Breast cancer is one of the most common malignancies affecting women in America. Despite considerable advances in diagnosis and treatment, the mortality rate from breast cancer has only recently started to decline. Because it is so common, we chose this topic for today's chat.

Is there an age that breast cancer becomes less likely, or does it get more likely the older you get?

Breast cancer becomes more common with increasing age. Although young women with breast cancer are of concern to everyone, it remains largely a disease of older women. There is no age beyond which a woman may be considered immune to breast cancer.

What is the best regiment to follow for breast cancer detection, such as home exams, so on?

I recommend that women establish a regular monthly routine of breast self-examination. Get someone to show you how to do it. Once you reach age 40, you should have a baseline mammogram. Annual mammograms are recommended after age 40. You should have an examination by a professional (your gynecologist, primary care provider, or internist) once a year. Some women may need more frequent checkups.

Why is breast cancer more frequent in women than men?

That's an excellent question. Some people are not even aware that men get breast cancer. It probably relates to the much higher levels of estrogen and other similar hormones in women. It is likely that the male breast, normally inactive, is not as susceptible to cancer formation.

And should men be concerned about breast cancer?

Men should be aware that they COULD develop breast cancer. The breast tissue in a man is mainly right under the nipple and areola (pigmented area). If a man notices a lump, nipple discharge, or other change in his breasts, he should consult a physician. Just as with women, most breast lumps in men are benign. But they should be checked out.

Are there any newer, more reliable methods of detection than the mammogram?

The mammogram remains the main adjunct to physical examination. But it is not perfect; some breast cancers are not seen on mammogram. Newer tests include breast ultrasound, fine needle aspiration, and magnetic resonance imaging. Breast ultrasound and fine needle aspiration are particular useful if a lump can be felt. Ultrasound is getting better all the time. Magnetic resonance imaging and other experimental methods hold a lot of promise for the future. But, for now, we rely on breast examination and mammography.

What is a large needle biopsy?

A large needle biopsy involves using a big enough diameter needle to actually remove a fine core of tissue (imagine a pencil lead). It is in contrast to a fine needle aspiration. A large needle biopsy takes an actual piece of tissue. A fine needle aspiration just obtains individual cells. Both can be useful.

At what age should most women have their first mammogram?

Most women should have their first mammogram at age 40. Some women, those with a strong family history, or those with a breast lump or other problem, may have their first mammogram earlier.

So going thru menopause does not lessen your chance?

Unfortunately going through menopause does not decrease your risk of breast cancer. Breast cancer is most common in older women. However, breast feeding does reduce your chances of breast cancer.

Do women with fibrocystic breast have a higher incidence of breast cancer risk in the future?

Most women with fibrocystic breasts do not have a higher risk of breast cancer. If a person has had a biopsy that shows certain (rare) kinds of fibrocystic disease, she may be at increased risk. This is uncommon and can only be determined by biopsy.

How much does heredity play a part in breast cancer?

Most women with breast cancer do not have a family history. However, we DO know that heredity plays a role. A woman whose mother, sisters, or even father have had breast cancer is at increased risk. We are starting to learn more about the genetics of breast cancer. At least two genes have been identified (BRCA1 and 2), and we expect more to be identified in the future.

I heard about a new blood test that can detect breast cancer. Do you think this will play a major part in future detection?

What a great question! We are all looking forward to the day when a blood test could help us tell who has breast cancer (or is at risk for breast cancer). We are not there yet; maybe in years to come.

At age 40 I had a base line mammogram. And after 10 years they threw it away because that is as long as they keep records. What do you think of that?

That happens unfortunately. I recommend several things: first of all, get all your mammograms at the same (accredited) facility if possible. Second, if you do not plan to have another study for several years, ASK how long the films will be kept. Third, if you move, request your mammograms (or copies), and take them with you. You may have to pay a small fee, but it is worth it. Hopefully this practice has become less common as people have realized the need to compare films.

I had my annual mammogram a few months ago. I noticed that this year, it was much less uncomfortable than in previous years. Have they improved the technology?

