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A WORKBOOK FOR PATIENT’S & SURVIVORS
Introduction
The goal of this workbook is to facilitate communication between patients and
doctor regarding breast disease. When a women develops a breast lump or any new
abnormality or change in the breast she becomes involved in an often-confusing
process of evaluation and possible treatment. Facing a possible diagnosis of
breast cancer with the psychological implications of treatment makes this and
emotionally difficult situation.
Bosom Buddies, a volunteer organization that provides support for women with
breast cancer has underscored the gap which often exits between a patient and
her doctor. There are many questions that women are often too overwhelmed,
intimidated or frightened to ask. Many of the question in the workbook address
topics which survivors wish in retrospect they they had known more about and had
been able to ask.
A board certified radiologist with 30 years of experience and specialization in
breast disease and diagnosis, Marion Jabczenski, M.D. and Judy Sipes, R.T., R.M.,
R.D.M.S., a practicing mammographer and sonographer with 19 years experience
carefully composed this workbook. This was edited with loving care by a number
of women that have been where you are now and who understand what you are
experiencing. Take this book with you when you meet with your doctor and jot
down notes and questions. We also recommend you ask a close friend or relative
to go with you to your medical consultation. Remember too, there are women out
there who want to help. When you are ready to and need to talk to someone who
understands your fear, anger and questions, please call the volunteers at the
Bosom Buddies hotline 602 231 6648 or one of the organizations in your area.
Acknowledgements
We acknowledge all who have contributed to the publication of this workbook.
General Information About Breast Cancer
In 1995, approximately 182,000 women in the United States unwillingly became
members of a large and increasing sisterhood comprised of those diagnosed with
breast cancer. Most of these women were over 50 years of age. An estimated
46,000 mothers, wives, sisters, daughters, aunts and cousins died of breast
cancer in 1995. Second only to lung cancer, breast cancer is the leading cause
of cancer death in women. There has been a reported overall increase in the
incidence of breast cancer, which is partially attributable to increased
screening and earlier detection. However, the survival has increased. This is
almost certainly due to the fact that breast cancer is being diagnosed at
earlier stages. Although men too can get breast cancer it is quite rare
comprising only 1100 new cases per year.
Cancer begins when a single normal cell undergoes genetic changes referred to as
mutations. These changes result in loss of the normal mechanisms, which control
the rate of cell growth and division. Cancer cells grow much more quickly than
normal cells and instead of stopping, continue to divide and ultimately invade
the surrounding tissue. Under the microscope the cells have visibly abnormal
characteristics. They do not function like normal tissue and due to the
increased rate of metabolism they consume nutrient supply. Breast cancer arises
primarily from the main structural elements of the breast, ducts, and lobules.
The cancer, which arises from the genetic mutation eventually amasses into a
tumor.
Genetic Risks
The risks for Breast and Ovarian cancer can be inherited from your parents. If
you have any of the following in your medical history you may want to have your
risk assessed:
• A personal or family history of breast cancer before age 50.
• A personal or family history of ovarian cancer at any age
• A personal or family history of breast and ovarian cancer in the same
individual
• A family history of male breast cancer.
Breast Structure
The breast is a milk-producing fatty gland which is organized into lobes
arranged like petals of a flower. These contain smaller lobules that end in
little bulbs where milk can be produced. They are linked by the thin tubular
milk ducts which open onto the surface of the nipple in the center of the darker
skin called the areola. The breast is roughly circular in structure and shape
with a majority of tissue extending upward toward the armpit known as the
axillary tail. The breast has a very rich blood supply which increases
dramatically during pregnancy .
Breast volume increases as much as 50% before menstruation due to both the
increase in blood flow as well as fluid retention. Tremendous enlargement occurs
during pregnancy, with a fundamental change in the underlying structure of the
breast. With aging and after menopause there is both volume loss and replacement
by fatty tissue.
