (referred to as DCIS) and lobular carcinoma in situ (referred to as LCIS).
It is known that hormones in a woman's body, such as estrogen and progesterone, can play a role in the development of breast cancer. In breast cancer, estrogen causes a doubling of cancer cells every 36 hours. The growing tumor needs to increase its blood supply to provide food and oxygen. Progesterone seems to cause stromal cells (the woman's own cells to send out signals for more blood supply to feed the tumor. (Source: Dr. V. Craig Jordan, vice president and scientific director for the medical science division at Fox Chase Cancer Center in Philadelphia as quoted in NY Times, Hormones And Cancer: By Gina Kolata, Published: December 26, 2006)
If you're worried about developing breast cancer, or if you know someone who has been diagnosed with the disease, one way to deal with your concerns is to get as much information as possible. In this section you'll find important background information about what breast cancer is and how it develops.
Breast cancer is a malignant tumor that grows in one or both of the breasts. Breast cancer usually develops in the ducts or lobules, also known as the milk-producing areas of the breast.
Breast cancer is the second leading cause of cancer death in women (after lung cancer). Although African-American women have a slightly lower incidence of breast cancer after age 40 than Caucasian women, they have a slightly higher incidence rate of breast cancer before age 40. However, African-American women are more likely to die from breast cancer at every age. Breast cancer is much less common in males; by comparison, the disease is about 100 times more common among women. According to the American Cancer Society, an estimated 1,910 new cases of invasive breast cancer are expected to be diagnosed among men in the United States in 2009.
Types of breast cancer
There are several different types of breast cancer that can be divided into two main categories - noninvasive cancers and invasive cancers. Noninvasive cancer may also be called "carcinoma in situ." Noninvasive breast cancers are confined to the ducts or lobules and they do not spread to surrounding tissues. The two types of noninvasive breast cancers are ductal carcinoma in situ (referred to as DCIS) and lobular carcinoma in situ (referred to as LCIS).
It is known that hormones in a woman's body, such as estrogen and progesterone, can play a role in the development of breast cancer. In breast cancer, estrogen causes a doubling of cancer cells every 36 hours. The growing tumor needs to increase its blood supply to provide food and oxygen. Progesterone seems to cause stromal cells (the woman's own cells to send out signals for more blood supply to feed the tumor. (Source: Dr. V. Craig Jordan, vice president and scientific director for the medical science division at Fox Chase Cancer Center in Philadelphia as quoted in NY Times, Hormones And Cancer: By Gina Kolata, Published: December 26, 2006)
- Non-invasive breast cancer. The majority of non-invasive breast cancers are DCIS. In DCIS, the cancer cells are found only in the milk duct of the breast. If DCIS is not treated, it may progress to invasive cancer.
In LCIS, the abnormal cells are found only in the lobules of the breast. Unlike DCIS, LCIS is not considered to be a cancer. It is more like a warning sign of increased risk of developing an invasive breast cancer in the same or opposite breast. While LCIS is a risk factor for invasive cancer, it doesn't actually develop into invasive breast cancer in many women. - Invasive breast cancer. Invasive or infiltrating breast cancers penetrate through normal breast tissue (such as the ducts and lobules) and invade surrounding areas. They are more serious than noninvasive cancers because they can spread to other parts of the body, such as the bones, liver, lungs, and brain.
There are several kinds of invasive breast cancers. The most common type is invasive ductal carcinoma, which appears in the ducts and accounts for about 80 percent of all breast cancer cases. There are differences in the various types of invasive breast cancer, but the treatment options are similar for all of them.
Not all breast cancers are alike
Not all breast cancers are alike - there are different stages of breast cancer based on the size of the tumor and whether the cancer has spread. For doctor and patient, knowing the stage of breast cancer is the most important factor in choosing among treatment options. Doctors use a physical exam, biopsy, and other tests to determine breast cancer stage.
Stages of Breast Cancer
The most common system used to describe the stages of breast cancer is the AJCC/TNM (American Joint Committee on Cancer/Tumor-Nodes-Metastases) system. This system takes into account the tumor size and spread, whether the cancer has spread to lymph nodes, and whether it has spread to distant organs (metastasis).
