BREAST CANCER

Screening And Diagnosis

Screening is the key to finding breast cancer in its early, treatable stages. Depending on your age and risk factors, screening may include examination by your nurse or doctor (clinical breast exam), mammograms (mammography) and breast self-examination.

Breast self-examination

Many women start examining their breasts regularly around age 20. The first step is to become familiar with the usual appearance and feel of your breasts. The second is to make monthly self-exams a regular part of your life.

Examine your breasts on the same day each month if you're past menopause. Otherwise, the best time is about 7 days after the start of your last menstrual period. Look for a lump that seems to appear suddenly, is different from the tissue around it, and either doesn't go away or changes in texture. Lumps vary in size and firmness and often feel hard with irregular edges. They may also feel like thickened areas without distinct outlines. In addition, look for skin that thickens or dimples. Once you become familiar with your breasts, it will be easier to notice any changes.

A Canadian study published in June 2001 concluded that breast self-exams may not be as beneficial as once thought. The results of this study showed that breast self-exams do not lead to fewer deaths from breast cancer and may cause women to have unnecessary biopsies. However, the American Cancer Society continues to recommend breast self-exams as part of a comprehensive screening program that includes mammograms and clinical breast exams.

Clinical breast exam

Unless you have a family history of cancer or other factors that place you at high risk, the American Cancer Society (ACS) recommends having clinical breast exams once every 3 years until age 40. After that, the ACS recommends having a yearly clinical exam.

During this exam, your doctor examines your breasts for lumps or other changes. He or she may be may be able to feel lumps you miss when you examine your own breasts and will also look for enlarged lymph nodes in your armpit (axilla).

Mammogram

A mammogram is a series of X-rays that shows images of your breast tissue. These X-rays are capable of detecting tumors up to 2 years before you or your doctor can feel them. Yet mammograms aren't perfect. In fact, about 10 percent of breast cancers — sometimes even lumps you can feel — don't show up on X-rays (false-negative result). The rate may be even higher for younger women, whose breasts tend to be very dense. That's one reason regular mammograms usually aren't recommended for young women.

At other times, mammograms may indicate a problem when none exists (false-positive result). Still, right now mammograms are the best available method of detecting breast cancer in its early stages. This is especially true when they're combined with self-exams and exams done by your doctor.

During a mammogram, your breasts are compressed between plastic plates while a radiology technician takes the X-rays. The whole procedure should take less than 30 minutes. You may find mammography somewhat uncomfortable. If you have too much discomfort, inform the technician. If you have tender breasts, schedule your mammogram for a time after your menstrual period. Avoiding caffeine for 2 days before the test also helps reduce breast tenderness.

Don't let a lack of health insurance keep you from having regular mammograms. Many state health departments and Planned Parenthood clinics offer low-cost or free screenings. So does the Encore Plus program available through many YWCAs.

If you, your doctor or a mammogram detects a lump in your breast, you will likely have one or more diagnostic procedures to determine if the lump is cancerous.

Ultrasound

Often, your doctor will suggest a less invasive procedure, such as ultrasound, before deciding on a biopsy. Ultrasound is a procedure that uses sound waves to create an image of your breast on a computer screen. By analyzing this image, your doctor may be able to tell whether a lump is a cyst or a solid mass. Cysts, which are sacs of fluid, usually aren't cancerous, although you may want to have a painful cyst drained with a needle.

Biopsy

In some cases, your doctor may want to remove a small sample of tissue (biopsy) for analysis in the laboratory. To do so, he or she may use one of the following procedures:

• Fine-needle aspiration biopsy. This is the simplest type of biopsy. It's used for lumps that can be felt. In this procedure, your doctor inserts a thin, hollow needle into your breast to withdraw cells from a lump. The procedure is painless, takes less than a minute and is similar to drawing blood. The cells are then checked in a lab. Another simple procedure, fine-needle aspiration, attempts to remove fluid from a lump. It is mainly used to help distinguish cysts from solid masses.

• Core needle biopsy. This type of biopsy is used for a lump that can be seen only on a mammogram or ultrasound. During the procedure, your surgeon uses a hollow needle to remove samples of tissue from a breast lump. As many as 15 samples may be taken, each about the thickness of a grain of rice. The tissue is then analyzed for malignant cells. The advantage of a core needle biopsy is that it removes tissue, rather than just cells, for analysis. Core needle biopsies are often performed with the help of live, moving images on a mammogram (stereotactic core needle biopsy). This helps your surgeon locate the tissue to be sampled. The procedure usually takes about an hour under local anesthesia.

• Wire localization. Your doctor may recommend this technique when a worrisome lump is seen on a mammogram but can't be felt. Using your mammogram as a guide, a thin wire is placed in your breast and the tip guided to the lump. Wire localization is usually performed right before a surgical biopsy.

• Surgical biopsy. This remains one of the most accurate methods for determining if a breast change is cancerous. During this procedure, your surgeon removes all or part of a breast lump. In general, a small lump will be completely removed (excisional biopsy). If the lump is larger, only a sample will be taken (incisional biopsy). The biopsy is generally performed on an outpatient basis in a clinic or hospital.

Estrogen and progesterone receptor tests

If a biopsy reveals malignant cells, your doctor will recommend additional tests — such as estrogen and progesterone tests — on the malignant cells. These tests help determine whether female hormones affect the way the cancer grows. If the cancer cells have receptors for estrogen and progesterone, your doctor may recommend treatment with a drug that prevents estrogen from binding to these sites.

Staging tests

Staging tests help determine the size and location of your cancer, and whether it has spread. They also help your doctor determine the best treatment for you. Cancer is staged using the numbers 0 through IV.

Stage 0 cancers are also called noninvasive, or in situ (in one place) cancers. Although they don't have the ability to spread to other parts of your body or invade normal breast tissue, it's important to have them removed because they eventually can become invasive cancers. Finding and treating a cancerous lump at this stage offers the best chance for a full recovery.

Stage I to IV cancers are invasive tumors that have the ability to spread to other areas. A stage I cancer is small and well localized, and has a very successful treatment rate. But the higher the stage number, the lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your bones, lungs or liver. Although it may not be possible to eliminate the cancer at this stage, its spread may be controlled with radiation, chemotherapy or both.

Genetic testing

The discovery of BRCA1, BRCA2 and other genes that may significantly increase breast cancer risk has raised a number of emotional and legal questions about genetic testing.

A simple blood test can help identify defective BRCA genes, but it is only 85 percent accurate, and most experts believe that only those women at high risk of hereditary breast or ovarian cancers should be referred for testing.

If you're one of these women, it's important to know that having a defective BRCA gene does not mean you'll get breast cancer. In addition, test results cannot determine how high your risk is, at what age you might develop cancer, how aggressively the cancer might progress or what your risk of death may be.

In general, you should be tested only if the results of the test will help you make a decision about how you might best reduce your chance of developing breast cancer. Options range from lifestyle changes, closer screening and therapy with medications such as tamoxifen to extreme measures such as preventive (prophylactic) bilateral mastectomy or removal of your ovaries (oophorectomy). These can be wrenching decisions for any woman to make. Be sure to thoroughly discuss all your options with a genetic counselor. It can also help to talk to other women who have had to make similar decisions.