"We gain strength, and courage, and confidence by each experience in which we really stop to look fear in the face... we must do that which we think we cannot."
~ Eleanor Roosevelt
Breast Cancer
October was Breast Cancer Awareness Month: It is not so much that we need a month to remind us of the prevalence of breast cancer (1 in 8), but if this short article teaches you anything, I hope it is that breast cancer detection is important.
After age 50: everyone should aim for an annual mammogram. Betweeb 40 and 50 it is more controversial. The data is controversial, as we weigh the risks between radiation exposure and likelihood of pick up of an abnormality...
At least every 1-2 years, between 40-50, we think a mammogram is valid for patients of average risk. For more info from a favorite patient: peaceloveboobies.org
Breast Cancer: 1 in 8
(edited from komen.org, cancer.gov)
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 slightly less than 1 in 8: (12%).
The American Cancer Society's recent estimates for breast cancer in U.S. for 2009:
- about 192,370 new cases of invasive breast cancer will be diagnosed in U.S.
- about 62,280 new cases of carcinoma in situ (CIS) will be diagnosed (noninvasive)
- about 40,170 women will die from breast cancer in the U.S.
- caught early breast cancer has a 98% 5-year survival
- more than 40,000 U.S. women will die of breast cancer this year
- fully 1/3 U.S. women who are candidates for, do not get mammograms done
- 1 in 10 mammogram patients will need more films taken
- only 2-4 per 1,000 mammograms will have cancer
After increasing for more than 2 decades, female breast cancer incidence rates decreased by about 2% per year from 1999 to 2006. This decrease may be due at least in part to less use of hormone replacement therapy (HRT) after the results of the Women's Health Initiative were published in 2002. This study linked HRT use to an increased risk of breast cancer and heart diseases.
Breast cancer is the #2 leading cause of cancer death in women: but deaths are on the decline since 1990!
Breast cancer mortality is exceeded only by lung cancer. The chance that breast cancer will be responsible for a woman's death is about 1 in 35 (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.
Survivors: At this time there are over 2.5 million breast cancer survivors in the United States. (This includes women still being treated and those who have completed treatment.)
Susan G. Komen Recommends that you:
1. Know your risk
- Talk to your family to learn about your family health history
- Talk to your health care provider about your personal risk of breast cancer
2. Get screened
- Ask your health care provider which screening tests are right for you if you are at a higher risk
- Have a mammogram every year starting at age 40 if you are at average risk
- Have a clinical breast exam at least every three years starting at 20, and every year starting at 40
3. Know what is normal for you and see your physician right away if you notice:
- Lump, hard knot or thickening
- Swelling, warmth, redness or darkening
- Change in the size or shape of the breast
- Dimpling or puckering of the skin
- Itchy, scaly sore or rash on the nipple
- Pulling in of your nipple or other parts of the breast
- Nipple discharge that starts suddenly
- New pain in one spot that doesn't go away
4. Make healthy lifestyle choices
- Maintain a healthy weight
- Add exercise into your routine
- Limit alcohol intake (</= 3 drinks/week increases your risk by 15%.)
If you find a lump or change in your breast:
Questions for your doctor:
Breast lumps are actually very common, especially in women who still have periods. They normally go away by the end of your period. Most lumps are not cancerous. But do not ignore a change in your breast. The best advice is to see your physician.
Answers to the following questions will help you understand tests that may be necessary to diagnose a breast problem.
1. Do I need a mammogram or ultrasound?
2. When will I receive the results of the mammogram or ultrasound?
3. What is the next step if the mammogram and ultrasound are inconclusive?
4. Should I get an MRI (Magnetic Resonance Imaging)?
5. Can this lump be aspirated (fluid or cells removed with a needle)?
If so, who will perform the test?
6. Will I need a biopsy (tissue is examined under a microscope)?
7. If further tests are needed, will you refer me to a breast specialist?
8. Do you recommend any special follow-up?
9. Other than cancer, what causes breast lumps or changes?
Early Detection Issues
Breast cancer is a terrible disease. It is the most frequently diagnosed cancer among women and the second leading cause of cancer death for women in the U.S. More than 190,000 women in the U.S. will be diagnosed with breast cancer this year, and more than 40,000 will die.
