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The Importance of Mammography

Olive Peart

Program Director – Fortis College, Landover

www.opeart.com

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Objectives

Definition

Breast Cancer Stats

Breast Anatomy

Breast Cancer Risks

Screening Guidelines

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What is Breast Cancer?

Breast cancer is a disease condition that develops in the breast.

Cells in the ducts or lobules of the breast begin an uncontrolled growth

Earliest know breast cancer documentation was in 1600BC

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Breast Cancer Today

2^nd most common cancer in women in US
Can occur in men but is far more common in women
Overall, the cancer survival rates have increased

Early detection #1 reason

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Caribbean Stats

Higher mortality rate compared with North American and European countries which have higher incidence rates
Leading cause of cancer deaths in 21 of 23 Caribbean territories

Caribbean suffers higher mortality comparable to that of Africa
In Dominica (2003 -2013) breast cancer was the leading cause of cancer death among women

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Areas of Concern

Approximately 42,000 women a year still die of breast cancer, and about one in eight women will be diagnosed with invasive breast cancer in their lifetime
Black women have the highest death rate from breast cancer

Mostly due to the type of cancer many Black women have

TNBC has limited treatment options, is prone to recurrence and metastasis, and has a poor prognosis

Barriers to accessing breast cancer services include both financial and personal

Limited screening locations, transportation concerns, fear of the technology, fear of the results and/or language barriers

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Special Needs

Culturally sensitive care – promoting trust between patient and provider
Collaboration and coordination with local agencies – follow-up on positive results
Provide initial and follow-up care – financial support/transportation
Provide outreach – promote screening/provide education

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Breast Anatomy

Nipple

Center point of breast
15-20 orifices or collecting ducts
Can be flattened or inverted normally

Areola

Circular darkened area around nipple

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Breast Facts

One breast is often bigger than the other. This may be more pronounced in women who have nursed babies.

For the majority of women, the left breast is the bigger one. The difference in boob size can be up to 20 percent.

The breast the baby prefers then to be more stretched out

Source: health.com. May 2015

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Breast Facts

Nipples vary in size as well as shape.
They can also point in different directions.

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Breast Cancer Treatment

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Breast cancer is not an emergency

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Second opinions are often recommended

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Treatment options include surgery, radiation, drugs – or any combination

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Treatment cannot begin until stage, size & location of cancer is known

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Important Cancer Facts

Staging

How extensive is the cancer?
Is there distant metastasis?

Tumor size, margins, lymph node involvement

Antibodies, enzymes or proteins

Estrogen (+ or -)
Progesterone (+ or -)
HER-2 (+ or -)

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Stage grouping classifies breast cancer patients in four stages (stages 0–IV). A cancer’s stage depends on the extent of the primary tumor, the spread of the cancer to regional lymph nodes, and whether there is distant metastasis. In staging, lower numbers represent less spread of the cancer. The tumor, represented by the letter T, describes the size of the cancer.

Estrogen receptor (ER+), progesterone receptor (PR+), human epidermal growth factor receptor 2 (HER-2), HER-1, and cytokeratin 5/6 (CK 5/6). The protein receptors control how the breast cells divide and repair themselves. Cancers with the ERBB2 protein marker do not respond to treatment ,with tamoxifen or other antiestrogen drugs.

The ERBB2 gene makes HER2 protein and, normally, HER2 receptors help control how a healthy breast cell grows, divides, and repairs itself. When the gene malfunctions in a process known as gene amplification, HER2 receptors are overproduced, leading to uncontrolled growth of breast tissue cells

HER2 gene (HER2-positive cancers) produce too much of the growth-promoting protein called HER2. Targeted therapy drugs are available to shut down the HER2 protein, thus slowing the growth and killing these cancer cells.

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What Are My Risks?

