GUIDELINES & DIRECTIVES FOR BREAST CANCER DETECTION, DIAGNOSIS & TREATMENT:

A WORKBOOK FOR PATIENT’S & SURVIVORS

Introduction

The goal of this workbook is to facilitate communication between patients and doctor regarding breast disease. When a women develops a breast lump or any new abnormality or change in the breast she becomes involved in an often-confusing process of evaluation and possible treatment. Facing a possible diagnosis of breast cancer with the psychological implications of treatment makes this and emotionally difficult situation.

Bosom Buddies, a volunteer organization that provides support for women with breast cancer has underscored the gap which often exits between a patient and her doctor. There are many questions that women are often too overwhelmed, intimidated or frightened to ask. Many of the question in the workbook address topics which survivors wish in retrospect they they had known more about and had been able to ask.

A board certified radiologist with 30 years of experience and specialization in breast disease and diagnosis, Marion Jabczenski, M.D. and Judy Sipes, R.T., R.M., R.D.M.S., a practicing mammographer and sonographer with 19 years experience carefully composed this workbook. This was edited with loving care by a number of women that have been where you are now and who understand what you are experiencing. Take this book with you when you meet with your doctor and jot down notes and questions. We also recommend you ask a close friend or relative to go with you to your medical consultation. Remember too, there are women out there who want to help. When you are ready to and need to talk to someone who understands your fear, anger and questions, please call the volunteers at the Bosom Buddies hotline 602 231 6648 or one of the organizations in your area.

Acknowledgements

We acknowledge all who have contributed to the publication of this workbook.

General Information About Breast Cancer

In 1995, approximately 182,000 women in the United States unwillingly became members of a large and increasing sisterhood comprised of those diagnosed with breast cancer. Most of these women were over 50 years of age. An estimated 46,000 mothers, wives, sisters, daughters, aunts and cousins died of breast cancer in 1995. Second only to lung cancer, breast cancer is the leading cause of cancer death in women. There has been a reported overall increase in the incidence of breast cancer, which is partially attributable to increased screening and earlier detection. However, the survival has increased. This is almost certainly due to the fact that breast cancer is being diagnosed at earlier stages. Although men too can get breast cancer it is quite rare comprising only 1100 new cases per year.

Cancer begins when a single normal cell undergoes genetic changes referred to as mutations. These changes result in loss of the normal mechanisms, which control the rate of cell growth and division. Cancer cells grow much more quickly than normal cells and instead of stopping, continue to divide and ultimately invade the surrounding tissue. Under the microscope the cells have visibly abnormal characteristics. They do not function like normal tissue and due to the increased rate of metabolism they consume nutrient supply. Breast cancer arises primarily from the main structural elements of the breast, ducts, and lobules. The cancer, which arises from the genetic mutation eventually amasses into a tumor.

Genetic Risks

The risks for Breast and Ovarian cancer can be inherited from your parents. If you have any of the following in your medical history you may want to have your risk assessed:
• A personal or family history of breast cancer before age 50.
• A personal or family history of ovarian cancer at any age
• A personal or family history of breast and ovarian cancer in the same individual
• A family history of male breast cancer.

Breast Structure

The breast is a milk-producing fatty gland which is organized into lobes arranged like petals of a flower. These contain smaller lobules that end in little bulbs where milk can be produced. They are linked by the thin tubular milk ducts which open onto the surface of the nipple in the center of the darker skin called the areola. The breast is roughly circular in structure and shape with a majority of tissue extending upward toward the armpit known as the axillary tail. The breast has a very rich blood supply which increases dramatically during pregnancy .

Breast volume increases as much as 50% before menstruation due to both the increase in blood flow as well as fluid retention. Tremendous enlargement occurs during pregnancy, with a fundamental change in the underlying structure of the breast. With aging and after menopause there is both volume loss and replacement by fatty tissue.

Discharge of clear or bloody fluid from the nipple may occur when when a woman is not breast feeding. Although a bloody discharge is most often caused by a non-cancerous growth within the milk duct, in a small percent it can be a sign of breast cancer. Clear and bloody discharges should be evaluated by a breast specialist. The best methods for evaluation will include cell cytology, ultrasonography and ductography.

1. What kind of changes to the breast, that can be seen or felt are associated with breast cancer?
2. Is it normal to have breast lumps during pregnancy or breast feeding? Should these lumps be checked by a physician?
3. What should I do if I feel a lump under my arm?
4. What should I do if I notice a discharge from the nipple?

Breast Self Examination

Breast self-examination (BSE) is an important component of early detection of breast cancer. Women should do breast self-exam on a monthly basis. The breast changes in shape, size, and texture during the course of a woman’s life, reproductive cycle and within the monthly hormone cycle. Many women are uncomfortable about performing breast self-examination because they are not sure what they should be feeling. The normal quality of the breast is “lumpy and bumpy”. Benign fibrous lumps come and go monthly; however, lumps that persist should be evaluated first by mammography and ultrasound. With regular examination, women can develop familiarity with their breasts so that it becomes easier to notice changes. The best time to perform self-examination is two to three days after the end of the menstrual cycle when the breasts are smallest. Many post-menopausal and post-hysterectomy women find the first of each month or their birthdate as an easy way to remember BSE.

1. When do I do Self Examination, what am I looking for?
2. What should I do if my breasts are always lumpy?
3. What is the best way to perform BSE? Can you show me how to do it?
4. What should I do if I notice a difference?

