The Self Breast Exam – It can save your life

I often ask my patients, “Are you routinely feeling your breasts?”  The answers I commonly get are:

My breasts are always lumpy.

I don’t know what I am supposed to be feeling for.

I am too afraid to do it.

I cannot even begin to tell you how many women find their own breast cancers by feeling a lump in their breast.  40% of breast cancers are found through feeling a lump or changes noticed in the breast by patients.  Some women come in when the cancer is quite large, but many have found them when they have been small.  I am often surprised at how good patients are at finding masses in their breasts.  Many of them are young as well.  For example, one 40 year old woman felt a 7 mm cancer in her breast, one that was hard to see on mammography because of her implants. (Stage 1 tumor size is under 2 cm. I consider anything under 1 cm to be really small!)  Also, small cancers can hide on mammograms in your normal breast tissue and many women are able to feel their breast cancers before they will manifest on mammograms.

If you are younger than 40 years old, it is really the only way to detect breast cancer, as screening mammograms are recommended beginning at age 40.  I saw a 36 year old who noticed a tiny bit of dimpling of the skin on her breast and could feel a 6 mm lump.  When I did her mammogram, half her breast was filled with DCIS and in the middle of it, there was a small invasive cancer, which is what she felt.  If she had waited until 40 for her screening mammogram, she would probably have metastatic breast cancer.  Instead, she saved her own life.

So, how to I respond to my patients?

My breasts are always lumpy.  That is normal.  Most women’s breasts are lumpy.  You need to get to know what your normal lumps and bumps are, so that if something changes or a new lump shows up, you will know that it is different.

I don’t know what I am supposed to be feeling for.  You don’t have to know what cancer feels like.  You just have to know when something is different.  I advise my patients to feel their breasts once a month.  If you are still having regular periods, do it 3-5 days after you first get your period.  You breasts tend to swell right before you get your period, so any lumps or bumps or benign things, such as cysts, will tend to be more pronounced at that time.  These tend to go away or lessen after your period.  If you feel something new, don’t freak out.  Come back to it in a few weeks and if you can go right back to the same area and feel it without any difficulty, then you need to have imaging done.  Don’t feel your breasts too often either, or you will not be able to appreciate change.  You know how your parents notice how big your children have grown because they don’t see them every day?  It’s the same thing with feeling your breasts.

I’m too afraid to do it.  Why?  If you get to know your breasts now, there is nothing to be afraid of.   Not all masses are cancer.  The important thing is you might be able to find a cancer when it is smaller.  Do you want to wait until there is cancer sticking out of your breast (which I have seen many women in denial do)?  You could very well save your own life.

Here are the reasons why I recommend doing self breast examination:

1.  It doesn’t cost you anything to do it.

2.  It rarely leads to unnecessary procedures.

3.  It allows your breasts to be checked at monthly intervals instead of yearly as with mammograms.

4.  It covers the areas that mammograms and ultrasounds might miss.  I had one patient who had a negative mammogram.  She came in a few days after her mammogram complaining of a lump.  I though it might have been related to trauma from the mammogram as her breasts were fatty and really easy to read.  Well, it was a cancer.  Even after I knew where it was, we still had trouble getting that part of the breast onto the mammogram.  She saved her own life.

5.  You will be better at it than your doctor (who feels a lot of women’s breasts but only yours once a year).

In my opinion, there is almost no downside to doing it.  There was one patient who insisted that there was something that felt different in one of her breasts.  She had a mammogram and ultrasound done which were negative.  She was told by several people that there was nothing there and not to worry about it.  She finally convinced a breast surgeon to do a surgical biopsy and guess what?  He found an invasive lobular cancer (which is often difficult to detect with mammogram and ultrasound).  She saved her own life.

You could save your own life too.  In this day and age, none of the tests we have are perfect.  So we should try to use everything we’ve got to help find cancers when they are small and the self breast exam is one of those tools.

Here are some links that describe how to do self breast exams:

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The Truth About Mammograms – What should you do?

In September 2011, I was interviewed for an article in the hospital magazine about mammograms, in preparation for Breast Cancer Awareness month in October.  The one question I was asked that stuck out in my mind was, “What is you want readers to know about mammograms?”  My immediate answer was, “They are not perfect.”  Somehow that was not really explored in more detail and the point never really made it into the article.  I guess it might have discouraged women from getting mammograms.

