Tag Archives: Breast

Straight, No Chaser: Signs, Symptoms and Prognosis of Breast Cancer

stage-2-breast-cancer

So, after all we’ve discussed this week, this is what it comes down to: the one in eight lifetime risk has landed at your doorstep. What happens next is very important. The ability to recognize and obtain early treatment for breast cancer (or not) will determine the length and quality of the rest of your life. Remember, most women survive breast cancer; there are approximately 3 million breast cancer survivors in the U.S. That said, also remember that there are about 40,000 annual deaths from breast cancer. The combination of breast self-exams and widespread use of screening mammograms has increased the number of breast cancers found before they cause any symptoms. Unfortunately, many others go undetected because of the limitations or failure to engage those two modalities.

I really want you to become familiar with your bodies (in this instance, your breasts). The most common symptom of breast cancer is a new lump, but you should be in tune with any new change or irregularity, including pain, swelling, redness, irritation, nipple inversion or other irregularity. Remember, breast tissue extends into the armpit (axilla), and you may find swollen and tender lymph nodes in the axilla or near the collarbone (clavicle). My bottom line: you be responsible for diligently assessing any abnormalities, and your healthcare team will determine the cause and if it’s cancer.

One more pitch for early detection: if breast cancer is detected prior to spread to the lymph nodes, the 5-year survival rate (with appropriate treatment) is as high as 98%. If it’s reached the lymph nodes, that drops to approximately 84%, and if it has spread to other body parts (e.g. the lungs, liver and bone – this is called metastatic cancer or carcinoma), the average 5-year survival rate drops to 23%.

This represents a drop in mortality rates by about 25% since 1990. Unfortunately, survivors must live with the uncertainties of possible recurrent cancer and some risk for complications from the treatment itself. That said, recurrences of cancer usually develop within 5 years of treatment. About 25% of recurrences and 50% of new cancers in the opposite breast occur after 5 years.

Many of you have asked about tumor ‘predictors’. I’ll end this post with a look at three considerations, although there are many others:

1. Breast cancer cells may contain binding sites for hormones (estrogen and progesterone). When that’s the case, these cells are called hormone receptor-positive; if not, they’re called hormone receptor negative. When cancer cells are hormone receptor positive, they are responsive to certain medications (such as tamoxifen and others). This improves prognosis. These types of cells also happen to grow more slowly, which also helps. On the other hand, hormone receptor-negative cells only respond to chemotherapy.

2. Tumor markers are proteins released from cancer cells that are able to be identified during the disease. They are notable for demonstrating (or predicting) how aggressive one’s cancer may be. The one I will mention (yes, there are others) is the HER2 marker, which is especially quick-growing and aggressive. The American Cancer Society recommends all newly diagnosed women be tested for this. Fortunately, only 20% women with invasive breast cancer are positive for HER2.

3. Curiously, tumor location within the breast has proven to be an important predictor. Tumors in the middle of the breast are most serious than those toward the outside.

I wish all of you breast cancer survivors or those with family members affected all the best with this. I hope these posts have again pointed out the importance of lowering your risk profile and early detection and treatment. This is another illustration of the shortcomings of our typical approach to health care; relying on medical care is not the same as comprehensive healthcare. The time to engage the fight against breast cancer is not in the midst of advanced disease.

I welcome your comments or questions.

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Straight, No Chaser: How to Perform the Breast Self-Exam

self-breast-exam

Beginning in their 20s, women should be aware of the benefits and limitations of breast self-exam (BSE). Women should know how their breasts normally look and feel and report any new breast changes to a health professional as soon as they are found. Finding a breast change does not necessarily mean there is a cancer.

A woman can notice changes by being aware of how her breasts normally look and feel and by feeling her breasts for changes (breast awareness), or by choosing to use a step-by-step approach (with a BSE) and using a specific schedule to examine her breasts.

If you choose to do BSE, the information below is a step-by-step approach for the exam. The best time for a woman to examine her breasts is when they are not tender or swollen. Women who examine their breasts should have their technique reviewed during their periodic health exams by their health care professional.

