Be breast aware

Tracey Delaplain, MD, FACOG, is the board certified gynecologist at the Center for Women’s Health, 6536 S. McCarran Blvd. She also blogs about women’s health concerns, healthy living and recipes at www.whatsfordinnerdoc.com.

We first talk about breast awareness for all women, and that includes even our teens. We start talking early on about being aware of your own breasts. Check them occasionally. We don’t have to check them every month anymore. That stresses people out, but just being aware of changes in the skin, discharge from the nipple, and obviously, feeling for any lumps in the arm pit or in the breast. So breast awareness is number one. And then you should probably have a formal breast exam when you start your annual check-ups. Probably at 21 we’ll start doing a breast exam every year or two, and then after 35/40, we’re doing a breast physical exam with a physician or nurse practitioner every year.

Well, the American Cancer Society came out with a paper that said breast self-exam doesn’t really save anyone’s life and that we may scare patients and they may end up with more biopsies than they need by making them do breast self-exams. So it’s not popular anymore to tell people to do that, and now the phraseology is to be breast aware. Pay attention to your breasts and report things to the doctor, but you don’t need to check your breasts every month. … Touch your breasts occasionally, but you don’t need to do it in a regimented way. If you do do a breast exam, you want to do it after your menstrual period so that you’re less lumpy and you’re less tender.

We look at the breast to see if there’s any skin changes. We usually press on the breast to see if there’s any discharge from the nipple. And then we just press the breast tissue down against the chest wall looking for any lumps or skin changes in the breast and into the arm pit and the neck.

Well, that’s very controversial these days. If you have a strong family history of breast cancer, then we may start your mammograms early in your life by 35 for some women with strong family histories. But the American College of OBGYN recommends that you start mammograms at 40 and then every one to two years after 40, and then every year after 50. There’s controversy about that now because we do too many mammograms, which leads to too many biopsies, and we’re not really saving that many lives with it. So there’s talk about cost cutting and doing less mammograms, but I still say, “See your physician. Have your exam. Talk about what you need in particular and probably everyone needs at least a mammogram by 40.”

If we feel a lump, then we want to know what it is, and if we don’t have an answer and the mammogram is negative, the breast ultrasound is negative, then a biopsy is indicated because a mammogram is only going to pick up about 80 percent of cancers. So it’s a three-pronged approach. Physician or provider’s exam, mammogram, breast ultrasound, sometimes MRIs of the breast are indicated, and then if you need a biopsy, some of those can be done with a radiologist. Most of them get a surgeon involved, a general surgeon who does breast surgery to biopsy or excise the mass.

That’s correct. And it’s also age-dependent. So in a young woman, it’s very unlikely to be a cancer, but still ask the question, go and get it checked out. The older you get, the more likely it is to be cancer, but probably 20 to 30 percent of the lumps we feel in the office are going to end up being benign conditions. So it’s more likely to be more benign than cancerous if we feel a lump.

You could have a cyst in the breast, which are almost never associated with cancer. You could have calcifications. Some of them look like benign calcifications that are not significant. Might be from old milk in the ducts from nursing, something like that or cancerous calcifications have a different look to the radiologists. If we feel a lump, we’re always looking for cysts, something looks cancerous or benign tumors have some characteristic appearances on a mammogram.

Probably no answer to that. Women in their reproductive years are more likely to have cysts probably because hormones are activating the breasts. … We used to say caffeine increased lumps in the breasts. Not true from the literature that I’ve read.

We say that, but I reviewed the literature a few times and it really wasn’t a good study. And there really isn’t proof of it, but you’re still likely to hear that from your doctor. There’s some thought that Vitamin E might reduce your chance of getting breast cysts. That data didn’t really pan out, though, either.

