Breast Health is one aspect of our overall health. For women, this is particularly important. The breasts serve unique physiological and psychological functions, and are also one of the most common sources for cancer.
Nearly one in eight women will be diagnosed with breast cancer during her lifetime. Early detection is the key to successful treatment. The guidelines for breast cancer screening are constantly in flux. While we debate the details, everyone agrees that any screening is better than no screening.
While attempts are being made to create a national standard for breast cancer screening, it will never be able to adapt to the needs of every individual. Women with a family history of breast cancer in close relatives, and who have specific risk factors will require earlier and more frequent screening. These types or decisions will always be best made after a detailed and thoughtful consultation with your primary medical doctor.
If you have a lump in your breast, the best advise is to seek prompt treatment. If it is not cancer, you can relax. If it is cancer, the sooner treatment is started, the less treatment is needed and the better your chances for a cure.
Breast Cancer Risk Factors
Breast Cancer Risk Factors fall into two categories: those we can do something about and those we can’t. Let’s look at the ones we can do anything about first.
- Age: The risk of breast cancers increases with age. Only one eighth of all breast cancers are found in women younger than 45. On the other hand, two thirds of all invasive breast cancers are found in women older than 55.
- Gender: The main risk factor for breast cancer is being female. 99% of all breast cancers occur in women. Not only do women have more breast cells, but they also have higher levels of the hormones that promote breast cancer growth. Although men do not develop breast cancer as often as women, the prognosis is often worse, because there is less breast tissue to stop the tumor from spreading.
- Genetics: While many genes seem to predispose to breast cancer, it is important to remember that fewer than 15% of breast cancer patients have a family history of the disease. The best know mutations are in the BRCA1 and BRCA2 genes. These mutations can lead to risks as high as an 80% chance of developing breast cancer during your lifetime.
Other genes’ mutations have been associated with breast cancer including: ATM, p53, CHEK2, PTEN, CDH1 and STK11. These mutations are much rarer and do not increase the risk of breast cancer as much as mutations in the BRCA1 and BRCA2 genes. More mutations are likely to be identified as more investigations are performed. Genetic testing may be helpful for patients with a family history of breast cancer, but all genetic screening should be guided by your doctor and a genetic counselor to explain the implications.
- Family History: Women with a mother, sister or daughter with breast cancer are at higher risk of developing breast cancer themselves. If one of the above relatives have breast cancer, your risk of breast cancer is doubled. If two in this group have breast cancer, your risk is tripled. 85% of all breast cancer patients have no family history of breast cancer.
- Previous Breast Cancer: If you have previously had breast cancer, your risk is 3 to 4 times higher of developing a new breast cancer than the risk for women in general. This is not the same as a recurrence of the previous cancer.
- Race and Ethnicity: White women are more likely to develop breast cancer than African-American women; however African-American women are more likely to develop breast cancer before age 45, and are more likely to die from breast cancer. Asian, Hispanic, and Native American women have a lower risk of developing and dying from breast cancer.
- Dense Breast Tissue: Women with dense breast tissue on a mammogram are more likely to develop breast cancer, and the dense breast tissue can make diagnosis on mammogram more difficult. Adjuncts like Ultrasound or MRI may be recommended.
- Other Breast Diseases: Most breast masses are cysts and benign fibroadenomas. These are non-proliferative, and are not associated with an increased risk of breast cancer. Other lesions are proliferative and depending on the amount a atypia (abnormalities seen in the cells under the microscope) they can raise your risk of breast cancer. Lesions like usual ductal hyperplasia (without atypia), complex fibroadenoma, sclerosing adenosis, multiple papillomas or papillomatosis and radial scar can double the risk of breast cancer. Lesions with atypia, like atypical ductal hyperplasia (ADH), and atypical lobular hyperplasia (ALH), can increase the risk of breast cancer by 4 to 5 times
- Lobular Carcinoma in Situ: Lobular carcinoma in situ is not a breast cancer; however, it is associated with a 7 to 11 times increase in the risk of developing breast cancer.
- Menstruation: The early onset on menstruation (before age 12) and the late occurrence of menopause (after age 55) are associated with a slightly higher risk of breast cancer.
- Chest Wall Radiation: Radiation treatments to the chest that occur before age 40 slightly increase the risk of breast cancer.
- DES (Diethylstilbestrol) Exposure: From 1940 through the early 1970’s DES was used to prevent miscarriages. Women who received this drug during pregnancy and their daughters are at slightly higher risk for breast cancer.
Risk factor for breast cancer that we have control over include:
- Having Children: Women who have their first child before age 30 have a slightly lower risk of breast cancer. Multiple pregnancies also reduce your risk of breast cancer.
- Recent Oral Contraceptive Use: Women using birth control pills have a slightly higher risk of developing breast cancer. Once the pills are stopped, the risk gradually returns to normal. After stopping for 10 years, there is no increase in breast cancer risk.