Women with breast implants can do BSE, too. It may be helpful to have the surgeon help identify the edges of the implant so that you know what you are feeling. There is some thought that the implants push out the breast tissue and may actually make it easier to examine. Women who are pregnant or breastfeeding can also choose to examine their breasts regularly.

It is acceptable for women to choose not to do BSE or to do BSE once in a while. Women who choose not to do BSE should still be aware of the normal look and feel of their breasts and report any changes to their doctor right away.

How to examine your breasts

  • Lie down and place your right arm behind your head. The exam is done while lying down, not standing up. This is because when lying down the breast tissue spreads evenly over the chest wall and is as thin as possible, making it much easier to feel all the breast tissue.
  • Use the finger pads of the 3 middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue.

 

  • Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. It is normal to feel a firm ridge in the lower curve of each breast, but you should tell your doctor if you feel anything else out of the ordinary. If you’re not sure how hard to press, talk with your doctor or nurse. Use each pressure level to feel the breast tissue before moving on to the next spot.
  • Move around the breast in an up and down pattern starting at an imaginary line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entire breast area going down until you feel only ribs and up to the neck or collar bone (clavicle).

  • There is some evidence to suggest that the up-and-down pattern (sometimes called the vertical pattern) is the most effective pattern for covering the entire breast, without missing any breast tissue.
  • Repeat the exam on your left breast, putting your left arm behind your head and using the finger pads of your right hand to do the exam.
  • While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. (The pressing down on the hips position contracts the chest wall muscles and enhances any breast changes.)
  • Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder to examine.

This procedure for doing breast self-exam is different from some previous recommendations. These changes represent an extensive review of the medical literature and input from an expert advisory group. There is evidence that this position (lying down), the area felt, pattern of coverage of the breast, and use of different amounts of pressure increase a woman’s ability to find abnormal areas.

I need to acknowledge and thank the multiple sources that continue to compile and disseminate information to the public, including the Centers for Disease Control and Prevention, the American Cancer Society and the Susan G. Komen Foundation. I have used these and other sources over the course of the week to integrate my practices and have distilled their information in many cases. I highly recommend them should you need additional or more thorough information. I welcome your questions and comments.

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Straight, No Chaser: This is How You Self-Assess For Breast Cancer, Part 1

breastcaassessment

When I started this point, my first thought was “Why reinvent the wheel? There is a massive amount of information available on the web about breast cancer.” However, as I looked through it all, I was equally amazed at how technical and filled with medical jargon much of it is. I guess that’s why Straight, No Chaser comes in handy! With that in mind, today I’m going to address specific simple steps you should be taking to assess yourself for breast cancer.

1. Reduce your risk factors

  • Discuss with your physician balancing the need for birth control with the use of oral contraceptives
  • When you are pregnant, breast feed
  • Exercise and reduce your obesity
  • Limit alcohol intake
  • If you’re post-menopausal, discuss with your physician balancing the need for hormone use with your breast cancer risks

2. Get screened

  • Learn your body better than anyone else; learn to do breast exams at and after age 20
  • Have a clinical breast exam at least every three years starting at age 20, and every year starting at age 40
  • Have a mammogram every year starting at age 40 unless your physician places you on a different schedule

3. Know the signs of concern and prompts to see your health care provider

  • Lump, hard knot or change in consistency inside the breast or underarm area
  • Persistent pain, swelling, warmth, redness or discoloration of the breast
  • Change in the size or shape of the breast
  • Dimpling, puckering or pulling in of the skin, nipple or other parts of the breast
  • Itchy, scaly sore or rash on the nipple
  • Nipple discharge that starts suddenly

I welcome your questions and comments.