Breast Lumps

It is important to know that most women will have some type of breast lump or mass during their lives, and most of these tumors are not breast cancer. The most common type of lump is a cyst, which is a fluid filled sac. Fibroadenomas are solid, usually benign lumps which occur most often in younger women. Both cysts and fibroadenomas may feel tender and change in size with your menstrual cycle. An injury to the breast may cause bruising and scarring of the fat which feels like a separate lump. However, a new lump or a lump that has changed in size or shape should be promptly evaluated and diagnostically proven. An immediate ultrasound can determine whether the formation is a cyst or a solid tumor. While any of these lumps may be benign it is important that they first be diagnostically proven through mammography or ultrasound. No matter what kind of lump you feel, a diagnosis must be made with the appropriate diagnostic tool to evaluate the nature of the lump.

The American College of Radiology has established guidelines for the management of breast lumps. The paradigm is designed for standardization of diagnostic protocols for evaluation based on use of specific clinical tools.

1. If I find a new breast lump do I need a mammogram?
2. What are the chances that a breast lump is cancer?
4. Does the breast lump need to be biopsied? What other types of tests can be done to find out what it is?

Mammography

The mammogram is considered the gold standard for clinical evaluation of the breast. Mammograms are performed with special x-ray machines designed specifically for use of the breast and produce low dose x-rays. Dedicated mammography machines provide specialized x-ray production that is ideal to visualize the fatty and glandular tissues that make up the breast glands. Each picture requires a certain amount of compression to see between the tissue and allows the radiation dose to be kept at a minimum. Abnormalities are detected from the mammogram pictures through a series of evaluations that include identifying architectural changes, skin changes, microcalcific clusters, changes from previous mammograms and mass formations. Each finding in turn may require additional pictures. All certified radiologists must follow a strict guideline specifically for mammography interpretation. This is a requirement by the FDA and the ACR (American College of Radiology) that licenses each certified facility.

Magnification of an area utilizes the mammography equipment to enlarge the picture. Calcifications are usually magnified for proper identification type and amount characteristics. There are many causes of microcalcifications, which are small deposits of calcium within the breast tissue that cannot be felt but can be visualized well on mammography. Causes of microcalcifications include infection, previous trauma and changes in blood flow. Microcalcifications can also be a sign of breast cancer.

Women who have implants should have a mammogram that includes a technique for implant displacement. Current recommendations for mammography includes a baseline between 35 and 40 years for all women, and high risk women should begin before forty and all women should have yearly mammograms from age 40 years on.

1. Do I need a mammogram?
2. When is the best time to get a mammogram?
3. Is it okay to have a mammogram if I have breast implants?
4. What are the next steps if something looks suspicious?

Ultrasound

Ultrasound in most cases is performed for additional information to aide mammography or in extremely young people. Ultrasound is a method that does not use radiation, rather it uses sound waves to detect differences between types of tissue. The sound waves bounce off structures and produce waves that are made into a picture. In this way, immediate identification of a cystic or solid lump is obtained. Cysts, when identified this way can be managed with ultrasound guided techniques when fluid removal is necessary. When the breast tissue is very dense with fibrous tissue, such as in the young women or those with fibrocystic tissue without much fatty replacement, ultrasound can be very helpful in tissue separation. Because the mammogram may be more difficult to evaluate, the ultrasound will help identify any masses that may be obscured within the dense tissues.

MRI (Magnetic Resonance Imaging)

The MRI is performed for specific information, usually when the mammogram and ultrasound are inconclusive due extremely dense tissue or in certain cases for the patient with implants. Magnetic resonance imaging uses radio frequencies which are manipulated with magnets. The MRI is the most physiological of all the diagnostic tools. The information gained is typically used to evaluate the cellular activity which provides information to assist further diagnostic evaluation. The MRI is not approved at this time for breast screening.

Breast Biopsy

A breast biopsy is the final step in obtaining tissue to get a definitive diagnosis. There are several methods of performing breast biopsy. Biopsies are usually performed as fine-needle or large core aspirations which can be done under a stereotactic mammogram machine or under ultrasound guidance. For certain tissue abnormalities, such as microcalcifications that are scattered throughout the tissue or are very deep in the breast, a method of positioning a guided wire under mammographic control will precede an open biopsy. Once the tissue is removed, the surgeon submits it to the pathologist who subsequently examines the tissue specimen under a microscope. A final diagnosis of cancer can only then be made.

After the pathologist performs complete review of the tissue specimen, classification and staging is made. This provides the surgeon and oncologist with appropriate information to properly plan the type of surgery ( lumpectomy, sub-total mastectomy, radical mastectomy), chemotherapy options and radiation therapy recommendations. Each cancer stage and classification will necessitate a specific protocol of treatment.

1. Will I have a scar and what will it look like?
2. What are my choices of biopsy technique?
3. Will the entire lump be removed or just a part of it?
4. How long will it take to get the results?
5. Are there any other tests that can be used other than needle biopsy or surgery?

Risk Factors for Developing Breast Cancer

The main risk factors for the development of breast cancer include a strong family history or previous personal history of breast cancer. This is especially true if a woman’s mother, sister or maternal aunt had breast cancer diagnosed before menopause, or the woman’s father at any age. In certain families, there may be a history of cancer from other glandular organs such as ovarian cancer, colon cancer, prostate cancer, and uterine cancer as well as breast cancer. Women from these families have a higher chance of getting breast cancer.

Other risk factors are linked to the hormone estrogen during a woman’s life or the length of her reproductive years: early menstruation, late menopause, time elapsed between the onset of menstruation and birth of a woman’s first child and first trimester abortions. Studies on the use of birth of birth control pills have not proven that there is an increase in the future of breast cancer. While the use of estrogen replacement therapy has been associated with an increase risk for developing breast cancer, the issue is controversial. The health benefits of taking hormone replacement therapy are still being carefully scrutinized.

1. What are my risk factors for developing breast cancer?
2. If someone in my family has had breast cancer when do I need to start being checked?
3. Is there anything I can do to minimize my risk of getting breast cancer?
4. Is it safe for me to take hormone pills?