All of this information is then combined in a process called stage grouping. The stage is expressed as a Roman numeral. After stage 0 (carcinoma in situ), the other stages are I through IV (1-4). Some of the stages are further sub-divided using the letters A, B, and C. In general, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more advanced cancer.
These are the stages of breast cancer:
Stage 0 - Stage 0 is carcinoma in situ, early stage cancer that is confined to the ducts or the lobules, depending on where it started. It has not gone into the tissues in the breast nor spread to other organs in the body.
- Ductal carcinoma in situ (DCIS): This is the most common type of noninvasive breast cancer, when abnormal cells are in the lining of a duct. DCIS is also called intraductal carcinoma. DCIS sometimes becomes invasive cancer if not treated.
- Lobular carcinoma in situ (LCIS): This condition begins in the milk-making glands but does not go through the wall of the lobules. LCIS seldom becomes invasive cancer; however, having LCIS in one breast increases the risk of cancer for both breasts.
Stage II - Stage II is one of the following:
- The tumor in the breast is no more than 2 centimeters (three-quarters of an inch) across. The cancer has spread to the lymph nodes under the arm.
- The tumor is between 2 and 5 centimeters (three-quarters of an inch to 2 inches). The cancer may have spread to the lymph nodes under the arm.
- The tumor is larger than 5 centimeters (2 inches). The cancer has not spread to the lymph nodes under the arm.
- Stage IIIA - Stage IIIA is one of the following:
- The tumor in the breast is smaller than 5 centimeters (2 inches). The cancer has spread to underarm lymph nodes that are attached to each other or to other structures.
- The tumor is more than 5 centimeters across. The cancer has spread to the underarm lymph nodes.
- Stage IIIB - Stage IIIB is one of the following:
- The tumor has grown into the chest wall or the skin of the breast.
- The cancer has spread to lymph nodes behind the breastbone.
- Inflammatory breast cancer is a rare type of Stage IIIB breast cancer. The breast looks red and swollen because cancer cells block the lymph vessels in the skin of the breast.
- Stage IIIC - Stage IIIC is a tumor of any size. It has spread in one of the following ways:
- The cancer has spread to the lymph nodes behind the breastbone and under the arm.
- The cancer has spread to the lymph nodes under or above the collarbone.
Stage IV - Stage IV is distant metastatic cancer. The cancer has spread to other parts of the body.
Recurrent cancer - Recurrent cancer is cancer that has come back (recurred) after a period of time when it could not be detected. It may recur locally in the breast or chest wall as another primary cancer, or it may recur in any other part of the body, such as the bone, liver, or lungs, which is generally referred to as metastatic cancer.
Recurrent cancer - Recurrent cancer is cancer that has come back (recurred) after a period of time when it could not be detected. It may recur locally in the breast or chest wall as another primary cancer, or it may recur in any other part of the body, such as the bone, liver, or lungs, which is generally referred to as metastatic cancer.
(For more information on this, please visit this site: http://www.nbcam.org/disease_breast_cancer.cfm )
- An estimated 182,800 new cases of invasive breast cancer will be diagnosed in 2000.
- Approximately 42,200 deaths will occur in women from breast cancer in 2000.
- One in eight women or 12.6% of all women will get breast cancer in her lifetime.
- Breast cancer risk increases with age and every woman is at risk.
- Every 13 minutes a woman dies of breast cancer.
- Seventy-seven percent of women with breast cancer are over 50.
- Approximately 1400 cases of breast cancer will be diagnosed in men in 2000 and 400 of those men will die.
- More than 1.7 million women who have had breast cancer are still alive in the United States.
- Breast cancer is the leading cause of cancer death in women between the ages of 15 and 54, and the second cause of cancer death in women 55 to 74.
- Seventy-one percent of black women diagnosed with breast cancer experience a five-year survival rate, while eighty-six percent of white women experience five-year survival.
- The first sign of breast cancer usually shows up on a woman's mammogram before it can be felt or any other symptoms are present.
- Risks for breast cancer include a family history, atypical hyperplasia, delaying pregnancy until after age 30 or never becoming pregnant, early menstruation (before age 12), late menopause (after age 55), current use or use in the last ten years of oral contraceptives, and daily consumption of alcohol.