Do mammograms save every woman with breast cancer’s life?  Unfortunately not.  As Peggy Orenstein in her recent article suggests, many women are under the misconception that if you have mammograms every year, it will save your life.  It can, but it does not necessarily mean that it will.  But just because it is not a perfect test, does it mean that it should not be utilized at all?  The media isn’t questioning the value of pelvic exams, prostate exams and colonoscopies and they are not perfect.  Patients are subject to false positives, false negatives and risks of procedures that result from those tests.  And, people are still dying from ovarian, prostate and colon cancer.

Do I believe that mammograms save women’s lives?  Absolutely.  I can for sure say that there are young women’s lives who have been saved by mammography.  The problem is that people have been made so aware of how mammograms have helped save lives, that not much has been discussed about the limitations of mammogram until recently.  As a result, people have lost faith in mammography.  However, if you understand the limitations in addition to the benefits of mammography, you can then choose how to best utilize it in screening yourself for breast cancer.

So what should you know about mammography other than it can save your life?

1.  Mammography is limited in dense breasts.  This point has been brought up in the media for a while now.  To understand in simple terms how the density affects mammography interpretation, see my blog “Breast Density and What Does It Mean?”

2. Mammography is not always able to image the entire breast.  The vast majority of breast cancers occur in the upper outer portions of the breast and so the views taken favor imaging those portions of the breasts.  However, the lower inner portions of the breast tend to be more difficult to image and as a result, some cancers that develop in the very inner and lower portions of the breast may not show up on mammography.  In general, the parts of your breasts that are the closest to your chest and farthest from your nipple can be difficult to image as it is difficult to pull every inch of your breast tissue into the machine.

3. The radiation dose of mammography is fairly low.  The dose of one mammogram is equivalent to seven weeks of radiation you get from natural sources in the environment.  The dose of a CT of your chest is equivalent to 10-25 mammograms.  The lifetime attributable risk of fatal radiation-induced cancer from mammograms is 1.3 to 1.7 cases per 100,000 women.  You have a greater chance of dying from a car accident (1 in 84 as quoted by the NY Times) but most people don’t even think twice when getting into their cars.

4. Not every mammogram reading is equivalent.  The number of false positives and negatives can vary depending on who is reading your mammogram.  The readings can also vary depending on how many comparison mammograms the radiologist has.

5. Some breast cancers are just plain difficult to see on mammography, even on easy to read mammograms.  The growth pattern can make some cancers easy to see and others not.  If the cancer grows along the breast tissues, as true of lobular type breast cancers, it can blend in with the normal breast tissue and be difficult to detect on mammograms.  These types of cancers tend to be larger by the time they are detectable by mammography.  However, if the cancer starts to distort the tissues around it, those changes tend to be more easily seen on mammograms, even dense ones.

6. Some breast cancers grow too fast to be detected at a small or early stage.  I have seen a perfectly clear mammogram one year and the next showing a large cancer that has spread to other parts of the body.  I really hate those cases.  I always ask, “What could’ve been done differently?”  Unfortunately, we can’t assume that because your mammogram is good today, you will be fine until you get your next mammogram.  Cancer can happen anytime.

So, what does this mean for you?

1.  Decide first if you want to be screened for breast cancer and at what stage you want to find your breast cancer.  Often DCIS (see my blog about DCIS) and sometimes very small invasive cancers are only seen on mammography.  Ultrasound tends to find breast cancers after they have formed a mass (i.e, become invasive).  If you want a chance at finding your breast cancer early, then have a mammogram done.  Remember that the cancers in women who are not in menopause (50’s and younger) tend to grow faster and be more aggressive than the ones that show up in those who are in menopause.

2.  If you decide on having a mammogram done, find out if that is enough when it comes to imaging studies.  If you have dense breasts, an ultrasound may indicated as an additional means of screening.  If you have a high risk or strong family history, MRI may be indicated for screening.  Talk to a radiologist whenever you can to find out what imaging tests are best for you.

3. Always feel your breasts, particularly in the areas farthest from your nipple.  THIS IS VERY IMPORTANT, for several reasons.  First, feeling your breasts allows the areas that can be missed on mammography and even ultrasound to be checked.  Second, it allows your breasts to be checked between the yearly mammograms should something grow in that interval period.  Third, no one is going to know your body better than you.  You are going to be better at finding that breast cancer than your doctor if you regularly check your breasts.  (Blog to follow about self breast exams…)

4. To reduce the false positives and negatives, be consistent.  Screening works the best when you have a timeline.  Get a mammogram done every year to reduce the chances that something might get missed.  Always have your prior films for comparison as it reduces the likelihood that you will get called back for additional imaging and helps the radiologist appreciate any change that might be significant.

