Your Best Insurance Against Breast Cancer

he best way to beat breast cancer is to catch it early. Detecting and treating a malignant tumor in its earliest stages gives you a better than 9 out of 10 chance of surviving the disease for at least 5 years.

Although breast cancer usually hits older women—two­thirds are over age 50—you're never too young to be on the lookout for this dangerous killer. The American Cancer Society and other health organizations have developed guidelines to help you and your doctor find the disease before it causes irreparable damage:

• Examine your breasts every month.
• Make sure a physician or other health care professional examines your breasts every year, beginning at age 20.
• Have a baseline mammogram by the time you reach 40, a screening mammogram every one or two years between 40 and 49, and a yearly mammogram beginning at age 50.

Unfortunately, studies indicate that fewer than one­third of American women give themselves monthly breast self­examinations (BSEs), even though more than 75 percent of all breast cancers are found by women themselves—usually by accident. Too often, women hesitate to perform a BSE because they are “too busy” or “don't know what to look for.” Some are simply afraid of finding the very thing they dread: a lump in their breast.

Likewise, fewer than half of the women who should receive routine mammograms actually do. Although the National Cancer Institute recently revised its guidelines, declaring that mammograms before age 50 save no additional lives, the move was extremely controversial, and the American Cancer Society continues to recommend mammograms for women in their 40s. Whichever guidelines you choose to believe, it's still clear that too many women neglect this potentially life­saving test. They may feel they do not need an annual mammogram because there is no family history of breast disease. If their first mammogram is normal, they may decide there's no need for another. They also avoid testing due to lack of insurance reimbursement, concern about radiation exposure, discomfort during the procedure, and failure to understand the benefits of mammography.

IS IT A LUMP...OR A GLAND?

Distinguishing a lump from a normal milk gland during your breast self-exam may be difficult at first. There's always a possibility, too, of overlooking a lump amid all the glandular tissue of the breast. Your doctor can help you learn to feel the difference; and regular monthly self-exams will quickly make you familiar with your breasts' own unique textures.

Nevertheless, this three­step approach to early breast cancer detection is just as important to a woman's overall physical health as proper diet, regular exercise, and the avoidance of tobacco and other harmful substances. BSE, clinical breast examinations, and mammography are a woman's best insurance against breast cancer.

The Breast Self­Exam

Every woman should perform a BSE once a month. Because breasts can be more tender, swollen, and lumpy prior to your period, the best time to do the exam is day 5 to day 7 of your menstrual cycle (5 to 7 days after your period starts). If you take oral contraceptives or hormones, check your breasts before starting a new pack of pills. Continue to examine your breasts during pregnancy, even though your breasts might feel lumpier and more swollen than usual; although rare, breast cancer can appear while you are pregnant. If you've had a hysterectomy or have passed menopause, you should schedule a BSE for the first day of each month.

You may feel embarrassed about examining your breasts—especially if you haven't done so in the past. Remember that you should know your body better than anyone else, and a BSE allows you to become better acquainted with the unique appearance and texture of your own breasts. Noncancerous breast conditions are common in many women, and regular BSEs can help you to distinguish between “normal” and “suspicious” tissue. In fact, some experts recommend that, initially, women conduct a BSE every day for a month until they learn the “geography” of their breasts.

If you don't know how to get started, your doctor can provide you with additional information that describes the structure of the breast and the composition of its tissue. Your doctor may also have a model that allows you to feel the differences between breast lumps and the normal glandular tissue involved in milk production, as well as underlying fatty tissue.

The Visual Inspection

Breast self­examination is not difficult to master and requires only a few minutes each month. To begin, stand in a comfortable, private, well­lighted room, where you can view your breasts in a large mirror. First inspect them visually to check for anything unusual, such as discharge from your nipples, or puckering, dimpling, or scaling of the skin. Then, clasp your hands behind your head and press your hands forward while watching your breasts closely in the mirror. Finally, press your hands firmly on your hips and bow slightly toward the mirror, pulling your shoulders and elbows forward.