Discharge of clear or bloody fluid from the nipple may occur when when a woman
is not breast feeding. Although a bloody discharge is most often caused by a
non-cancerous growth within the milk duct, in a small percent it can be a sign
of breast cancer. Clear and bloody discharges should be evaluated by a breast
specialist. The best methods for evaluation will include cell cytology,
ultrasonography and ductography.
1. What kind of changes to the breast, that can be seen or felt are associated
with breast cancer?
2. Is it normal to have breast lumps during pregnancy or breast feeding? Should
these lumps be checked by a physician?
3. What should I do if I feel a lump under my arm?
4. What should I do if I notice a discharge from the nipple?
Breast Self Examination
Breast self-examination (BSE) is an important component of early detection of
breast cancer. Women should do breast self-exam on a monthly basis. The breast
changes in shape, size, and texture during the course of a woman’s life,
reproductive cycle and within the monthly hormone cycle. Many women are
uncomfortable about performing breast self-examination because they are not sure
what they should be feeling. The normal quality of the breast is “lumpy and
bumpy”. Benign fibrous lumps come and go monthly; however, lumps that persist
should be evaluated first by mammography and ultrasound. With regular
examination, women can develop familiarity with their breasts so that it becomes
easier to notice changes. The best time to perform self-examination is two to
three days after the end of the menstrual cycle when the breasts are smallest.
Many post-menopausal and post-hysterectomy women find the first of each month or
their birthdate as an easy way to remember BSE.
1. When do I do Self Examination, what am I looking for?
2. What should I do if my breasts are always lumpy?
3. What is the best way to perform BSE? Can you show me how to do it?
4. What should I do if I notice a difference?
Breast Lumps
It is important to know that most women will have some type of breast lump or
mass during their lives, and most of these tumors are not breast cancer. The
most common type of lump is a cyst, which is a fluid filled sac. Fibroadenomas
are solid, usually benign lumps which occur most often in younger women. Both
cysts and fibroadenomas may feel tender and change in size with your menstrual
cycle. An injury to the breast may cause bruising and scarring of the fat which
feels like a separate lump. However, a new lump or a lump that has changed in
size or shape should be promptly evaluated and diagnostically proven. An
immediate ultrasound can determine whether the formation is a cyst or a solid
tumor. While any of these lumps may be benign it is important that they first be
diagnostically proven through mammography or ultrasound. No matter what kind of
lump you feel, a diagnosis must be made with the appropriate diagnostic tool to
evaluate the nature of the lump.
The American College of Radiology has established guidelines for the management
of breast lumps. The paradigm is designed for standardization of diagnostic
protocols for evaluation based on use of specific clinical tools.
1. If I find a new breast lump do I need a mammogram?
2. What are the chances that a breast lump is cancer?
4. Does the breast lump need to be biopsied? What other types of tests can be
done to find out what it is?
Mammography
The mammogram is considered the gold standard for clinical evaluation of the
breast. Mammograms are performed with special x-ray machines designed
specifically for use of the breast and produce low dose x-rays. Dedicated
mammography machines provide specialized x-ray production that is ideal to
visualize the fatty and glandular tissues that make up the breast glands. Each
picture requires a certain amount of compression to see between the tissue and
allows the radiation dose to be kept at a minimum. Abnormalities are detected
from the mammogram pictures through a series of evaluations that include
identifying architectural changes, skin changes, microcalcific clusters, changes
from previous mammograms and mass formations. Each finding in turn may require
additional pictures. All certified radiologists must follow a strict guideline
specifically for mammography interpretation. This is a requirement by the FDA
and the ACR (American College of Radiology) that licenses each certified
facility.
Magnification of an area utilizes the mammography equipment to enlarge the
picture. Calcifications are usually magnified for proper identification type and
amount characteristics. There are many causes of microcalcifications, which are
small deposits of calcium within the breast tissue that cannot be felt but can
be visualized well on mammography. Causes of microcalcifications include
infection, previous trauma and changes in blood flow. Microcalcifications can
also be a sign of breast cancer.
