I endorse the following recommendations for breast cancer screening
- Annual mammograms, beginning at age 50
- Annual clinical breast exams
Self Breast Examination
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Recently, several scientific studies have created confusion by reporting that breast self-exams (BSE) do not reduce a woman's chances of dying of breast cancer, and implying that women no longer need to examine their breasts. However, most experts still agree that if women learn to perform BSE correctly, they could find a tumor earlier, when it is still very small. A smaller tumor improves the chances of saving a breast by avoiding a mastectomy, and may reduce the need for chemotherapy.
It is important to remember that mammography is still the gold standard for early detection of breast cancer. Many cancer organizations, including the American Cancer Society, recommend that every woman 40 or older should have a mammogram every year. Unfortunately mammography misses 10% of cancers. So, it is still important for women to have their breasts examined on a regular basis by a healthcare professional, and perform monthly breast self-exams.
In the fall of 2005, the results of the American College of Radiology Imaging Network’s (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST) were released. The trial showed with reasonable certainty that there was no difference in accuracy between full field digital mammography (FFDM) and screen-film mammography (SFM) for asymptomatic women in general. For three subgroups of women, however, FFDM performed better than SFM:
The Importance of Breast Self-Exam
Regularly examining her own breasts allows a woman to become familiar with how her breasts normally look and feel and can help her more readily detect any changes that may occur. Many women naturally have some lumpiness and asymmetry (differences between the right and left breast). The key to the breast self-exam is to learn how to find changes in the breasts that persist over time.
While most women are aware of monthly breast self-examination, many still do not know how to perform it properly. Performing BSE incorrectly can be almost as bad as not doing the exam at all since it can give women a false sense of security. After reading these sections on BSE, women should discuss any questions they might have about BSE techniques with their physicians and ask them to demonstrate how to perform BSE during the clinical breast exam portion of the physical exam.
The Best Time to Perform Breast Self-Exam
Breast Changes and Warning Signs To Watch for During Breast Self-Exam:
Women with Normally Lumpy Breasts Should Also Perform BSE
Even if a woman has normally lumpy breasts (typically called fibrocystic breasts), she can still learn the usual pattern of lumps and then point out new or unusual lumps to her physician. While lumpy breasts or breasts with benign (non-cancerous) masses or cysts can be more difficult to examine, monthly breast self-exams are still essential. In fact, without knowledgeable direction from the patient, it may be more difficult for a physician to differentiate between a new mass and a stable lump. If a woman’s breasts are normally lumpy, she should note how many separate lumps she feels and their corresponding locations when performing self-exams. Then, during subsequent exams, she should check for any changes, particularly an increase in the size of lumps that persist after her period. Any changes should be reported to a physician or healthcare provider.
Breast Examination During and After Pregnancy Is Critical
Women should continue monthly breast self-exams during pregnancy. Vigilant, monthly breast self-exams during pregnancy and afterwards, during breast-feeding, can help prevent a delayed diagnosis of breast cancer and improve the chances of successful treatment.
Clinical breast exams should also be performed by a healthcare professional on a monthly basis during pregnancy. It is especially important that a clinical breast exam be performed during the first doctor visit of the pregnancy, before the breasts go through significant physiologic changes. Some changes or lumps are more difficult to evaluate once the breasts have enlarged and become more nodular.
Traditionally, clinicians have strongly encouraged women to perform monthly breast self examination. However, some worry that BSE can give a woman a false sense of security, perhaps leading her to avoid mammography (the breast cancer screening method proven to provide a survival benefit). The monthly BSE dictum has other negative aspects: Some women might experience guilt if they do not perform the exam monthly and might fear that they are not "doing it right." Thus, the new message endorses no specific technique or schedule for BSE. Though the Canadian Cancer Society no longer recommends BSE as a monitoring method and the American Cancer Society agrees that it’s optional, both organizations advise women to practice periodic inspection and palpation to know the normal state of their own breasts.
