Screening for Better Health

Take control of your health with screening and prevention information

You are here: Home / Archives for Women's Health / Breast Cancer

The Controversy over Mammograms

by

nci-vol-7496-72
Image courtesy of the National Cancer Institute

In the past several years, many experts have come out against mammogram screening. The argument, which might seem counter-intuitive at first, is that women may be harmed more on average by a mammogram than they are helped. In fact, at least one expert even suggests that more women may die as a result of mammograms than are saved!

How might this be the case?

As I discussed in a previous article, false positives and false negatives are relatively common in mammography – up to 90% of “positive” tests for cancer (positive means that something, such as cancer, was detected) are actually false positives – the patient doesn’t have cancer after all, even though the mammogram seemed to show they did. And false negatives can happen about 20% of the time when someone actually has cancer, but the mammogram doesn’t detect it.

While these numbers aren’t perfect, many women would willingly take the trade-off between the stress of a misleading test over the possibility of life-saving early detection of real cancer.

But it’s not always that simple, either.

Many times it is unclear whether specific cases of breast cancer will ever develop into a life-threatening illness. Ductal carcinoma in situ, in particular, is when cancerous cells are found solely within the milk ducts, is frequently found during mammograms, and presents many problems with regards to treatment, as it can be extremely difficult to tell if a specific case will eventually become something life-threatening. In any case, women found with these cells are often treated aggressively – which carries a number of significant risks.

Radiation, biopsies, chemotherapy, and even car transit to and from hospitals and clinics can add up to provide very real risks over time – not to mention the stress and uncertainty with living with a cancer diagnosis, even one that might prove to be false upon further testing.

What to do?

This is still a very controversial topic, and we would need to see a lot more data before doctors change their minds about the importance of mammography screenings for women. Health organizations such as the CDC and the United States Preventive Services Task Force (USPSTF) still recommend breast cancer screening for women, though the age to begin screening has been creeping upward, and breast examinations are no longer universally recommended due to poor accuracy.

But it’s important to keep an eye on these types of studies, as the guidelines for screening for any disease are constantly changing and being re-evaluated.

Most importantly, controversies like this remind us that we need to keep pushing the boundaries of medical knowledge. We have to constantly work to improve the accuracy of our tests and the decisions we make for treatment based on our results. One day we will have even more accurate tools for detecting breast cancer; we can always do better.

Why family history can increase risk of breast cancer

by

All cancer (not just breast cancer) is the result of a mutation in the cells. Sometimes this mutation is passed down from parents to their children in their genes. Other times, this mutation arises over the course of a person’s life – for example, from exposure to common carcinogens, like cigarette smoke. While one of the pillars of preventive medicine is avoiding disease-causing agents such as carcinogens, there is nothing we can do to modify the genetics we received from our parents. As a result, when mutations may have been passed down to us, it is important we practice proper screening techniques in order to determine how how our risk might be and to catch any potential diseases early, while they still may be treatable.

canstockphoto3960617Breast cancer is common enough that about 1 in 8 women will develop some form of it in their lifetimes. It is a disease that all women need to be aware of and should be screened for at the appropriate age. Even men can develop breast cancer; we all share some amount of risk.

But of these women, between 5 and 10% of them are thought to develop breast cancer as a result of hereditary mutations in their genes. This might seem like a relatively small number, but still impacts thousands of women each year. And some of these mutations result in cancer a very high rate – as much as 80% of women with the well-known BRCA1 may develop breast cancer over their lifetimes. And while other relatively common mutations may have lower rates of cancer, many of these cancers tend to develop in both breasts, or at earlier ages, during periods of women’s lives when they would not normally be tested for cancers. As a result, these cancers may go undetected for long periods of time, leading to much greater mortality. Last but not least, these mutations often go hand-in-hand with other forms of cancer, such as ovarian cancer, making them even more dangerous if undetected.

The reason it is important to be highlight these genetic risk factors is not to scare or upset you – it’s to help you understand the importance of your family medical history. The best defense (in fact, the only defense) against these genetic factors is being aware of any family history of breast cancer or other cancers, and knowing when it’s right to bring this information to your doctor. At that point, the two of you can work together to form a screening and prevention strategy that is right for your particular case. Through early detection and proper preventive techniques, we can take the fight to breast cancer, instead of letting it come to us.

For a detailed chart of “red flags” in your family history that can help you know when to alert your doctor, take a look at this breast cancer family history infographic.

Should you consider Genetic Testing for breast cancer risk?

by

The most important thing to consider when it comes to genetic testing is family history. Typically, if you don’t have a family history of breast cancer, and are not of Ashkenazi Jewish heritage, you do not need to get genetic screening to determine if you might be a high-risk patient.