Unfortunately, having a mammogram is often uncomfortable because they must compress the breast to get a good picture. It is possible that you had your mammogram during a point in your cycle when your breasts were less tender, or that slightly less compression was used.

Do most mammograms cause discomfort and pain?

It's pretty common for women to be uncomfortable during mammography. It is a transient discomfort. When a mammogram is performed, the breast is gently pressed between two smooth flat plastic paddles. The goal is to thin out the tissue so that the x-rays go through easily. The discomfort usually passes rapidly. Most mammography techs are women, and most are quite sensitive to the needs of their patients!

What percentage of breast cancer patients need mastectomy?

Women with early stage breast cancer can be treated by breast conserving surgery (lumpectomy, axilliary node dissection, and radiation) OR mastectomy. It's up to individual preference; there is no survival difference. So if you consider women with early stage disease, potentially all could be treated with breast conservation. Later stage disease may need to be treated by mastectomy. Some women choose mastectomy because they do not want to go through radiation therapy. Nancy Reagan was the most recent, celebrated case of this kind that I recall. It is an individual decision.

I have heard that men who have a mutated breast cancer gene are more likely to develop prostate cancer. Is there cause for alarm when a woman has many male family members with prostate cancer to think she may get breast cancer?

That's an interesting question. I would recommend seeing a high-risk genetic cancer clinic. These are available at most University (and many other cancer centers) centers. They will do a detailed family history and tell you if you appear to be at high risk. Prostate cancer is extremely common; depending upon how carefully older men are screened for the disease.

If a lump is removed that is cancerous, what is the chance of another returning?

A woman who has had cancer in the breast is at increased risk to develop cancer in the opposite breast. If removing the lump treats breast cancer, it is important that the lump be removed with a rim of normal tissue (negative margins). It is also important that radiation treatment be given to decrease the chances of recurrence in the treated breast.

Is there a diet to follow that may help reduce the risk of developing breast cancer?

Following a low fat diet, following good general health habits, and limiting alcohol consumption all help decrease the risk of breast cancer. There is also evidence that women who smoke are at increased risk. Fortunately, the same diet that is good for you in terms of heart disease is also good for preventing breast cancer.

What is the connection between well-done or blackened meat and bacon and cancer?

There have been some studies that show that this may raise the risk of some cancers, for example non-Hodgkin's lymphoma (a kind of blood cancer). We do not know if it raises the risk of breast cancer.

Why is it so difficult to do studies with non-medical intervention like diet or exercise?

It is really hard to control these studies. Many years ago there was a very famous study called "Mr. Fit" where lots of men were enrolled - half of them got special instruction in diet and exercise and the other half didn't. The half that didn't get the special instructions started exercising and changing their diet because there was so much in the magazines and newspapers. So it was hard to show a difference.

Can you tell us about Paget's disease? I have this rash that the doctors assures me is only eczema on the areola. It keeps returning and no tests were ever done. My mammograms are negative.

Paget's disease is a tumor of the breast that actually grows out through the tiny ducts on the tip of the nipple. So it appears on the end of the nipple end first, then spreads to the areola. You are correct to worry that a rash on the nipple areola area could be Paget's disease, but if the nipple itself is not involved this is much less likely. A specific test for Paget's disease would be to scrape or do a small biopsy of the skin.

What is some of the new research for what's next in diagnosis, treatment and prevention?

There are new developments all the time. One of the guests asked about a blood test - that would have to be tops on my wish list for new developments in breast cancer detection. People are working on that. As far as treatment, sentinel node biopsy is being used instead of auxiliary node dissection at some hospitals. This is a surgical procedure where the lymphatic drainage of the breast is mapped and the single (sentinel) node is removed - if it is positive, the other nodes are removed. It is being done under clinical trials in many centers. As we understand the genetics and tumor biology of breast cancer better, we should be able to more accurately plan treatment that is tailored to an individual patient and tumor. This would minimize toxic effects while maximizing the chance of cure. An example of this would be Herceptin, which is useful if a tumor has a certain gene.