- Early detection of breast cancer, through monthly breast self-exam and particularly yearly mammography after age 40, offers the best chance for survival.
- Ninety-six percent of women who find and treat breast cancer early will be cancer-free after five years.
- Over eighty percent of breast lumps are not cancerous, but benign such as fibrocystic breast disease.
- Oral contraceptives may cause a slight increase in breast cancer risk; however 10 years after discontinuing use of oral contraceptives the risk is the same as for women who never used the pill.
- Estrogen replacement therapy for over 5 years slightly increases breast cancer risk; however the increased risk appears to disappear 5-10 years after discontinuing the use of estrogen replacement therapy.
- You are never too young to develop breast cancer! Breast Self-Exam should begin by the age of twenty.
For some more information, please take a look at this site: http://womenshealth.about.com/cs/breastcancer/a/breastcancfacts.htm
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 to be larger and are more likely to have already spread beyond the breast. In contrast, breast cancers found during screening exams are more likely to be small and still confined to the breast. The size of a breast cancer and how far it has spread are important factors in predicting the prognosis (outlook) for a woman with this disease.
Most doctors feel that early detection tests for breast cancer save many thousands of lives each year, and that many more lives could be saved if even more women and their health care providers took advantage of these tests. Following the American Cancer Society's guidelines for the early detection of breast cancer improves the chances that breast cancer can be diagnosed at an early stage and treated successfully.
Women at high risk include those who:
For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. But because the evidence is limited regarding the best age at which to start screening, this decision should be based on shared decision making between patients and their health care providers, taking into account personal circumstances and preferences.
Several risk assessment tools, with names like the Gail model, the Claus model, and the Tyrer-Cuzick model, are available to help health professionals estimate a woman's breast cancer risk. These tools give approximate, rather than precise, estimates of breast cancer risk based on different combinations of risk factors and different data sets. As a result, they may give different risk estimates for the same woman. For example, the Gail model bases its risk estimates on certain personal risk factors, like age at menarche (first menstrual period) and history of prior breast biopsies, along with any history of breast cancer in first-degree relatives. The Claus model estimates risk based on family history of breast cancer in both first and second-degree relatives. These 2 models could easily give different estimates using the same data. Results obtained from any of the risk assessment tools should be discussed by a woman and her doctor when being used to decide whether to start MRI screening.
It is recommended that women who get screening MRI do so at a facility that can do an MRI-guided breast biopsy at the same time if needed. Otherwise, the woman will have to have a second MRI exam at another facility at the time of biopsy.
There is no evidence right now that MRI will be 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.
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, 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 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.
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).
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.
To put dose into perspective, if a woman with breast cancer is treated with radiation, she will receive around 5,000 rads. If she had yearly mammograms beginning at age 40 and continuing until she was 90, she will have received 20 to 40 rads.
For a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. This may be uncomfortable for a moment, but it is necessary to produce a good, readable mammogram. The compression only lasts a few seconds. The entire procedure for a screening mammogram takes about 20 minutes. This procedure 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).
Some advances in technology, like digital mammography, may help doctors read mammograms more accurately. They are described in the section, "How is breast cancer diagnosed?"
Calcifications are tiny mineral deposits within the breast tissue, which look like small white spots on the films. They may or may not be caused by cancer. There are 2 types of calcifications:
You should also be aware that mammograms are done to find breast cancer that cannot be felt. If you have a breast lump, you should have it checked by your doctor and consider having it biopsied even if your mammogram result is normal.
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.
Mammograms are not perfect at finding breast cancer. They do not work as well in younger women, usually because their breasts are dense, and can hide a tumor. This may also be true for pregnant women and women who are breast-feeding. Since most breast cancers occur in older women, this is usually not a major concern.
However, this can be a problem for young women who are at high risk for breast cancer (due to gene mutations, a strong family history of breast cancer, or other factors) because they often develop breast cancer at a younger age. For this reason, the American Cancer Society now recommends MRI scans in addition to mammograms for screening in these women. (MRI scans are described below.)
For more information on these tests, also see the section, "How is breast cancer diagnosed?" and our document, Mammograms and Other Breast Imaging Procedures.
