Contributed by Richard Ellis, MD, clinical breast radiologist and co-director of the Norma J. Vinger Center for Breast Care at Gundersen Health System, La Crosse, Wis.
Q: Why do I need to get a mammogram every year?
Although women aged 40 to 50 have breast cancer less frequently than women aged 60 to 70, the type of tumors found in younger women tend to be faster growing and more aggressive. Annual screening affords a better opportunity than screening every two years to detect breast cancer while it is still small and confined to the breast.
With a greater percentage of women age 40 and older participating in annual screening mammography, monthly self-breast examination, and annual clinical breast examination, breast cancer is being detected earlier – and often smaller - than ever. Detection at Stage 0 (confined to the milk ducts) and Stage 1 (size of a raisin) is more common today than at Stage 4 (a lump the size of an egg and/or cancer spread outside the breast). The size of a malignancy at the time of detection governs long-term results and largely determines whether radiation and/or chemotherapy should follow surgery. Detecting cancer while it is small and still confined to the breast is the goal of screening mammography.
Q: What’s the best approach to detecting breast cancer early?
With the aid of screening mammograms, radiologists can identify approximately 80 to 85 percent of all breast abnormalities, including the six most common forms of breast cancer and a many benign (non-cancerous) tumors. To help identify the 10 to 15 percent of tumors not detected by screening, monthly self-breast exam and an annual clinical breast exam by one’s healthcare provider remain important. For women over age 40, an annual screening mammogram, an annual clinical breast exam and monthly self-breast exams are the best approach to early detection.
That being said, even screening mammography may not detect these two rare forms of breast cancer – all the more reason women must be familiar with their breasts’ appearance and “feel” during self-examination.
Q: What is a healthy approach to my monthly breast self-examination (BSE)?
- Paget’s disease involves the skin of the nipple. It frequently shows as etching or a rash on the nipple and/or the darker skin around the nipple, known as the areola.
- Inflammatory breast cancer is commonly mistaken for mastitis (a benign infection of the breast). Skin on the breast becomes thickened and red, and the breast may feel tender and warm to the touch. Any skin texture or color change on the breast should be treated with the same concern as a lump. Don’t wait until your next screening mammogram to be evaluated. Contact your doctor.
Many women skip monthly self-breast examination because their breasts are lumpy. They wonder how they’ll find a new lump with others in the way. Still, those lumps represent what’s “normal” in YOUR breasts so get to know them! How big are they and where are they from month-to-month? You won’t notice changes if you aren’t checking. Changes in lump size, nipple retraction, or skin thickening that continue for a couple of months deserve medical attention, even if you’ve had a recent normal mammogram or breast ultrasound.
Ask the basic question: “Do my breasts feel about the same as last month?” If the answer is yes, don’t worry yourself. If the answer is no, then continue to evaluate the area over the next one to two months. If you remain concerned after a couple months, contact your healthcare provider and schedule an appointment.
Q: What can I do to reduce my risk of breast cancer?
Not much. Lifestyle changes like healthy diet and exercise slightly reduce the risk of breast cancer, as do pregnancy and breast-feeding. Most risks for breast cancer can’t be controlled, especially since the greatest risk is just being female. Family history and having a breast cancer gene (BRAC1 or BRAC2) gene are the next highest predictors of breast cancer potential. Other uncontrollable risks of less importance are the age at which a woman begins to menstruate, menopause and race. Factors that cause relatively small increases in risk include having no children, taking oral contraceptives or postmenopausal hormone replacement therapy, drinking alcohol, eating a high-fat diet and becoming obese.
Q: What is the breast cancer gene, and what does it mean?
Body organs, including breasts, are comprised of cells. These in turn are made of proteins, lipids, DNA, and RNA. The cell’s blueprint, coded in its DNA, determines each cell’s role and function. If a cell has a breast cancer gene, such as BRAC1 or BRAC2, it may develop “a mind of its own,” taking over normal breast tissue to grow at all costs. Patients may think because they have no family history of breast cancer, they don’t need to be concerned. Unfortunately, statistics say otherwise. Of 100 women diagnosed with breast cancer, approximately 75 will have no family history of breast cancer. Having no family history does not mean you are immune to breast cancer.
Q: What is being done to improve detection and survival of breast cancer?
By increasing the number of women participating in breast cancer screening and by establishing and maintaining high-quality standards in detection, diagnosis, and treatment, we achieve the greatest improvement in detection and outcomes with breast cancer. Health insurance companies, healthcare institutions, private practitioners, and businesses with women employees should be encouraging regular screening mammograms. Cancers found at earlier stages are far more likely to be treatable and survivable.
Q: Have surgical options improved for women with breast cancer?