It is important to remember that mammography is still the gold standard for early detection of breast cancer.
- Lie down and put a pillow under your right shoulder. Place your right arm behind your head.
- Use the finger pads of your three middle fingers on your left hand to feel for lumps or thickening in your right breast. Your finger pads are the top third of each finger.
- Press firmly enough to know how your breast feels. If you?re not sure how hard to press, ask your health care provider. Or try to copy the way your health care provider uses the finger pads during a breast exam. Learn what your breast feels like most of the time. A firm ridge in the lower curve of each breast is normal.
- Move around the breast in a set way. You can choose either the circle (A), the up and down (B), or the wedge (C). Do it the same way each month. It will help you to make sure that you've gone over the entire breast area, and to remember how your breast feels.
- Now examine your left breast using the right hand finger pads.
- Repeat the examination of both breasts while standing, with one arm behind your head. The upright position makes it easier to check the upper and outer parts of the breasts (toward your armpit). You may want to do the standing part of the BSE while you are in the shower. Some breast changes can be felt more easily when your skin is wet and soapy.
Recently, several scientific studies have created confusion by reporting that breast self-exams (BSE) do not reduce a woman's chances of dying of breast cancer, and implying that women no longer need to examine their breasts. However, most experts still agree that if women learn to perform BSE correctly, they could find a tumor earlier, when it is still very small. A smaller tumor improves the chances of saving a breast by avoiding a mastectomy, and may reduce the need for chemotherapy.
It is important to remember that mammography is still the gold standard for early detection of breast cancer. Many cancer organizations, including the American Cancer Society, recommend that every woman 40 or older should have a mammogram every year. Unfortunately mammography misses 10% of cancers. So, it is still important for women to have their breasts examined on a regular basis by a healthcare professional, and perform monthly breast self-exams.
In the fall of 2005, the results of the American College of Radiology Imaging Network’s (ACRIN) Digital Mammographic Imaging Screening Trial (DMIST) were released. The trial showed with reasonable certainty that there was no difference in accuracy between full field digital mammography (FFDM) and screen-film mammography (SFM) for asymptomatic women in general. For three subgroups of women, however, FFDM performed better than SFM:
- women under age 50;
- pre- or perimenopausal women;
- and women with heterogeneously dense or extremely dense breasts.
The Importance of Breast Self-Exam
Regularly examining her own breasts allows a woman to become familiar with how her breasts normally look and feel and can help her more readily detect any changes that may occur. Many women naturally have some lumpiness and asymmetry (differences between the right and left breast). The key to the breast self-exam is to learn how to find changes in the breasts that persist over time.
While most women are aware of monthly breast self-examination, many still do not know how to perform it properly. Performing BSE incorrectly can be almost as bad as not doing the exam at all since it can give women a false sense of security. After reading these sections on BSE, women should discuss any questions they might have about BSE techniques with their physicians and ask them to demonstrate how to perform BSE during the clinical breast exam portion of the physical exam.
The Best Time to Perform Breast Self-Exam
- Menstruating women: Hormonal changes due to the menstrual cycle may make the breasts more lumpy or swollen. Women who are menstruating should perform breast self-exam from a few days to about a week after menstruation (period) has ended, when breasts are usually less tender or swollen.
- Women who are no longer menstruating: should do their BSE on the same day every month. Try to pick a day that is easy to remember, such as the first or fifteenth of every month, and make that the day each month for breast self-exam.
- Women using oral contraceptives: are encouraged to do their BSE each month on the day they begin a new package of pills.