During this inspection, check for the following characteristics:

Size and Symmetry: Breasts vary greatly in size based on age, heredity, childbirth, breastfeeding, weight changes, and birth control pills or other hormones. In any event, they should be fairly symmetrical and point slightly to the outside. Your physician should examine any deviation.

Texture and shape: Most breasts are firm and rounded, though your breasts may become more flaccid after pregnancy, breastfeeding, or menopause.

Skin color: The color of your breasts depends on your own individual pigmentation. Although your breasts may be lighter than other areas not usually exposed to the sun, the color should be uniform throughout. Unusual coloration may indicate underlying problems. Redness suggests an infection, such as mastitis, a common inflammation of the mammary glands during breastfeeding. A blue hue might be caused by an increased blood supply to the area. Because this may indicate an abnormality, be sure to discuss it with your doctor.

Surface appearance: Breast skin normally looks smooth, although during pregnancy, breastfeeding, or a sudden weight gain, you may develop stretch marks that are reddish when they first appear and whiten with age. When these occur on both breasts, there is no cause for concern. Skin that develops an “orange peel” texture or dimpling, however, may be a sign of cancer.

Moles, growths, and sores: Watch for the appearance of any unusual growth on the skin, and be alert for a change in any existing growth.

Nipples and areola: Inspect the nipples and areola (the pigmented skin surrounding the nipple) for size, symmetry, color, direction, rashes, lesions, or discharge. Both nipples should be about the same size, as should the areola. Pregnancy and breastfeeding cause the size of these breast structures to increase and become more prominent.

Like the surrounding skin, pigmentation of the nipples varies in hue; but the color should be the same on both breasts. Any abnormal coloration—redness or a bluish hue—may indicate infection or an increased blood supply to the area and should be evaluated by a physician.

Most nipples point outward, though some women have nipples that are retracted, or pointed inward. If a nipple normally points outward but suddenly pulls in either spontaneously or when you move your arms, there may be a growth nearby. If you notice any rashes, growths, or ulcerations on the nipples, bring them to your doctor's attention.

Spontaneous nipple discharge is another warning sign, though many women can squeeze a tiny amount of clear, yellowish or milky discharge from their nipples—especially toward the end of pregnancy and throughout breastfeeding. Be sure to discuss any pinkish, bloody, or foul­smelling discharge with your physician.

The Manual Examination

The second half of your breast self­exam may be easier to complete in the shower, where your fingers can glide over soapy skin and make it easier for your to concentrate on the texture of your breasts. Raise your left arm and use the sensitive pads—not the tips—of the first three fingers of your right hand to begin pressing, or exploring, your left breast. Make small, circular motions. Begin at the outermost part of your breast and move slowly clockwise around the breast toward the nipple and areola. Vary the pressure in each spot from light to heavy, checking changes in skin texture, changes below the surface, and changes closer to your ribs. Complete this portion of the exam without lifting your hand, then squeeze your nipple to check for a discharge. Finally, repeat the entire process with the other breast.

Feeling the lymph nodes is the next step in your exam. The first sign of many breast cancers is a hardened, enlarged or fixed lymph node. Raise your left arm and again use the pads of your first three fingers to explore the area in and around your armpits for any unusual lump or mass under the skin; then repeat under the opposite arm.

THREE THINGS TO CHECK IN YOUR MANUAL EXAM

Although thoroughly exploring your breast tissue is the longest part of the self-exam, other elements are just as important. A hard or swollen lymph node in the armpit area near your breast may be the first tip-off that cancer is developing. A pinkish discharge from the nipple could also be a warning sign. Note the circumference-to-tip pattern you should follow as you feel each breast. Remember, too, that you should vary the pressure so that you feel both the superficial texture and the tissue deep within.

