Every woman is at risk for breast cancer.

• Breast cancer among men is relatively rare, with about 1,500 cases diagnosed in the U.S. annually. This makes the breast cancer risk for women about 100 times the risk for men.

• Over a woman's lifetime (if she were to live until age 95 or older), she has a one in eight chance of developing breast cancer and a one in 28 risk of dying from breast cancer.

• Ten-year probability estimates may be a better way to determine your risk. For example, a 60-year-old woman has a 1 in 29 probability of developing breast cancer over the next ten years. A 50-year-old woman has a 1 in 41 probability of developing the disease in the next ten years.

• According to the American Cancer Society, more than 211,300 women will be diagnosed with breast cancer in 2003, and an estimated 39,800 will die from the disease.

• Breast cancer is the second leading cause of cancer-related death among women ages 35 to 54 (lung cancer is number one). Among African-American women, breast cancer is the single greatest cause of cancer-related death.

• The five year survival rate following early diagnosis and treatment is 96 percent. There are more than 1.6 million breast cancer survivors in America today.

• About 77 percent of women diagnosed with breast cancer are over the age of 50.

• 75 percent of breast cancers occur in women with no known risk factors.

• For the best potential of early diagnosis of breast cancer, a three-step breast cancer screening program is recommended for women - monthly breast self-exams, annual examinations by a physician or other qualified health care provider, and annual mammograms starting at age 40. Women with a history of breast cancer occurring in close family members before menopause should consider starting annual screening at an earlier age.

• In 1997, the American Cancer Society began recommending that women in their forties have a mammogram every year.

• Women who notice unusual changes in their breasts such as a lump, nipple discharge, skin dimpling, or skin irritation should see a physician or other qualified health care provider for a breast exam.

• Treatment of breast cancer varies depending on the stage of the disease at the time of diagnosis, but generally includes surgery, either lumpectomy or mastectomy, and radiation therapy, chemotherapy, hormone therapy and in some cases, reconstructive surgery may also be used.

Both a visual inspection and palpation (examination by touch) are necessary to perceive changes in the breasts which may indicate breast cancer. A physician's examination every three years beginning at age 20 and annually starting at age 40, along with an annual mammogram beginning at age 40, are also very important in diagnosing the presence of breast cancer.

Warning signs of breast cancer include:

• A lump or thickening in the breast.
• Skin dimpling or puckering on either breast.
• Any changes in the shape, texture, or color of the skin.
• A nipple that has become inverted, or looks pushed in.
• Discharge from the nipples which expresses involuntarily.
• Localized breast pain not related to the hormonal cycle.

Risk Factors:

As a woman ages, her risk increases. Among all women with breast cancer, 75 percent show no risk factors other than gender and age. According to the American Cancer Society, estrogen appears to be a key factor in breast cancer risk. First menstruation at an early age, pregnancy after age 30 or not at all, and late onset of menopause have been shown to be related to increased risk of breast cancer.

Other risk factors include:

• Personal history of breast cancer.
• Family history of breast cancer, especially in a first-degree relative such as mother, sister, or daughter.
• Personal history of breast biopsy showing atypical cells.
• Obesity.
• Excessive use of alcohol.
• Personal history of benign breast biopsy.
• Excessive amount of fat in diet.

Potential risk factors still under scientific investigation:

• Smoking.
• Miscarriage.
• Hormonal replacement therapy.

A woman is considered to be at particularly high risk for breast cancer if:

• Mother or sister was diagnosed with breast cancer BEFORE menopause.
• Known breast cancer gene carrier (genetic testing shows BRCA1/BRCA2).
• History of high-dose radiation to breasts in past (such as for Hodgkin’s Lymphoma).

For these women, screening mammograms are recommended at an earlier age, usually 10 years before the primary relative was diagnosed with breast cancer.

SRH recommends a three-step breast health plan to include:

Mammography - Annual screening mammograms starting at age 40. Women who have a strong family history of breast cancer should start screening 10 years before the age that the primary relative (mother or sister) was diagnosed.

A mammogram is a low-dose X-ray of the breasts. It is the single best method for early detection of breast cancer while the disease is at its most curable stage. A mammogram takes just a few minutes and can detect most breast cancers early, before it can be discovered through palpation (touch).

How mammograms are performed: Two images are taken of each breast from different angles. In order to get the most detailed image, while also diminishing the amount of direct X-ray exposure, the breast tissue must be compressed. This is accomplished by compressing each breast between two plastic plates for a few seconds. For most women, this is not an uncomfortable process. Some mild discomfort may be experienced when a woman's breasts are sensitive. This can be minimized by scheduling the mammogram just after the menstrual period ends and by avoiding caffeinated foods and beverages one to two weeks prior to the examination.