Well, those are the things that get the most attention. But women can have breast pain, some women more than others. It’s usually from hormonal changes before the period. The breasts swell. There’s more adema and water in the breast, so they have more tenderness before their periods. It’s not a bad thing. I mean, it’s nothing that we have to treat, but it can be quite uncomfortable for people. You can have discharge from the nipple, sometimes lasting after you’ve had your baby, which is completely normal. And sometimes abnormal if there’s a thyroid problem or a pituitary tumor in the brain cause breast discharge, so that’s one of the other reasons that we check for breast discharge. So really, pain—chief complaint of patients, maybe nipple discharge and then they feel a mass or I feel a mass. Those are the big three problems you can find in a breast.

Well, women. That’s our biggest risk factor, being female. Men can get breast cancers, but it’s very, very uncommon. So being female. Your age matters. The older you get, the more risk there is for breast cancer. And then family history, there are families that have very, very high risks of breast cancer. If you actually have a BRCA gene, you have a 40 to 80 percent chance of getting breast cancer. So that’s huge, but that’s maybe 20 to 30 percent of the breast cancers in the world that are in those family groups. … The majority of women that get breast cancer didn’t have a family history. So we’re more worried when you have a family history, and you’re more likely to have malignant tumors, but the majority of women who get breast cancer don’t have a family history. … Alcohol, though, increases the risk of breast cancer in all women, so that’s a modifiable risk factor. Obesity and being overweight increases your risk of breast cancer. There’s probably some environmental factors, too. The foods that we eat. I try to eat more of an organic diet and stay away from hormones in my food.

The younger you are, the more density you have in your breast. So when you do a mammogram on a younger woman, it’s going to be a harder test to read because it’s like looking through a snow storm because of the density in the breast and the glands in the breast. As you get older, the breast becomes fattier, so that window pane opens up. You get clearer areas, and it’s easier to see a cancer. … The important thing about a dense breast is that if your mammogram is not adequate and the doctor finds a lump, you don’t take the mammogram’s answer as there’s nothing wrong with you. You do more testing. You do the breast ultrasound, the MRI. … But I don’t believe in doing additional testing just because you have a dense breast when there’s no family history or no lumps.

Because when you’re in your reproductive years, you need more glands to produce milk and it’s a more active breast. As we get older, you get less and less activity so more and more fat replaces the glands.

I still believe that women should have an annual physician exam or a nurse practitioner exam every year to talk about their concerns, and women should talk about the breasts. They should have an examination. They should be breast aware. And I feel very strongly about looking at lifestyle modifications that you can change your cancer risk by avoiding hormones in your food, antibiotics in your food. I think that foods that have a lot of pesticides or insecticides, I think you should avoid them. I feel strongly about that. I think women should modify their alcohol. Women who never drink have less breast cancer. All women who drink at all have an increased risk, but women who drink a lot have a very high risk of breast cancer. That’s a modifiable risk of breast cancer. And then maintaining normal weight and exercising reduces your breast cancer risk and also your risk for other diseases.

There’s national studies coming out that say we do too many mammograms, we do too many biopsies and that women in their 40s shouldn’t have mammograms, but those studies are coming out of countries where they have socialized medicine, where they’re trying to cut costs. And we find that the more testing we do doesn’t mean that we save that many more lives. So on one camp they’re saying do more and more testing, but it’s not necessarily saving any more lives. And on the other side they’re saying don’t do any testing because we can lose a few women and it’s ok. … We’re having lots of discussions about how much testing we should do.

Well, I think it’s a personal decision with your physician. If you don’t want a mammogram, I think you should at least have a discussion with your physician about what your risks are if you don’t do the mammogram every year. And I think it’s open for discussion. But if you make the choice that you don’t want a mammogram, you take the consequences of that as well and you’re saying that it’s ok if someone misses my breast cancer for two years, three years, or however long you decide not to have your mammogram. That’s always the case. You can always have less testing. You can always say no, but there’s also consequences for the decisions you make.

Yes. And ask advice from your provider and not just random people or read it on Dr. Google because Dr. Google doesn’t know you. I think those decisions should be made in the doctor’s office with your provider and you can make your own personal decision about it.