Breast Changes and Warning Signs To Watch for During Breast Self-Exam:
- Any new lump or hard knot found in the breast or armpit
- Any lump or thickening that does not shrink or lessen after your next period
- Any change in the size, shape or symmetry of your breast
- A thickening or swelling of the breast
- Any dimpling, puckering or indention in the breast
- Dimpling, skin irritation or other change in the breast skin or nipple
- Redness or scaliness of the nipple or breast skin
- Nipple discharge (fluid coming from your nipples other than breast milk), particularly if the discharge is bloody, clear and sticky, dark or occurs without squeezing your nipple
- Nipple tenderness or pain
- Nipple retraction: turning or drawing inward or pointing in a new direction
- Any breast change that may be cause for concern
Women with Normally Lumpy Breasts Should Also Perform BSE
Even if a woman has normally lumpy breasts (typically called fibrocystic breasts), she can still learn the usual pattern of lumps and then point out new or unusual lumps to her physician. While lumpy breasts or breasts with benign (non-cancerous) masses or cysts can be more difficult to examine, monthly breast self-exams are still essential. In fact, without knowledgeable direction from the patient, it may be more difficult for a physician to differentiate between a new mass and a stable lump. If a woman’s breasts are normally lumpy, she should note how many separate lumps she feels and their corresponding locations when performing self-exams. Then, during subsequent exams, she should check for any changes, particularly an increase in the size of lumps that persist after her period. Any changes should be reported to a physician or healthcare provider.
Breast Examination During and After Pregnancy Is Critical
Women should continue monthly breast self-exams during pregnancy. Vigilant, monthly breast self-exams during pregnancy and afterwards, during breast-feeding, can help prevent a delayed diagnosis of breast cancer and improve the chances of successful treatment.
Clinical breast exams should also be performed by a healthcare professional on a monthly basis during pregnancy. It is especially important that a clinical breast exam be performed during the first doctor visit of the pregnancy, before the breasts go through significant physiologic changes. Some changes or lumps are more difficult to evaluate once the breasts have enlarged and become more nodular.
Traditionally, clinicians have strongly encouraged women to perform monthly breast self examination. However, some worry that BSE can give a woman a false sense of security, perhaps leading her to avoid mammography (the breast cancer screening method proven to provide a survival benefit). The monthly BSE dictum has other negative aspects: Some women might experience guilt if they do not perform the exam monthly and might fear that they are not "doing it right." Thus, the new message endorses no specific technique or schedule for BSE. Though the Canadian Cancer Society no longer recommends BSE as a monitoring method and the American Cancer Society agrees that it’s optional, both organizations advise women to practice periodic inspection and palpation to know the normal state of their own breasts.
It is important to remember that mammography is still the gold standard for early detection of breast cancer.
The Hoffman Breast Center
at
Mount Auburn Hospital
617-499-5755
For the convenience of patients the center is open four evenings a week until 7:30pm
Dense Breasts May Obscure Mammogram Results
By Roni Caryn Rabin : NY Times : June 16, 2014
The doctors were pleased to inform me, the letter said, that the results of the mammogram were normal. Early detection of cancer is important, a report was sent to my referring physician, I should report any lumps, see my health provider, have a physical.
A sentence in the fourth paragraph grabbed me by the throat. “Your breast tissue is dense.”
In journalism, we call this “burying the lead” — tucking the really significant information far down in the story. I knew that having dense breast tissue makes it hard to read mammograms and may increase the risk of breast cancer. I just never knew I had dense breasts.
I’ve had at least half a dozen mammograms, and each one has come back normal. Now I discover these images have been obscured. Dense tissue shows up white on the scans. So do tumors.
“It’s like looking through a window with snow on it, searching for a drop of milk,” said Dr. Carolyn D. Runowicz, a professor of obstetrics and gynecology at the Herbert Wertheim College of Medicine at Florida International University in Miami.
No wonder mammograms miss half of all breast cancers in women with dense tissue.
About 40 percent of women who have mammograms have dense breast tissue, which means they have more connective and fibrous tissue than usual. Until recently, that information was rarely relayed to women, though it was routinely noted in the radiologist’s medical report to the doctor (as “dense parenchyma” that “lowers the sensitivity of mammography”).
