• Menopausal women who are on hormone replacement should consider stopping their hormones one week prior to the exam.
• All women who are concerned about discomfort should consider taking ibuprofen or their favorite anti-inflammatory an hour before the examination.
• If you had a bad experience with your previous mammogram, tell the person setting up the equipment. In some cases, an experienced technician can make adjustments that will improve the experience.
With this exam, two other issues become important. The first is underarm deodorant, which should be avoided the day of the procedure (and all traces of prior deodorant should be washed off). Particles in the product, such as aluminum, can cause confusion and may lead to needless additional views. The second issue is the need for convenient clothing; women should wear a two-piece outfit with an easily removable top.
New Advances in Screening
Critics eagerly point out that screening mammograms fail to visualize many breast cancers, and, unfortunately, they are correct. One of the most frustrating aspects of my practice occurs when one of my patients, who for years has followed all of the early detection guidelines, is diagnosed with a late-stage breast cancer (see chapter ten). Fortunately, this situation is unusual.
The good news is that recent technology is coming to the rescue. One of the major advances in detecting cancers missed on mammographic screening is adding additional screening for the approximately 50 percent of patients who, on mammograms, are found to have dense breasts (see chapter fourteen).
Studies have demonstrated that the number of small cancers detected in women with dense breasts almost doubles when ultrasound is added.
A second fallback is the breast MRI, which is even more effective than ultrasound in detecting small cancers missed on mammograms. Because of the cost and inconvenience, we limit screening MRIs to women who are at very high risk for developing cancer, such as Angelina Jolie.
A third advance is tomosynthesis, or 3-D mammography. The 3-D mammogram is just what it states. Rather than the standard 2-D image of the breast, multiple images are taken. The images are fed into a computer and a three-dimensional image is provided. One recent study concluded that 3-D detected 27 percent more cancers than did screening with 2-D mammograms. In addition, there was a 15 percent reduction in need to call women back for additional views.
My Advice on Mammograms
Although some experts might conclude that my approach to screening is overly cautious, I am convinced it will save lives and lead to less aggressive treatment. In the long run, I believe it will prove to be cost-effective, considering the rapid increase in the expense of chemotherapy drugs.
I do agree with critics that women should be given an informed choice. The reality is that most primary care physicians, who are likeliest to order screening studies, do not have time to provide the information necessary for fully informed consent.
Although our primary goal in detecting cancers in women forty and over is to diagnose them before symptoms occur, it is not always possible. This is especially true in the underserved population, not because mammograms don’t work in this population, but because this population is less likely to participate in screening.
Knowing what to do about breast problems as they arise often means the difference between a potentially curable cancer and one in which the prognosis is poor. The answer to this problem is quite simple: Educate yourself. Just reading this book will provide you with more information than you will ever get from the vast majority of physicians.
WHAT I’D TELL MY DAUGHTER
• Start yearly mammograms at age forty (or earlier if high risk; see Appendix I).
• Start monthly self-exams at age twenty-one, and see your physician if you detect a new lump or other changes.
• Report spontaneous nipple discharge to your physician, but do not squeeze your breast looking for discharge.
• Breast pain is common so don’t worry unless it is in one spot and increasing in intensity.
For Women of Childbearing Age: Birth Control, Pregnancy, and Lactation
FINDING SMALL BREAST CANCERS during pregnancy and lactation is a huge challenge, mainly because significant changes take place in the size, shape, and texture of the breasts while women are pregnant or nursing. As a result, the diagnosis of breast cancer is often delayed, and delays can be associated with adverse consequences.
Since the problems of early detection during pregnancy are different from those of lactation, it is best to consider the two issues separately. However, this section covers a number of issues besides cancer. Amid lingering but mostly unfounded concern about birth control pills and breast cancer, we also discuss the surprising number of options for birth control that women now have available to them.
BIRTH CONTROL
The “pill” first became available to the public in 1960 and proved to be an immediate success. Despite ongoing controversies, its popularity has only increased with time. Millions of young American women are now on this medication and with good reason. Not only is the pill effective in protecting against an unwanted pregnancy, it also has other desirable benefits, including the reduction of mood swings, the limiting of heavy menstrual flow, the improvement of acne, and a lowering of the risk of developing ovarian cancer.
Although this form of birth control has proven to be safe and effective for the majority of women, it does have some limitations, and it is important that young women be aware of them. One significant concern is that the pill is not 100-percent effective. It is estimated that one in 100 women who take it will nevertheless become pregnant. The primary explanation for failure in some women is simple: Usually it’s because they forget to take it on a daily basis.
Another worry is that the pill may influence a woman’s risk of developing breast cancer. The standard combination tablet contains two hormones: estrogen and progesterone. Both are synthetic, or manmade, hormones, designed to match the two naturally occurring hormones in a woman’s body. The first BCPs (birth control pills), which were introduced in the 1960s, contained high levels of estrogen. It was subsequently shown that high-estrogen medications were associated with an increased risk of breast cancers. Today’s BCPs contain a much lower dose of estrogen—but even with these diminished doses, concerns linger about the pill’s safety.
Recent studies have clearly demonstrated that, for the vast majority of healthy young women, these fears are unfounded. The modern combination pill has become the first choice in birth control for most young women up to the age of thirty-five.
However, some users should strongly consider other options. Certainly, if you have either a personal history or a strong family history of breast cancer, an estrogen-containing BCP should be avoided. For example, if your grandmother was diagnosed with breast cancer in her eighties, the risk is inconsequential. But if your mother or sister was diagnosed before the age of fifty, alternative methods of birth control need to be considered.
Women who are concerned about their personal risk should discuss other types of birth control with a doctor, or go to a family planning clinic to get additional, specific information. It is also worth noting that women sometimes overestimate their personal risk, so expert advice on this subject is valuable in making an informed