Breast cancer screening is now more available to medically underserved women through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This program provides breast and cervical cancer early detection testing to women without health insurance for free or at very low cost. Although the program is administered within each state, the Centers for Disease Control and Prevention (CDC) provide matching funds and support to each state program. Each state's Department of Health has information on how to contact the nearest program.
The program is only designed to provide screening. But if a cancer is discovered, it will cover further diagnostic testing and a surgical consultation.
The Breast and Cervical Cancer Prevention and Treatment Act gives states Medicaid funds to pay for treating breast and cervical cancers that are detected through the NBCCEDP. This helps women focus their energies on fighting their disease, instead of worrying about how to pay for treatment. All states participate in this program.
To learn more about these programs, please contact the CDC at 1-800-CDC INFO begin_of_the_skype_highlighting 1-800-CDC INFO end_of_the_skype_highlighting (1-800-232-4636 begin_of_the_skype_highlighting 1-800-232-4636 end_of_the_skype_highlighting) or online at www.cdc.gov/cancer/nbccedp.
Special attention will be given to the shape and texture of the breasts, location of any lumps, and whether such lumps are attached to the skin or to deeper tissues. The area under both arms will also be examined.
The CBE is a good time for women who don't know how to examine their breasts to learn the proper technique from their health care professionals. Ask your doctor or nurse to teach you and watch your technique.
A woman can notice changes by being aware of how her breasts normally look and feel and by feeling her breasts for changes (breast awareness), or by choosing to use a step-by-step approach (see below) and using a specific schedule to examine her breasts.
If you choose to do BSE, the information below is a step-by-step approach for the exam. The best time for a woman to examine her breasts is when the breasts are not tender or swollen. Women who examine their breasts should have their technique reviewed during their periodic health exams by their health care professional.
Women with breast implants can do BSE, too. It may be helpful to have the surgeon help identify the edges of the implant so that you know what you are feeling. There is some thought that the implants push out the breast tissue and may actually make it easier to examine. Women who are pregnant or breast-feeding can also choose to examine their breasts regularly.
It is acceptable for women to choose not to do BSE or to do BSE once in a while. Women who choose not to do BSE should still be aware of the normal look and feel of their breasts and report any changes to their doctor right away.
MRI scans use magnets and radio waves (instead of x-rays) to produce very detailed, cross-sectional images of the body. The most useful MRI exams for breast imaging use a contrast material (gadolinium) that is injected into a vein in the arm before or during the exam. This improves the ability of the MRI to clearly show breast tissue details. (For more details on how an MRI test is done, see the section, " How is breast cancer diagnosed?")
MRI is more sensitive in detecting cancers than mammograms, but it also has a higher false-positive rate (where the test finds something that turns out not to be cancer), which results in more recalls and biopsies. This is why it is not recommended as a screening test for women at average risk of breast cancer, as it would result in unneeded biopsies and other tests in a large portion of these women.
Just as mammography uses x-ray machines that are specially designed to image the breasts, breast MRI also requires special equipment. Breast MRI machines produce higher quality images than MRI machines designed for head, chest, or abdominal scanning. However, many hospitals and imaging centers do not have dedicated breast MRI equipment available. It is important that screening MRIs be done at facilities that can perform an MRI-guided breast biopsy. Otherwise, the entire scan will need to be repeated at another facility when the biopsy is done.
MRI is more expensive than mammography. Most major insurance companies will likely pay for these screening tests if a woman can be shown to be at high risk, but it's not yet clear if all companies will do so. At this time there are concerns about costs of and limited access to high-quality MRI breast screening services for women at high risk of breast cancer.
Most doctors feel that early detection tests for breast cancer save many thousands of lives each year, and that many more lives could be saved if even more women and their health care providers took advantage of these tests. Following the American Cancer Society's guidelines for the early detection of breast cancer improves the chances that breast cancer can be diagnosed at an early stage and treated successfully.
American Cancer Society recommendations for early breast cancer detection
Women age 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health.- 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.
- 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.
- 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 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. However, by doing the exam regularly, you get to know how your breasts normally look and feel and you can more readily detect any signs or symptoms if a change occurs, such as development of a lump or swelling, skin irritation or dimpling, nipple pain or retraction (turning inward), redness or scaliness of the nipple or breast skin, or a discharge other than breast milk. Should you notice any changes you should see your health care provider as soon as possible for evaluation. Remember that most of the time, however, these breast changes are not cancer.
