Who's at Risk and What You Can Do?

If you have knowledge, let others light their candles in it.

— Margaret Fuller

There are two main areas in the breast where cancer can occur: the lobules (lobular breast cancer), which produce milk when a woman is breastfeeding, and the ducts (ductal breast cancer), which carry the milk from the lobule to the nipple. The rest of the breast is mostly fat, connective tissue, and lymph and blood vessels.

Most breast cancers begin in the cells of the ducts (ductal breast cancer). Some begin in the cells of the lobules (lobular breast cancer) or in other tissue in the breast.

RISK FACTORS FOR BREAST CANCER

Who’s at risk?
Scientists estimate that one in eight women in the United States (about 13.4%) will develop breast cancer in their lifetime. Another way to think of breast cancer risk is that seven of every eight women in America (about 86.6%) will never develop breast cancer.

Women in the United States are diagnosed with breast cancer more than any other type of cancer except for skin cancer. Breast cancer is also the second leading cause of cancer death in women (lung cancer is first). However, breast cancer death rates are decreasing, probably as a result of better and earlier detection and treatment.

The exact causes of breast cancer are unknown. However, the risk of breast cancer increases as a woman gets older. Older women are much more likely to get breast cancer than young women. Nearly eight out of ten breast cancers are found in women over age 50.

What are the risk factors for breast cancer?
Anything that increases your chance of getting a disease is called a risk factor. Below is a list of risk factors that may increase a person’s chance of developing breast cancer. However, these risk factors do not predict who will get breast cancer and who will not. Someone with many of these risk factors may never get breast cancer, while someone with no risk factors could still develop it. There may be other risk factors we do not know about yet. Risk factors for breast cancer include:

• Older age (especially after age 50)
• Menstruating (having periods) at an early age (before age 12) or going through menopause at a late age (after age 55)
• Older age at first birth (30+) or never having given birth
• Having breast cancer before or having certain types of benign (non-cancer) breast disease
• A mother or sister with breast cancer (especially if they had it prior to age 50)
• Treatment with radiation therapy to the breast/chest (especially if at a young age)
• Breast tissue that is dense on a mammogram*
• Taking hormones, such as estrogen and progesterone
• Drinking alcoholic beverages (more than one per day)
• Being white
• Being overweight, especially after menopause (when monthly periods end).

*A breast is said to be dense if it consists mainly of ductal tissue rather than fatty tissue. A mammogram cannot “see” through the ductal tissue in dense breasts and is not as effective as a mammogram on a breast with more “see-through” fatty tissue. The only sure way to tell if a breast is mostly fatty or dense is to have a mammogram.

REDUCING YOUR RISK

What can reduce the risk of breast cancer?
The following lifestyle changes have been shown to decrease a woman’s chance of developing breast cancer:

• Maintaining a healthy weight, especially after menopause. A healthcare provider can give you guidance on what is a healthy weight for you.
• Reducing alcohol intake. Limit yourself to one drink per day or less.
• Breastfeeding for 12 months or more (combined over all pregnancies).
• Taking certain medications. For some women at very high risk of breast cancer, tamoxifen or raloxifene may lower their risk of the disease. Researchers are still studying their long-term side effects. Talk to your healthcare provider if you have any questions about these drugs.
• Exercising regularly.

SCREENING

What is screening for breast cancer?
Screening looks for cancer before there are any symptoms. The goal is to find cancers before they start to cause symptoms, when they are most treatable. Mammography does not detect all cancers, but it is the best tool available to detect breast cancer at its earliest stage.

The current screening tests to find breast cancer are not perfect, but they are the best available right now. Most doctors feel that these early detection tests for breast cancer save many thousands of lives every year. Screening will not reduce your risk, but it will help find cancer early, when it is more likely to be treated successfully.

Three tests are commonly used to screen for breast cancer: mammography, clinical breast examinations and breast self examinations.

MAMMOGRAPHY

Mammography is currently one of the most effective tools used to detect breast cancer and other abnormalities in breast tissue. A mammogram is a safe, low-dose, X-ray picture of the breast. It can often show changes in the breast before you or your doctor can feel them.