There is no absolute risks.
But risks can be divided into 2 basic categories

Risks associated with lifestyle
Risks that are genetic

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Abortion and Breast Cancer

Myth vs. Fact

Abortion will increase breast cancer risk

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Researched Results

Terminating an unintended pregnancy sacrifices the protective effect of a term delivery – results in delay childbearing

Delayed pregnancy and the loss of protection creates the net effect of an increased risk

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Age

Myth vs. Fact

After being cancer free for 65 yrs. you do not need a mammogram

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Researched Results

Each woman’s breast cancer risk is based on population averages, however, as a woman ages her risk of getting cancer also increases

Under 30 – 0.3% of breast cancer cases
30’s – 3.5% of breast cancer cases
40’s - 18% of breast cancer diagnosed
Over 50 – 77% of breast cancer diagnosed

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Alcohol

Myth vs. Fact

Drinking alcohol will increase breast cancer risk

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Researched Results

Research from Kaiser Permanente followed 1, 897 women (2009)

Alcohol increases the circulation levels of estrogen and increase estrogen metabolism causing cancers to grow

Moderate alcohol consumption can cause a modest increase in breast cancer risk

Heavy drinking - 4 or more drinks a day – doubles risk

Women who drank 3-4 glasses of wine were 34% more likely to have a recurrence of breast cancer. Risks greater with post-menopausal and overweight women.

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Antiperspirants

Myth vs. Fact

Antiperspirants can cause breast cancer

Prevent the armpits from purging cancer toxins through sweat
Toxins accumulate in the lymph nodes
Chemical in antiperspirants are absorbed in the skin causing cancer

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Researched Results

Toxins are eliminated by the kidneys not through sweat

Sweat consist mainly of minerals and water

If antiperspirant is absorbed & stored in armpit (as toxins) – cancer should develop in armpit not the breast

Lymph drains (through one-way valves) AWAY from the breast not TO the breast

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Breast Cancer Is an Emergency

Myth vs. Fact

A diagnosis of breast cancer is an emergency and needs immediate surgery

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Researched Results

A cancer can take 6-8 years to grow from 1 cell to 1cm

A palpable lump could have taken 8-10 years to grow

Proper staging, second opinions and full exploration of all options is the best policy

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Dense Breast

Myth vs. Fact

Age and not the density of breast tissue will determine a woman’s risk of developing breast cancer

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Researched Results

Women with dense breast face a higher risk of missed breast cancer if the mammogram is the only screen tool used
Density is a factor in breast cancer risks in younger women.

Breast cancers tend to develop in the glandular tissue. Women with dense breast tissue therefore at a higher risk of developing breast cancer than a woman of the same age with fatty breast.

Breast ultrasonography, 3D digital mammogram or MRI are more accurate than 2D mammography for assessing tumor size in breasts with a higher BD

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Cancer

Myth vs. Fact

Having ovarian, uterus or colon cancer increases your risk of developing breast cancer

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Researched Results

Ovarian cancer slightly increase the risk of breast cancer

Uterine (endometrial) or colorectal cancer doubles the risks of breast cancer

Risks will increase significantly if women also carry the BRCA1 or BRCA2 gene

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Coffee Use

Myth vs. Fact

Caffeine in coffee will increase symptoms of fibrocystic disease therefore breast cancer

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Researched Results

Fibrocystic breast is not a disease
However, the density associated with fibrocystic change can make breast cancer more difficult to detect with mammography
Caffeine has no effect on breast cancer

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Exercise & Breast Cancer

Myth vs. Fact

Exercise will substantially lower risk of breast cancer

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Researched Results

Study by Washington University School of Medicine in St. Louis and Harvard University in Boston . Published in Journal of the National Cancer Institute-2009

Girls and young women who exercise regularly between the ages of 12 and 35 have substantially lower risk of breast cancer before menopause compared to those who are less active

Physically active women had 23% lower risk of breast cancer

Activity equivalent of running 3.25 hours a week or walking 13 hours a week

Benefit not linked to intensity of exercise but to total activity

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Family History - Immediate

Myth vs. Fact

If breast cancer is not in your family, you will not get it

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Researched Results

70% - 80% of women who get breast cancer have no known family history of the disease

Age – normal wear & tear on the body – is the is biggest risk factor for breast cancer

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Family History – Mothers’

Myth vs. Fact

Only your mothers’ family history of breast cancer can affect your risk

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Researched Results

Half your genes comes from your mother and half from your father, therefore both parents will influence your cancer risk.