Women who have implants should have a mammogram that includes a technique for
implant displacement. Current recommendations for mammography includes a
baseline between 35 and 40 years for all women, and high risk women should begin
before forty and all women should have yearly mammograms from age 40 years on.
1. Do I need a mammogram?
2. When is the best time to get a mammogram?
3. Is it okay to have a mammogram if I have breast implants?
4. What are the next steps if something looks suspicious?
Ultrasound
Ultrasound in most cases is performed for additional information to aide
mammography or in extremely young people. Ultrasound is a method that does not
use radiation, rather it uses sound waves to detect differences between types of
tissue. The sound waves bounce off structures and produce waves that are made
into a picture. In this way, immediate identification of a cystic or solid lump
is obtained. Cysts, when identified this way can be managed with ultrasound
guided techniques when fluid removal is necessary. When the breast tissue is
very dense with fibrous tissue, such as in the young women or those with
fibrocystic tissue without much fatty replacement, ultrasound can be very
helpful in tissue separation. Because the mammogram may be more difficult to
evaluate, the ultrasound will help identify any masses that may be obscured
within the dense tissues.
MRI (Magnetic Resonance Imaging)
The MRI is performed for specific information, usually when the mammogram and
ultrasound are inconclusive due extremely dense tissue or in certain cases for
the patient with implants. Magnetic resonance imaging uses radio frequencies
which are manipulated with magnets. The MRI is the most physiological of all the
diagnostic tools. The information gained is typically used to evaluate the
cellular activity which provides information to assist further diagnostic
evaluation. The MRI is not approved at this time for breast screening.
Breast Biopsy
A breast biopsy is the final step in obtaining tissue to get a definitive
diagnosis. There are several methods of performing breast biopsy. Biopsies are
usually performed as fine-needle or large core aspirations which can be done
under a stereotactic mammogram machine or under ultrasound guidance. For certain
tissue abnormalities, such as microcalcifications that are scattered throughout
the tissue or are very deep in the breast, a method of positioning a guided wire
under mammographic control will precede an open biopsy. Once the tissue is
removed, the surgeon submits it to the pathologist who subsequently examines the
tissue specimen under a microscope. A final diagnosis of cancer can only then be
made.
After the pathologist performs complete review of the tissue specimen,
classification and staging is made. This provides the surgeon and oncologist
with appropriate information to properly plan the type of surgery ( lumpectomy,
sub-total mastectomy, radical mastectomy), chemotherapy options and radiation
therapy recommendations. Each cancer stage and classification will necessitate a
specific protocol of treatment.
1. Will I have a scar and what will it look like?
2. What are my choices of biopsy technique?
3. Will the entire lump be removed or just a part of it?
4. How long will it take to get the results?
5. Are there any other tests that can be used other than needle biopsy or
surgery?
Risk Factors for Developing Breast Cancer
The main risk factors for the development of breast cancer include a strong
family history or previous personal history of breast cancer. This is especially
true if a woman’s mother, sister or maternal aunt had breast cancer diagnosed
before menopause, or the woman’s father at any age. In certain families, there
may be a history of cancer from other glandular organs such as ovarian cancer,
colon cancer, prostate cancer, and uterine cancer as well as breast cancer.
Women from these families have a higher chance of getting breast cancer.
Other risk factors are linked to the hormone estrogen during a woman’s life or
the length of her reproductive years: early menstruation, late menopause, time
elapsed between the onset of menstruation and birth of a woman’s first child and
first trimester abortions. Studies on the use of birth of birth control pills
have not proven that there is an increase in the future of breast cancer. While
the use of estrogen replacement therapy has been associated with an increase
risk for developing breast cancer, the issue is controversial. The health
benefits of taking hormone replacement therapy are still being carefully
scrutinized.
1. What are my risk factors for developing breast cancer?
2. If someone in my family has had breast cancer when do I need to start being
checked?
3. Is there anything I can do to minimize my risk of getting breast cancer?
4. Is it safe for me to take hormone pills?
Source :
http://www.bcfaz.com/articles/guidelines.html