Mammography detects 75 to 90 percent of breast cancers. Mammograms are less effective in younger women than in older women because younger women tend to have more dense breast tissue (harder to read on a mammogram).

Mammograms cannot diagnose breast cancer without other follow-up tests. (An abnormal finding requires further testing, such as biopsy, to be able to diagnose whether breast cancer is present.) Also, mammograms have a high “false positive” rate, meaning that they sometimes show something abnormal in the breast when no cancer is present.

For more information about follow-up tests, see Making the Diagnosis.

Do I need a prescription (order) or physician referral to get a mammogram?
In most cases, yes, you need a referral. It could be from a doctor, physician’s assistant or nurse practitioner. However, some facilities have a list of physicians who will take “self-requesting” women. The woman’s mammography results will be sent to this physician for follow-up and further care, if needed. The reason for this is to make sure women are receiving follow-up care after they get a mammogram. You do not need a referral to go to a public health department and ask for a mammogram.

What is the difference between a screening mammogram and a diagnostic mammogram?
A screening mammogram is performed when the breast is normal (there are no signs or symptoms of anything abnormal) in order to detect the disease early. In the screening mammogram, usually two pictures of each breast are taken. Women should usually begin regular screening mammograms at age 40.

A diagnostic mammogram is performed if you notice changes in your breasts such as a lump, thickening, swelling, pain, nipple discharge or retraction (the nipple or skin being pulled in). It may also be performed if something abnormal shows up on your screening mammogram. The diagnostic mammogram involves extra pictures that are not included in the screening mammogram.

If you notice any lumps or changes in your breasts, it is important to tell your doctor or mammography provider. They may want to order extra views of your breast and perform a diagnostic rather than a screening mammogram. They may also perform an ultrasound test.

One “normal” mammography report alone does not equal good breast health practice. Regular (yearly) mammograms—not just one—find breast cancer at its earliest, most treatable stage. If your doctors have prior mammogram pictures of your breasts, they will be better able to tell if something in your breast looks abnormal later.

The best way for your doctor or mammography provider to interpret mammography film is by comparing the films with your previous mammogram. If you are going to a new facility, bring your prior films with you if at all possible, or have a copy sent to your new mammographer or doctor.

Are mammograms covered by insurance?
North Carolina law requires health insurance to cover screening mammograms, including one baseline exam for women ages 35-39, a mammogram every other year for women ages 40-49, and an annual mammogram for women age 50 and over. Coverage may include more frequent exams for women at high risk. Medicare now covers mammograms every year.

Are mammograms safe?
Strict guidelines are in place to ensure that mammography equipment is safe and uses the lowest dose of X-ray radiation possible. To put the dose in perspective, the American Cancer Society notes that one mammogram exposes a woman to roughly the same amount of radiation as flying from New York to California on a commercial jet.

During a mammogram, the breast is placed between two plates to flatten the tissue for a few seconds and produce a good, readable picture of the breast. It may be uncomfortable for a few moments, but it does not harm the breast. The thinner the breast can be compressed, the less radiation is required to obtain a good picture.

Are mammograms effective for women of any age?
For the majority of women, mammograms can detect abnormalities in breast tissue. However, for younger women, especially those under age 40, mammograms may not be as effective in detecting breast cancer. This is because younger women tend to have more “dense” breast tissue, and dense breast tissue is harder to read on a mammogram. Mammograms tend to be most effective in women over age 50.

Breast implants can be a problem in obtaining accurate mammogram readings because silicone implants are not transparent on X-rays and can block a clear view of the tissues behind them, especially if the implant has been placed in front of—rather than beneath—the chest muscles.

How do I find a mammography facility in my area?
There are more than 250 North Carolina mammo-graphy facilities (including mobile mammography) that are accredited by the American College of Radiology. In North Carolina, to be FDA certified, a facility must first be accredited by the American College of Radiology. To find a certified mammography facility, ask your doctor or see the Resources at the end of this section.