Early detection is a key to surviving the disease: When breast cancer is detected early, the 5-year relative survival rate is 98 percent, but declines to 84 percent for regional disease and 23 percent when cancer has spread to other parts of the body.
Unfortunately, we see racial, ethnic, geographic and socio-economic disparities in access to breast health care, which in turn leads to disparities in survival rates. Fully one-third of women in the U.S. today — some 23 million women — are already not receiving regular recommended screening due to lack of access, education or awareness. This is especially concerning in light of the confusion generated by the new screening guidelines announced by the U.S. Preventive Services Task Force last year.
Regardless of their intent, the Task Force recommendations, combined with budget cuts to NBCCEDP screening programs at the state level, give the mistaken impression that cancer screening is not important.
Women Age 40 to 49: Do we really stop the mammograms??? Not so fast...
In November, the U.S. Preventive Services Task Force released the following new guidelines for screening mammography:
•For women ages 40-49, the guidelines for screening mammography changed from a B rating (recommended) to a C rating
•For women ages 50-74, the guidelines for screening mammography remains a B (recommended), but the recommended frequency changed from “every 1-2 years” to biennial (every other year)
•For women ages 75 and over, the guidelines for screening mammography changed from a B (recommended) to an I (insufficient evidence)
•The guideline for teaching regular breast self-examination (BSE) changed from an I (insufficient evidence) to a D (not recommended)
•A guideline was added, rating digital mammography and magnetic resonance imaging (MRI) over film mammography as an I (insufficient evidence).
These changes have again reignited the controversy over mammography screening, a debate that has raged for a number of years. It is important to remember the following:
•While there is some disagreement about when mammograms should begin and on what schedule, all agree — including the USPSTF — that mammograms save lives in women 40 to 49, as well as women over 50.
•Susan G. Komen for the Cure continues to recommend annual mammography beginning at age 40 for women of average risk and earlier for women with known risks for breast cancer. We are constantly evaluating our guidelines and would not change them without serious consideration.
•Our real focus, however, should be on the fact that one-third of the women who qualify for screening under today’s guidelines are not being screened due to lack of access, education or awareness. That issue needs focus and attention: if we can make progress with screening in vulnerable populations, we could make more progress in the fight against breast cancer.
What Is Breast Cancer?
Breast cancer is a malignant (cancer) tumor that starts from cells of the breast. It is found mostly in women, but men can get breast cancer, too. Here we will only talk about breast cancer in women. You can learn more about breast cancer in men in our document, Breast Cancer in Men.
Parts of the normal breast
A woman's breast is made up of glands that make breast milk (called lobules), ducts (small tubes that carry milk from the lobules to the nipple), fatty and connective tissue, blood vessels, and lymph (pronounced limf) vessels. Most breast cancers begin in the cells that line the ducts (ductal cancer), some begin in the lobules (lobular cancer), and a small number start in other tissues.
The lymph system
The lymph system is one of the main ways in which breast cancers can spread. Lymph nodes are small, bean-shaped groups of immune system cells (cells that fight infections) that are connected by lymphatic vessels. Lymphatic vessels are like small veins, except that they carry a clear fluid called lymph (instead of blood) away from the breast. Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes.
Most lymph vessels of the breast lead to lymph nodes under the arm. These are called axillary nodes. If breast cancer cells reach the underarm lymph nodes and keep on growing, they cause the nodes to swell. The doctor needs to know whether cancer cells have spread to lymph nodes because if they have, there is a higher chance that the cells have also gotten into the bloodstream and spread to other places in the body. The more lymph nodes that have cancer in them, the more likely it is that the cancer will be found in other organs, too. This could affect the treatment plan.
