Breast Cancer: Be Ye Not Afraid!

By: David Pryor, MD on (0 comments)

In a 2011 survey conducted by BlackWomensHealth.com, survey responders indicated that one of the main reasons that they are reluctant to complete mammograms is that they are “scared” of finding out the results. The idea is that “no news is good news” and that the more testing and screening that is done will only lead to the doctor finding out “bad” things about my health.

My message to you is simply “Be Ye Not Afraid!” If the mammogram comes back negative (“normal”), then you can rest assured that you have passed this part of your annual or semi-annual health check-up and you can concentrate on maintaining a healthy lifestyle with plenty of exercise and health eating. If the mammogram comes back positive (“showing the presence of a mass that maybe cancer”), then it is likely that you have been diagnosed early in the process and that your chances for a full recovery are very high.

The worse thing that can happen is that you wait too long to be screened (avoid getting your mammogram) and you are diagnosed with breast cancer at an advanced stage. At that point, your chance for survival is greatly reduced. Be Ye Not Afraid—we cannot afford to sit back and hope things will turn out well. We have to be proactive and obtain the appropriate health screenings so that we can be around for our family and friends.

What are the key statistics about breast cancer?

White women are slightly more likely to develop breast cancer than are African-American women, but African-American women are more likely to die of this cancer. However, in women under 45 years of age, breast cancer is more common in African American women. Breast cancer is the most common cancer among American women, except for skin cancers. The chance of developing invasive breast cancer at some time in a woman's life is a little less than 1 in 8 (12%).

The American Cancer Society's most recent estimates for breast cancer in the United States are for 2011:

About 230,480 new cases of invasive breast cancer will be diagnosed in women.
About 57,650 new cases of carcinoma in situ (CIS) will be diagnosed (CIS is non-invasive and is the earliest form of breast cancer).
About 39,520 women will die from breast cancer

After increasing for more than 2 decades, female breast cancer incidence rates decreased by about 2% per year from 1999 to 2005. This decrease was seen only in women aged 50 or older, and may be due at least in part to the decline in use of hormone therapy after menopause that occurred after the results of the Women's Health Initiative were published in 2002. This study linked the use of hormone therapy to an increased risk of breast cancer and heart diseases.

Breast cancer is the second leading cause of cancer death in women, exceeded only by lung cancer. The chance that breast cancer will be responsible for a woman's death is about 1 in 36 (about 3%). Death rates from breast cancer have been declining since about 1990, with larger decreases in women younger than 50. These decreases are believed to be the result of earlier detection through screening and increased awareness, as well as improved treatment.

At this time there are more than 2.6 million breast cancer survivors in the United States.

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.
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.

Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional, at least every 3 years. After age 40, women should have a breast exam by a health professional every year.

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.

Breast self exam (BSE) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away.

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 Breast Self Exam 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 (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.

Women at high risk include those who:

Have a known BRCA1 or BRCA2 gene mutation (In a family with a history of breast and/or ovarian cancer, it may be most informative to first test a family member who has breast or ovarian cancer. If that person is found to have a harmful BRCA1 or BRCA2 mutation, then other family members can be tested to see if they also have the 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 Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes

Women at moderately increased risk include those who:

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

If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is because while an MRI is a more sensitive test (it's more likely to detect cancer than a mammogram), it may still miss some cancers that a mammogram would detect.

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 single 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.