So what should you look out for when it comes to family history? We’ve made a handy infographic to help outline the major red flags.

efcd57b4-2835-48bd-901b-adbbeca31975 (3)

Frequently Asked Questions about Breast Cancer Screening

by

While writing our recently released e-book on breast cancer screening, we spoke to a number of doctors about some of the most frequently asked questions they received from their patients. Many of them address popular myths about breast cancer; others were about the mammogram procedure itself, or about what happens after you get your result back. We’ve included some of these questions, and their answers, below.

  1. What is mammography?
  2. How accurate is mammography?
  3. How is it performed?
  4. What is the radiologist looking for?
  5. Can breast cancer be missed?
  6. Are there other screening options?
  7. Is it possible for my screening mammography to be normal and yet I may be harboring cancer?
  8. When do I start breast cancer screening?
  9. My mother and my aunt were diagnosed with breast cancer. When do I start breast cancer screening?
  10. Do insurance companies cover breast cancer screening?
  11. What is BRCA genetic testing?
  12. If I test positive for BRCA-1 or BRCA-2 mutation, what are my chances for developing breast cancer?
  13. I have a BRCA-1 mutation, what are my options?
  14. Can men get breast cancer?
  15. I have big breasts. I’ve been told that I will probably get breast cancer in the future. Is this correct?
  16. What is a sentinel lymph node?
  17. How do I prevent breast cancer?

What is mammography?

Mammography is an x-ray test to look at the inside of your breasts. It uses ionizing radiation to detect abnormal breast architecture and to evaluate for any abnormal lumps, lesions, tumors, mineralization, or signs of cancer.

Back to top

How accurate is mammography?

Mammography is able to detect very small lumps and lesions. It can detect a lesion as small as 1 mm. It is able to pick up lesions about two years before the physician can detect it clinically in the office during the routine physical examination. A lesion has to be about 10 mm before a physician can feel it.

Back to top

How is it performed?

The breast tissue is compressed against a plate. This may be uncomfortable but only lasts a few minutes. Compression is needed to accurately visualize all the breast tissue on the film. Four films of the breasts are taken from different angles by the radiology technician. The 4 images are then examined by a radiologist (MD, DO, or MBBS) trained in this field.

Back to top

What is the radiologist looking for?

The radiologist examines the films to assess for suspicious findings that may be consistent with cancer. The physician examines for lesions, masses, micro-calcifications, and distortion of the breast tissue architecture.

Back to top

Can breast cancer be missed?

Mammography is not 100 percent accurate. Yes, it can miss breast cancer, but it is the most widely available breast cancer screening test we have. It is also of note that the “axillary tail” is difficult to visualize on the films and may be missed. This is the part of your breasts that extends into the armpit. A mammography can also give a false-positive test. This means that the test comes back positive (something abnormal) even though you do not really have cancer.

Back to top

Are there other screening options?

The magnetic resonance imaging (MRI), digital mammography and positron emission tomography (PET) are in experimental stages of development. They are not yet available for routine breast screening. Ultrasound of the breast is performed after the patient has been found to have a lump or palpable mass during the physical examination.

Back to top

Is it possible for my screening mammography to be normal and yet I may be harboring cancer?

Yes, this is known as the false-negative test. This means that your mammography shows no evidence of cancer, lumps, or tumors, and yet you may have cancer in your breasts. This is very disturbing. This gives you the false sense of security. Younger women and women who have dense breasts have problems with false-negative tests. However, USPSTF states that it found no data that these false-negative tests led to any delay in the proper diagnosis of true breast cancer.

Back to top

When do I start breast cancer screening?

These are the recommendations. You may follow one of the two.
1. Begin at age 45 as recommended by the American Cancer Society.
2. Begin at age 50 as recommended by the US Preventive Services Task Force.
This is assuming you are average risk for breast cancer. The ACS recommends annual screening as long as the patient is in good health. The USPSTF recommends screening every two years and stopping at age 74.

Back to top

My mother and my aunt were diagnosed with breast cancer. When do I start breast cancer screening?

At a much earlier age depending on your risk factors. Your doctor will determine for you the age at which you should begin screening. Mammograms and MRI are used in some high risk individuals annually beginning at earlier age.

Back to top

Do insurance companies cover breast cancer screening?

Yes, all the insurance companies I know of cover most health screening including breast cancer. If your insurance company does not cover common types of screening procedures, I suggest you change your insurance company.

Back to top

What is BRCA genetic testing?

This is breast carcinoma (cancer) genetic blood testing to identify if you carry this marker of malignancy.

Back to top

If I test positive for BRCA-1 or BRCA-2 mutation, what are my chances for developing breast cancer?

If you test positive for BRCA-1 or BRCA-2 gene, your chances of developing breast cancer are very high by age 70. For Ashkenazi women, the chances of developing cancer range anywhere from 26 to 81 percent.

Back to top

I have a BRCA-1 mutation, what are my options?

For women who have either BRCA-1 or BRCA-2 mutation, the options are the following:
1. Intensive screening with MRI
2. Prophylactic mastectomy or oophorectomy
3. Chemo-prevention
Women who have a BRCA-1 mutation have estrogen receptor negative malignancy. BRCA-2 breast cancers are usually estrogen receptor positive. These women respond to tamoxifen with reduction in incidence of breast cancer.

