The Key:
Early Detection
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Reading a
Mammogram The mammogram is first checked by the technologist and then read by a diagnostic radiologist,
a doctor who specializes in interpreting x-rays. The
radiologist looks for unusual shadows, masses, distortions, special
patterns of tissue density, and
differences between the two breasts. The shape of a
mass can be important, too. A growth that is benign
(noncancerous) such as a cyst, looks smooth and round and has a clearly
defined edge. Breast cancer, in contrast, often has an irregular outline
with finger-like extensions.
Many mammograms show nontransparent white specks. These are calcium
deposits known as calcifications.
Macrocalcifications
are coarse calcium deposits. They are often seen in both breasts.
Macrocalcifications are most likely due to aging, old injuries, or
inflammations. They usually are not signs of cancer. Macrocalcifications are usually associated with benign
breast conditions; many clusters of macrocalcifications in one area may be
an early sign of breast cancer.
Microcalcifications
are tiny flecks of calcium found in an area of rapidly dividing cells.
Clusters of numerous microcalcifications in one area can be a sign of
ductal carcinoma in situ. (See DCIS, page 8.) About half of the cancers
found by mammography are detected as clusters of microcalcifications.
Reporting the
Results The radiologist will report the findings from your
mammogram directly to you or to your doctor, who will contact you with the
results. If you need further tests or exams, your doctor will let you
know. If you don't get a report, you should call and ask for the
results.
~ Don't simply assume that the
mammogram is normal
if you do not receive the results. ~
Your mammograms are an important part of your health history. Being
able to compare earlier mammograms with new ones helps your doctor
evaluate areas that look suspicious. If you move, ask your radiologist for
your films and hand-carry them to your new physician, so they can be kept
with your file. Always make sure that the radiologist who reads your
mammogram has the old films to use for comparison.
Mammograms and Breast Implants A
woman who has had breast
implants should continue to have mammograms. (A woman who has had
an implant following breast cancer surgery should ask her doctor whether a
mammogram is still necessary.) However, the woman should inform the
technologist and radiologist beforehand and make sure they are experienced
in x-raying patients with breast implants.
Because silicone implants are not transparent on x-ray, they can block
a clear view of the tissues behind them. This is especially true if the
implant has been placed in front of, rather than beneath, the chest
muscles.
Experienced technologists and radiologists know how to carefully
compress the breasts to avoid rupturing the implant. They can also use
special techniques to detect abnormalities, sliding the implant backward
against the chest wall, and pulling the breast tissue over and in front of
it. Interpreting the mammogram can also be difficult, especially if scar
tissue has formed around the implant or if silicone has leaked into nearby
breast tissues.
Choose a Mammography Facility Many
places--breast clinics, radiology departments of hospitals, mobile vans,
private radiology practices, doctors' offices--offer high-quality
mammography. Your doctor can arrange for a mammogram for you, or you can
schedule the appointment yourself. You can call NCI's Cancer Information
Service (1-800-4-CANCER) to find a mammography facility in your
community.
All facilities must be certified by the Food and Drug Administration
(FDA). (See Assuring High-Quality Mammography, page 13.) Staff of the
facility are required to post the FDA certificate in a prominent place; if
you don't see it, you should ask about certification. Without the FDA
"seal of approval," it is now illegal for mammographic facilities to
operate.
In addition to quality, another important consideration is cost. Most
screening mammograms cost between $50 and $150. Most states now have laws
requiring health insurance companies to reimburse all or part of the cost
of screening mammograms; check with your insurance company. Medicare pays
some of the cost for screening mammograms; check with your health care
provider or call the Medicare Hotline (1-800-638-6833) for details.
Some health service agencies and some employers provide mammograms free
or at low cost. Low cost does not mean low quality, however. A large
government survey found that some of the facilities charging the lowest
fees (often because they serve large numbers of women) were among the best
in terms of complying with high-quality standards.
Your doctor, local health department, clinic, or chapter of the
American Cancer Society, as well as NCI's Cancer Information Service at
1-800-4-CANCER (1-800-422-6237), may be able to direct you to low-cost
programs in your area.
Schedule a Regular Mammogram Early
detection of breast cancer is crucial for successful treatment, and
regular screening mammography is currently the best tool for early
detection. A 1993 survey by the National Center for Health Statistics
found that 60 percent of all women ages 40 to 49 got a mammogram in the
preceding 2 years, and 65 percent of women ages 50 to 64 had done so, but
only 54 percent of women ages 65 and over had been screened during
that time. It is clear that many women still do not get mammograms at
regular intervals. Sadly, the women least likely to have regular exams
include those at highest risk, women ages 60 and older.
The reason women most frequently give for having--or not
having--a
mammogram is whether or not the doctor suggested it. Although surveys show
that more doctors routinely advise women about mammography, some fail to
do so--because they forget, or because they assume that another doctor has
done so. If your doctor doesn't suggest mammography, it will be up to you
to raise the issue.
Other Techniques for
Detecting Breast Cancer
Clinical Breast
Exam
Most professional medical organizations recommend that a
woman have periodic breast exams by a doctor or nurse along with getting
regular screening mammograms. You may find it convenient to schedule a
breast exam during your routine physical.