What if I can’t afford a mammogram?
North Carolina has programs in place to help women pay for mammograms. One such program is the North Carolina Breast and Cervical Cancer Control Program (NC BCCCP), available through local health departments. The BCCCP provides free screening for breast or cervical cancer at no cost for women who have limited or no insurance, do not have Medicare or Medicaid, and who meet certain income guidelines. BCCCP does have age limitations, and funding is limited. Most money is allocated to the 50 and above age group.

CLINICAL BREAST EXAMINATIONS

A clinical breast examination (CBE) is usually performed by your doctor at an annual or biannual visit. CBE may be done during a routine physical exam or together with a mammogram. Your doctor or health professional will carefully examine the breasts and under the arms for lumps or other abnormalities. You should also be given the opportunity to ask questions and express any concerns you may have. Let your doctor know of any changes you may have noticed in your breasts, such as lumps, pain, nipple discharge, changes in shape, differences between breasts, tenderness or skin changes.

BREAST SELF EXAMINATIONS

Breast self examination (BSE) consists of looking at and feeling the breasts every month to detect a change in one or both breasts. BSE is recommended a few days after your period ends, when your breasts are least tender and not swollen.

By performing BSE on a regular basis, you will be able to know your breast tissue and recognize changes more quickly. Some women may not perform monthly BSE because they do not know, or have not been taught, how to do it. A healthcare provider can give you guidance about how to do breast self-exam. You can also see the Resources at the end of this section for organizations that have BSE instructions and pictures.

HOW OFTEN SHOULD YOU HAVE MAMMOGRAMS AND CLINICAL BREAST EXAMS

The American Cancer Society offers the following screening guidelines:

• Women age 40 or older should have a screening mammogram every year and a clinical breast exam by a health professional every year.
• Women in their 20s and 30s should have a clinical breast exam (CBE) as part of a regular health exam by a health professional, preferably every three years.
• Monthly breast self-exam is an option for women beginning in their 20s. Women should report any breast changes to their healthcare professional right away.

The above recommendations are for women who are at average risk of breast cancer.

Women who are at higher than average risk for breast cancer, such as women with a family history, should talk with their healthcare providers about the benefits and limitations of starting mammography when they are younger, having additional tests (such as breast ultrasound or MRI), or having more frequent exams.

Material in this section was compiled from National Cancer Institute and American Cancer Society educational publications.

RESOURCES

Organizations

American Cancer Society (ACS)
800.ACS.2345 or 866.228.4327 (TTY)
www.cancer.org
Provides information, services and free booklets for all forms of cancer; information on local financial assistance and mammography facilities in your area, diagnosis, treatment, and many other topics, including quality mammography and a breast health card.

American College of Radiology (ACR)
703.648.8900 or 800.227.5463
www.acr.org
Provides information about mammography and other tests used to detect breast cancer.

National Breast Cancer Coalition
202.296.7477 or 800.622.2838
www.stopbreastcancer.org
The nation’s largest breast cancer advocacy group, NBCC publishes fact sheets and position papers on breast cancer issues and an excellent Guide to Quality Breast Cancer Care.

National Cancer Institute’s Cancer Information Service
800.4.CANCER (800.422.6237) or 800.332.8615 (TTY)
www.cancer.gov
One of the best resources available for cancer patients, CIS provides the toll-free hotline above in English and Spanish for questions about any type of cancer or to order free booklets. Call to find mammography facilities in your area or to order free booklets about breast cancer, breast changes, and mammograms.

Susan G. Komen Breast Cancer Foundation
800.I’M.AWARE (800.462.9273)
www.komen.org
Foundation for breast cancer research, education, screening and treatment. Call the toll-free helpline above for breast health/cancer questions or to order information about how to do BSE.

U.S. Food and Drug Administration (FDA) - Center for Devices and Radiological Health
800.838.7715
www.fda.gov/cdrh/mammography
At the FDA web site, under Consumer Information, there is a list of all mammography facilities certified in the United States (updated monthly). You can locate mammography practices by zip code, state, city and facility name, or call Cancer Information Service at 800.4.CANCER.

Y-ME National Breast Cancer Organization
312.986.8338 or 800.221.2141
800.986.9505 (Spanish)
www.y-me.org
Offers breast cancer education and support, and a national 24-hour toll-free breast cancer information hotline.