Screening & Early Detection
by Hannah Brooks, MD, OBGYN.net Editorial Advisor

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Early Detection: 
Because of advancements in imaging and increased public awareness of the disease, almost two-thirds of all breast cancers are detected while the tumors are very small and limited to only the breast. In fact, the majority of women diagnosed with early stage breast cancer are candidates for treatment that saves the breast (breast conservation) and have very positive outcomes when treatment is completed.

Finding the cancer before there are any symptoms of disease is the key to effective management of breast cancer and may often lead to a complete cure if detected at its earliest stages. The three most important tools in controlling this disease include monthly breast self-examination (BSE), screening mammography, and a clinical breast examination (CBE) by an appropriately trained physician or nurse. 

Breast Self Examination (BSE):
All women over 20 years of age should do BSE once a month.

In premenopausal women, BSE should be done 7-10 days after the first day of the menstrual period, when breasts are least likely to be tender or lumpy. Post-menopausal women should choose the same day each month to perform this exam. For those on Hormone Replace Therapy (HRT), it is recommended that BSE be performed when you start your next months supply of pills. 

One of the most important things about BSE is learning to recognize normal breast variability and changes over time. In this way, a woman is able to detect subtle changes and bring them to the attention of her physician.

A monthly self-examination is the ideal schedule. Any more frequently, and gradual changes may not be noticed as ‘different,’ any less frequently, and the potential to miss a growing mass or other change is increased.

Performing the Breast Self Exam:
BSE begins first with physical inspection of the breasts. In front of a mirror, the breasts should be inspected in a number of positions, including hands at sides, hands and arms raised above the head, then hands squeezing hips. In each position, the woman should look carefully for changes in the general size, shape and contour of each breast. Any dimpling, thickening, redness or puckering of the skin or any crusting around the nipple should be noted. Finally, the nipples should be squeezed VERY GENTLY, to look for discharge. 

The palpation (feeling) of the breasts can be done while lying down in bed , or standing in the shower. Some women report greater sensitivity when using soapy water and prefer the shower method. If the first method is used, place a small pillow or folded towel under the shoulder of the first breast to be examined, and place the same side arm overhead. The right breast is examined with the left hand and vice versa. 

Using the finger pads of the three middle fingers, and alternating light and deep pressure for each area of the breast, feel for lumps in each breast A firm ridge of tissue, known as the inframmamary tissue, in the lower curve of each breast is normal. A circular, up and down line, or wedge pattern may be used. The important thing is to be consistent and use the same method during each examination. 

The three patterns of BSE that are recommended are the vertical, circular and wedge. The vertical strip method is thought to give a more complete exam, but the best approach is to use the method one is most comfortable with.

Whichever method is chosen, the goal is to make sure all of the breast tissue is covered during the examination. Often, if a woman has questions or concerns, her physician and/or nurse can review and instruct her in self-examination techniques. 

Clinical Breast Examination:
A clinical breast examination by an experienced physician or nurse should be performed on a regular basis. For younger women, this may be at two or three year intervals, while women over forty should have a clinical examination each year. The clinical breast examination is part of a full screening examination and contributes to the identification and diagnosis of breast problems. A breast exam by an experienced doctor or nurse may identify some cancers missed by mammography. More often, it provides reassurance and guidance, as most conditions of the breast are, fortunately, benign.

The examiner will proceed with a detailed history including questions regarding risk factors. The examination will proceed first with inspection, followed by palpation. The examiner will examine the breasts carefully for changes in the skin such as dimpling or puckering; any discharge from the nipples; or masses or other abnormalities in the breast and surrounding lymph nodes. 

A lump is generally the size of a pea before a skilled examiner can detect it. Lumps that are soft, round and smooth tend not to be cancerous. An irregular hard lump, that feels firmly anchored within the breast tissue, is more likely to be a cancer. However, these are general observations only, so that additional tests or tissue biopsy may be necessary to fully evaluate an abnormal finding. 

Screening Mammography:
Studies done over the past 30 years clearly show that regular screening mammography significantly reduces the death rate from breast cancer in women over the age of 40 and is especially effective in women over 50. 

High-quality screening mammography is the most effective tool now available to detect breast cancer before symptoms appear. Mammography can often locate an abnormality in the breast years before a breast lump can be felt. Lumps that are seen only on mammograms but that cannot be felt (nonpalpable) are usually smaller than lumps that can be felt (palpable). 

If a lump is benign, it can often be monitored, though sometimes further testing will be needed to prove this. If a mass turns out to be cancerous on further testing, a smaller cancer, detected by mammography only, is less likely to have spread. In fact, for women with mammographically-detected cancers, early detection may prevent the need to remove the entire breast or receive chemotherapy.

Mammography is not foolproof. Some breast changes, including some palpable do not show up on a mammogram. Changes can be especially difficult to spot in the dense, glandular breasts of younger women. This is why women of all ages should perform monthly BSE and have clinical examinations of the breasts every year by a physician or trained healthcare professional. (Photo: very dense, difficult to read mammogram)

Diagnostic Mammography:
If a woman has a suspicious screening mammogram, or unusual visible or palpable breast changes such as a lump, pain, nipple thickening or discharge the doctor will often recommend a diagnostic mammogram. This x-ray of the breast helps to further assess her symptoms. A diagnostic mammogram is a basic medical tool and, unlike screening mammograms, which are used in women over forty, it is a diagnostic test that may be appropriate for a woman of any age, if an abnormality is suspected. Additional diagnostic imaging studies, such as ultrasound (sonography) may also be recommended to further evaluate a suspicious finding on the screening mammogram or clinical examination.

Interpreting a mammogram:
Radiologists look for unusual shadows, masses, distortions, special patterns of tissue density or calcifications. Part of this reading includes being able to compare one breast with the other, as well as evaluating changes in any suspicious areas that may have been present on earlier mammograms. Because of this, the radiologist interpreting a mammogram should always have any older films available for comparison. 

The shape of a mass may indicate whether a growth is benign (noncancerous) or malignant (cancerous). For example, a cyst appears smooth and round and has a clearly defined edge. Breast cancer, in contrast, often has an irregular outline with finger-like extensions. 

Many mammograms show calcium deposits (calcifications) that appear like white specks on the x-ray.

Macrocalcifications are coarse calcium deposits. They are often seen in both breasts and are most likely due to aging, old injuries, or inflammations. They usually are not signs of cancer; however, they may very rarely present as clusters, and may signal a cancer.

Microcalcifications are tiny flecks of calcium found in an area of rapidly dividing cells. Clusters of numerous microcalcifications in one area can be a sign of ductal carcinoma in-situ or even invasive carcinoma. About half of the cancers found by mammography are detected as clusters of microcalcifications. 

A special scoring system, developed by the American College of Radiology, has been in effect since 1998. This system was designed to assist in the interpretation of mammograms and to provide guidelines for follow up. It is called the BI-RADS system (insert table with BIRADS scoring system).

A normal mammogram in a woman with symptoms (i.e. an abnormal CBE or BSE) does not rule out breast cancer. About 10-15% of mammograms can miss a breast abnormality that is present on clinical breast examination.

References for further reading:

National Cancer Institute - http://www.nci.nih.gov/ 

American Cancer Society - http://www.cancer.org