After towel drying, repeat the inspection while lying flat on your back. Place a pillow or your folded towel under your left shoulder to flatten your left breast, then raise your left arm over your head. If you're large­breasted, roll slightly away from your left side to make it easier to examine your breast tissue. Palpate the left breast using the circular technique described earlier. Check the nipple and palpate the lymph nodes, then repeat on your right side.

Women with breast implants should perform a BSE every month and get a doctor's examination every 6 months to a year. Contact your physician if you notice any change in the texture, size, shape, color, or appearance of either breast; a discharge or unusual sensation around the nipple; burning or pain in the chest area; stiffness in the chest, shoulder, or upper arm; or lumps in the breast or underarm area.

What Else A Lump Could Be

Even if you discover something unusual during your BSE, don't panic. Many women have harmless breast conditions, and four­fifths of the lumps found during a self­exam turn out to be noncancerous, or benign.

One thing you may detect is a thickening in the breasts. This is often the result of a fibrocystic condition marked by localized solid or fluid­filled lumps that form and swell somewhat during the premenstrual period. The condition is benign; and it's estimated that up to half of all women between the ages of 35 and 50 develop it. After menopause, it gradually diminishes. Though fibrocystic lumps pose no threat to your health and most researchers believe the condition is too widespread to be considered a risk for cancer, the lumps are often difficult to distinguish from malignancies and should be evaluated by a doctor.

Benign lumps also come in other shapes and sizes:

Cysts are smooth, fluid­filled sacs that can be soft or firm. They are often sensitive to the touch during the premenstrual period. Cysts are typically found in both breasts and appear most often when a woman is 35 to 50 years of age.

Fibroadenomas are composed of fibrous and glandular tissue. They feel solid, round, and rubbery. They often move freely and are painless to the touch. These lumps appear most often in women under the age of 30 and are twice as common in black women. Although they are benign, most doctors recommend that they be removed since they will not clear up on their own and may continue to grow—especially during pregnancy and breastfeeding.

Lipomas are single, painless lumps that most often appear in older women. Varying in size from a dime to a quarter, they are composed of fatty tissue. They are slow­growing, soft, and movable. Doctors often recommend laboratory examination of a sample of the tissue (a biopsy), or complete removal, to confirm a diagnosis.

Intraductal papillomas are small, wart­like growths in the milk ducts near the nipple. Usually occurring in women during their 40s, these nodules develop near the edge of the nipple and can cause it to bleed.

NONCANCEROUS LUMPS

If you do feel a lump, chances are it's a false alarm. Four out of five lumps are the harmless growths illustrated here: Fibrocystic lumps, which tend to swell in rhythm with the menstrual cycle, and diminish after menopause Cysts, which generally are found in both breasts and appear most often between the ages of 35 and 50 Fibroadenomas, solid, round, and rubbery, which are found more often in younger women Lipomas—painless lumps the size of a coin—which develop slowly, primarily in older women Intraductal papillomas, small nodules underneath the edge of the nipple, which typically appear during your 40s Even if you feel certain that a lump is just one of these growths, you should still see your doctor. Diagnostic tests are needed to conclusively rule out cancer.

Though these conditions are no cause for alarm, only your doctor can make an accurate diagnosis. Be sure that he or she knows about any change in your breasts—no matter how small or seemingly insignificant. If you are still menstruating, the doctor may advise you to monitor the lump for one or two cycles to see if it varies with your normal hormonal fluctuations. If you are past menopause, immediate evaluation may be necessary, since older women are at higher risk for breast cancer. A woman of 70 is twice as likely to develop the disease as a woman aged 50.

A monthly BSE is a woman's first line of defense. It is especially important for younger women and is crucial for detecting changes that may develop between annual medical checkups. Nevertheless, BSE is not a substitute for clinical examinations and regular screening mammograms. All women should have a doctor examine their breasts every year as part of their annual checkup. If your physician skips your breast exam, ask for one.