Breast lumps that are not cancer
Most breast lumps are benign. This means they are not cancer. Benign breast tumors are abnormal growths, but they do not spread outside of the breast and they are not life threatening. But some benign breast lumps can increase a woman's risk of getting breast cancer.
Most lumps are caused by fibrocystic changes. Cysts are fluid-filled sacs. Fibrosis is the formation of scar-like tissue. These changes can cause breast swelling and pain. They often happen just before a woman's period is about to start. The breasts may feel lumpy, and sometimes there is a clear or slightly cloudy nipple discharge.
ACS recommendations for finding breast cancer early
The ACS recommends the following guidelines for finding breast cancer early in women without symptoms:
Mammogram: Women age 40 and older should have a screening mammogram every year and should keep on doing so for as long as they are in good health. While mammograms can miss some cancers, they are still a very good way to find breast cancer.
Clinical breast exam: Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular exam by a health expert, at least every 3 years. After age 40, women should have a breast exam by a health expert every year. It might be a good idea to have the CBE shortly before the mammogram. You can use the exam to learn what your own breasts look and feel like.
Breast self-exam (BSE): 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 changes in how their breasts look or feel to a health expert 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. If you decide to do BSE, you should have your doctor or nurse check your method to make sure you are doing it right. If you do BSE on a regular basis, you get to know how your breasts normally look and feel. Then you can more easily notice changes. But it's OK not to do BSE or not to do it on a fixed schedule.
Women at high risk: Women with a higher risk of breast cancer should talk with their doctor about the best screening plan for them. This might mean starting mammograms when they are younger, having extra screening tests (such as an MRI), or having exams more often.
Mammograms
A mammogram is an x-ray of the breast. A screening mammogram is used to look for breast disease in women who do not seem to have breast problems. A mammogram can also be used when women have symptoms such as a lump, skin change, or nipple discharge. This is called a diagnostic mammogram.
During a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. The pressure lasts only for a few seconds. Although this may cause some pain for a moment, it is needed to get a good picture. Very low levels of radiation are used. While many people are worried about exposure to x-rays, the low level of radiation used for mammograms does not increase the risk of breast cancer. You might think of it this way: if a woman with breast cancer is treated with radiation, she will get around 5,000 rads (a term used to measure radiation dose). If she had a mammograms every year from age 40 to age 90, she will have had 20 to 40 rads total.
For the mammogram, you undress above the waist. You will have a wrap to cover yourself. A technologist (most often a woman) will position your breast for the test. The pressure lasts only a few seconds while the picture is taken. The whole process takes about 20 minutes. You should get your results within 30 days or even sooner. About 1 in 10 women who get a mammogram will need more pictures taken. But most of these women do not have breast cancer, so try not to worry if this happens to you.
Only 2 to 4 of every 1,000 mammograms leads to a diagnosis of cancer.
MRI (magnetic resonance imaging)
For certain women at high risk for breast cancer, screening MRI is recommended along with a yearly mammogram. It is not generally recommended as a screening tool by itself because it may miss some cancers that mammograms would find. MRI also costs more than mammograms. Most major insurance companies will likely pay for a screening MRI if a woman can be shown to be at high risk, but it's not yet clear if all companies will do so. More details about MRI can be found below.
Genetics and Breast Cancer
What are genes?
Every cell in your body contains genetic material, or genes. Genes are the blueprints for your body. They determine what color eyes you have and how tall you are. They also affect other functions of your body. For example, they tell your body to repair tissue that has been injured and help a woman’s body prepare for a growing baby during pregnancy.
Sometimes though, your genes do not work like they should. This is due to an error in one or more of your genes, called a mutation. Mutations may be inherited or spontaneous. Inherited mutations are those you were born with — a defective gene that one of your parents passed on to you at birth. Spontaneous mutations are those that may occur in a single cell during the course of your life. There are many ways a spontaneous mutation can happen.
However, scientists do not yet know exactly how, or if, these mutations are related to a woman’s lifestyle (such as diet and exercise), chemical changes inside the body or exposure to environmental toxins such as radiation or chemicals — or if these mutations can even be prevented.
