At what age should a woman start getting mammograms?

Most women should have their first mammogram when they are 40. If your mother had breast cancer at a young age, or if several female relatives have had breast cancer young, many physicians recommend starting 10 years younger than the youngest relative. Thus, if your mother was 45 when she had breastcancer, you should have your first mammogram when you are 35.

What is tamoxifen?

Tamoxifen is a drug that is very similar to estrogen. It binds to the sites on breast tissue cells where estrogen would bind, and therefore blocks estrogen. Because estrogen cannot bind, it cannot stimulate the breast. Ithas effects on other parts of the body as well.

Do women with fibrocystic breasts have a higher incidence of breast cancer?

Fibrocystic changes are very common, in fact, most American women have it. Most women are not at an increased risk of breast cancer. There isa very small subset of women with fibrocystic tendency who are at increased risk,based upon findings at biopsy or on mammography. Most women are not at increased risk.

Can breast cancer be treated with surgery alone?

There are two kinds of "breast cancer." Cancer in situ--DCIS--can be treated with just surgery under certain circumstances. Invasive breast cancer (which is what most people mean when they say breast cancer) is generally treated with several modalities. For early stage breast cancer, modified radical mastectomy (surgery) is effective treatment. Breast conserving therapy (surgery plus radiation to the breast) is also effective and increasingly preferred. Even for early stage disease, many physicians recommend additional systemic therapy. This might be Tamoxifen or it might be chemotherapy. The purpose of this additional systemic therapy is to kill any circulating breast cancer cells and prevent spread.

Are cysts anything to be concerned about?

Cysts are just collections of fluid. They can be detected on physical examination or on ultrasound. Aspirating the fluid collapses the cyst and makes the lump go away. These simple cysts have no relationship to breast cancer that we know of. The crucial thing is to be certain that the lump is justa cyst. That is why confirming the diagnosis with ultrasound and aspiration is soimportant. If you feel a lump in your breast, even if you think it is just a cyst, you should see your primary care provider. Additional evaluation with ultrasound and/or aspiration to confirm that it is just a cyst is important. If these tests confirm that it is a simple cyst, there is no reason for concern.

Is there anything you can do to lower your risk of developing breast cancer?

Good general health habits certainly help. A low-fat diet, exercise, avoiding tobacco smoke and alcohol are all part of a healthy lifestyle and decrease risk slightly. Early pregnancy appears to decrease risk slightly. Women who are at high risk due to a family history, or due to a history of breast cancer of one breast (and therefore at risk to develop breast cancer in the other breast) may be candidates for "chemoprevention." This means taking a drug like Tamoxifen to decrease the risk. There is currently a national trial of two drugs, Tamoxifen and Raloxifene, both thought to be effective as chemoprevention for breast cancer. This trial is called the STAR trial. It is available through the University of Iowa and many other sites around the region and nationally.

I've been diagnosed with Fibrocystic Breast Disease. How can I do monthly breast exams when my breasts feel lumpy already?

This is a difficult dilemma for many women. I would encourage you to continue with monthly breast self-examination. As you become familiar with your own breasts, you will more easily detect any change. Pick a time of your menstrual cycle (usually just after your period) when your breasts are least swollen and tender. Examine your breasts at that same time in your cycle every month. Ask your primary care provider to teach you how to examine your breasts. Many physicians have plastic models of breasts, with lumps, that women can practice on. Finally, I should tell you that not all physicians believe that breast self-examination is a good thing. Some physicians feel that women are too likely to be worried by general lumpiness. Other physicians feel as I do that a women is more likely to notice a change in her own breast. This is particularly true for women with "lumpy" breasts.

Is there a genetic test that can tell if you are pre-disposed to developing breast cancer?

Several genes have been identified that are associated with increased risk. Here is the approach currently recommended--determine, by your family history, if you may be at increased genetic risk. A family history of breast and ovarian cancer, particularly at a young age, is one thing to look for. This is the first step. Next, have this confirmed, preferably at a familial cancer clinic, by a trained geneticist. These clinics are available at most university medical centers. Finally, have an affected family member (that means someone who has already developed breast cancer) tested so that the specific mutation can be identified. The final step would be to test you for the (known) specific mutation that was present in your family. Because this is so complicated and costly, most physicians rely upon strong family history as a marker and few women actually choose genetic testing. Some genetic predispositions are more common in particular ethnic groups. Your physician can give you more information, and there is additional information on the Web.