How mammograms are interpreted: In order to maximize our ability to detect breast cancer, all screening mammograms are read individually by a radiologist with expertise in breast imaging, aided by a state-of-the-art Computer-Assisted Detection system.

Clinical Examination - Annual exams starting at age 20.

Clinical breast examination should be part of an annual well-woman exam for every adult woman. During the exam, the health care provider must look at the breasts to determine whether there is any change in size or shape and any dimpling or discoloration of the skin. The provider will also palpate the breasts, chest, and armpits searching for any lumps.

Breast Self Exam - Monthly self exams starting at age 20.

A monthly breast self exam (BSE) is a tool women of all ages should use to detect breast cancer early. This frequency will help you become familiar with the usual appearance and feel of your breasts, making it easier to notice any changes in the breast from one month to the next. For women who menstruate, the optimal time of the month to do a BSE is two to three days after your menstrual period ends. If you no longer menstruate, pick a day such as the first day of the month or other regularly occurring event, such as the date your phone bill is due, to help remind yourself that it is time to do your BSE.

How To Do A Breast Self Exam

A breast self exam (BSE) should be done each month. This frequency will help. There are two main components to the BSE — visual inspection and palpation. Palpation is done in two steps — standing and lying down. During visual inspection, look for: discharge or scaling of the nipples, puckering, dimpling or redness of the skin, and changes in the size and shape of the breast.

How to do the visual inspection:

1. Stand facing a mirror. With your arms down at your sides, turn side to side. Inspect both breasts for any changes in the skin or nipples.
2. Raise your hands above your head and turn side to side while watching closely in the mirror. Again, inspect both breasts for any change.
3. Place hands palm to palm and press together so that you can feel your chest muscles tighten. Look for any changes in the shape or contour of your breasts.
4. Next, with your hands firmly on your hips, bow slightly toward the mirror as you pull your shoulders and elbows forward. Again, look for changes in the shape or contour.

To be effective, palpation must be done both lying down and standing up. When palpating, you are feeling for a lump that stands out or one you've never felt before. If you find a new lump or change in your breast, call your health care provider for a clinical breast exam.

How to do the first phase of palpation, lying down:

1. Lie flat on your back with your left arm raised over your head and a pillow or folded towel under your left shoulder. This position flattens the breast and makes it easier to examine.
2. Use the pads of your middle three fingers of your right hand to explore your left breast. Firmly roll the tissue between your fingers and ribs. Using lotion may help your fingers glide more easily.
3. Using either the circular, vertical, or wedge examination method, palpate outward from the nipple. Choose the method with which you are most comfortable and use it consistently each month.
4. Repeat the first three steps on right breast.

How to do the vertical exam method:

1. Beginning at the outer edges where your collar bone and chest bone meet, press the flat part of your fingers in small circles, moving the circles vertically up and down the breast.
2. Gradually work across the nipple. Be sure to check the entire breast. Pay special attention to the area between the breast and the underarm, including the underarm itself. Feel for any unusual lump or mass under the skin.
3. Repeat the first two steps on your right breast.

How to do the second phase of palpation standing (Note that some women do this while in the shower using soap and water to help fingers glide easily):

1. Use either the vertical, circular or wedge examination method on your left breast while in a standing position.
2. Repeat examination on your right breast.

In about 10% of screening mammograms, a question arises about a finding on the films. These are interpreted as “Incomplete.” This means that more mammogram views and/or an ultrasound exam may need to be performed in order to finish the exam. Most of these follow-up studies are normal, however, sometimes a biopsy is necessary to further evaluate a finding. Fortunately, most breast biopsies can be accurately performed with a needle and do not require surgery. Depending on the finding, a needle biopsy is performed - using either stereotactic, ultrasound, or MRI guidance.

Biopsy

A mammogram may reveal an abnormal lump or lesion in the breast which cannot be felt. The American Cancer Society recommends that even when the mammogram is normal, a lump that can be felt should always be biopsied. A biopsy will clarify whether a lump is a benign or malignant (cancerous) lesion. A biopsy is the only method of determining whether a breast abnormality is cancer. This removal (tissue sampling) of the tissue can be done through surgery or by needle. The type of procedure used is determined by the appearance, feel (palpability) and location of the lump or abnormality. When the tissue is sampled, it is sent to a pathology lab for analysis.

Stereotactic-Guided Breast Biopsy –With the use of a specially designed table, two digital X-ray images are taken from different angles, allowing the radiologist to precisely localize the area to be biopsied. Once the area has been located, the radiologist numbs the area with a local anesthetic, then uses computer guidance for precise needle placement and collection of small tissue samples.

Ultrasound-Guided Breast Biopsy – Ultrasound uses sound waves to produce a picture of the breast tissue. This picture helps identify lumps or other changes in the breast. The radiologist uses ultrasound to locate the area for biopsy and to direct the needle used in collecting breast tissue samples.