Genes and breast cancer
Scientists have found two specific genes that when mutated are important in the development of breast cancer. They are called BRCA1 and BRCA2. Everyone has these genes, but some have inherited a mutated form of one or both genes. Inheriting a mutated form of BRCA1 or BRCA2 increases a woman’s risk of breast and ovarian cancer.
However, not all breast cancers are due to inherited mutations. Inherited gene mutations, including mutations in BRCA1 and BRCA2, account for only about 5 to 10 percent of all cases of breast cancer in the U.S.1 Most breast cancers are due to spontaneous gene mutations. Who has mutations in BRCA1and BRCA2?
The likelihood that you have a mutation in the BRCA1 or BRCA2 gene is greater if one or more of the following statements is true:
- you are young and have been diagnosed with breast cancer (under age 50)
- your mother, sister or daughter has had breast cancer before age 50 or ovarian cancer at any age
- a woman in your family has had both breast cancer and ovarian cancer
- a woman in your family has had breast cancer in both breasts
- your family is of Ashkenazi Jewish descent
- a male in your family has had breast cancer
- For example, actress Christina Applegate was tested for these mutations based on her family history. When she tested positive for the BRCA 1 gene mutation, she underwent a prophylactic bilateral mastectomy. After the surgery was completed and tests done on the removed breast tissue, it was discovered that she had very early breast cancer. Her courage to act likely saved her life.
"Life shrinks or expands in proportion to one's courage." ~ Anais Nin
Remember, most women who get breast cancer do not have an inherited gene mutation in BRCA1 or BRCA2. All women should be screened with routine mammograms and clinical breast exams. Mutations in the BRCA genes are not only found in women. Men can also carry the abnormal genes, which may increase their risk of prostate cancer. Men with a BRCA2 mutation also have an increased risk of breast cancer
Where can I get genetic testing?
If you are interested in genetic testing, Northern Westchester Hospital (nwhc.net) has a genetics counselor with extensive experience in breast, ovarian and other genetic syndromes that can increase your cancer risk. Call: Nancy Cohen, 914.242.7640, to schedule an appointment if you think you may be at increased risk because of your family history. In addition, you can call The National Cancer Institute or the National Society of Genetic Counselors. They can give you a referral to the health centers nearest you with genetic counselors on staff. They can also provide additional information about BRCA1, BRCA2 and genetic testing. These organizations may be able to provide additional information:
Can I find out if I have an inherited gene mutation?
Yes, you can. Women who have a family history of breast cancer and are interested in being tested for an inherited gene mutation should seek a referral to a genetic counselor. Genetic counselors are trained health professionals who can interpret a woman’s family health history as well as the results of genetic testing. The process includes:
STEP 1: You will provide a thorough family health history and the counselor will explain your personal risk.
STEP 2: Pre-test counseling will be done to help you decide whether or not to proceed with genetic testing. This counseling includes:
- an overview of the procedure
- a review of the risks and benefits of genetic testing, such as cost, privacy and the potential knowledge that you carry the gene mutation
- a discussion of what you will do with the information once you know the test result
- a discussion of the emotional impact of this information, as well as implications for your family
STEP 3: A sample of your blood will be drawn for the test if you decide to proceed..
STEP 4: The sample will be sent for testing. It usually takes 3 weeks to obtain results.
STEP 5: Interpretation of the results will be explained to you by the genetic counselor.
Some people are concerned about being treated unfairly based on the result of a genetic test. State and federal laws protect you, including the Genetic Information Nondiscrimination Act (GINA). GINA prevents health insurers from denying coverage or charging higher premiums for a person with an increased genetic risk of breast cancer. GINA also protects employees from unfair treatment in the workplace as a result of genetic testing.