I've read about new types of mammograms. Are the new machines better at diagnosing breast cancer earlier? Are they less painful?

The new machines are more sensitive. Most of the mammogram units that I am familiar with require compression of the breast (which is the painful squeeze). There are experimental studies going on with magnetic resonance imaging and other modalities. Someday it may be possible to get earlier diagnosis with less pain. For now, most physicians recommend finding an accredited mammography facility. Have your mammogram done at the end of your period, when your breasts are least tender. If your breasts are very tender, take a mild analgesic before you go. And remember how important the x-ray is.

I heard on the news just yesterday, that there is a new study linking birth control pills and breast cancer. My doctor tells me not to worry, that I can take the pill (I don't smoke and I'm 37) for many more years. What is your opinion?

Information on birth control pills (oral contraceptives, OC's) to date has indicated that these do not increase a woman's risk of breast cancer. There are multiple formulations, however, and various doses of hormones. If there is any effect at all toward increasing risk, it must be a very small one, because there have been numerous studies over the years that have failed to show this.

Do women who have not given birth have a higher or lower risk of developing breast cancer?

Women who have never given birth are at slightly increased risk than women who have given birth, particularly those who have had a pregnancy at a young age. The effect is extremely small, however.

What are the chances of breast cancer spreading to other parts of the body if caught and treated early?

The chance of breast cancer spreading is substantially less if it is caught and treated early. For Stage 1 cancer, approximately 90% of the women can be cured with surgery alone. The problem is that we don't have good ways to identify the small percentage of women with early stage disease in whom the cancer will spread. That is the reason that virtually all women are recommended for systemic therapy (Tamoxifen or chemotherapy) even with early stage invasive breast cancer. The purpose of that is to prevent potential spread.

Are there any cancers that don't first appear as lumps?

The earliest form of breast cancer, ductal carcinoma in situ (DCIS) is almost always found on mammography as a cluster of tiny microcalcifications. These look like little grains of sand. There is no lump. If DCIS is not treated, it develops into invasive breast cancer. There are also some situations where the breast cancer feels similar in texture to the rest of the breast, rather than firm or nodular. In these cases it may not be felt as a lump but show up on mammogram or ultrasound. That is why we consider both palpation (feeling for lumps) and mammography important for early detection.

What are the risks to taking Tamoxifen to reduce the risk of breast cancer?

There are side effects to any medication. There was a lot of discussion as to whether you could justify giving women a medication (with potential side effects) to prevent something that might or might not happen. That is why it is only given to women at sufficiently high risk to justify use. The side effects include an increased risk of endometrial cancer (cancer of the uterus). This is not a problem for a woman who has had a hysterectomy. There are other side effects, including a slight increase in the tendency to form clots in the veins.

Will Tamoxifen prevent reoccurrence in the other breast?

Tamoxifen does decrease the risk of a second cancer developing in the other breast. This is usually a second breast cancer, rather than a recurrence (as physicians use the terms). Actually it was through this observation that physicians recognized it might decrease the risk of breast cancer for other women. There was a study in which women received Tamoxifen after treatment for breast cancer. Those women had substantially fewer new cancers develop in the opposite breast.

How many cancers are missed in mammograms?

I don't have statistics that I can quote, but every physician who takes care of women with breast cancer has seen numerous cases where a mammogram was normal but the woman had breast cancer. Just as some breast cancers can be seen on mammogram but not felt (because the texture of the cancer is similar to the texture and feel of the breast), there are also cancers that radiologically look very similar to breast tissue. This is why we insist on both mammography and physical examination. If you feel a lump in your breast, even if the mammogram is normal, your physician should evaluate it further. This can be done with fine needle aspiration cytology, or with biopsy, or with ultrasound.

I was diagnosed recently with BC. Already had surgery. Tumor was only 1.3 cm. About how long had it been growing? Any ideas?