However, a man with an abnormal breast cancer gene is less likely to develop breast cancer than a woman with a similar gene.

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Genetic Link��

Myth vs. Fact

Having the BRCA1 or BRCA2 gene means you will get breast cancer

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Researched Results

Only 5 - 10% of breast cancer cases are associated with the abnormal genes
20 – 60% of patient with these genes will never get breast cancer
80% of women who get breast cancer have no identifiable risk factors
Other genes can modify the BRCA1 & BRCA2

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Gender

Myth vs. Fact

Males will not get breast cancer

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Researched Results

Only about 1,600 male get diagnoses with breast cancer each year
Incidence of breast cancer in males has increased 25% in the past 20 years
Breast cancer kills 25% of men who develop it

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�High-Fat Foods �

Myth vs. Fact

High-fat foods increase breast cancer risk

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Researched Results

Healthy choice in eating is a good option
NO definitive link found... However,

Excess body weight = extra fat = increases estrogen outside of the ovaries
Postmenopausal obesity & having fat stores in the waistline linked to increased breast cancer risks
Lignans – found in whole grains & vegetable – lowers hormone levels and cancer in postmenopausal women
Grapefruit has enzyme – CYP 3A4 – which increase body estrogen, but no related increased risk found

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Hormone Therapy (HT)

Myth vs. Fact

HT causes breast cancer

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Researched Results

HT - combining estrogen and progestin – taken for 5-years will double your risks
Estrogen only therapy - carries lower risks of breast cancer but increase risks of endometrial cancer
HT associated risk returns to normal within 2-yrs after stopping HT

(Women’s Health Initiative (WHI) study conducted on women over 60. Advice low dose for shortest possible time)

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Injury to the Breast

Myth vs. Fact

Trauma or injury to the breast can cause cancer

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Researched Results

Trauma or injury can cause hematoma or fat necrosis and the signs & symptoms can be mistaken for a lump or abnormal scarring
A cancer can be found after the injury but the two events are not related

Eur J Cancer Prev. 2002 Jun;11(3):307-11
Approximately 200 women aged 50-65 years

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Breast Facts

6% of people have accessory breast tissue

Extra breasts can lactate and respond to regular hormonal fluctuations, for example, become more sensitive during menstruation which is often the first time women notice it (women are more prone than men, although men also get it).

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Lumps & Breast Cancer

Myth vs. Fact

All lumps are cancerous

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Researched Results

Majority of breast lumps are benign
However, lumps - especially new or hard immovable lumps - can be a sign of breast cancer and should be investigated.

While a breast lump can certainly be a sign of breast cancer (as well as a number of non-cancerous conditions), not all women who are diagnosed with breast cancer will have a noticeable lump. Therefore, women should check for the following warning signs while performing monthly BSE:

Any new lump found in the breast or armpit

Any lump or thickening that does not shrink or lessen after your next period

Any change in the size, shape or symmetry of your breast

A thickening or swelling of the breast

Any dimpling, puckering or indention in the breast

Dimpling, skin irritation or other change in the breast skin or nipple

Redness or scaliness of the nipple or breast skin

Nipple retraction: turning or drawing inward or pointing in a new direction

While one or more of these changes warrants clinical examination, these changes do not mean that a woman has breast cancer. In addition, breast cancer can be present without any symptoms.