Now women from Hawaii to California, New Jersey to New York, are receiving letters about their breast density because of state legislation championed by Nancy Cappello, a 61-year-old Connecticut woman. Her breast cancer had spread to her lymph nodes by the time it was diagnosed 10 years ago, even though she had had normal mammograms every year.
Her tumor was an inch in size when it finally became palpable, Ms. Cappello said in an interview. Her doctor estimated it had been growing for four or five years, even as Ms. Cappello went faithfully for mammograms and received assurances that she was cancer-free. No one warned her that dense breast tissue could obscure the radiologist’s view.
Unfortunately, there’s still no clear medical guidance on how women should proceed once they’ve been told they have dense breasts. Some experts even question whether having dense breasts significantly increases breast cancer risk.
The letters mandated by New York law suggest women “use this information to talk to your doctor about your own risks for breast cancer” and ask their doctor “if more screening tests might be useful.” The Connecticut law goes further; women with dense breasts are told to consider an ultrasound or magnetic resonance imaging test.
But the American Congress of Obstetricians and Gynecologists doesn’t recommend using additional screening tests just because a woman has dense breasts. The American College of Radiology acknowledges that other types of scans may detect tumors missed on mammograms, but notes that there are no good data showing that women who add an ultrasound or an M.R.I. to mammography live longer.
I did what the New York letter suggested: I called my doctor. He emailed back right away, saying he was not concerned. The density of my breasts was not news to him.
I called my health plan to see if it would cover an ultrasound. I was pleasantly surprised: It would, though not at the same rate as a mammogram, which is considered preventive care that most health plans must cover in full.
Then I called the radiology center to make an appointment, and learned I could drive over and pick up a CD with my mammography images on it at no charge.
I picked up the disc and popped it in my computer. As soon as the images appeared on screen, I could see what the doctors were talking about: Big white clouds were floating in the middle of each dark half-moon image.
“One thing women shouldn’t do is start to worry that there is something wrong” if she has dense breast tissue, said Dr. Carol Lee, a diagnostic radiologist at Memorial Sloan Kettering.
Although the benefits of routine mammography have been debated for years, many women continue to choose it, and experts say they need not stop just because they have dense breasts.
“Mammograms pick up cancers in women with dense breasts every day,” Dr. Lee said.
For dense breasts, however, a digital mammogram is preferable to film, and a three-dimensional mammogram is even better, Dr. Runowicz said.
But there’s a definite downside, other experts note: Additional scans will pick up other suspicious spots that may require intervention, such as biopsy to rule out cancer, even though most of them will turn out to be harmless. Learn about your risk factors for breast cancer at cancer.gov (breast density is not listed here), and use the online calculator to gauge your risk. A woman’s risk increases with age.
Talk to a trusted physician and consider adding an ultrasound or an M.R.I. scan to your screening if you have dense breasts. An ultrasound is cheaper and less invasive, said Dr. Regina Hooley, an assistant professor of diagnostic radiology at Yale.
Mammograms pick up two to seven cancers per 1,000 women screened, and subsequent ultrasounds pick up another three to four small invasive cancers, Dr. Hooley said. Even though there may not be scientific evidence proving a survival benefit from the additional scans, she said, “these are exactly the cancers we want screening to detect.”
By Roni Caryn Rabin : NY Times : June 16, 2014
The doctors were pleased to inform me, the letter said, that the results of the mammogram were normal. Early detection of cancer is important, a report was sent to my referring physician, I should report any lumps, see my health provider, have a physical.
A sentence in the fourth paragraph grabbed me by the throat. “Your breast tissue is dense.”
In journalism, we call this “burying the lead” — tucking the really significant information far down in the story. I knew that having dense breast tissue makes it hard to read mammograms and may increase the risk of breast cancer. I just never knew I had dense breasts.
I’ve had at least half a dozen mammograms, and each one has come back normal. Now I discover these images have been obscured. Dense tissue shows up white on the scans. So do tumors.