BRCA1 and BRCA2 and female breast cancer
Women who carry a BRCA1 or BRCA2 genetic mutation have a much higher risk of breast cancer. Between 1 in 400 and 800 women in the U.S. are BRCA1 or BRCA2 carriers [5]. A woman's chance of getting breast cancer in her lifetime (assuming she lives until the age of 85) is about 12 % if she does not have a BRCA1/2 mutation. Estimates of a woman's chance of getting breast cancer if she has a BRCA1 or BRCA2 mutation vary greatly. For BRCA1 carriers, the lifetime risk of breast cancer ranges from 60 to 90 %. For BRCA2 carriers, estimates range from 30 to 85 % .
This means that in a group of 100 women without a mutation, around 12 will develop breast cancer. While in a group of 100 women with either mutation, between 30 and 90 will develop breast cancer. Because these numbers represent average risk, the risk of breast cancer for any one woman with a BRCA1/2 mutation may fall outside this range. Also, the definition of lifetime risk varies among studies. Some studies measure risk assuming a woman lives to age 70; others use age 80 or age 85.
Together, the BRCA1 and BRCA2 genes are thought to explain a large portion of hereditary breast cancers [5]. However, most breast cancers are not hereditary or genetic. And, even among BRCA1/2 carriers, genes do not equal destiny. Up to 40 % of women with a BRCA1 mutation will never have breast cancer. It is likely that a combination of factors determines who will get breast cancer.
It can be hard to understand some of the words your doctor uses to talk about breast cancer. Here are some of the key words you might hear:
Carcinoma: This is a term used to describe a cancer that begins in the lining layer of organs such as the breast. Nearly all breast cancers are carcinomas (either ductal carcinomas or lobular carcinomas).
Adenocarcinoma: An adenocarcinoma is a type of cancer that starts in gland tissue (tissue that makes and secretes a substance). The ducts and lobules of the breast are gland tissues because they make breast milk, so cancers starting in these areas are often called adenocarcinomas.
Carcinoma in situ: This term is used for the early stage of cancer, when it is still only in the layer of cells where it began. In breast cancer, in situ means that the cancer cells are only in the ducts (ductal carcinoma in situ) or lobules (lobular carcinoma in situ). They have not spread into deeper tissues in the breast or to other organs in the body. They are sometimes called non-invasive or pre-invasive breast cancers.
Invasive (infiltrating) carcinoma: An invasive cancer is one that has already grown beyond the layer of cells where it started (unlike carcinoma in situ). Most breast cancers are invasive carcinomas -- either invasive ductal carcinoma or invasive lobular carcinoma.
Sarcoma: Sarcomas are cancers that start from connective tissues such as muscle tissue, fat tissue or blood vessels. Sarcomas of the breast are rare.
Inflammatory breast cancer (IBC): This uncommon type of invasive breast cancer accounts
for about 1% to 3% of all breast cancers. Usually there is no single lump or tumor. Instead, IBC makes the skin of the breast look red and feel warm. It also makes the skin look thick and pitted, something like an orange peel. The breast may get bigger, hard,tender, or itchy.
In its early stages, inflammatory breast cancer is often mistaken for infection. Because there is no defined lump, it may not show up on a mammogram, which may make it even harder to catch it early. It usually has a higher chance of spreading and a worse outlook than invasive ductal or lobular cancer.
Survival Rates for Breast Cancer
Some people with cancer may want to know the survival rates for their type of cancer.
Others may not find the numbers helpful, or may even not want to know them. Whether or not you want to read about survival rates is up to you. Also, staging for breast cancer changed in 2010. The survival data listed here is based on the older staging system.
These numbers are based on women treated a number of years ago. Because we now find more cancers early and use newer, better treatments, the survival rates are getting better all the time.
Stage 5-year Relative Survival Rate 0 100%
I 100%
II 86%
III 57%
IV 20%
While these numbers provide an overall picture, keep in mind that every woman is unique and the statistics can't predict exactly what will happen in your case. Talk with your cancer care team if you have questions about your own chances of a cure or how long you might survive your cancer. They know your situation best.
Helpful links on breast cancer:
Powerful Women: Breast Cancer Survivors
"The most common way people give up their power is by thinking they don't have any. " ~ Alice Walker