The examiner will look at your breasts while you are sitting and while
you are lying down. You may be asked to raise your arms over your head or
let them hang by your sides, or to press your hands against your hips. The
examiner checks your breasts carefully for changes in the skin such as
dimpling, scaling, or puckering; any discharge from the nipples; or any
difference in appearance between the two breasts, including differences in
size or shape. The next step is palpation:
Using the pads of the fingers to feel for lumps, the examiner will
systematically inspect the entire breast, the underarm, and the collarbone
area, first on one side, then on the other.
A lump is generally the size of a pea before a skilled examiner can
detect it. Lumps that are soft, round, and smooth tend not to be
cancerous. An irregular, hard lump that feels firmly anchored within the
breast tissue is more likely to be a cancer. However, these are general
observations, not hard and fast rules.
~ The only sure way to know if
a solid lump
is cancer is to have some tissue removed
and examined
under the microscope. ~
A breast exam by a doctor or nurse can find some cancers missed by
mammography, even very small ones. In addition to the skill and
carefulness of the examiner, the success of a physical exam can be
influenced by your monthly cycle and by the size of your breast, as well
as by the size and location of the lump itself. Lumps are harder to find
in a large breast.
Currently, mammography and breast exams by the doctor or nurse are the
most common and useful techniques for finding breast cancer early. Other
methods such as ultrasound may be helpful in clarifying the diagnosis for
women who have suspicious breast changes. However, no other procedure has
yet proven to be more effective than mammography for screening women with
no symptoms; thus, most alternative methods of breast cancer detection are
used primarily in medical research programs.
Ultrasound
Ultrasound works by sending
high-frequency sound waves into the breast. The pattern of echoes from
these sound waves is converted into an image (sonogram)
of the breast's interior. Ultrasound, which is painless and harmless, can
distinguish between tumors that are solid and cysts, which are filled with
fluid. Sonograms of the breast can also help radiologists to evaluate some
lumps that can be felt but are hard to see on a mammogram, especially in
the dense breasts of young women. Unlike mammography, ultrasound cannot
detect the microcalcifications that sometimes indicate cancer, nor does it
pick up small tumors.
CT Scanning
Computed
tomography, or CT
scanning, uses a computer to organize and stack the information
from multiple x-ray, cross-sectional views of a body's organ or area. The
scans are made by having the source of an x-ray beam rotate around the
patient. X-rays passing through the body are detected by sensors that pass
the information to
computers. Once processed, the information is
displayed as an image on a video screen. CT can separate overlapping
structures precisely and is sometimes helpful in locating breast
abnormalities that are difficult to pinpoint with mammography or
ultrasound--for instance, a tumor that is so close to the chest wall that
it shows up in only one mammographic view.
Research on New
Techniques
Several new techniques for imaging the breast are in
the research stage. These include the use of magnetic
resonance imaging (MRI) and positron
emission tomography (PET scanning) to identify tissues that are
abnormally active. MRI uses a large magnet to surround the patient along
with radio frequencies and a computer to produce its images. PET scanning
uses signals from radioactive traces to construct images. Laser
beam scanning shines a powerful laser beam through the breast,
while a special camera on the far side of the breast records the
image.
Researchers are also striving to improve the detection power and
diagnostic accuracy of mammography. Digital
mammography is a technique for recording x-ray images in computer
code, improving the detection of breast abnormalities. Computer-aided
diagnosis, or CAD,
uses special computer programs to scan mammographic images and alert
radiologists to areas that look suspicious.
Finally, medical researchers are exploring the use of biological tests
to detect tumor markers for breast cancer in blood, urine, or nipple
aspirates.
Gene Testing for Breast
Cancer Susceptibility A breast cell progresses from normal to
cancerous through a series of several distinct changes, each one
controlled by a different gene or set of genes. Researchers have precisely
located the BRCA1
and BRCA2
genes, key regions within a woman's chromosomes
that control cell growth in breast tissue. A woman can inherit a mutation,
an alteration in these genes that are essential for normal growth of
breast cells, and this inherited change may put her at greater risk for
eventually developing breast cancer. The recent identification of genetic
changes in BRCA1 and BRCA2 makes a gene test possible.
Scientists estimate that alterations in
the BRCA1 and BRCA2 genes may be responsible for about 5 to 10 percent of
all the cases of breast cancer and for about 25 percent of the cases in
women under the age of 30. BRCA1 mutation testing is primarily done in
certain families whose members are inclined to develop breast cancer at an
early age because of an inherited change. Special counseling programs
occur before and after the testing to inform women about the possible
consequences of receiving test results. It is hoped that these genetic
tests may one day enable scientists to delay or prevent breast cancer in
high-risk families. Positive results may enable careful watchfulness when
appropriate; negative results may reassure those women in high-risk
families who are at no greater than average risk for breast cancer.
Scientists at NCI and elsewhere believe that tests for alterations in
genes that control growth in breast tissue and in other genes throughout
the body require careful study to establish their appropriate use. In
addition to BRCA1 and BRCA2, other genes and the proteins they control may
be involved in breast cancer, and much more needs to be learned about the
risk associated with particular genetic alterations. NCI supports research
on the development of new genetic tests offered within a research setting
and accompanied by genetic counseling. Counseling is important because
test results must be properly understood, and a counselor can help persons
with a positive test to handle possible discrimination in health or life
insurance or in the workplace.
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