Your annual checkup is also an ideal time to learn how to perform a BSE. Ask your doctor to demonstrate the technique, then repeat it so he or she can see whether you're doing it correctly. BSE training also may be available through health education classes at your local hospital, women's center, or corporate wellness program.

Mammograms

For detecting breast cancer in its earliest stages, screening mammography is the single most effective method of all. Mammograms are vital because they can locate a lump too small to be found during a self­exam.

Mammography is simply a breast x­ray. It allows the x­ray specialist, or radiologist, to see the internal structures of your breasts without the need for injection of dyes or contrast materials. Screening mammography can uncover unexpected problems in women with no other symptoms. Diagnostic mammograms—which are conducted in virtually the same manner—help identify a lump or other change found during a BSE or clinical breast examination. Overall, the accuracy of mammography in combination with BSE is greater than 90 percent, though mammography can fail to show some tumors—even some large enough to be felt—especially in dense breasts of younger women.

In addition to following the general American Cancer Society mammography screening guidelines, your physician may recommend the use of mammograms earlier or more frequently if he or she thinks you may be at higher risk for breast cancer. About 1 in every 5 women is at greater risk due to a family history of the disease (a mother, sister or aunt with breast cancer). You are also at greater risk if you have never been pregnant or had your first child after age 30, began menstruating early, or had a late menopause. In addition, some research studies have indicated that women over 40 whose mammograms reveal especially prominent milk ducts or dense breast tissue have a greater chance of developing breast cancer.

Radiation exposure from a mammogram is minimal. There is much evidence to support the belief that the benefits of detecting and successfully treating early breast cancer far outweigh any hypothetical risks from the x­ray—especially for women over age 50. Other imaging technologies, such as magnetic resonance imaging (MRI), are under investigation as alternatives to mammography, but their development may take years.

An estimated 12,000 U.S. medical facilities perform and interpret mammography tests. Recent federal regulations required all of them to meet national quality control standards and receive federal certification by October 1, 1994. The new standards are similar to but stronger than voluntary guidelines in effect since the late 1980s. When scheduling a mammogram, double-check to be sure the facility observes these new standards.

What To Expect

Mammography requires no special dietary or physical restrictions, though your doctor may advise you not to use deodorant, talcum powder, or skin lotions on your breast or underarms on the day of the test. You should also wear a two­ piece outfit, since you'll have to undress from the waist up. You may feel nervous, frightened or embarrassed by the idea of disrobing to the waist and having your breasts manipulated for various x­ray views. Don't hesitate to voice your concerns to your physician and the mammography technologist prior to the procedure. Ask the technologist to explain beforehand what to expect. Many of these professionals are sensitive to a woman's desire for modesty and a sense of self­control.

During a mammogram, each breast will be gently flattened between two plastic plates so all of the tissue can be viewed. The x­ray machine will send a tiny amount of radiation through your breast to create an image. Generally, screening mammograms include two views of each breast—from the top and from the side—and take only 10 to 15 minutes to complete.

Although mammography is relatively painless, some women feel uncomfortable because the breast is compressed during the procedure. This pressure is necessary to obtain good detail of the breast on the x­ray film and only lasts a few seconds. Though mammography is effective at any time during the menstrual cycle, women who are still having periods may want to schedule the procedure during the first two weeks of their cycle, when their breasts are less swollen and tender.

Be sure to ask your doctor when the test results will be available. A long delay causes many women intense anxiety; so, many hospitals and women's health centers have responded with full­service screening programs that offer results within 30 minutes of the test. Your doctor or the radiologist who reads the x­ray films should be on hand to talk with you about the results. If any additional views are necessary, you can often have more x­rays taken on the spot. Your doctor can also schedule procedures such as a biopsy within 24 hours.

Women with breast implants should also follow regular screening guidelines for mammography. Tumor detection is more difficult after breast enlargement, especially in women who have developed scar tissue around the implants, have their implants in front of muscle, or have little breast tissue to begin with—which is often the case after implant surgery. The Food and Drug Administration (FDA) recommends that you choose a radiologist who has experience with breast implants. The mammo-gram should be taken with a more thorough technique called a “modified compression view,” since both saline and silicone implants can obscure x­ rays.

