Breast Cancer Screening – In October We Wear Pink

It’s October and that means post-season baseball, (sorry Yankees), football season is in full swing and it is Breast Cancer Awareness month. Many athletes, celebrities and people affected by breast cancer in some way are sporting pink clothes or accessories and advocating for breast cancer screening. Why has breast cancer gotten such universal recognition in the US?

Breast Cancer Statistics

  • 1 in 8 women will get breast cancer in the US
  • About 300,000 women will be diagnosed this year
  • About 2300 men will be diagnosed as well
  • 40,000 women will die from their cancer this year – a death rate that is decreasing due to early diagnosis and treatment advances
  • Breast cancer is the 2nd most common cancer in women – the first is skin cancer
  • Breast cancer is the 2nd leading cause of cancer death in women – the first is lung cancer
  • 2.8 million women in the US are either living with breast cancer or post treatment
  • having a 1st degree relative with breast cancer doubles breast cancer risk
  • 85% of women diagnosed have no family history
  • 8-10% of breast cancers are linked to a genetic risk such as the BRCA gene
    • BRCA-1 carries a 55-65% risk
    • BRCA-2 carries a 45% risk as well as an increase in ovarian cancer risk

Breast Cancer Screening Guidelines

Given the number of women affected by breast cancer, as well as the high death rates and the fact that early detection and treatment have improved survival, one would think there would be little debate about the value of breast cancer screening. However, there are conflicting guidelines regarding screening – what age to start, when to stop, and how often to test.

The American Cancer Society (ACS) recommends yearly mammograms beginning at age 40 and continuing as long as a woman’s health and activity level make it feasible to continue.

In 2009 the US Preventive Services Task Force (USPSTF), a key driver of guidelines in the US, changed its recommendation from the ACS guideline to mammograms starting at age 50 and repeating them every other year, stopping after age 74, and eliminating self breast exams.

This change caused a lot of confusion and backlash, and later the USPSTF “softened” its recommendation to include a section stating that all women should discuss the risks and benefits of breast cancer screening with their doctors and make a decision based on their individual concerns.

So there are somewhat conflicting guidelines, but a decision about breast cancer screening should be based on your preference, your doctor’s assessment of your risks and likely your insurance company’s willingness to pay.  As of now, there have not been any major changes to the reimbursement of mammograms.

So how do we screen for breast cancer?

The main screening tool we use is a history!

  • What age did you start menstruating
  • Do you have a family history of breast cancer
  • Have you had breast surgery
  • Have you ever been pregnant

The answer to these questions add context to the next part of screening – a mammogram. A mammogram is an x-ray of the breast taken from 2 angles with the breast pressed against the machine to give a standard view. That image is evaluated for irregularities that suggest cancer.

There are many variables that go into a mammogram – size of the breast, age, and density are several. Density describes the ambient of breast tissue and fat in a breast. Denser breast make it harder to detect abnormalities on a mammogram. Denser breasts tend to be found in younger women, those who never had children, and athletic women. When this occurs, adding an ultrasound of the breasts can improve the reliability of the results.

MRI has been looked at recently as a screening tool – attractive because it does not use radiation, and can create very detailed images. Therefore, it can detect much smaller abnormalities. Currently this is only recommended for very high risk women.

Another technology recently developed is called Digital Tomosynthesis. Similar to a mammogram, the breast is pressed into position but 11 x-rays are taken instead of two. The images are fed into a computer and a 3-D image of the breast is created and evaluated for abnormalities.

MRI and tomosynthesis are not currently recommended for routine screening.

What do I tell my patients?

  • Every patient is unique, and needs their risk factors evaluated
  • Based on the risk assessment, a mammogram and possibly an ultrasound will be ordered
  • I reserve MRI and tomosynthesis to those women with very high risk
  • Breast implants do not change the need for a mammogram – the implants can be maneuvered out of the image so the breast can be assessed

After the study is done, we will decide when to repeat it – usually yearly based on the ACS guidelines.

One important aspect of breast cancer screening that is overlooked is communication – any test, especially one looking for cancer will provoke anxiety, and I try to get results to my patients as soon as possible. In fact, reducing test anxiety was one of the reasons the USPSTF recommended less testing!

Often there will be an area that was not well seen on the mammogram. In this situation, close up views of the area need to be done – called spot compression views. This does not mean you have cancer – it means a closer look is needed.

Regardless of which screening guideline one follows, one thing must be stressed – if you feel something that does not seem normal to you – bring it to your doctor’s attention! Breast tissue does change and often develops cysts (tender lumps) throughout the menstrual cycle, and where you are in your cycle as well as caffeine intake can influence cysts.  These changes tend to go away at the end of a period. When there is a lump – especially if it persists through a complete menstrual cycle – it is not considered screening and all guidelines stress the need to further diagnose a lump – regardless of age. When discussing self breast exams with my patients I tell them to learn what is normal for them – all breast tissue has some irregularities. If something is different from your normal, see your doctor. It may be nothing but all evidence shows early detection improves outcomes – and ignoring a lump will delay things – either peace of mind that everything is ok or the opportunity to find a cancer early.

The path to wellness begins with a proper diagnosis