Breast pain is one of the most common symptoms that send women to a breast care center. While it is unusual for a breast cancer to cause pain, it can be the first indicator of an underlying malignancy. Pain that is centered in one specific area and becomes more intense in a matter of weeks merits the attention of a specialist. For further details, see chapter six.
Breast Infections
Breast infections are relatively common in nursing women, an issue covered in chapter four.
In non-lactating females such infections are rare but require immediate medical attention. With most patients, the inflammatory process responds to standard antibiotics. After treatment, an attempt should be made to determine the root cause. Infections that don’t respond to antibiotics, or episodes that recur, should be referred to a breast care specialist.
MAMMOGRAMS
One of the biggest breakthroughs in the history of women’s health care was the development of screening mammography. Initial studies in the United States and Sweden demonstrated a 30 percent or greater reduction in breast cancer mortality for women undergoing screening mammography. With improvements in technology and a better understanding of who is at risk, there is now an incredible opportunity for making even more dramatic improvement in the rate of survival of this number-one cancer killer of young women.
That said, age is one of the critical factors that increases a woman’s chance of developing breast cancer. The older she gets, the greater her peril. By forty, vulnerability has reached the point where it’s appropriate to start routine annual mammographic screening—and as always, the goal is to detect small cancers before they cause symptoms or even before they grow large enough to be felt.
Despite the well-established benefits of mammographic screening, we’re seeing an increasingly strident disagreement over several issues: the best age to start, how often women should be tested, and the proper age to quit. This controversy will be explored in more detail in chapters fifteen and sixteen. It is first necessary to understand the basics of mammographic screening.
Screening vs. Diagnostic Mammogram
One of the first issues that needs clarification is the difference between a screening and a diagnostic mammogram. The screening mammogram is for women who are symptom free. They have no suspected breast lumps, no new patterns of breast pain, no nipple discharge, and basically no newly revealed breast symptoms. Diagnostic mammograms, on the other hand, are for women who have breast symptoms.
Women who are about to undergo their yearly screening exam should make certain they alert the technician or support staff about any recently discovered breast problems. Such symptoms will be reported to the radiologist (mammographer), who will then determine what additional procedures might be helpful to evaluate the new issues.
When to Start Screening
Despite all this recent controversy, there is a general consensus that starting mammographic screening at age forty saves lives. A government funded task force is now recommending women start mammographic screening at age fifty. However, this approach ignores an important group of women.
Approximately 20 percent—one out of five—cancers we see in our practice are in women under fifty. Patients with cancer who started mammographic screening at age forty tend to be diagnosed with small, treatable breast cancers, while most of the advanced cancers are found in patients who have never had a mammogram.
Self-proclaimed “experts” who advise that screening start at age fifty have two reasons: One is that most women in their forties have such dense breasts on mammographic imaging (see chapter fourteen) that it’s hard to find small cancers . . . and, besides, “we all know” that fewer women in their forties develop breast cancer than women over fifty. The other is the much-touted concern about the issue of false positive biopsies. When the radiologist sees a worrisome spot on the mammogram, a needle biopsy is recommended. It is well-known that many of these biopsies will prove to be benign. The chance of a false positive is higher for younger women, in large part because many of these women are receiving their first mammogram and there are no previous images to check. When previous films are available for comparison, the number of false positive biopsies drop.
As the critics of early screening point out, a great deal of anxiety occurs when a woman is told she needs a breast biopsy. They conclude that the anxiety associated with a false positive biopsy is just one more reason why starting screening at age forty is not justified.
The critics, however, are not fair and balanced. They manage to overlook the downside—the anxiety associated with a delayed diagnosis. In my experience, most women are willing to take the chance of a false positive when it’s associated with a potential for detecting a breast cancer at an earlier stage—that interval when treatment is less aggressive and the probability of survival is improved. As one of my patients noted, “Both ways it’s good news: Either my doctor caught a malignancy early, while it’s easily treatable, or I learn I don’t have cancer.”
My advice to patients: Start mammographic screening at age forty and do it yearly. This advice applies to women at normal risk for breast cancer. Those with strong family histories or others who have been exposed to radiation at a young age are followed more aggressively, which may include yearly clinical exams starting at age twenty-one, yearly MRIs starting at age twenty-five, and yearly mammograms starting at age thirty.
BI-RADS CLASSIFICATION
The American College of Radiology established a standardized reporting system called BI-RADS (or Breast Imaging Reporting and Data System) that is used by all mammography centers in the USA—a major advance, as before we had such a system screening reports were often difficult to interpret. All mammogram reports are given a final BI-RADS score ranging from zero to six.
• A category 0 report means additional imaging is required.
• Categories 1 and 2 indicate a completely normal exam. A category 2 score means something is seen on the mammogram, like a cyst, but because it is inconsequential, the exam is still considered to be normal. For both categories, a one-year follow-up is recommended.
• Category 3 indicates the presence of something that is probably benign. A six-month follow-up is indicated.
• Categories 4 and 5 indicate a cancer is suspected (more so in 5 than in 4) and a biopsy is mandatory.
• Category 6 means the diagnosis of breast cancer has been made and further treatment is required.
How Often to Do Screening
There is also ongoing controversy about how often to do mammographic screening. Some guidelines suggest every other year is sufficient. I am not convinced and will not be until there is more data to prove that this is just as safe as yearly.
When to Stop Screening
Limited data indicates that screening beyond age seventy-four saves lives. The explanation for ever selecting this particular age as an endpoint is that previous studies arbitrarily stopped with women older than seventy-four. Despite the lack of proof, I recommend that yearly screening continue as long as a woman remains in good health.
Tips for Women Undergoing Screening
The most common complaint about screening mammography is the pain that occurs when the breast is compressed. Although many women breeze through the process, there are others who dread the anticipated discomfort. A few steps can be taken to reduce apprehension.
• Menstruating women should