Breast Cancer Early Detection and Risk Stratification By Michael Berry, MD, FACS and Susan Hoover, MD, FACS The Breast Clinic of Memphis One in 8. That’s the lifetime risk of the average woman for developing breast cancer. In 2008, approximately 200,000 women will be diagnosed and unfortunately 40,000 women will die of the disease. Tennessee accounted for 3,690 of the new breast cancer cases nationally, with 890 deaths. However, there are proactive measures women can do to either reduce their risk or at least give themselves every chance at catching breast cancer early in its course. Breast cancer is the most common cancer in women, and it does not discriminate. It can affect women of all age groups, races and ethnicities. Being a women, getting older, having a personal or family history of breast cancer, and carrying an inherited genetic mutation are some of the factors that increase a woman’s breast cancer risk. Other potential factors include early menstrual cycles (prior to age 12), late menopause (after age 55), no childbirth or childbirth after age 30, not breast-feeding, alcohol consumption, obesity, and lack of physical activity. A key component in a woman’s outcome from breast cancer is early detection. Finding breast cancer early can save lives. An overall reduction in breast cancer death rates is in part due to the combination of early detection and better therapies that exist today. Self breast exam, clinical breast exam by a health care provider, and breast imaging are the triad quintessential to breast cancer detection. A woman should begin monthly self breast examination at the age of 20. Clinical breast exam every 2 to 3 years by a health care professional is recommended for women in their 20s and 30s with yearly clinical exam starting at age 40. Mammography should be performed yearly at age 40. Potential signs of breast cancer that women should look for are a breast lump, swelling, skin irritation, skin dimpling, redness, nipple retraction, nipple discharge, or pain. As well, one should be aware of a lump or swelling in the armpit area as cancer of the breast can spread to lymph nodes in this area. Any of the above changes should be reported to one’s health care provider for evaluation. Work up of abnormal breast findings will typically involve breast imaging followed by tissue biopsy if indicated. Most diagnoses of breast abnormalities can be achieved with minimally invasive needle biopsies done in an office setting. Surgical biopsy in the operating room is employed for those abnormalities not amenable to the needle technique, which saves women the risks and expense of an operative procedure. Of course if a cancer diagnosis is made, then treatment by surgery to include lumpectomy or mastectomy with lymph node evaluation is performed. Women at Particularly High Risk for Breast Cancer Development The previously outlined screening recommendations are for the general population. They take into account cost, likelihood of compliance, and the possibility for developing breast cancer based on age. In many cases lives are saved by women following these recommendations when compared to those who don’t follow screening guidelines. We frequently hear of women developing cancer several years prior to when they were scheduled to start standard screening. What do we do about this? We must realize that we aren’t going to catch every cancer in time. With some cancers, there has been spread outside of the breast long before any imaging tool could have detected it. Fortunately, these are not the majority of cancers and early detection has been shown to save lives in most women. Women who fall outside of our screening recommendations do develop breast cancer and we must work to try and find them and find some way to detect their cancer as early as we can or prevent it entirely. Family history is helpful in detecting women who should start screening early. Screening should begin a decade prior to the age of any family member developing cancer less than age 50. For example, if a mother developed breast cancer at age 45 her daughter should begin annual mammograms starting at age 35. This moves a high risk woman into screening early and may lead to detection of cancer that she could develop prior to age 40. Family history can also lead to the detection of genetic mutations that have been shown to cause breast cancer in up to 80% of the women who possess them. Fortunately, these genetic mutations (BRCA 1 & 2) are found in less than 1% of the population. Families that would raise suspicion have multiple breast cancers, especially in women less than age 50. Breast and ovarian cancers in the same family, men with breast cancer, and cancer in both breasts in a single patient also would raise suspicion. When these situations are encountered we will work with genetic counselors and often test patients for these mutations. If one is found to possess a mutation and yet to develop cancer, we often will recommend preventative surgery or medications. Depending on the preventative option chosen, a patient may end up reducing her risk for developing breast cancer from 80% to 2%. The higher the level of risk the more often we will recommend a more aggressive preventative approach such as surgery. Sometimes breast biopsies can shed light on a woman’s risk. The discovery of atypia or a process called lobular carcinoma in situ confers a risk for developing breast cancer to a level as high as 30%. These pre-malignant or “high risk lesions” can be present even if there is no family history of breast cancer. Preventative surgery or medicine can also be used in this population. When elevated risk is closer to normal levels we will tend to recommend medications proven to reduce risk. Medications such as tamoxifen and raloxifene are FDA approved to reduce one’s risk for developing breast cancer. Women with high risk lesions such as lobular carcinoma in situ have a 30% chance for developing breast cancer. Taking tamoxifen for 5 years would reduce this risk by 50% to about 15% (normal risk is 12%). In some instances risk reduction may be as high as 80%. These medications are tablets taken daily and are generally well tolerated. There are some infrequent but serious side effects to these preventative medications, and therefore they are not for everyone. If one is at elevated risk by family history or previous biopsy results a discussion with a breast specialist is in order to establish the best course of action. Lifestyle changes have shown success in reducing the risk of developing breast cancer. Recent studies have shown that vigorous exercise for 45 minutes a day 3-4 days a week can reduce one’s risk by nearly 50%. Weight loss, low fat diets and decreased alcohol consumption also have shown to reduce risk. Whether one is low, moderate or high risk, these lifestyle changes have been shown to help. Even though there are effective treatments for most cases of breast cancer and our ability to detect them is improving, it is still most important for women to remember that their first line of defense is themselves. Adhering to regular self-examinations, clinical exams by their physicians, as well as following recommended mammography screening guidelines remains of critical importance. Since October is National Breast Cancer Awareness Month, it is a good time for women to start or renew their personal commitment to themselves to take charge of their breast health. Early detection is important and can make the difference in a woman’s outcome from the most common cancer that affects them. About The Authors Both Drs. Berry and Hoover are Breast Surgical Oncologists and are board certified by the American Board of Surgery. Both completed additional surgical training in breast diseases through the Susan G. Komen/University of Texas Southwestern Multidisciplinary Fellowship of Breast Oncology. Drs. Berry and Hoover exclusively treat diseases of the breast and breast cancer. They are active and serve leadership roles in national committees and organizations such as the American Cancer Society, Susan G. Komen for the Cure, the American Society of Breast Surgeons, and the Society of Surgical Oncology. They practice at The Breast Clinic of Memphis, located at 1385 W. Brierbrook Rd., Germantown, TN, 38138. For more information, call 901-692-9600 or visit www.BreastClinicMemphis.com. http://www.BreastClinicMemphis.comshapeimage_2_link_0
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