5.  Have a breast radiologist read your mammograms.  The more mammograms someone reads, the better they will be at knowing what is normal and what is abnormal.  Also, radiologists who perform biopsies get feedback after getting the results, thus learning what varying forms cancer can present as.

The problem with breast cancer screening is that everyone’s breasts look different and not every breast cancer acts or presents the same way.  It’s hard to have a “one size fits all” approach.  Mammography is not perfect but the things listed above can help overcome its shortcomings and improve detection of breast cancer at an early stage.   If you don’t do mammography, what are you left with?  You are left with waiting until you develop a mass, or invasive breast cancer.  The larger the cancer, the higher the risk of it spreading to other parts of your body.  That’s the risk of not doing mammography.

As you will find on my blog, my philosophy is that the patient always has a choice.  Just be properly informed of the risks and benefits of the choices you have.  Don’t be afraid to ask what your options are.   It is your body and ultimately you are the one who has to live with the decision you make, not anyone else.

Stay tuned for upcoming posts about self breast examination, breast MRI and ultrasound.

Breast Density and What Does It Mean?

I requested a patient return for a screening ultrasound of her breasts.  When she returned, she wanted to know what it meant to have dense breasts and if she needed to have ultrasound ever year.  We hear about breast density quite often and how mammography is limited in people with dense breasts.  But what does that really mean?  How does it affect mammography?

To make it simple for people to understand, I compare reading mammograms with hunting for deer (no, I do not actually hunt):

I am the hunter looking for deer (breast cancer).   If I am looking for a deer in a field with no trees, the deer is easily seen.  In fact, I will be able to see a small deer easily in a field.  If I am looking in a densely wooded forest, I may have more difficulty seeing deer, particularly smaller deer.

If you have fatty (not dense) breasts, you have the “field”.  If you have dense breasts you have the “forest”.  The density of your breasts depends on whether you have mostly fields or forests in your breast.

We grade density on what percentage of your breast is filled with “trees”.  If 0-25% is filled with trees, then you are predominantly fatty;  25-50% is graded as scattered densities, 50-75% heterogeneously dense, and 75-100% is extremely dense.

In reality, it is not that simple.  The distribution of “trees” in the breast can vary significantly and makes classification difficult.  Suppose one acre has 100 trees but they are spread out over the entire acre (100%).   There is enough space between the trees that you would probably be able to see a small deer between the trees.  But what if the 100 trees were packed into 1/10th of an acre (10%)?  If the deer happens to show up in that 1/10th of an acre, you might have difficulty seeing it.  The first scenario would be classified as dense (>50%) and the second would be classified as not dense (<50%).  And what does it mean if we are around 50% (borderline scattered versus heterogeneously dense)?  Our current system of grading breast density doesn’t necessarily correlate with our ability to find breast cancers.

Unfortunately, determining the density of your breasts and the likelihood of finding a breast cancer is not a perfect science.  It is left at the discretion of the radiologist.  Not every radiologist may necessarily agree on whether or not you need additional testing, such as MRI or ultrasound.  So what should you do?

1.  Have a mammogram done.  You cannot tell density by how firm your breasts feel.  There is no correlation.  If your breasts are fatty, then it mammograms may be a really good screening test for you and you may not need anything else.

2.  Have your mammogram read by a breast imaging expert.  The radiologists who read more mammograms are going to be better at it.  An easy way to tell who is an expert is to see if they have received additional training (“fellowship”) in breast imaging.

3.  Have a discussion with the radiologist when you can.  If you get called back for additional imaging, ask to speak with the radiologist.  That is the best person to tell you about your breast density and whether or not you may benefit from additional testing.

4.  If you have family history, consider seeing a breast surgeon.  If you are at increased risk of developing breast cancer, you may benefit from having breast MRIs for screening.  The breast surgeon can determine your risk and also provide you with genetic testing.  If your risk is high enough, you may benefit from additional imaging, even if your breasts are not dense.

I spent about 10 minutes with the patient I described above explaining what her breast density was and what it meant for her.  She was borderline dense and although I felt that I would probably be able to find a small cancer in her breast, her ultrasound was negative and posed no risks (such as short interval followups or benign biopsies).  I told her I was not sure she needed the ultrasound every year, but that if she wanted it, there would likely be no downsides to having it done.  So at the end, we decided together that she should have a mammogram and ultrasound together every year.

As she was walking out the door, my patient turned around and said to me, “Thank you for what you do.  I know you are trying to save lives.”  I was incredibly touched by what she said.  It makes every minute I spend talking to a patient worthwhile.