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Straight, No Chaser: The Reach of Breast Cancer and Your Risk Factors

breastcancerincidence

Even as a physician, I am left to think about the horror of being a woman with a lifetime risk of acquiring breast cancer that’s 1 in 8. The only thing I can think of off-hand and relate to similarly is the risk for trauma being an inner-city minority kid. This risk of breast cancer is compounded by the reality that there is no way to prevent it. Thus, it must be emphasized early and often: risk factor identification and reduction, coupled with early evaluation, detection and treatment are absolutely vital.

Breast cancer is the second most common cancer contracted by American women (after skin cancer), and it is the second most common cause of death from cancer (after lung cancer). More than a quarter of a million new cases will be diagnosed in women yearly, and approximately 40,000 women will die from complications of breast cancer annually (that’s over 100 deaths every day).

In the event the previous information seemed like too much gloom and doom, understand that the tide has been stemmed. After more than two decades of increase, rates of new cases of breast cancer began dropping in 2000 and have stabilized.  This is largely thought to be due to declining rates of post-menopausal hormone use in response to results from major research projects. As you may know, such hormone use has been shown to increase the risk of both breast cancer and heart disease.

Speaking of risks, I don’t especially like this part of the conversation because it always comes across as if everything is a risk factor, and there are still controversies about what is or isn’t a risk. As a result, patients end up confused and paralyzed into inaction. Therefore, I’ll mention just enough for you to understand and work with; if you have specific questions on what you’ve heard that I haven’t already addressed in the breast cancer myth posts (Parts I and II), feel free to ask.

There are risk factors you can’t change, like aging, family history and being a woman. Having these risk factors simply means you need to be more diligent in performing self exams and seeking early care for suspicious findings.  Now, there are other risk factors you can minimize. Oral contraceptive use, postmenopausal hormonal therapy, choosing not to breast feed, alcohol use and obesity are all risk factors for breast cancer that are under your control.

The bottom line is your risk factors don’t cause cancer, and the absence of risk factors doesn’t ensure you won’t have breast cancer. For example, men contract breast cancer as well. What it all comes down to is you must be diligent in performing exams and getting evaluated and treated if something abnormal is discovered. We’ll discuss some of that next.

I welcome your questions and comments.

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Straight, No Chaser: (El)even More Myths Regarding Breast Cancer

Breast-Cancer-Myths2

Continuing from the earlier post with additional myths, well because you have so many questions!  In fact, I’m doubling up on what you received earlier in Part I of Breast Cancer Myths.  

6. “Breast cancer is preventable.”

  • Unfortunately, this is not true.  All of our efforts are geared toward lowering risks, early detection and effective treatment.

7. The risk of breast cancer isn’t affected by obesity.

  • Not true. The risk is particularly increased in post-menopausal women with weight gain.

8. African-American women have an increased risk due to hair straighteners and relaxers.

  • This myth was taken head on and debunked by the National Cancer Institute in a large 2007 study including women with significant use over a 20-year period.

9. Caffeine causes breast cancer.

  • Not according to the evidence. There’s even evidence suggesting a benefit, but the data on this is just as inconclusive as that suggesting a link to breast cancer.

10. Mammograms increase breast cancer risk due to the radiation load.

  • The risks of radiation are so relatively insignificant that they’re mentioned as an afterthought compared to the benefits received from early and frequent evaluation.

11. “Tight clothes and underwire bras will make me get breast cancer.”

  • Not true. Neither has any connection to breast cancer.

12. “I was told small breasts give me less of a chance of having cancer!”

  • Not true. Larger breasts are sometimes more difficult to evaluate, but that’s not the same as saying the risk of cancer is increased in women with larger breasts.

13. “These lumps I have are ok because I’m breastfeeding.”

  • The fact you can discover normal changes in your breast tissue doesn’t mean that all lumps discovered while breastfeeding are normal. Get evaluated.

14. “Deodorant and tanning cause breast cancer, don’t they?”

  • No. Cell phones don’t either. Tanning does increase the risk of skin cancer, but that’s a topic for another day.

15. “I heard having a baby when I’m older increases my risk of breast cancer.”

