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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DCIS, To Treat or Not to Treat? – 2nd part of response to Peggy Orenstein

What is DCIS, or ductal carcinoma in situ?

DCIS means that there are cancer cells in your breast but they have not gone anywhere.  They have not invaded beyond the normal breast structures (ducts and lobules) into the surrounding tissues.  Once the cells break through ducts and lobules, it is called “invasive”.  Once it is invasive, it can spread to your lymph nodes and the rest of your body.

Peggy Orenstein is correct in that DCIS alone will not kill you.  Breast cancer solely in your breast will not kill you.  Even breast cancer in your bones will not kill you.  However, when the cancer cells take over vital organs, such as the liver, lungs, and brain, that is when people eventually die from cancer.

Although some DCIS will never become invasive cancer, DCIS has the potential to become invasive.  Although there are some cancers that may never spread to other parts of your body, all invasive cancers have to potential to go to other parts of your body.   The problem is it can be hard to predict what the cancer cells in your body are going to do.  The blanket statement that DCIS in a 40 year old “quite likely would never become life threatening” (I have seen cases that have proven otherwise) is just not true.  It is not that simple and not everyone can be fit into a one size fits all category.  So, what is the likelihood that DCIS will become invasive cancer?   There are a few things to consider:

1.  How aggressive is the DCIS?   DCIS is broken down into low, intermediate and high grades, which are determined by characteristics indicative of cell growth.  High grade or comedo type DCIS means that the cells are rapidly growing and it is very likely that if you leave it in the breast, you will at some point develop invasive cancer.

2.  How much of it is there?    If you have a large area of DCIS, there are more cancer cells there, and thus a greater chance for one of those cells to start invading.

3.  How much life to you expect to have left?    The more time you let DCIS stay in your breast, the higher the risk for developing invasive disease, as you are giving it time to grow.

4.  Is it hormone sensitive and are you premenopausal?  If it is sensitive to estrogen and progesterone and you are still having menstrual cycles, then you are stimulating the cancer cells to grow.

So, if you are 40 year old woman with high grade comedo type DCIS, regardless of the size, I would say that it is in your best interests to remove whatever DCIS is there, as there is high risk that you will develop invasive breast cancer, probably sooner than later.  If you are 70 year old woman a small area of calcifications that showed low grade DCIS and you have diabetes and heart disease, the DCIS is probably not going to do you in before your diabetes and heart disease will.

And if you are somewhere in between?  It may not be so clear cut.  You will have to ask your doctors what they think the likelihood that your DCIS will be come invasive is.  Then you will have to decide, “Do I want to wait to see if this will become invasive cancer, or, do I want to remove these cells now and not give them a chance to become invasive.”  Most people would probably opt for the latter.  Perhaps the point Peggy is making is that we should be giving people the option, which is not something I am against.  It is okay not to treat DCIS as long as you understand the risks.

However, treating DCIS is reducing your risk for developing invasive breast cancer in the future.  Should it be grouped together with invasive cancers in the statistics? Maybe not.  Should it even be considered a cancer?  Maybe not.  (It should be called pre-cancerous in the least.)  To say that we are “over treating” DCIS is a matter of opinion.  Perhaps it should be looked at as a preventative measure rather than treatment.  It may be one of the few things you can do to reduce your risk of dying from breast cancer.  If someone chooses to do that, I ask, “What is so wrong with that?”