Breast Cancer: Screening, Diagnosis, and Treatment
by Alan Kronhaus, M.D., Health and Welllness Editor

The spectre of breast cancer looms large for most of us. Apart from skin cancer, it is the most common cancer in women, accounting for one third of all female cancer diagnoses in this country. So the chances are that each of us has a close friend or relative who has battled the disease. On a statistical basis, however, there are diseases to fear more. Heart disease kills more women than all forms of cancer combined, and more women die of lung cancer than breast cancer.

It is not difficult to understand why breast cancer evokes more fear in women than diseases that are more lethal. Undoubtedly it is related to the fact that 30 years ago, a diagnosis of breast cancer pretty much sentenced a woman to a radical mastectomy – the disfiguring removal of the entire breast, along with underlying skin, muscle, and the lymph nodes under the arm. Today there are more and better treatment options. Many women are candidates for breast sparing operations, and reconstructive surgery helps many more.

The best news about breast cancer is that we’re gaining ground against it. The death rate from the disease has fallen significantly over the last few decades, thanks to better screening, diagnosis and treatment.

Screening
The good news about breast cancer is that mortality rates have been dropping, especially over the past decade or so. The key to reducing morbidity and mortality from breast cancer is early detection, diagnosis and treatment. The key to early diagnosis is screening – looking for evidence of the disease before symptoms appear.

The cornerstones of screening are breast self-examination, which should be a monthly ritual, and mammography, which should be an annual event for all women over 40. Some organizations have suggested that women over 50 may only need mammograms every other year, while other organizations set the threshold for switching to biannual exams at age 65, but those recommendations have not been universally adopted.

There is no age when women should stop doing mammography. From a practical point of view, however, it makes sense to consider factors such as life expectancy, the presence of other debilitating diseases, and the risks and trauma of surgery when considering whether or not to screen elderly women for breast cancer. There are many of women who die with breast cancer, but not because of breast cancer.

If you're at greater risk of breast cancer because of your family history, genetic makeup, past breast cancer or other significant risk factors, talk with your doctor. You may benefit from more frequent mammography starting at an earlier age, or additional tests.

In addition to mammography, there are now other procedures that have or may have a role in screening for breast cancer in certain women.

Computer-aided detection (CAD). In traditional mammography, your X-rays are reviewed by a radiologist whose skill and experience play a large part in determining the accuracy of the test results. In CAD, a computer scans your mammogram after a radiologist has reviewed it. CAD identifies more suspicious areas on the mammogram, but many of these areas may later prove to be normal. Still, using mammography and CAD together may increase the cancer detection rate, and most mammography centers in the Triangle use this technique.

Magnetic resonance imaging (MRI). This technique is not used for routine screening. MRI can reveal tumors that are too small to detect through physical exams or are difficult to see on conventional mammograms. Some centers may use MRI as an additional screening tool for high-risk women who have dense breast tissue on a mammogram. MRI isn't recommended for routine screening because it has a high rate of false-positive results, leading to unnecessary anxiety and biopsies. It's also expensive, not readily available, and requires radiology experts who can interpret the images and findings appropriately.

Breast ultrasound (ultrasonography). This test is not used for routine screening, but rather to evaluate an abnormality seen on a mammogram or found during a clinical exam. It can help determine whether an area of concern is a cyst or solid tissue. Cysts, which are sacs of fluid, usually aren't cancerous, although you may want to have a painful cyst drained with a needle.
While screening – looking for disease in its asymptomatic stage – is the most important weapon in the fight against breast cancer, it is also important to know the signs and symptoms of the disease, so you can seek help at first signs. Acting swiftly can save your life: you have more treatment options and a better chance for long-term recovery.

The most common sign of breast cancer for both men (yes, men can also get breast cancer, although it is rare) and women is a lump, which is often painless, or thickening in the breast. That’s why monthly self-examination of your breasts is an important screening tool, and should be supplemented by a periodic “clinical” breast examination by a physician. Other signs of breast cancer include:

• A spontaneous clear or bloody discharge from your nipple
• Retraction or indentation of your nipple
• A change in the size or contours of your breast
• Any flattening or indentation of the skin over your breast
• Redness or pitting of the skin over your breast, like the skin of an orange

Not every lump in the breast is cancer, however; in fact, most lumps are not. Although factors other than cancer can change the size or feel of your breast, it is imperative to bring any change in your breasts to the attention of your physician, so together you can sort out the best next step in the evaluation process. The only situation where you may want to temporize just a bit is if you find a lump or other change in your breast and haven't yet gone through menopause. You may want to wait through one menstrual cycle before seeing your doctor. If the change hasn't gone away after a month, have it evaluated promptly.

Genetic testing
Only women at high risk of hereditary breast or ovarian cancers should be referred for genetic testing for mutation in the BRCA1 and BRCA2 genes. Having a defective BRCA gene doesn't mean you'll get breast cancer, even if you’re at high risk. In addition, test results cannot determine the magnitude of your risk, at what age you might develop cancer, how aggressively the cancer might progress or what your risk of death may be.