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Mammography Accuracy��

Myth vs. Fact

Mammography is 100% accurate

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Researched Results

Mammography detects 85-90% of all breast cancers
Accuracy is helped by:

Regular comparison studies
Regular mammograms
Using adjunctive imaging therapy
Skills of the radiologist & mammographer

Mammography is the most accurate screening tool for breast cancer. It is estimated that mammography detects 85% to 90% of all breast cancers. While annual screening mammograms will detect the vast majority of breast cancers, some cancers are extremely aggressive and can metastasize (spread) to other areas of the body before they are detected by mammogram , some are simply not detectable. In general, breast cancer has a slow rate of growth.

to help detect breast cancer early women 20 years of age and older should perform breast self-examination (BSE) every month. Women 20-39 should have a clinical breast examination (CBE) at least every three years in addition to monthly BSE.

Women 40 and older should practice monthly BSE, have CBE performed by a health care professional every year, and have mammograms every year to two years.

If a patient has a lump or other change and the mammogram is "negative" (interpreted as not suspicious or cancerous), the patient should still pursue that finding with her physician.

A study published in the Journal of the National Cancer Institute found that radiologists who read more than 300 mammograms a month were more accurate

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Mammography Value

Myth vs. Fact

Mammograms are worthless for younger patients and will not lower a woman’s risk of dying from breast cancer

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Researched Results

The sensitivity of the mammogram varies with breast tissue type and with age
Studies on regular screening of younger women are often inconclusive
Other factors to consider ability of the radiologist, utilization of additional imaging, adjunctive modalities and comparison studies

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Nipple Discharge

Myth vs. Fact

Nipple discharge is always cancerous

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Researched Results

Only 10% of all nipple discharge is abnormal

Clear, milky, yellow, green discharge are mostly normal
Bloody, brown or brackish discharge are mostly abnormal but can be associated with non-cancerous papillomas
20% of women experience nipple discharge during self-examination

Most nipple discharge do not indicate a cancerous condition. Up to 20% of women may experience spontaneous milky, opalescent, or clear fluid nipple discharge. Up to 60% of women experience nipple discharge during breast self-examination. Usually, if the discharge is clear, milky, yellow, or green, it does not indicate cancer. Bloody or watery nipple discharge is considered abnormal; however, only 10% of abnormal discharges are cancerous. Most bloody discharges are due to non-cancerous papillomas. Women should report any worrisome nipple discharges to their physician for clinical examination

Nipple discharge may be a concern if it is:

bloody or watery (serous) with a red, pink, or brown color

sticky and clear in color or brown to black in color (opalescent)

appears spontaneously without squeezing the nipple

persistent

on one side only (unilateral)

a fluid other than breast milk

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Oral Contraceptive

Myth vs. Fact

The birth control pill increases breast cancer risk

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Researched Results

Older birth control pills were associated with a slight increased risk
The modern birth control pill is not associated with any cancer risk, even after prolonged use

Exception:

Women carrying the BRCA1 gene – the pill can increase breast cancer risk
Women younger than 21 - if pill is taken over 10 years

The higher dose contraceptive pills used in the past were associated with an small increased risk for breast cancer but only in a few studies. Modern Birth control pills do not cause breast cancer, even after prolonged use (10+ years).

oral contraceptives contain small amounts of estrogen and progesterone (hormones often linked with increased risk over time), but the amount of these hormones is too small to pose a noteworthy risk. Today, most women are prescribed "low-dose" formulas which contain less than 50 micrograms of estrogen (50% to 100% less estrogen than most birth control pills contained before 1975).

Low-dose formulas were developed to ease bothersome side effects of the regular-dose pill such as bloating.

A definitive new study of 9,000 women, published in the June 2002 issue of the New England Journal of Medicine, found that use of the Pill had no effect on lifetime breast cancer risk. What’s more, the results showed that neither the length of time women had been on the Pill nor the dose of estrogen in their contraceptive of choice could predict the disease, says senior study author Robert Spirtas, Ph.D., chief of contraception and reproductive health at the National Institute of Child Health and Human Development

Another study of 3,383 cases of breast cancer from 1976 to 1992, no overall relationship was noted between the duration of oral contraceptive use and breast cancer risk, even among women who used oral contraceptives for more than 10 years. For women who began taking oral contraceptives after 1975 no significant risk of breast cancer has been noted even among those with a family history of breast cancer.