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 (such as the Claus model - see below)
- Had radiation therapy to the chest when they were between the ages of 10 and 30 years
- Have Li-Fraumeni syndrome, Cowden syndrome, or hereditary diffuse gastric cancer, or have first-degree relatives with one of these syndromes
- Have a lifetime risk of breast cancer of 15% to 20%, according to risk assessment tools that are based mainly on family history (see below)
- Have a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)
- Have extremely dense breasts or unevenly dense breasts when viewed by mammograms
For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. But because the evidence is limited regarding the best age at which to start screening, this decision should be based on shared decision making between patients and their health care providers, taking into account personal circumstances and preferences.
Several risk assessment tools, with names like the Gail model, the Claus model, and the Tyrer-Cuzick model, are available to help health professionals estimate a woman's breast cancer risk. These tools give approximate, rather than precise, estimates of breast cancer risk based on different combinations of risk factors and different data sets. As a result, they may give different risk estimates for the same woman. For example, the Gail model bases its risk estimates on certain personal risk factors, like age at menarche (first menstrual period) and history of prior breast biopsies, along with any history of breast cancer in first-degree relatives. The Claus model estimates risk based on family history of breast cancer in both first and second-degree relatives. These 2 models could easily give different estimates using the same data. Results obtained from any of the risk assessment tools should be discussed by a woman and her doctor when being used to decide whether to start MRI screening.
It is recommended that women who get screening MRI do so at a facility that can do an MRI-guided breast biopsy at the same time if needed. Otherwise, the woman will have to have a second MRI exam at another facility at the time of biopsy.
There is no evidence right now that MRI will be 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.
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, 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 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. 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 breast-feeding 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).
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.
To put dose into perspective, if a woman with breast cancer is treated with radiation, she will receive around 5,000 rads. If she had yearly mammograms beginning at age 40 and continuing until she was 90, she will have received 20 to 40 rads.
For a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. This may be uncomfortable for a moment, but it is necessary to produce a good, readable mammogram. The compression only lasts a few seconds. The entire procedure for a screening mammogram takes about 20 minutes. This procedure 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).
Some advances in technology, like digital mammography, may help doctors read mammograms more accurately. They are described in the section, "How is breast cancer diagnosed?"
What the doctor looks for on your mammogram
The doctor reading the films will look for several types of changes:Calcifications are tiny mineral deposits within the breast tissue, which look like small white spots on the films. They may or may not be caused by cancer. There are 2 types of calcifications:
- Macrocalcifications are coarse (larger) calcium deposits that are most likely changes in the breasts caused by aging of the breast arteries, old injuries, or inflammation. These deposits are related to non-cancerous conditions and do not require a biopsy. Macrocalcifications are found in about half the women over 50, and in about 1 of 10 women under 50.
- Microcalcifications are tiny specks of calcium in the breast. They may appear alone or in clusters. Microcalcifications seen on a mammogram are of more concern, but still usually do not mean that cancer is present. The shape and layout of microcalcifications help the radiologist judge how likely it is that cancer is present. If the calcifications look suspicious for cancer, a biopsy will be done.
- A cyst and a tumor can feel alike on a physical exam. They can also look the same on a mammogram. To confirm that a mass is really a cyst, a breast ultrasound is often done. Another option is to remove (aspirate) the fluid from the cyst with a thin, hollow needle.
- If a mass is not a simple cyst (that is, if it is at least partly solid), then you may need to have more imaging tests. Some masses can be watched with periodic mammograms, while others may need a biopsy. The size, shape, and margins (edges) of the mass help the radiologist determine if cancer is present.
Limitations of mammograms
A mammogram cannot prove that an abnormal area is cancer. To confirm whether cancer is present, a small amount of tissue must be removed and looked at under a microscope. This procedure, called a biopsy, is described in the section, "How is breast cancer diagnosed?"You should also be aware that mammograms are done to find breast cancer that cannot be felt. If you have a breast lump, you should have it checked by your doctor and consider having it biopsied even if your mammogram result is normal.
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.