Back to top

Can men get breast cancer?

Yes. Men do have some breast tissue under the nipples. One percent of all breast cancers occur in men. Roughly 500 cases of breast cancer are recorded in men each year in United States.

Back to top

I have big breasts. My friend told me that I will probably get breast cancer in the future. Is this true?

Your friend is misinformed. Large breasts do not increase your risk of getting breast cancer. However, large breasts often make it difficult to visualize breast cancer on mammography. This is because of dense tissue.

Back to top

What is a sentinel lymph node?

The sentinel lymph node is the first lymph node to which breast cancer will spread in a long chain of lymph nodes. This is a very important discovery because it allows surgeons to biopsy this node and assess if cancer has spread. The presence of cancer in this node means cancer has spread outside the breast.

Back to top

How do I prevent breast cancer?

Two preventive approaches are recommended in order to reduce the chances of getting breast cancer.
1. Obtain good health screening from your physician. Follow the recommended guidelines for the early detection of breast cancer as outlined in this book. Breast cancer screening begins at age 40 or 50.
2. Exercise and eat healthy. Engage in decent exercise 30 to 60 minutes a day. Eat healthy means consuming fruits and vegetables on a daily basis. These foods contain anti-oxidants that are believed to retard cancer growth.

Back to top

When Mammograms are Wrong: False-Positives and False-Negatives

by

First and foremost, let’s get this out of the way: Mammograms are often wrong. In fact, some estimates show that up to 90% of “positive” results (those that have detected abnormalities) are actually “false-positives”, meaning that there was no cancer despite the reading. And up to 20% of “negative” results are estimated to be “false-negatives,” meaning there actually was cancer present but it wasn’t detected.

Any screening test has a chance for false-negatives: it’s impossible to detect anything with 100% accuracy. Getting that percentage of false-negatives as low as possible is one of the reasons procedures are constantly re-evaluated and refined. But I want to focus today on the false-positive tests, because the impact of getting a false-positive on your mammography is a little less understood.

False-Positives

This number – up to 90% – may seem unacceptable at first glance. Getting something wrong 90% of the time is usually considered a deal-breaker elsewhere in life, after all!

According to the National Cancer Institute, false-positives are most common in young women, women who have had previous biopsies on their breasts, those with a family history of breast cancer, and women taken estrogen supplements.

Mammograms can also sometimes detect something known as localized ductal cancer. This is the finding of breast cancer that is localized to the ducts of the breasts known as ductal carcinoma in situ. The concern is that many women with ductal cancers may never die of breast cancer that was diagnosed with the screening mammography. These women may be are subjected to unnecessary breast surgery, radiation therapy and even chemotherapy in older age, leading to health problems and costs that were not truly contributing to their long-term survival.

False-positive tests can result in unnecessary procedures, stress, medical costs, lost time, and additional risks. Believing you have life-threatening breast cancer when you do not can be a tremendously disruptive, life-altering experience in the short term with long-term consequences. So how are you supposed to rely on a mammogram with such accuracy rates?

Using Mammograms the Right Way

It all comes down to how mammograms are utilized. The most important thing to understand is that an initial positive test does not necessarily mean you have cancer. In fact, odds are you do not! But follow-up tests will be needed to learn more information and get to the truth behind the positive result. Additional mammograms, ultrasounds, and surgery followed by biopsy are the typical followups, depending on what is found. It is important not to panic at this stage, and to understand that more information is needed before a complete diagnosis can be made.

Another important factor in using mammograms the right way is understanding when they should be conducted. Young women are much more likely to experience false-positive (and false-negative) results: as a result, for average-risk women the American Cancer Society recommends screening starting at age 45, while the United States Preventive Services Task Force recommends screening start at age 50. Screening in young women has not been shown to conclusively help prevent deaths from breast cancer, and may cause more harm than good in many cases. If you are at higher risk or want to begin screening earlier than these guidelines, you should discuss it with your doctor and understand some of the limitations inherent to mammograms.

As women reach their late years, the benefits of mammograms becomes difficult to determine. Women age 75 and older can still develop breast cancer, but in some cases their remaining life span may be less than the period required for breast cancer to become fatal. For women that are still healthy and likely have a number of years remaining, screening may be a good practice. For others, screening may cause more harm than help. It is recommended that you speak with your doctor and try to determine a plan that is right for you and your health as there are no set, agreed-upon guidelines.

canstockphoto7426580
Mammograms are still the best tool we have

For all their limitations, mammograms are the best tool for detecting early breast cancer and saving lives. Breast cancer is a fatal disease that takes the lives of about 40,000 women a year. If allowed to develop and spread to other parts of the body, it can be too late to save someone with breast cancer. By staying vigilant and following proper guidelines, it is possible to detect this dangerous disease early and save lives. Be sure to speak with your doctor and schedule the right tests at the right times for you!