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Each year, about 180,000 women in the United States discover they have breast cancer. Those at greatest risk are women over the age of 50. Nevertheless, it is important to keep in mind that younger women account for up to 30% of cases. (About 1400/year men also present with breast cancer).
Because of advancements in imaging and increased public awareness of the disease, almost two-thirds of all breast cancers are detected while very small and limited only to the breast. In fact, the majority of women diagnosed with early stage breast cancer are candidates for breast conservation and have excellent outcomes when treatment is completed.
Finding a breast cancer before there are any symptoms of disease is the key to effective management, and may often lead to complete cure in the earliest stages.
The three most important tools in controlling breast cancer include: monthly breast self exam (BSE), screening mammography, and 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 BSE.
- Women using Hormone Replace Therapy (HRT) should perform at the start of each months supply or pills.
In performing BSE, one learns to recognize normal breast variability and changes over time. Any concerns about a subtle change are then easily brought to a physician’s attention.
A monthly self-examination is the ideal schedule. If done more frequently, gradual changes may not be noticed as ‘different,’ and if done less frequently, there is the potential to miss a growing mass or other change.
Performing the Breast Self Examination
BSE begins with inspection of the breasts. In front of a mirror, inspect the breasts with hands at sides, hands and arms raised above the head, and hands squeezing hips. In each position, look carefully for changes in the size, shape and contour of each breast. Dimpling, thickening, redness, or puckering or crusting of the skin or nipple should be noted. The breast should be gently stroked toward the nipple, and the nipple squeezed very gently to look for discharge.
The palpation of the breasts can be done lying down or standing in the shower. If lying down, place a small pillow or folded towel under the shoulder of the breast to be examined. Place the same side arm overhead and examine the breast using the opposite hand. using the finger pads of the three middle fingers, feel for lumps in each breast using alternate light and deep pressure. A firm ridge, known as inframmamary tissue is normal and noticeable in the lower curve of each breast. Some women report greater sensitivity when using soapy water and prefer the shower method.
The vertical, circular, or wedge patterns are the three common methods used for BSE. The vertical strip method is thought to give the more complete exam, but the best approach is to use the most comfortable method and do it consistently and completely. The American Cancer Society has a diagram of these methods. (link will open in a new window)
|thickening of the nipple skin|
These physical findings are usually signs of a more locally-advanced breast cancer. Self examination, clinical examination and mammography for more subtle breast changes will diagnose breast cancers at an earlier, more curable, stage.
Clinical Breast Examination:
A clinical breast examination by an experienced physician or nurse should be performed on a regular basis. If a woman has questions or concerns, she can obtain further review and instruction in self-examination techniques or have a suspicious finding investigated properly. A breast examination by an experienced clinician (or an individual practicing regular correct BSE) may identify some cancers missed by mammography. More often, it provides reassurance and guidance, as most conditions of the breast are, fortunately, benign.
Women over forty should have a yearly clinical examination, while those under 40 may go two to three years between clinical exams if all else is normal.
A clinical examination begins with a detailed history, including questions regarding risk factors. The examination will proceed with inspection, followed by palpation of the breast and nearby lymph nodes. A lump is generally the size of a pea before a skilled examiner can detect it. Soft, round, smooth lumps tend not to be cancerous. Irregular, hard lumps that feel anchored within the breast tissue are more likely to be cancerous. However, these are general observations only, not hard and fast rules. Therefore, additional tests or tissue biopsy may be necessary to evaluate an abnormal finding. (See Diagnostic Mammography)
In fact, high-quality screening mammography is the most effective tool now available to detect breast cancer before symptoms appear. Mammography can often locate an abnormality when it is very small, years before a lump can be felt (i.e. it is nonpalpable).
|If a nonpalpable lump appears benign on mammography, it can often be monitored with serial examinations. Sometimes, further testing, (See Diagnostic Mammography), 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.
Nonpalpable cancer on a mammogram
|Mammography is not foolproof. Some breast changes do not show up on a mammogram. Changes can be especially difficult to spot in the dense, glandular breasts of younger women or women on hormone replacement therapy. This is why women of all ages should perform proper BSE and have a yearly clinical examination.
Mammogram of a very dense breast
Finally, a “normal” mammogram in a woman with an “abnormal” BSE or CBE does not rule out breast cancer: about 10-15% of mammograms can “miss” a breast abnormality that is present on physical examination and requires investigation.
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 on the mammogram. Part of the interpretation is dependent upon being able to compare changes or suspicious areas present on earlier mammograms. Thus, the radiologist should always be provided with older films for comparison.
A special scoring system known as the BI-RADS system for screening mammogram interpretation has been in effect since 1998. This system was designed to assist in the interpretation of mammograms and provide guidelines for follow-up. Further information can be viewed at the American College of Radiology website on BIRADS.
Diagnostic mammography is often used to assess whether a mass seen on screening mammogram is benign (noncancerous) or malignant (cancerous). For example, a benign cyst (fluid-filled lump) may appear smooth and round with a clearly defined edge. A cancerous mass, on the other hand, may have a more irregular outline with fingerlike extensions into the surrounding breast tissue. These findings, however, are not always conclusive, and further tissue biopsy may be needed in some cases.
Mammograms are also good tools for evaluating calcifications (calcium deposits) that appear as white flecks or specks in the breast.
Macrocalcifications are coarse calcium deposits that often indicate aging, old injuries, inflammation, or degenerating benign masses. They are usually not signs of cancer; however, they may rarely present as clusters and may signal a nearby cancer.
Microcalcifications are tiny flecks of calcium that often signal an area of rapidly dividing cells. Clusters of microcalcifications in one area may signal a nearby ductal carcinoma in situ or even an early invasive cancer. About half of the cancers found by mammography present as calcifications.