By Kimberly Blaker
Twelve percent of women today will develop invasive breast cancer, and more than 40,000 will die from it this year alone, reports BreastCancer.org. That’s why a refresher course on early detection and staying up-to-date on the latest studies is important and the reason for October’s Breast Cancer Awareness Month.
Risk factors
There are several risk factors for breast cancer as identified by the American Cancer Society (ACS). Some of these are unchangeable but should be taken into account in developing a screening plan. Other risk factors are lifestyle-related. So, women, particularly those at higher risk, should consider the factors she can control.
Still, the simple presence of risk factors doesn’t mean you’ll go on to develop breast cancer. Likewise, the lack of risk factors doesn’t mean you won’t develop the disease. For this reason, all women should be aware of the risks and symptoms and what screening does and doesn’t do.
Some factors that are unchangeable and increase risk, according to the ACS, are female gender, aging, genetics, and race and ethnicity (white women are at slightly higher risk). A greater number of menstrual cycles, previous chest radiation, and exposure to the drug diethylstilbestrol (DES) also puts women at a slightly higher risk.
Other risk factors can often be controlled. Pregnancy and childbirth are one of these factors. According to the National Cancer Institute (NCI), having more than one child provides increased protection with each successive birth.
Women who breastfeed also reduce their risk of breast cancer, the NCI explains. The greater the total length of time spent breastfeeding during child-rearing years, the greater the protection.
Oral contraceptives, says the ACS, slightly increase risk. Though once a woman is off contraceptives for 10 years, that risk is no longer present.
Hormone therapy menopausal women is another risk factor. The ACS says estrogen alone is not a concern. For certain women, it can even slightly reduce the risk. But estrogen combined with progestin can increase risk.
Another risk factor is alcohol. Having one drink daily increases risk only slightly. But the greater the consumption, the greater the risk. More than 5 drinks daily increase the risk for other cancers as well.
After menopause, being overweight or obesity increases risk says the ACS. But as the organization explains, the risk of breast cancer related to weight is complex. Those who were overweight as a child may not be affected. The distribution of excess body fat may also play a role. Waist area fat, in particular, may be more significant in increasing risk than fat in other parts of the body, such as hips and thighs.
Exercise has been shown to decrease risk, though, according to a study by the Women’s Health Initiative. Just 1.25 to 2.5 hours of brisk walking each week can reduce risk by 18%.
Several factors that were previously believed to increase risk are now disproven or deemed highly improbable, according to ACS and Memorial Sloan Kettering. These include antiperspirants, bras, abortion or miscarriage, dense breasts, fibrocystic disease, and breast implants.
Factors that remain unclear because studies have produced conflicting results include diet and vitamins, environmental chemicals, tobacco smoke, and night work. These require further study to determine any relationship.
Symptoms
There are several signs to watch for that might be indicative of breast cancer. Though, most of these symptoms could be caused by something else, such as caffeine, menstrual periods, infection, or other illness or factors. If you notice any of these symptoms, see your health care provider to rule out breast cancer.
Symptoms include:
- A new lump or breast change that feels different from the rest of your breast
- A new lump or breast change that feels different from your other breast
- You feel something different that you’ve not previously felt
- Nipple discharge that occurs without squeezing the nipple
- Nipple discharge that occurs in only one breast
- Bloody or clear discharge, rather than milky
- Thickening, a lump or hard knot inside the breast or in the underarm area
- Breast swelling, warmth, or redness
- Change in breast shape or size
- Breast skin dimpling or puckering
- A sore or rash on the nipple, particularly scaly or itchy
- Your nipple or other parts of your breast pulling inward
- Sudden nipple discharge
- Pain in one spot that doesn’t go away
Early detection and screenings
Screenings are an important means for detecting breast cancer, hopefully, in its early stages.
Until more recently, women were encouraged to do a monthly self-examination. But a major study reported in The Journal of the National Cancer Institute in 2002, concluded self-examination has played no role in improving cancer detection. It also found the extensive teaching of self-examination leads to an increased rate of benign breast biopsies.
Clinical breast exams are also no longer recommended for average-risk women, says the ACS.
Mammography, believed to be one of the most crucial tools in early detection for decades, first started in the 1960s. Early trials found mammography reduced breast cancer death rates by 25%. But Peggy Orenstein points out in her 2013, New York Times article, “The Feel-Good War on Breast Cancer,” such statistics have overstated mammography’s role in the reduction of breast cancer death rates. This is because the increased use of mammograms occurred along with much-improved treatments. Medical experts now believe treatments likely played a greater role in reducing deaths.
For this reason, mammograms have come under fire in recent years as more studies have revealed the debatable usefulness of this screening technique, at least for younger women. That’s because breast cancer and detection are more complex than it was once understood to be.
It’s now known there are at least four types and subtypes of breast cancer. Mammography often doesn’t detect the more lethal types until they’re in the later stages. Add to this, mammograms result in significant overdiagnosis leading to unnecessary treatment. This comes with its own risks.
Doctor Deanna Attai, president of the American Society of Breast Surgeons, explains, “Ductal carcinoma in-situ [DCIS] is also referred to as noninvasive, or Stage 0 breast cancer. It is primarily diagnosed by screening mammogram, as it often does not form a palpable lump. DCIS accounts for approximately 20% of mammographically detected breast cancers. As screening mammography has become more prevalent, the rate of DCIS detection has increased.”
Some medical experts say DCIS is really not a form of cancer at all. Referring to it as such results in overly aggressive treatment. The likelihood of low-grade DCIS developing into invasive breast cancer is only 16%, says Dr. Attai. While high-grade DCIS has a 60% chance over 10 years. The problem is there’s currently no way to determine which cases of DCIS will ultimately develop into breast cancer. This creates a major dilemma.
What is known is breast cancer is the second leading cause of cancer deaths among women in the United States. It’s true various studies reveal mammography screening seems to have very limited usefulness among women under 40. Still, it’s moderately effective for detection in women ages 40-49 and is most effective for those in the 50-69 age group.
The results of recent studies have, therefore, revealed several needs. First, more study is needed to better answer questions about the approach to both detection and treatment. Additionally, better screening techniques should be developed for detecting the more deadly forms of breast cancer.
Currently, there’s much debate among medical and cancer organizations regarding the recommended frequency of mammography, particularly among women ages 40 and up. These various organizations point to different studies with different conclusions about mammography’s safety and effectiveness.
The latest cancer screening guideline by the ACS (2015) recommends women with average risk should begin regular mammography screenings at age 45. Then they should be screened annually until they reach 54. After that, they should transition to every two years, as long as they’re in good health with a life expectancy of at least 10 years.
The American College of Physicians (ACP) has done a rigorous analysis of numerous studies and the guidelines of several organizations. The ACP says the methodology used by several organizations in determining guidelines isn’t sound. The organizations that scored highest for use of sound methodology include the ACS, World Health Organization, The Canadian Task Force on Preventive Health Care, and the U.S. Preventive Services Task Force.
Based on the ACP’s findings, it recommends, “In average-risk women aged 40 to 49 years, clinicians should discuss whether to screen for breast cancer with mammography before age 50 years.” Physicians should discuss the potential harms and benefits with women. The potential harms, argues the ACP, outweigh the benefits for most women in the 40 to 49 year age range.
Finally, there’s no one-size-fits-all plan that works best. So, mammography screening for breast cancer should be based on informed decisions and individualized plans taking into account a woman’s age, risk factors, and both the advantages and disadvantages of mammography for each woman’s unique circumstances.