- Hormone Therapy after Menopause: Combined hormone therapy (Estrogen and Progesterone) increases the risk of developing breast cancer. The risk is seen as soon as after two years of use, and returns to the normal risk after discontinuing combined hormone therapy for five years. The use of estrogen only hormone treatments do not seem to increase the risk of breast cancer.
- Breast Feeding: Some studies may show a decreased risk of breast cancer in women who breast feed. It is a difficult area to study, and the results are more clear if breast feeding is continued for 18 to 24 months.
- Alcohol Consumption: Consuming two to five drinks daily is associated with a breast cancer risk of one and a half times that of those that abstain.
- Obesity: Being overweight and obesity increase the risk of breast cancer, especially after menopause. The relationship is complex, not well understood, but true.
- Physical Activity: Exercise seems to decrease the risk of breast cancer. As little as two hours of brisk walking a week can reduce your risk of breast cancer by 18%.
Factor not associated with breast cancer include:
- Breast Implants: Multiple studies have found that breast implants do not increase breast cancer risk.
- Diet and Vitamin Intake: Many studies have been done, but there is a lack of consistent evidence of increased or decreased breast cancer risk.
- Antiperspirants: Large population based studies show no increase in breast cancer in women who used underarm antiperspirants and/or shaved their underarms.
- Bras: There is no good scientific or clinical research demonstrating that bras cause breast cancer by obstructing lymph flow.
- Abortion: Several studies demonstrate that neither induced abortions nor spontaneous abortions (miscarriages) have any effect on your risk of breast cancer.
- Tobacco: Although some studies have suggested smoking increases the risk of breast cancer, this remains controversial. Most studies have found no link between cigarette smoking and breast cancer. On the other hand, tobacco is a leading cause of lung cancer, and is the reason that lung cancer has passed breast cancer as the leading cause of cancer deaths in women.
- Night Shift: Several studies have suggested that women who work at night, such as nurses on a night shift, may have an increased risk of developing breast cancer. This is a fairly recent finding, and more studies are looking at this issue. Some researchers think the effect may be due to changes in levels of melatonin, a hormone whose production is affected by the body’s exposure to light, but other hormones are also being studied.
Breast Cancer Signs and Symptoms
Thanks to mammography, more and more breast cancers are being diagnosed before the development of signs and symptoms. However, mammograms do not find every breast cancer, so it is important to know the signs and symptoms of breast cancer:
- Breast Lumps: The most common symptom of breast cancer is a new lump or mass. A mass that is painless, hard, and has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or rounded. They can even be painful. For this reason, it is important that any new mass, lump, or breast change is checked by a health care professional with experience in diagnosing breast diseases. If you have any of the signs or symptoms listed below, do not delay seeking medical care.
- Breast Swelling: Unexplained, persistent swelling of all or part of the breast, even without a lump, can be a sign of breast cancer.
- Breast Skin Dimpling or Irritation: Breast cancers that are close to skin can invade it causing irritation or dimpling. A rare type of inflammatory breast cancer can have the appearance of an infection. This particular type of breast cancer tends to be more aggressive and carries a worse prognosis.
- Breast or Nipple Pain: While not the most common sign, breast cancer can present as breast or nipple pain.
- Nipple Retraction: Nipples that become inverted at an older age can be a sign of breast cancer, especially if associated with a mass or bleeding. Inverted nipples since birth, as not associated with an increased risk of breast cancer.
- Nipple Rash: Redness, scaliness, or thickening of the nipple or breast skin maybe a sign of Paget’s disease or breast cancer.
- Nipple Discharge: Any liquid coming from the nipple, other than breast milk, may be a sign of breast cancer.
Breast Cancer Screening
The American Cancer Society recommends the following for routine breast cancer screening in women who have no signs or symptoms of breast cancer:
- Beginning at Age 20: Breast self-examination (BSE) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away.
- From Age 20 to 39: Clinical breast exam (CBE) as part of a regular health exam by a health professional, preferably every 3 years.
- Beginning at Age 40: Women should have a CBE by a health professional every year. Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health.
- Women at High Risk for Breast Cancer: Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.
- Breast Ultrasound: Mammography is the current standard test for breast cancer screening. MRI is also recommended along with mammograms for some women at high risk for breast cancer. Ultrasound may also be helpful for some women as an adjunct, and may be helpful for women with dense breasts and fibrocystic changes.
Breast Cancer Screening will continue to change as we learn what methods work best, and as new technology develops. Prevention, is the best medicine, So avoiding behaviors that are know to increase the risk for breast cancer is paramount. At this time, is not possible to possible to truly prevent breast cancer, but early detection is the key to successful treatment. Breast Cancer Screening is designed to find breast cancer early, before it causes symptoms and before it spreads outside the breast. With early detection, a better prognosis and increased survival is much more likely.