You may be coming to this book from any one of a variety of different situations. Perhaps you are interested in learning more about breast cancer in general (after all, it is the most common solid tumor to affect women in the United States). Maybe you consider yourself to be at risk for the disease and are trying to arm yourself with the best information for the future, or you have a family member or friend whom you are hoping to support in her diagnosis. For the majority of readers, however, the most likely scenario is that you yourself have been diagnosed with breast cancer or have found something that has a high likelihood of turning out to be breast cancer. If that’s the case, then you may think that you should just skip over this chapter. Why read about risk for breast cancer or how to detect it when you’ve already been found to have it? In fact, the information in this chapter is still relevant to you. Understanding the risk factors that may or may not have contributed to your diagnosis could be important. You’ll also learn about mammograms and other different types of imaging that can still come into play even after you have received a diagnosis of breast cancer and in the years ahead.
Mammograms
For many women, the diagnosis of breast cancer starts with a mammogram. These women in particular usually do not need much convincing of the value of mammograms in the early detection of breast cancer. Over the past few years, however, there has been a huge amount of conflicting information out there regarding mammograms, leaving many other women feeling uncertain and confused. As a breast cancer surgeon and specialist, I’m often asked to speak to the general public about issues surrounding breast cancer screening, treatment, and care. Some of the most common questions I get during the Q&A portion go something like this:
“My sister was diagnosed with breast cancer when she felt a lump one month after a normal mammogram. Why should I get one if it didn’t work for her?”
“I have a friend who was diagnosed with breast cancer at age thirty-eight, before she had even started mammograms. Shouldn’t we all be starting earlier?”
“I heard that sonograms and MRIs are better than mammograms at picking up cancers in women with dense breasts. Why aren’t they recommended for all women?”
It doesn’t surprise me that so many women have so many questions about mammograms and screening: they are looking for answers on some very controversial issues.
“Mammograms aren’t flawless—no test is. Mammograms have been associated with both underdiagnosis (missing cancer) and overdiagnosis (when we find things on a mammogram that, if left alone, would not have caused a problem). Hence the frequent controversy about when and whether to use them. But even when all these variables are taken into account, mammograms are still the best tool currently available for identifying breast cancer in the vast majority of women.
It’s important to get the facts straight, beginning with this one: the mammogram is the only test that has been shown to decrease the actual risk of dying from breast cancer by detecting cancer earlier—effectively reducing mortality by 15 percent or more in women from ages forty to seventy.
And here’s a lesser-known fact: 80 to 90 percent of women diagnosed with breast cancer have no preexisting risk factors—no family history, no genetic issue, nothing. So we are all at risk, and that’s why appropriate screening is relevant to all women.
When we look at the breast cancer cure rate, the good news is that it has increased substantially in the past few decades. To a large degree, this is because of early detection—a direct result of better screening, primarily with mammograms. Currently over 60 percent of newly diagnosed breast cancers are early stage. These cancers are localized, and are usually detected by mammography before a woman or her doctor could feel anything on examination. So with all the conflicting information out there, it can be easy to lose sight of the bottom line here: mammograms help to detect breast cancer earlier and save lives.
Mammograms: what to expect
A mammogram is an X-ray of the breasts. Most often—including during a routine, annual mammogram—both breasts are X-rayed. This is called a bilateral mammogram, and two pictures are taken of each breast, resulting in a total of four pictures. A unilateral mammogram (just one side, right or left) consists of two pictures. There are a variety of different reasons why a woman may need a mammogram on only one side: occasionally a follow-up at a shorter interval, usually six months, for one side only will be needed to make sure something we saw previously is indeed normal or has not changed. In addition, for women who have had a prior breast cancer and had one breast removed, we only perform mammograms on the one remaining breast. Finally, if a recent bilateral mammogram was normal but a few months later a woman feels a lump on self-examination, repeating the mammogram just on that one side might be needed. In any case, when a mammogram is done, the breast is pressed between two paddles to flatten out the breast tissue, and the entire process of positioning and shooting the picture takes about a minute for each picture, or a couple of minutes for each side. I don’t think anyone would argue that having your breast pressed between two paddles is exactly pleasant. Women do sometimes complain that mammograms are painful or at least uncomfortable, and there are many jokes circulating about how men could never tolerate the same procedure on certain parts of their anatomy. But the discomfort should be short and tolerable, especially at a mammography facility with experienced, well-trained technicians. If you are someone with especially sensitive breasts, discomfort may be minimized by making sure your mammogram is not scheduled right before or during your menstrual period, when breasts are usually most sensitive.
On a mammogram, cancers typically show up as white, irregular spots against the darker background of regular, mostly fatty breast tissue. Denser normal breast tissue also shows up as whiter, so in dense breasts it can be harder to see the white cancer against a white background (imagine trying to spot a polar bear in a snowstorm). If you do have dense breasts (very common in younger women), you may get a recommendation for additional tests, such as a sonogram, and you also may want to make sure that you are getting a digital mammogram. Digital mammograms have been shown to be better at picking up cancers in younger women with denser breast tissue. Other findings that we look for on a mammogram that could indicate cancer are areas of calcifications, which are tiny clusters of white spots, almost like grains of salt grouped together. And lastly, an area of asymmetry, where the tissue looks distorted or pulled, especially if different from what is seen in the other breast, could raise suspicion for a cancer as well.
One of the most exciting new developments currently available is 3-D mammography. Although it is associated with a slightly higher dose of radiation exposure with each mammogram, the 3-D images that we capture extend through the breast, section by section, in great detail. Looking at the results is a little like looking through the pages of a book, and we can pick up more cancers that are hidden among overlapping dense breast tissue as a result. In addition, 3-D mammograms have been shown to significantly reduce callbacks for additional tests, which means fewer scary phone calls and less nail-biting time for you. This new mammography technique has been widely integrated into many practices, but not everywhere.
MYTH: “If you don’t have a family history of breast cancer, then you are not really at risk and there’s no reason to start mammograms at forty.”
The normal screening guidelines are for women at average risk for breast cancer. The reality is that 80 to 90 percent of women diagnosed with breast cancer have no special risk factors. So we are all at risk, and that’s why appropriate screening is relevant to all women.
Copyright © 2015 by Elisa Port, MD. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
