Breast Cancer Prevention (cont.)
How frequently should women undergo mammography and breast examinations?
The American Cancer Society (ACS) recommends a baseline mammogram for
all women by age 40 and annual mammograms for women 40 and older for as
long as they are in good health.
In women with "lumpy breasts" or breast symptoms, and also in women with a high
risk of developing breast cancer, sometimes a baseline mammogram at 35 years of
age is recommended. This recommendation is somewhat controversial, and there are
other viewpoints.
Mammograms and young women
There is a special issue regarding mammograms in young
women. Since young women have dense glandular breast tissue, routine mammograms
have difficulty "seeing through" the dense breast tissue. Therefore mammograms
may not be able to detect cancer in the breast because the dense breast tissue
around the cancer obscures it. However, this problem can be partly offset by the
use of special breast ultrasound, which is now
an extremely important additional imaging technique used to supplement
mammography in difficult cases. Ultrasound can make visible a lump hidden within
dense breast tissue. It may also detect lumps and early breast cancers when
mammograms fail to identify a problem. Ultrasound can also help doctors locate
specific areas in the breast for
biopsy (obtain small samples of tissue to study under a microscope). Sometimes
doctors also suggest the use of magnetic resonance imaging (MRI) screening
(see below) in younger women with
dense breast tissue.
Magnetic resonance imaging (MRI) scanning
Recent research has shown that MRI scanning may be a useful screening tool
for breast cancer in certain high-risk populations. In 2004, a team of Dutch
researchers published a study of over 1,900 women at high risk for breast cancer
in the New England Journal of Medicine. These women underwent breast-cancer
screening that included physical exams every six months along with yearly
mammograms and MRI scans of the breasts. While conventional mammography did
detect many cancers at an early stage, some tumors were identified by MRI that were not detected by mammography. Overall, MRI led to the identification of 32 tumors, of which 22 were not seen on the corresponding mammogram. Likewise, some tumors appeared on mammograms that were not visible on the MRI scan. Mammography detected a total of 18 tumors, of which
eight were not identified by MRI.
The routine use of MRI, however, has many limitations. While it enabled the detection of some tumors in high-risk women, it also detected more noncancerous lesions (false-positives), which lead to many more follow-up examinations and potentially unnecessary medical procedures. In fact, MRI led to twice as many unnecessary examinations and three times as many unneeded surgical biopsies of the breast than screening by mammography alone. MRI is also approximately
10 times more costly (average cost $1000 to $1500) than mammography.
Because of these limitations, experts believe that screening with MRI is impractical for women who do not have an elevated risk of developing breast cancer. However, its benefits appear to outweigh its limitations in certain high-risk populations.
In March 2007, the American Cancer Society Breast Cancer Advisory Group issued new breast-cancer-screening recommendations that include MRI scanning along with mammography for women aged 30-69 who are considered to have an estimated lifetime risk of developing breast cancer of 20%-25%.
The previous screening recommendations regarding breast self-examinations, clinical breast exams, and mammograms were not altered in the 2007 screening recommendations. Adding a yearly breast MRI was recommended for women who:
- have a BRCA1 or BRCA2 mutation, indicative of a strong inherited risk of breast cancer,
- have a first-degree relative with a BRCA1 or BRCA2 mutation but have not been tested for the mutation, or
- received chest radiation—to treat Hodgkin's disease or other cancers, for example—between ages 10 and 30.
The new guidelines state that there is at present insufficient evidence to recommend the use of routine MRI screening in women with other risk factors, including a personal history of breast cancer, a history of carcinoma in situ or atypical hyperplasia, or dense breast tissue that makes the interpretation of mammograms difficult. Women with these risk factors may want to discuss their screening program with their physician to better determine whether MRI may be useful in their own case.
It is important to note that MRI should not be considered a substitute for regular mammography, and mammography is the only screening tool for which a reduction in mortality (death rate) from breast cancer has been proved.
Breast self-examination and breast examinations by your doctor
- All women over age 20 should perform breast self-examination monthly.
- Those over age 40 should also have annual breast
examinations by their doctors.
- Those younger than 40 years can have breast
examinations by their doctors every three years.
- For women with higher than normal risk, a good
program would include monthly breast self-examination and twice-yearly focused
physician
examination. Any palpable changes in the breasts require further
evaluation with mammography and ultrasound.
How to perform a breast self-examination
Breast self-examination is best performed when the hormone stimulation of the
breast is the least. This typically occurs seven to 10 days after the start of a
menstrual cycle (or three days after a period). At that point, the fluid
retention of the breast and the cellular proliferation are the lowest. An ideal
setting in which to conduct the exam is the bath or shower.
- With the hand and breast wet with soap, begin with
the fingers flat together and work sweeping from the outer part to the center
of the breast. It helps to mentally divide the area to be examined into
quadrants and work around the quadrants sequentially. The upper outer quadrant
should be
mentally extended into the armpit along the chest wall. This area should be
carefully included in the examination.
- The process is repeated in the same sequence with the
fingers moving in a fluttering motion. These different motions, flat fingered
stroking and fluttering fingertips, allow detection of somewhat different
tissue abnormalities.
- This examination by feeling the breast (palpation)
should be accompanied by a brief visual exam. With the arms at the side
looking in a mirror, note the symmetry. Then raise the arms slowly overhead,
checking for any areas of pulling in of the skin or visible lumps or distortion.
The entire examination process can be done in a few minutes' time.
Any detected change from the usual appearance or feel should be reported to
the doctor. If there are any areas of concern that can be felt (palpable) and
the mammogram does not show an abnormality, then a specialized breast ultrasound
can be extremely helpful.
For women who are concerned that they have lumpy breasts
and can't make any sense of their exam, it is best to do a careful exam after a
physician's examination. This serves as the baseline for normal "lumps." The
exam should be repeated several days in a row so that the findings are clearly
recalled. Subsequently, if a new or progressive change develops, it is much more
likely to be detected. The aim is to maintain an appropriate degree of alertness
without creating continuous anxiety. Do the exam and put it aside mentally until the
next time.
Next: What is the risk of radiation with repeated mammography screening over the years? »
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