A biopsy from 5 years ago was atypical hyperplasia. I'm 49 and had my last period over a year ago. Would you recommend raloxifene?

There is currently a national trial available in most parts of the country. It is called the STAR trial. It is designed to answer this type of question, and I refer patients, such as yourself, to centers where this trial is being done. You can find a center where the trial is being done by calling your local American Cancer Society or by checking PDQ on the Web. The trial is sponsored by the NSABP (National Surgical Adjuvant Breast Program).

Has tamoxifen and raloxifene proven effective in preventing breast cancer?

We have limited data to suggest that both lower the incidence of breast cancer in certain cases. For Tamoxifen, it has been shown that the incidence of breast cancer is lowered in women at high risk. We do not know if raloxifene is better than tamoxifen. That is what the STAR trial is designed to determine. We don't know if the side effects of these drugs will outweigh the benefits. It's important to remember that when you talk about preventing breast cancer, you are talking about giving a drug (with potential side effects) to someone who may never develop cancer. Clinical trials ensure that you are properly monitored while taking the drug and help answer these questions.

What does receptor positive and negative mean?

Normal breast tissue has "receptors" for estrogen and progesterone on the cell surface. "Well-behaved" breast cancers have receptors also. Cancers that are less well behaved tend not to have receptors. Cancers that are receptor-positive can be treated with hormone-blocking agents. So it gives us both predictive (prognostic) and therapeutic information.

Does raloxifene show any positive effects for heart disease also?

I don't know. In general, we are still learning about the effects of these drugs.

What is the relationship between breast cancer and heart disease?

I don't know of any relationship between the two. Some similar factors (high fat diet) may cause both. The preventive therapy (estrogen replacement after menopause) for heart disease may cause an increased risk of breast cancer.

Is hormone replacement therapy needed after a mastectomy?

Most women who have been treated for breast cancer will not be given hormone replacement therapy, particularly if their breast cancer was "receptor positive". Some of the drugs, such as tamoxifen, which are used to treat breast cancer, have similar effects to those of hormone replacement therapy.

How often should a person with atypical hyperplasia be monitored?

Women with atypical hyperplasia generally need closer monitoring than women of the same age who do not have this problem. A physician may recommend more frequent mammograms (particularly if the problem was first diagnosed on mammography). I would strongly recommend annual follow-ups with the same physician, someone who is especially skilled in breast examination, and staying with the recommended mammogram routine. This may be as often as every 3-6 months for a while. These women should ideally be followed in a special "breast clinic" staffed by experienced professionals.

What can be done to help the family cope with a new diagnosis of breast cancer?

There are a lot of resources available through the American Cancer Society. Support groups help not just the patient, but also the entire family. More and more people are turning to the Web; there are number of Web-based support groups. There are even books available for children (to help them understand the problem their Mother is going through). Your local librarian may be a resource. Many hospitals and cancer centers maintain information centers or have volunteers who can point to resources in the community. People tend to forget how a diagnosis of breast cancer affects the whole family, so that is a really important question.

What is the normal recovery time after a mastectomy?

Most women are in the hospital for two to three days. Generally they go home with a small drainage tube and are seen back in the office or clinic within a week to have the drain removed. During that week, a woman may have a visiting nurse if necessary to help with dressings. The woman will begin exercising and using the arm during the next week. Depending upon the kind of activity, a woman may return to activities within two or three weeks. Generally by that time a plan has been made as to further treatment. For example, if the mastectomy reveals that lymph nodes are involved, chemotherapy may be needed. So I tell women that we cannot plan for certain how long they will be out from work (for example) or need help at home until we have all the information and have made a plan. It could be two weeks or even 6-12 months.

In summary, we have more options for treating breast cancer than ever before. If breast cancer is diagnosed early, we do not have to do a mastectomy. I look forward to better ways to diagnose breast cancer. Right now early detection requires a combination of mammography, physician examinations, and breast self-exam.