Rates of survival based on type of surgery have not changed dramatically over the years, but the appearance of the post-surgical breast has. Today, thanks to earlier detection of smaller confined cancers, more women are offered the choice of lumpectomy, not just mastectomy. Less tissue is removed around a smaller lump. After lumpectomy, radiation therapy is most often recommended to reduce the likelihood that another cancer will develop in the same breast. With very small breast cancer and appropriate surgery, some women’s risk of developing breast cancer again is so low that radiation therapy may be of little benefit. Radiation oncologists on our team review each patient’s level of risk to help them make an informed choice.
Mastectomy’s old look – the flattened, disfigured chest common 30 to 40 years ago – has been replaced with more shapely alternatives, thanks to improvements in reconstructive surgery. For example, skin-sparing mastectomy (removal of the tumor, breast tissue, nipple and areola, leaving the overlying skin) has become a favored option for many women. The breast is re-filled and re-shaped with the patient’s own tissue, frequently from the abdomen, or a breast implant.
Q: What about chemotherapy, hormonal therapy, and radiation therapy?
These are adjuvant therapies, that is, additional therapies that increase or aid the effect of surgery. If breast cancer has spread beyond the breast, which is called a metastasis, then treatment in addition to surgery is usually required to help arrest and control the disease. Chemotherapy and hormonal therapy are medical treatments that help destroy or control the growth of cancer cells, while radiation therapy aims special types of x-rays at and near the area where cancer was removed. The more advanced the cancer (its size and degree of spread), the greater need for additional treatment beyond breast surgery. Small, localized cancers of the breast are less likely to require or benefit from adjuvant therapies. Patients are fully informed about their risks and potential benefits by the medical and radiation oncologists on our team so they can make informed decisions about whether to undergo chemotherapy, hormonal therapy or radiation.
Q: What is interdisciplinary breast care and what difference does it make in breast cancer care, outcomes, and medical costs?
Having multiple departments available to provide breast care isn’t enough. The best care is interdisciplinary, meaning medical and support staff members from each discipline work as a team to deliver the best and most individualized care to each patient. Interdisciplinary care streamlines and integrates the work of every specialist involved whenever breast cancer is diagnosed. At Gundersen, this approach means the right care begins as quickly as possible, saving our patients from the weeks of anxious waiting that are common at many health care facilities.
Preliminary results show that with interdisciplinary breast care, we could achieve a 20% to 40% reduction in total cost for breast cancer detection, diagnosis, and treatment when compared to the traditional, disconnected approach. It is our responsibility to improve quality of care and improve outcomes, as well as to be fiscally responsible. Interdisciplinary care, in our experience, makes it possible to accomplish all three.
Q: What difference does interdisciplinary care have on me as a patient?
Interdisciplinary care streamlines and integrates the work of every specialist involved whenever breast cancer is diagnosed. At Gundersen, we bridge the boundaries of traditional medical disciplines because we believe it is essential to minimize an anxious patient’s waiting time and begin treatment as soon as possible. Medical and support staff from radiology, pathology, surgery, medical oncology, radiation oncology, and plastic surgery are on our team. From the moment a screening mammogram detects an abnormality, through diagnostic evaluation, biopsy, and subsequent treatment, patients receive expedited, individualized care. Weekly breast conferences allow team members to discuss and agree on what’s best for each patient and to schedule services as quickly as possible.
Through disciplined, objective study of quality indicators, we’ve documented both strengths and opportunities to enhance our system. For the past five years, internal audits have led to further improvements in the quality of care we offer. Given our experience and proven record of quality monitoring, we hope to lead a Breast Care Demonstration Project as part of the Wisconsin Collaborative for Healthcare Quality. Because our efforts have been noted at the national level, we are in a position to influence national breast care standards through consultations with federal agencies and national medical organizations, including the National Consortium of Breast Centers.
Q: What’s the difference between “healing” and “curing” breast cancer?
It is important to recognize the difference between healing and curing. A cure affects the physical body. Healing affects the mind and spirit. Our goal is to help heal all our patients, and, if treatment is successful, provide a cure. Healing measures our success in providing quality care. Curing helps measure medical outcomes.
Q: How do physicians involved in breast care at Gundersen address national quality standards for breast cancer?
We record and track over 200 metrics that measure our level of care to include screening, diagnosis, treatment, and follow-up care. Our list far exceeds the number of national quality standards available for comparison. We hope our experience, in combination with results from other institutions that share our commitment, will help update and expand current quality standards against which all breast imaging should be measured.
For example, recall rate (number of women asked to return for additional evaluation after the initial screening mammogram) is typically 10 in 100 women at many radiology facilities. Our recall rate for 2002-2006 was 5.56% (approximately 5 out of 100 women asked to return for additional evaluation after screening mammography). Women deserve to feel confident that their annual mammogram is a one-time event. Maintaining a low recall rate through proper positioning and compression is a top priority for our technologists, day in and day out.