Both methods are as accurate as a surgical biopsy and are performed on an outpatient basis, taking less than an hour to perform and requiring no stitches. Furthermore, the patient can resume normal, non-strenuous activities immediately after the procedure is done.

Magnetic Resonance Imaging

High quality magnetic resonance imaging of the breast is performed at SRH. We use state-of-the-art equipment, including a dedicated bilateral breast surface coil. Magnetic resonance imaging is a technique that is used to evaluate the integrity of breast implants and to better define the presence, or state, of breast cancer. Medical indications (reasons) for breast MRI’s are evolving and are the subject of many studies around the country.

The patient lies on her stomach within the scanning field for approximately 25 minutes. Images are obtained without and with intravenous contrast material. If the examination is simply for implant evaluation, no contrast material may be needed.

Our radiologists, specifically trained in MRI and breast-related diseases, perform and interpret the study. This allows for maximal integration of breast imaging studies so that the patient achieves the best possible care.

Tremendous strides have been made in the treatment of breast cancer. The treatment choice is guided primarily by the stage of the cancer, but there are also personal considerations for each patient. In addition to reading about the procedures, you may want to seek a second medical opinion or contact a breast cancer support group to talk to women who have already undergone these treatments.

Mastectomy

Surgical treatment of breast cancer has made great advances over the past four decades. The most significant has been the replacement of the once common and only surgical option available, radical mastectomy, with less disfiguring, yet highly effective surgeries and other therapies. Today the total removal of chest muscles, breast tissue, and lymph nodes is likely to be done only when a tumor has invaded the muscle beneath the breast.

There are three other types of mastectomy, which may be offered by your surgeon — modified radical mastectomy, simple mastectomy, and subcutaneous mastectomy. In the modified radical mastectomy, the chest muscles are spared and the breast and lymph nodes are removed. Over the years it became clear that survival was not increased by the removal of the chest wall muscles, so modified radical mastectomies replaced the radical mastectomy. Prosthetic reconstruction is easier than in a radical mastectomy and problems with the arm are not as likely to occur. In a simple mastectomy, the surgeon removes only the breast. A subcutaneous mastectomy removes only the breast tissue, leaving the skin and some superficial tissue.

Lumpectomy

Breast conservation therapy, or lumpectomy, is the removal of the malignant lump and the lymph nodes under the arm leaving the remainder of the breast intact. A lumpectomy is a viable choice for breast cancer treatment when the tumor is small. The procedure is almost always followed by five to six weeks of radiation therapy to destroy any remaining cancer cells. Studies have revealed that in early stage breast cancer, the combination of lumpectomy and radiation therapy has the same success rate as modified radical mastectomy. Some women prefer a lumpectomy because it allows them to keep their breast. However, it should be noted that lumpectomy may not be an option for pregnant women, those whose tumor is large relative to the size of the breast, those who have had previous radiation therapy to the breast, and those who are unwilling or unable to have radiation therapy.

Radiation Therapy

Early studies demonstrated that lumpectomy alone may not eradicate the presence of breast cancer. In fact, breast cancer will recur in approximately 20 percent of lumpectomy patients who do not also receive radiation therapy. Radiation treatment to decrease risk of local reoccurrence almost always follows a lumpectomy and is recommended whenever the cancer has reached the lymph nodes. Before treatment, the patient's skin is marked to identify the area where radiation must be targeted. The painless treatment usually involves five to six weeks of X-rays to the chest and/or underarm area for a few minutes at a time. When cancer metastasizes to the bone, radiation is often used to ease the pain. The specialist who administers this treatment is a radiation oncologist or radiotherapist. There are several side effects to radiation. Fatigue is commonly experienced toward the end of the radiation series. The skin in the treated area will look and feel slightly sunburned. This problem fades about a month or more after the treatments end. Care should be taken when exposing the treated area to the sun. Protective clothing and sunscreen are advised.

Chemotherapy

Surgery and radiation therapy are intended to treat a localized area of the body. If the breast cancer cells migrate or metastasize to other parts of the body, medicine is needed that can be distributed throughout the body. Chemotherapy is that medicine. Chemotherapy drugs — chemicals that destroy tumor cells — are given either intravenously, in pill form, or through a combination of the two methods. The course of treatment may be over a four to six month period in three or four week cycles. A medical oncologist provides the chemotherapy. Because chemotherapy can also injure healthy cells, a medical oncologist must adjust the dosage and combination of drugs for each breast cancer patient. Chemotherapy works best for women who have not yet gone through menopause. Several side effects are associated with chemotherapy. They are nausea, vomiting, hair loss, mouth sores, vaginal sores, and fatigue. Certain chemotherapies also cause infertility and premature menopause.