Mammograms are not perfect at finding breast cancer. They do not work as well in younger women, usually because their breasts are dense, and can hide a tumor. This may also be true for pregnant women and women who are breast-feeding. Since most breast cancers occur in older women, this is usually not a major concern.
However, this can be a problem for young women who are at high risk for breast cancer (due to gene mutations, a strong family history of breast cancer, or other factors) because they often develop breast cancer at a younger age. For this reason, the American Cancer Society now recommends MRI scans in addition to mammograms for screening in these women. (MRI scans are described below.)
For more information on these tests, also see the section, "How is breast cancer diagnosed?" and our document, Mammograms and Other Breast Imaging Procedures.
What to expect when you have a mammogram
- To have a mammogram you must undress above the waist. The facility will give you a wrap to wear.
- 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 flatten the breast slightly. The technologist places the breast on the mammogram machine's lower plate, which is made of metal and has a drawer to 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 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 may 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.
- Only 2 to 4 mammograms of every 1,000 lead to a diagnosis of cancer. About 10% of women who have a mammogram will require more tests, and the majority will only need an additional mammogram. Don't panic if this happens to you. Only 8% to 10% of those women will need a biopsy, and most (80%) of those biopsies will not be cancer.
Tips for having a mammogram
The following are useful suggestions for making sure that you will receive a quality mammogram:- If it is not posted visibly near the receptionist's desk, ask to see the FDA certificate that is issued to all facilities that offer mammography. The FDA requires that all facilities meet high professional standards of safety and quality in order to be a provider of mammography services. A facility may not provide mammography without certification.
- Use a facility that either specializes in mammography or does many mammograms a day.
- If you are satisfied that the facility is of high quality, continue to go there on a regular basis so that your mammograms can be compared from 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 have had before.
- If you have had mammograms at another facility, you should make every attempt to get those mammograms to bring with you to the new facility (or have them sent there) so that they can be compared to the new ones.
- On the day of the exam don't wear deodorant or antiperspirant. Some of these contain substances that can interfere with the reading of the mammogram by appearing on the x-ray film as white spots.
- You may find it easier to wear a skirt or pants, so that you'll only need to remove your blouse for the exam.
- Schedule your mammogram when your breasts are not tender or swollen to help reduce discomfort and to ensure a good picture. Try to avoid the week just before your period.
- Always describe any breast symptoms or problems that you are having to the technologist who is doing the mammogram. Be prepared to describe any medical history that could affect your breast cancer risk -- such as surgery, hormone use, or family or personal history of breast cancer. Discuss any new findings or problems in your breasts with your doctor or nurse before having a mammogram.
- If you do not hear from your doctor within 10 days, do not assume that your mammogram was normal -- call your doctor or the facility.
Help with mammogram costs
Medicare, Medicaid, and most private health insurance plans cover mammogram costs or a percentage of them. Low-cost mammograms are available in most communities. Call us at 1-800-227-2345 begin_of_the_skype_highlighting 1-800-227-2345 end_of_the_skype_highlighting for information about facilities in your area.Breast cancer screening is now more available to medically underserved women through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). This program provides breast and cervical cancer early detection testing to women without health insurance for free or at very low cost. Although the program is administered within each state, the Centers for Disease Control and Prevention (CDC) provide matching funds and support to each state program. Each state's Department of Health has information on how to contact the nearest program.
The program is only designed to provide screening. But if a cancer is discovered, it will cover further diagnostic testing and a surgical consultation.
The Breast and Cervical Cancer Prevention and Treatment Act gives states Medicaid funds to pay for treating breast and cervical cancers that are detected through the NBCCEDP. This helps women focus their energies on fighting their disease, instead of worrying about how to pay for treatment. All states participate in this program.
To learn more about these programs, please contact the CDC at 1-800-CDC INFO begin_of_the_skype_highlighting 1-800-CDC INFO end_of_the_skype_highlighting (1-800-232-4636 begin_of_the_skype_highlighting 1-800-232-4636 end_of_the_skype_highlighting) or online at www.cdc.gov/cancer/nbccedp.