It's important to tell your mammography technologist that you have breast implants so that he or she can exercise special care during the test. The radiologist will take 4 to 6 low­dose x­rays of each augmented breast, pushing the implant away from your breast tissue to get the best possible views. The technique requires more time—about 20 to 30 minutes—and generally costs slightly more than a basic screening mammogram.

Some groups have suggested that women with breast implants have more frequent mammograms in order to detect implant rupture or silicone that has leaked into breast tissue. However, an FDA advisory panel has recommended against this because of the danger posed by increased radiation exposure. In addition, the FDA warns that compression of the breast during mammography may rupture the implant, particularly if it's the type filled with saline. If you have breast implants, talk to your doctor about the advisability of having more frequent mammography. He or she will help you decide whether the benefits outweigh the possible risks.

Next Steps When There's A Problem

If any lumps are found during an examination and screening, your doctor will need to do additional tests. At this point, you should remember that only about 20 percent of biopsied breast lumps are cancerous. Even malignant masses, when diagnosed early, respond very favorably to treatment. If surgery is required, often removal of the lump and a small amount of surrounding tissue is all that's necessary. And, most women treated for early breast cancer do not experience a recurrence.

The first step will probably be a diagnostic mammogram to assess the mass. If this raises any suspicion of breast cancer, your physician may recommend one or more of these additional diagnostic tests:

Ultrasound sends high­frequency sound waves into the breast, then converts the echoes from those waves into an image of the breast's interior. Ultrasound is an accurate way of distinguishing between solid and fluid­filled lumps; but it cannot detect small calcium deposits that may indicate cancer, and it does not identify small tumors. If your doctor discovers a suspicious lump during pregnancy, ultrasound may be preferable to a mammogram for the sake of the baby.

Thermography measures heat patterns given off by the skin. “Hot spots” may suggest an abnormality. Although thermography has no known risks, doctors do not consider it as reliable as mammography. However, it is sometimes used as a supplement to the x­ray procedure.

Diaphanography, or transillumination, shines a bright light through the breast. This experimental technology can indicate the difference between a solid mass and a cyst but does not detect the small cancers that a mammography can reveal.

Needle aspiration determines whether a lump is solid or fluid­filled. If the lump is a cyst, the doctor drains the fluid and sends it to a laboratory to check for the presence of cancer cells. The procedure is generally done in a physician's office or clinic using a local anesthetic, and further treatment is rarely needed.

Needle core biopsy (also called stereotactic breast biopsy and mammo­test) is used to remove a core of tissue from a solid lump. Using a computerized x­ray technique, your doctor will guide a needle into the suspicious breast area to obtain a sample for microscopic examination. The procedure uses a local anesthetic, leaves no scar and is considered highly accurate. More and more physicians are choosing this technique to confirm a diagnosis and develop a treatment plan.

Surgical biopsy is still the predominant method of confirming a suspicion of cancer. After removing the breast lump surgically, your doctor will have the tissue examined under a microscope. You can usually have this procedure done in a walk­in care center under local or general anesthesia and go home the same day.

If you are uncertain about the need for any of these tests, don't hesitate to discuss your concerns frankly with your physician, and feel free to get a second opinion, perhaps from a breast specialist or breast health clinic. The American Cancer Society has chapters in every major U.S. city that can provide you with additional information.

The National Cancer Institute hotline at (800) 4­CANCER can send you publications or a refer you to a specialist if you want a consultation.

Above all, remember that self­exams and mammograms can truly be life­savers. Though they seem a nuisance, they are a critical safeguard you should never pass up. Every year, 46,000 American families lose a mother, sister, wife, or daughter to breast cancer. Don't allow yourself to become a part of the statistic. 

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