Still, women at high risk for breast cancer should discuss any concerns about oral contraceptives with their physicians

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Mastectomy

Myth vs. Fact

A mastectomy guarantees that the cancer will not recur at the site of the mastectomy

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Researched Results

8 – 10% of women will have a recurrence in the scar after a mastectomy
Before the mastectomy, the cancer could have already spread to the lymph nodes or other areas of the body.

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Menarche

Myth vs. Fact

Early menarche i.e. onset of menstruation before age 12 increases breast cancer risk

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Researched Results

Early onset of menstruation means longer lifetime exposure to estrogen, which could increase your risk of breast cancer

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Menopause

Myth vs. Fact

Late menopause increase your breast cancer risk

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Researched Results

Breast cancer risk rises by about 3 percent for each year of delayed menopause

"Delayed" means onset after age 51, the average age of menopause for women in the United States.

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Painful Breast Lump

Myth vs. Fact

A painful breast lump is always benign

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Researched Results

Pain, especially bilateral pain, is less likely to be associated with breast cancer
However, 10% of invasive breast cancers are associated with pain

Cancers can form within a cyst – intracystic carcinoma

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Pregnancy

Myth vs. Fact

Women who have had breast cancer should not become pregnant
High estrogen levels during pregnancy will cause cancers to grow

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Researched Results

The hormonal & metabolic changes that occur during pregnancy have not been shown to have any noticeable effect on long-term breast cancer prognosis
Breast cancer survivors should consult their physicians before planning a pregnancy

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Pregnancy & Breast Feeding

Myths vs. Fact

Never having children increase your breast cancer risk
Breast feeding decrease your breast cancer risk

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Researched Results

Never having children or giving birth at a later age (over age 30) nearly doubles the risk of breast cancer
Breastfeeding at any age lowers risk

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Prophylactic Mastectomy

Myth vs. Fact

A prophylactic mastectomy will prevent breast cancer

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Researched Results

Some studies shows it can reduce the risk by 90%
A woman is at risk as long as there is breast tissue present

Breast tissue extending to the neck, under the arms, and into the chest wall will not be removed

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Risk Factor��

Myth vs. Fact

Having a risk factor for breast cancer means that you are sure to get cancer

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Researched Results

Risk factors gives only the probability of breast cancer and are not a certainty, even if you have a strong risk factor
Also 80% of women get breast cancer and have NO identifiable risk factors

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Statistic - "One in Eight "

Myth vs. Fact

The statistic "one in eight women will develop breast cancer," means that if eight women are randomly selected, then one of those eight women is guaranteed to get breast cancer

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Researched Results

The risk is calculated over a lifetime - i.e. to age 95

If a large group of girls are tracked, approx. 12.5% would develop breast cancer sometime in her lifetime

The one-in-eight-women statistic is not a per year estimate. Rather, it is calculated over a lifetime to age ninety-five. If researchers were to follow a large group of girls born today and track them until they became ninety-five years old, then one out of every eight of those girls (approximately 12.5%) would develop breast cancer sometime in her lifetime.

The good news is that seven out of eight people will never get breast cancer.

The widely quoted "one in eight" figure applies to a woman closer to the end of her lifetime. A 20-year-old, for example, has a one in 2,500 chance of developing breast cancer in the next ten years, and a 30-year-old's probability is one in 250 in the next decade. At age 40, it's one in 67; from 50-60, it's one in 30, and from 60-70 it's one in 29. The one-in-eight risk is a cumulative lifetime risk of developing breast cancer if you live at least to age 85.

