During this time of COVID epidemic, many of us have put preventative medicine and general health on a back burner, and unfortunately many have lost or are at risk of losing that all-important health insurance that provides preventative screening services. Please reconsider! We will get through COVID; cancer and chronic diseases are here to stay. Preventative care remains important!
October is Breast Cancer Awareness month. Breast cancer remains the most frequent type of non-skin cancer and the most frequent cause of cancer death in women worldwide (the second most frequent cause of women’s cancer death in the United States). Men are not exempt: the incidence of male breast cancer is thought to have increased 26% in the last 25 years. It is important to note that breast cancer is most frequent in white women, but mortality (death) rates are higher in the black population.
The symptoms of breast cancer are most frequently noted by patients themselves. Symptoms can include: a change in appearance or size of the breast (usually one-sided), dimpling of the skin, a sometimes painful lump under the arm, clear or bloody nipple discharge, and sometimes a painless palpable lump in the breast. In men, it is most often found to be a painless lump in the area of the nipple. However (and this is important!) it is mammogram that finds most breast lesions in women –there are rarely symptoms until cancer is more advanced.
Screening for breast cancer is of greatest value for patients who are at higher risk to develop breast cancer and for whom early treatment is more effective in reducing mortality. Risk is increased beyond Average in women by the following:
- Personal history of breast, ovarian, tubal, or peritoneal cancer
- Family history of breast, ovarian, tubal, or peritoneal cancer (first degree particularly)
- Being a known carrier of a pathogenic mutation such as BRCA1 or 2
- Ancestry (eg Ashkenazi Jewish) associated with BRCA1 or 2 mutations
- Previous breast biopsy with a high-risk lesion (eg atypical hyperplasia)
- Radiation treatment to the chest between ages 10 and 30
ADDITIONALLY, there are other factors that raise the risk up to 2-fold. These include the age of a first-degree relative with breast cancer, increased density of breast tissue on mammogram (BI-RADS 3 or 4), or a history of a benign prior biopsy. Oral contraceptives, women who have never had children or were >/= 30 years old with their first baby also have increased risk.
In men, risk factors include:
- Testosterone supplementation
- Liver dysfunction
- Obesity
- Regular marijuana use
- Thyroid disease
- Inherited genetic mutations such as Klinefelter syndrome or BRCA2
Without these risk factors in men, incidence of breast cancer is so low that screening is not advised. In women who have none of the risk factors listed, they are considered at Average Risk (12.4% risk of being diagnosed with breast cancer, NOT dying from breast cancer). Many women who have a family history of breast cancer can still have an Average Risk – discuss this with your provider.
Breast examination by the provider or by the patient is actually controversial. It is not clear that this manual exam is beneficial unless mammography is not available. Mammography is the only imaging technique that has been shown to decrease mortality from breast cancer. However, since even mammography will miss up to 20% of cancers, I continue to recommend at least annual provider exams as well as routine mammograms in Average Risk women and High Risk men.
So who should be screened with mammogram, and how often? Because breast cancer incidence increases with age and is quite low in those in the Average Risk group who are under 40, screening is not recommended in this group. ALL women should be screened with mammogram every 1 to 2 years from age 50-75. The American Cancer Society and women’s medical group’s advise annual screening from age 45-54, every 1 to 2 years after that. Screening between age 40 and 50 is generally individualized. Why do they stop at age 75? There does not appear to be any benefit in screening (without symptoms) in women over 75, and there is no difference in the breast cancer rate, stage, or death when screened (again – no symptoms) after age 80. In other words, older women can get breast cancer but it is not usually a dangerous or metastatic form. Why do we not screen earlier? Mammography is less sensitive in younger women and false positives are more common. 10% of the positives in young women go for biopsy, but 90% of those biopsies are negative/benign. There are other risks with mammography including anxiety and over-diagnosis leading to unnecessary surgery.
So this Breast Cancer Awareness month REMEMBER that the primary benefit of screening with mammography is to DECREASE DEATH/MORTALITY FROM BREAST CANCER. Do this for YOU!
Mary Hutton Eyer, ARNP