Genetic testing can be beneficial if the results help you make a decision about strategies that might reduce your chance of developing breast cancer. Options range from screening earlier and more often for the disease, therapy with medications such as tamoxifen, and extreme measures such as preventive (prophylactic) bilateral mastectomy and removal of your ovaries (oophorectomy). These can be wrenching decisions for any woman. Be sure to thoroughly discuss all your options with a genetic counselor, who can explain the risks, benefits and limitations of genetic testing. It can also help to talk to other women who have had to make similar decisions.

Diagnosis
If you detect a lump or change in your breast, or there is an area of concern on your screening mammogram, the next step in the evaluation process is a diagnostic study. The following studies may be done to determine whether or not a lump or other “lesion” is cancer.

Ultrasound
Ultrasound may be recommended before deciding on a biopsy, to determine whether a lump is a cyst or a solid mass. Cysts, which are sacs of fluid, usually aren't cancerous.

Biopsy
Biopsies are procedures that remove a small sample of tissue that is analyzed to yield information about whether surgery is needed and if so, the type of surgery required. To obtain a tissue sample, any one of the following procedures may be used:

• Fine-needle aspiration biopsy. The simplest type of biopsy, this is used for lumps you or your doctor can feel. During the procedure your doctor uses a thin, hollow needle to withdraw cells that are sent for analysis. Although it sounds scary, the procedure isn't supposed to be more uncomfortable than drawing blood, and only takes about 30 minutes. This technique is used to remove the fluid from a painful cyst, or to help distinguish a cyst from a solid mass.
• Core needle biopsy. During this procedure, a radiologist or surgeon uses a hollow needle to remove tissue samples from a breast lump. The advantage of a core needle biopsy is that it removes tissue, rather than just cells, for analysis. Sometimes your radiologist or surgeon may use ultrasound to help guide the placement of the needle.
• Stereotactic biopsy. This technique is used to sample and evaluate an area of concern that can be seen on a mammogram but that cannot be felt or seen on an ultrasound. During the procedure, a radiologist takes a core needle biopsy, using your mammogram as a guide. Stereotactic biopsy usually takes about an hour and is performed using local anesthesia.
• Wire localization. In this technique a thin wire is placed in your breast and the tip guided to the lump. It is performed right before a surgical biopsy, as a way to guide the surgeon to the area to be removed and tested.
• Surgical biopsy. Performed on an outpatient basis, this procedure involves the removal of some (incisional biopsy) or all (excisional biopsy) of a suspicious lump or area in the breast. Because it secures more tissue than the above techniques, it remains one of the most accurate methods for determining whether a breast change is cancerous.
• Estrogen and progesterone receptor tests. If a biopsy reveals malignant cells, they will be tested for estrogen and progesterone receptors. These tests help determine whether female hormones affect the way the cancer grows. If the cancer cells have receptors for estrogen or progesterone or both, your doctor may recommend treatment with a drug such as tamoxifen, which prevents estrogen from binding to these sites and prodding the growth of the cancer.
• Staging tests
  Staging tests help determine the size and location of a cancer, and whether or not it has spread, which helps determine the best way to treat the problem. Cancer is staged using the numbers 0 through IV.

Stage 0 indicates that the cancer is noninvasive, or in situ (in one place). Although these lesions are not harmful when they’re discovered, it's important to have them removed because they eventually can become invasive cancers. Finding and treating a cancerous lump at this stage offers the best chance for a full recovery.

Stage I to IV cancers are invasive tumors that have the ability to spread to other areas. A stage I cancer is small and well localized and has a very successful treatment rate. But the higher the stage number, the lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your bones, lungs or liver. Although it may not be possible to eliminate the cancer at this stage, its spread may be controlled with radiation, chemotherapy or both.

Treatment
The Mayo Clinic website (www.mayoclinic.com) offers the best advice I’ve read regarding the general approach to treating breast cancer. Here’s what it says:

“A diagnosis of breast cancer is one of the most difficult experiences you can face. In addition to coping with a life-threatening illness, you must make complex decisions about treatment. In most cases no one right treatment exists for breast cancer. Instead, you'll want to find the approach that's best for you.

“To do that, you'll need to consider many different factors, including the type and stage of your cancer, your age, risk factors, where you are in your life, the size and shape of your breasts, and your feelings about your body.

“Treatments exist for every type and stage of breast cancer. Most women will have surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy. And several experimental treatments are now offered on a limited basis or are being studied in clinical trials.”

The Web site goes on to describe in detail the various surgical and other treatment options, and is worth visiting for this information if you are faced with making treatment decisions. Here’s how they conclude their section on treatment advice:

“Before making any decisions, learn as much as you can about treatment options. Talk extensively with your health care team. Consider a second opinion from a breast specialist in a breast center or clinic. Don't be afraid to ask questions. In addition, look for breast cancer books, Web sites, and information from organizations such as the American Cancer Society and the Susan G. Komen Breast Cancer Foundation. Talking to other women who have faced the same decision also may help. This may be the most important decision you ever make."

Alan Kronhaus, M.D. is owner of Doctor’s Making Housecalls, 919.932.5700 or online at www.doctorsmakinghousecalls.com