  • Well, not just any baby, but having one’s first baby later in life is a significant consideration. Women who give birth for the first time after age 35 are 40 percent more likely to get breast cancer than women who have their first child before age 20.

16. “Breast cancer is a death sentence.”

  • Most women survive breast cancer. Give yourself the best opportunity to do so by reducing your risks, learning the principles of early detection and getting prompt treatment if ever diagnosed. We’ll focus on these considerations in the next posts.

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Straight, No Chaser: Five Myths Surrounding Breast Cancer

bustingthemyths

Before I get into the details of what you need to know about breast cancer, it’s important to clear the table of some of the persistent myths and fears that exist. The disease is tough enough as it is without the fear factor impeding our ability to fight back. Please be patient with me here. If you find these myths ridiculous, then good for you, as it indicates that you’re informed on the matter. Just understand that these are real questions that other physicians and I hear often. Remember, knowledge is power.

1. “If a family member of mine has breast cancer, that means I’ll get it too.”

  • It is only true to say that women who have a family history of breast cancer have a higher risk of developing it. Overall, only approximately 10% of women diagnosed with breast cancer have a family cancer, and most women with breast cancer have no family history. In other words, a family member with breast cancer isn’t a life sentence for you, and it shouldn’t stop your efforts to lower your other risks and focus on early detection and treatment.

2. “All lumps in my breast are breast cancer.”

  • There are two important points for you to remember. First, any persistent change in the breast or armpit (axilla) should not be ignored. Remember, I will be stressing the importance of early evaluation for the purposes of detection. That said, only a small percentage of breast changes represent cancer (about 80% of lumps are benign). The really good news is if you learn and perform consistent breast exams, you will detect these changes earlier than anyone else and very often early enough to make a difference.

3. “Men don’t get breast cancer.”

  • Unfortunately, I know this not to be the case within my family. Annually, there are over 400 breast cancer deaths among men from over 2000 new cases being diagnosed. Men should pay attention just as women do because unfortunately, in part due to the delayed detection, the death rate of breast cancer in men is higher than in women.

4. “I heard breast implants cause cancer.”

  • No. There’s no increased risk with breast implants and breast cancer. However, you can legitimately say implants sometimes obscure the view of possible cancer on a mammogram.

5. “The risk of breast cancer is always 1 in 8.”

  • Actually it’s 1 in 8 during a woman’s lifetime. The important distinction is the risk increases as one ages, from 1 in 233 in a woman’s 30s up to 1 in 8 across the board by age 85.

Check back this afternoon for even more breast cancer facts and myths busted.

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Straight, No Chaser: October is Breast Cancer Awareness Month

pink_breast_cancer_ribbon

Breast cancer disturbs me deeply, and if it doesn’t affect you as well, you haven’t been paying attention. One in eight women will be diagnosed with breast cancer in their lifetime. It’s more likely than not that every single one of us has been affected by this, either directly or through a friend or family member.

Breast cancer is different. We’ve found the way to eradicate certain cancers and have made remarkable progress on others. Aside from the hereditary component, breast cancer seems so…random, so dehumanizing and so debilitating to so many. Unlike so many of the things I address as an emergency physician, breast cancer isn’t like trauma, STDs and many other conditions, where one is often directly suffering the consequences of their behavior. It is vital that you appreciate the need and value for early detection to give yourself the best possible chance for the best possible outcomes. I’ll be discussing all these considerations in detail throughout the week.

I appreciate the sentiment behind a National Breast Cancer Awareness Month, but if I could offer you anything on this, it would be a plea to be ‘aware’ every month, and use this month as a (re)commitment to take basic steps that will reduce your risk, a charge to maintain steps for early evaluation and a prod to point you toward prompt treatment if and when needed. In fact, those three areas will be the topics of my next few posts. In the meantime, please share this or other information about breast cancer to any and all females in your life. I also hope you choose to engage your family, friends and others in conversations geared to improving breast cancer awareness. Odds are many of them have been or will be affected by breast cancer.

I welcome your comments or questions.

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