Clinical breast exam
A clinical breast exam (CBE) is an exam of your breasts by a health care professional, such as a doctor, nurse practitioner, nurse, or doctor's assistant. For this exam, you undress from the waist up. The health care professional will first look at your breasts for abnormalities in size or shape, or changes in the skin of the breasts or nipple. Then, using the pads of the fingers, the examiner will gently feel (palpate) your breasts.Special attention will be given to the shape and texture of the breasts, location of any lumps, and whether such lumps are attached to the skin or to deeper tissues. The area under both arms will also be examined.
The CBE is a good time for women who don't know how to examine their breasts to learn the proper technique from their health care professionals. Ask your doctor or nurse to teach you and watch your technique.
Breast awareness and self exam
Beginning in their 20s, women should be told about the benefits and limitations of breast self-exam (BSE). Women should know how their breasts normally look and feel and report any new breast changes to a health professional as soon as they are found. Finding a breast change does not necessarily mean there is a cancer.A woman can notice changes by being aware of how her breasts normally look and feel and by feeling her breasts for changes (breast awareness), or by choosing to use a step-by-step approach (see below) and using a specific schedule to examine her breasts.
If you choose to do BSE, the information below is a step-by-step approach for the exam. The best time for a woman to examine her breasts is when the breasts are not tender or swollen. Women who examine their breasts should have their technique reviewed during their periodic health exams by their health care professional.
Women with breast implants can do BSE, too. It may be helpful to have the surgeon help identify the edges of the implant so that you know what you are feeling. There is some thought that the implants push out the breast tissue and may actually make it easier to examine. Women who are pregnant or breast-feeding can also choose to examine their breasts regularly.
It is acceptable for women to choose not to do BSE or to do BSE once in a while. Women who choose not to do BSE should still be aware of the normal look and feel of their breasts and report any changes to their doctor right away.
How to examine your breasts
- Lie down 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.
- Use the finger pads of the 3 middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue.
- Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. It is normal to feel a firm ridge in the lower curve of each breast, but you should tell your doctor if you feel anything else out of the ordinary. If you're not sure how hard to press, talk with your doctor or nurse. Use each pressure level to feel the breast tissue before moving on to the next spot.
- Move around the breast in an up and down pattern starting at an imaginary line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entire breast area going down until you 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 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 your left arm behind your head and using the finger pads of your right hand to do the exam.
- While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. (The pressing down on the hips position contracts the chest wall muscles and enhances any breast changes.)
- Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder to examine.
Magnetic resonance imaging (MRI)
For certain women at high risk for breast cancer, screening MRI is recommended along with a yearly mammogram. It is not generally recommended as a screening tool by itself, because although it is a sensitive test, it may still miss some cancers that mammograms would detect.MRI scans use magnets and radio waves (instead of x-rays) to produce very detailed, cross-sectional images of the body. The most useful MRI exams for breast imaging use a contrast material (gadolinium) that is injected into a vein in the arm before or during the exam. This improves the ability of the MRI to clearly show breast tissue details. (For more details on how an MRI test is done, see the section, " How is breast cancer diagnosed?")
MRI is more sensitive in detecting cancers than mammograms, but it also has a higher false-positive rate (where the test finds something that turns out not to be cancer), which results in more recalls and biopsies. This is why it is not recommended as a screening test for women at average risk of breast cancer, as it would result in unneeded biopsies and other tests in a large portion of these women.
Just as mammography uses x-ray machines that are specially designed to image the breasts, breast MRI also requires special equipment. Breast MRI machines produce higher quality images than MRI machines designed for head, chest, or abdominal scanning. However, many hospitals and imaging centers do not have dedicated breast MRI equipment available. It is important that screening MRIs be done at facilities that can perform an MRI-guided breast biopsy. Otherwise, the entire scan will need to be repeated at another facility when the biopsy is done.
MRI is more expensive than mammography. Most major insurance companies will likely pay for these screening tests if a woman can be shown to be at high risk, but it's not yet clear if all companies will do so. At this time there are concerns about costs of and limited access to high-quality MRI breast screening services for women at high risk of breast cancer.
Last Medical Review: 09/17/2010
Last Revised: 09/17/2010
(The above is from the national cancer society. To go to the site, please click the large link at the beginning of the article.)
Remember, be safe. Thousands of families and friends lose someone dear to them everyday to breast cancer. Do self exams -- even if you're a man, because men can and do get breast cancer. Check every month and save a life -- maybe yours.
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