We think that many (maybe most) women with breast cancer have had the tumor growing for five or more years before it becomes large enough to feel or to see on mammogram. We use the "iceberg" analogy. The tip of the iceberg is the lump you feel or the shadow you see on mammography. About the smallest is around 1 cm or so, similar to what you describe. Based upon experimental studies, observations both in the lab and in actual patients, we think it takes at least 5 years from the first genetic alterations that make a cell malignant, until the point when you can detect it.

What does it mean when I'm told I have to come back for extra views after my mammograms?

That is always an anxiety-provoking message. Frequently it just means that there is an area that may be abnormal, or may not, and they simply want to repeat the study with a slightly different method (that magnifies the area, for example). Sometimes there may have been a technical problem with the study. Sometimes we see "superimposition of shadows" which just means that it relates to how the breast was compressed in the mammogram unit. The important thing is to go back and have the additional views done. Call your physician and ask him or her to find out what it means. Many mammography facilities have a radiologist on site who will talk with you if you request it, and explain why they need to do more views. Finally, they may be comparing your current study with older mammograms and may want additional view to make sure nothing has changed.

How many different types of biopsies are there and how many people are involved in the diagnosing process?

"Biopsy" can involve anything from fine needle aspiration (which is actually cytology - because just single cells and clumps of cells are aspirated) to actual biopsy in the operating room where a lump is removed. Here are the various kinds: fine needle aspiration cytology, core needle biopsy, mammotome biopsy, open incisional biopsy, excisional biopsy, and needle-localized biopsy. Which one is chosen depends upon whether the lump can be felt easily or not, and how suspicious it is for cancer. For example, a teenager with a fibroadenoma (fibroid tumor) may choose to have the lump removed by excisional biopsy. A woman with a mass that cannot be felt, but that CAN be seen on mammography might have a mammotome or stereotactic core biopsy. People who are involved include a breast surgeon, a radiologist, and a pathologist. Then, of course, there are nurses, technicians, and so on. Once the biopsy has been performed, slides are made. These slides can be sent to other pathologists for consultation (second opinion) if necessary.

Are biopsies painful?

The breast is a sensitive part of the body. We use local anesthesia and numb the area thoroughly. Many women choose to have intravenous sedation, which can cause a sleep-like state. Some women choose general anesthesia (that is, to be put to sleep).

Why is breast cancer more frequent in women than men?

Men do get breast cancer, but only rarely, as you have noted. That is because the hormone balance in a man's body keeps the breast tissue from growing. All men have small nodules of rudimentary breast tissue. Sometimes a hormone imbalance, or a genetic abnormality, or other factors that are poorly understood, cause that rudimentary nubbin of breast tissue to turn into breast cancer. In many ways, the relative size (bulk) of breast tissue between women and men is similar to the relative risk of breast cancer. Breast cancer in men is still poorly understood, and many men do not know that men get breast cancer.

I've read about lymph node testing. Can you tell me what that is?

Traditionally, surgeons have done axillary node dissection (removing many of the nodes under the arm) to tell if breast cancer has spread and to help control the spread. There is a new method under testing. It is called "sentinel node biopsy". This is a method in which the surgeon attempts to identify the first, or sentinel, node to which the tumor would have drained. If the sentinel node is positive, the woman then has a lymph node dissection. This method is still being proven for breast cancer. Studies are underway to determine whether or not it is sufficiently accurate (or even too accurate) and how and when to use it.

Have there been any new developments in treating breast cancer?

There are several new developments. For one kind of breast cancer with a certain genetic alteration (HER-NEU) there is a new drug that is helpful. This is being used under clinical trials when other methods have failed. There are several promising new chemotherapy regimens. The most promising thing is that the basic tumor biology is being better understood. We all hope this will lead to more options for treatment.

What is the normal recovery time after a mastectomy?

Most women stay in the hospital overnight. Some women may stay an additional day. Women usually go home with a drainage tube under the arm. I tell women to expect to feel tired, sore, and weak for a couple of weeks. Generally they start to feel better after a week or two. We start arm motion exercises to encourage return of mobility. Generally by two weeks after surgery women are ready for any additional treatment (chemotherapy, for example) that may be required. Many women return to their normal activities, although at a reduced pace, at around that time.