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Race and Breast Cancer

Myth vs. Fact

Black women get a more aggressive form of breast cancer
White women have a higher incidence of breast cancer

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Researched Results

After 5ys - 86% of whites with a diagnosis of breast cancer are alive vs. 71% of blacks
Experts attribute the difference to

Poorer access to health care among blacks
Poor treatment planning

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Radiation

Myth vs. Fact

Past radiation treatment will increase your breast cancer risk

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Researched Results

Women who have had chest wall radiation - e.g. for Hodgkin’s lymphoma - are significantly likely to develop breast cancer later in life
Primary radiation to breast tissue during the adolescent years will increase your risks.

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ACR Screening Guidelines

Women ages 40 to 44

Start annual breast cancer screening with mammograms if they wish to do so.

Women aged 45 to 54

Mammograms every year.

Women 55 and older

Mammograms every 1 or 2 years

Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer

American Cancer Society

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Medical History Documentation

Family or personal history of breast cancer
History of breast surgery

Biopsies, lumpectomy, augmentation, reduction

History of breast trauma

Symptoms

Skin thickening
Unusual lumps
Dimpling/puckering
Moles, eczema, ulcers
Nipple changes

Abnormalities

Accessory breast/nipple

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Breast Compression

Makes the breast more uniform by reducing tissue thickness
Reduces radiation dose to the breast
Brings lesions closer to the IR
Reduces the possibility of motion
Increases contrast by reducing scattered radiation
Separates superimposed areas

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Avoiding Painful Mammogram

Communication
Use of pain medication
Avoid caffeine
Planned scheduling
Patient assumes control

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Why Supplementary Projections

Image the non-conforming patient

Suspicious area seen on one projection only

Suspicious area needs work-up to avoid the trauma of surgery

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Imaging Modalities

Digital mammography – 2D
3D mammography – Digital Breast Tomosynthesis (DBT)
Ultrasound
Magnet Resonance Imaging (MRI)
Molecular imaging

PEM – FDG
Breast scintigraphy/
Lymposcintigraphy/sentinel node mapping

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Fact

A Good Bra is...��Hard to Find,�Supportive,�Comfortable,�Always Lifts You Up,

Never Lets You Down or Leaves You

Hanging,� And Is Always Close To Your Heart!!!

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Thank You!

Olive Peart
olive@opeart.com
www.opeart.com

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References:

Samaroo, K., Hosein, A., Olivier, L. K., & Ali, J. (2021). Breast Cancer in the Caribbean. Cureus, 13(8), e17042. https://doi.org/10.7759/cureus.17042. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8428164/
Leading causes of cancer mortality - Caribbean region, 2003-2013. Razzaghi H, Quesnel-Crooks S, Sherman R, et al. https://www.cdc.gov/mmwr/volumes/65/wr/mm6549a3.htm. MMWR Morb Mortal Wkly Rep. 2016;65:1395–1400. [PubMed]
National Center for Health Statistics, National Vital Statistics Reports, Vol. 48, No. 11, July 24, 2000.
Myths and Facts, American Cancer Society; www.cancer.org/NBCAM_myths_vs_facts.html
National Alliance of Breast Cancer Organizations, "Facts About Breast Cancer in the U.S.A." February 2001.
“Myths Abound on the Internet," Breast Cancer Action Newsletter #56, October/November 1999.
Robert T. Greenlee, Ph.D., M.P.H., Mary Beth Hill-Harmon, M.S.P.H., Taylor Murray, Michael Thun, M.D., M.S., "Cancer Statistics, 2001," CA, A Cancer Journal for Clinicians 2001;51:15-36.
http://www.acr.org/SecondaryMainMenuCategories/BusinessPracticeIssues/FeaturedCategories/MedicalLiability/BreastCancerRanksHighforMalpracticeClaimsDoc1.aspx
http://www.msnbc.msn.com/id/16673818/
http://www.medicalnewstoday.com/articles/80168.php
Peart O. Mammography and Breast Imaging: Prep. New York, NY: McGraw-Hill, 2012.