Updated Guidelines for Early Breast Cancer Detection
The American Cancer Society has updated its guidelines for early breast cancer detection and suggests that women with an unusually high risk of developing breast cancer should receive annual MRIs as well as mammograms. In addition, a new medical study recommends that all women newly diagnosed with breast cancer should get MRIs. However, MRI screening is not recommended for most women, because of a high rate of false-positive results. Women should discuss screening options with their doctor to determine the most appropriate tests for their individual risk level. Early screening is considered the most effective way to detect breast cancer, even before any symptoms appear.
"American Cancer Society Recommendations for Early Breast Cancer Detection:
- Women age 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health.
- Womens in their 20s and 30s should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional preferably every 3 years. After age 40, women should have a breast exam by a health professional every year.
- BSE (breast self exam) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away.
- Women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15-20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%."
The following excerpt from the Breast Cancer Guide of the American Cancer Society's website provides detailed recommendations for each of the following screening methods: mammogram, clinical breast exam (CBE), breast self exam (BSE), and MRI.
Mammogram: "A mammogram is an x-ray of the breast. A diagnostic mammogram is used to diagnose breast disease in women who have breast symptoms. Screening mammograms are used to look for breast disease in women who are asymptomatic; that is, they appear to have no breast problems. Screening mammograms usually involve 2 views (x-ray pictures) of each breast. For some patients, such as women with breast implants, additional pictures may be needed to include as much breast tissue as possible. Women who are breast-feeding can still get mammograms, although these are probably not quite as accurate.
Although breast x-rays have been performed for more than 70 years, the modern mammogram has only existed since 1969. That was the first year x-ray units specifically for breast imaging were available. Modern mammogram equipment designed for breast x-rays uses very low levels of radiation, usually a dose of about 0.1 to 0.2 rads per picture.
Strict guidelines are in place to ensure that mammogram equipment is safe and uses the lowest dose of radiation possible. Many people are concerned about the exposure to x-rays, but the level of radiation used in modern mammograms does not significantly increase the risk for breast cancer.
To put dose into perspective, if a woman with breast cancer is treated with radiation, she will receive around 5,000 rads (a rad is a measure of radiation dose). If she had yearly mammograms beginning at age 40 and continuing until she was 90, she will have received 20 to 40 rads. As another example, flying from New York to California on a commercial jet exposes a woman to roughly the same amount of radiation as one mammogram.
For a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. Although this may be uncomfortable for a moment, it is necessary to produce a good, "readable" mammogram. The compression only lasts a few seconds. The entire procedure for a screening mammogram takes about 20 minutes. This procedure produces a black and white image of the breast tissue on a large sheet of film that is read, or interpreted, by a radiologist (a doctor specially trained to interpret images from x-rays, ultrasound, MRI, and related tests)."
Clinical Breast Exam (CBE): "A clinical breast exam (CBE)is an exam of your breasts by a health care professional, such as a doctor, nurse practitioner, nurse, or doctor's assistant. For this exam, you undress from the waist up. The health care professional will first look at your breasts for changes in size or shape. Then, using the pads of the fingers, the examiner will gently feel (palpate) your breasts.Special attention will be given to the shape and texture of the breasts, location of any lumps, and whether such lumps are attached to the skin or to deeper tissues. The area under both arms will also be examined.
During the CBE is a good time for the health care professional to teach breast self-examination to the woman who does not already know how to examine her breasts. Ask your doctor or nurse to teach you and watch your technique. "
Breast Self Exam (BSE): "Beginning in their 20s, women should be told about the benefits and limitations of breast self exam (BSE). Women should be aware of how their breasts normally look and feel and report any new breast change to a health professional as soon as they are found. Finding a breast change does not mean there is a cancer.
Women can notice changes by being aware of how their breasts normally look and feel and by feeling their breasts for changes (breast awareness) or by choosing to use a step-by-step approach (see below) and using a specific schedule to examine her breasts.
Women with breast implants can do BSE. It may be helpful to have the surgeon help identify the edges of the implant so that you know what you are feeling. There is some thought that the implants push out the breast tissue and actually make it easier to examine.
If you choose to do BSE, the following information provides a step-by-step approach for the exam. The best time for a woman to examine her breasts is when the breasts are not tender or swollen. Women who are pregnant, breast feeding, or have breast implants can also choose to examine their breasts regularly. Women who examine their breasts should have their technique reviewed during their periodic health exams by their health care professional. It is acceptable for women to choose not to do BSE or to do BSE occasionally.
For women who choose not to do BSE, they should still be aware of their breasts and report any changes without delay to their doctor.
How to Examine Your Breasts
- Lie down and place your right arm behind your head. The exam is done while lying down, not standing up. This is because when lying down the breast tissue spreads evenly over the chest wall and it is as thin as possible making it much easier to feel all the breast tissue.
- Use the finger pads of the 3 middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue.
- Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. A firm ridge in the lower curve of each breast is normal. If you're not sure how hard to press, talk with your doctor or nurse. Use each pressure to feel the breast tissue before moving on to the next spot.
- Move around the breast in an up and down pattern starting at an imaginary line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entire breast area going down until you feel only ribs and up to the neck or collar bone (clavicle).
- There is some evidence to suggest that the up and down pattern (sometimes called the vertical pattern) is the most effective pattern for covering the entire breast, without missing any breast tissue.
- Repeat the exam on your left breast, using the finger pads of the right hand.
- While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. (The pressing down on the hips position contracts the chest wall muscles and enhances any breast changes.)
- Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it difficult to examine.
This procedure for doing breast self exam is different than in previous procedure recommendations. These changes represent an extensive review of the medical literature and input from an expert advisory group. There is evidence that the woman's position (lying down), area felt, pattern of coverage of the breast, and use of different amounts of pressure increase the sensitivity of BSE as measured with silicone models. Lying down also increased the sensitivity of CBE using patient models with known small non-cancerous lumps in their breasts."
Magnetic Resonance Imaging (MRI): "For certain women at high risk for breast cancer, screening MRI is recommended along with a yearly mammogram. It is not generally recommended as a screening tool by itself, as it may miss some cancers that mammograms would detect.
MRI uses magnets and radio waves, instead of x-rays, to produce very detailed, cross-sectional images of the body. The most useful MRI exams for breast imaging use a contrast material (gadolinium DTPA) that is injected into a small vein in the arm before or during the exam. This improves the ability of the MRI to clearly show breast tissue details.
While MRI is more sensitive in detecting cancers than mammograms, it also has a higher false-positive rate (where the test finds something that turns out not to be cancer), which results in more recalls and biopsies. This is why it is not recommended as a screening test for women at average risk of breast cancer, as it would result in unneeded biopsies and other tests in a large portion of these women.
Just as mammography uses x-ray machines designed especially to image the breasts, breast MRI also requires special equipment. Higher quality images are produced by dedicated breast MRI equipment than by machines designed for head, chest, or abdominal MRI scanning. However, many hospitals and imaging centers do not have dedicated breast MRI equipment available. It is important that screening MRIs are done at facilities that are capable of performing an MRI-guided breast biopsy at the time of the exam if anything abnormal is found. Otherwise, the scan will need to be repeated at another facility at the time of the biopsy.
MRI is also more expensive than mammography. Most major insurance companies will likely pay for these screening tests if a woman can be shown to be at high risk, but it's not yet clear if all companies will. At this time there are concerns about costs of and limited access to high-quality MRI breast screening services for women at high risk of breast cancer."