Hormone Therapy

In treating breast cancer, hormone therapy may be used on its own, in conjunction with chemotherapy or following chemotherapy. The most commonly used hormone drug is an anti-estrogen agent called tamoxifen. The role of estrogen in causing breast cancer is still debated, but scientists have found that the hormone can be used to block the production of cancer cells. In order to determine whether anti-estrogen treatment will be effective, a pathologist will study the biopsied breast tissue. If the tissue is found to be estrogen-receptor positive, hormone therapy may be able to fight the cancer. The side effects of hormone therapy can include weight gain, mood swings and hot flashes. One serious side effect of using tamoxifen is an increase in the risk of endometrial cancer or cancer of the uterus. Many physicians believe that the benefits of using tamoxifen outweigh that potential risk.

Reconstructive Surgery

Reconstructive surgery and cosmetic prosthesis are two options for breast cancer patients who have had surgery to remove part or all of their breast tissue. Those who prefer to have breast reconstruction may choose an implant or an autologous reconstruction. The latter uses a woman's own fatty tissue, muscle, and skin from her back or belly to create a breast shape. In either case, it is also possible to have the nipple and the areola reconstructed. Responding to reports that implants were making women ill, the United States Food and Drug Administration now regulates the use of breast implants. Implants are made of either saline or silicone. Silicone-filled implants may only be used by women who have had a mastectomy, and then only if they agree to participate in a clinical trial. Mastectomy patients may also use saline-filled implants, and they are encouraged to participate in a clinical study. By participating in a study, a woman will receive close follow-up for five years and may also get some financial assistance.

SRH encourages patients to learn more about breast cancer. In addition to the information provided on this site, there are books and other breast cancer sites that may be useful to you and your family.

The following sites offer valuable information and resources. Keep in mind that no information should replace your doctor’s advice or medical treatment.

Other Internet Sites To Visit

RadiologyInfo.com: Radiologic Society of North America’s website features general patient information site and frequently asked questions. http://www.radiologyinfo.org/content/mammogram.htm

Imaginis: General information for patients about mammography. http://www.imaginis.com/breasthealth/mammography.asp

FDA's Mammography Today: The Food and Drug Administration mammography guide for patients (PDF format). http://www.fda.gov/cdrh/mammography/pubs/mambrochure.pdf

FDA Online guide for Mammography Consumers: General mammography information for patients including FDA Consumer Mammography-related articles. http://www.fda.gov/cdrh/mammography/consumers-rev.html

MEDLINE Mammography: Up-to-date news and information on Mammography plus links to other useful sites and resources. http://www.nlm.nih.gov/medlineplus/mammography.html

American Cancer Society: This site has basic cancer information and details about breast cancer. ACS programs and special events as well as recent news about breast cancer are also available here. http://www.cancer.org/docroot/cri/cri_2x.asp?sitearea=cri&dt=5

NCCN Guidelines for patients: National Comprehensive Cancer Network’s website offering guidelines for patients with breast cancer. http://www.nccn.org/patient_gls/_english/_breast/index.htm

National Cancer Institute Breast Information: The National Cancer Institute’s website providing information on all forms of cancer. http://www.cancer.gov/cancerinfo/pdq/screening/breast/Patient

Memorial Sloan-Kettering: This New York- based cancer center’s website offers information on breast anatomy, screening, diagnosis, and breast cancer treatment. http://www.mskcc.org/mskcc/html/1577.cfm

Susan G. Komen Foundation: Information about the Komen foundation and its efforts to support breast cancer research. Find out more about the organization’s annual fundraising event, the Race for the Cure. http://www.komen.org/

Cancer Lifeline: A local cancer resource and support center offering classes, support groups, 24-hour lifeline, family programs, healing arts and other programs. http://www.cancerlifeline.org/

Oncolink: Find out about clinical trials and review regularly updated news about breast cancer on this site. http://www.oncolink.com/

Facing Our Risk: This web site is for women who have a high hereditary risk for breast cancer. It addresses the issues around family history and genetic status in relation to detection and treatment. http://www.facingourrisk.org/resources.php

HealthTalk Interactive - Breast Cancer Education: Personal stories about living with breast cancer from actress Rue McClanahan and other survivors.http://healthtalk.com/bcen/

"Informed Decisions - The Complete Book of Cancer Diagnosis, Treatment, and Recovery" (April, 1997) Gerald P. Murphy, MD, Lois B. Morris, and Dianne Lange.

"Dr. Susan Love's Breast Book" (1995), Susan Love, M.D.

"A Cancer Survivor's Almanac - Charting Your Journey" (1996), National Coalition For Cancer Survivorship

"When The Woman You Love Has Breast Cancer" (1996), Larry Eiler

"When A Parent Has Cancer - A Guide To Caring For Your Children" (1997), Wendy S. Harpham