“It’s like looking through a window with snow on it, searching for a drop of milk,” said Dr. Carolyn D. Runowicz, a professor of obstetrics and gynecology at the Herbert Wertheim College of Medicine at Florida International University in Miami.
No wonder mammograms miss half of all breast cancers in women with dense tissue.
About 40 percent of women who have mammograms have dense breast tissue, which means they have more connective and fibrous tissue than usual. Until recently, that information was rarely relayed to women, though it was routinely noted in the radiologist’s medical report to the doctor (as “dense parenchyma” that “lowers the sensitivity of mammography”).
Now women from Hawaii to California, New Jersey to New York, are receiving letters about their breast density because of state legislation championed by Nancy Cappello, a 61-year-old Connecticut woman. Her breast cancer had spread to her lymph nodes by the time it was diagnosed 10 years ago, even though she had had normal mammograms every year.
Her tumor was an inch in size when it finally became palpable, Ms. Cappello said in an interview. Her doctor estimated it had been growing for four or five years, even as Ms. Cappello went faithfully for mammograms and received assurances that she was cancer-free. No one warned her that dense breast tissue could obscure the radiologist’s view.
Unfortunately, there’s still no clear medical guidance on how women should proceed once they’ve been told they have dense breasts. Some experts even question whether having dense breasts significantly increases breast cancer risk.
The letters mandated by New York law suggest women “use this information to talk to your doctor about your own risks for breast cancer” and ask their doctor “if more screening tests might be useful.” The Connecticut law goes further; women with dense breasts are told to consider an ultrasound or magnetic resonance imaging test.
But the American Congress of Obstetricians and Gynecologists doesn’t recommend using additional screening tests just because a woman has dense breasts. The American College of Radiology acknowledges that other types of scans may detect tumors missed on mammograms, but notes that there are no good data showing that women who add an ultrasound or an M.R.I. to mammography live longer.
I did what the New York letter suggested: I called my doctor. He emailed back right away, saying he was not concerned. The density of my breasts was not news to him.
I called my health plan to see if it would cover an ultrasound. I was pleasantly surprised: It would, though not at the same rate as a mammogram, which is considered preventive care that most health plans must cover in full.
Then I called the radiology center to make an appointment, and learned I could drive over and pick up a CD with my mammography images on it at no charge.
I picked up the disc and popped it in my computer. As soon as the images appeared on screen, I could see what the doctors were talking about: Big white clouds were floating in the middle of each dark half-moon image.
“One thing women shouldn’t do is start to worry that there is something wrong” if she has dense breast tissue, said Dr. Carol Lee, a diagnostic radiologist at Memorial Sloan Kettering.
Although the benefits of routine mammography have been debated for years, many women continue to choose it, and experts say they need not stop just because they have dense breasts.
“Mammograms pick up cancers in women with dense breasts every day,” Dr. Lee said.
For dense breasts, however, a digital mammogram is preferable to film, and a three-dimensional mammogram is even better, Dr. Runowicz said.
But there’s a definite downside, other experts note: Additional scans will pick up other suspicious spots that may require intervention, such as biopsy to rule out cancer, even though most of them will turn out to be harmless. Learn about your risk factors for breast cancer at cancer.gov (breast density is not listed here), and use the online calculator to gauge your risk. A woman’s risk increases with age.
Talk to a trusted physician and consider adding an ultrasound or an M.R.I. scan to your screening if you have dense breasts. An ultrasound is cheaper and less invasive, said Dr. Regina Hooley, an assistant professor of diagnostic radiology at Yale.
Mammograms pick up two to seven cancers per 1,000 women screened, and subsequent ultrasounds pick up another three to four small invasive cancers, Dr. Hooley said. Even though there may not be scientific evidence proving a survival benefit from the additional scans, she said, “these are exactly the cancers we want screening to detect.”
