Читать книгу Prevent, Survive, Thrive - John G. West - Страница 12
ОглавлениеFor Children, Teens, and Women Under Forty
JUST AS “ONE SIZE FITS ALL” doesn’t work in clothing, neither does it work in breast care. As you’ll see in this section, different rules apply to different age groups—and what might be considered optimal care for one group can be detrimental to another.
Women in their thirties, for instance, whose breasts tend to be dense, are screened differently than their older sisters . . . and for them breast care deals primarily with the treatment of symptoms. Though we do address pain, infection, and nipple discharge, the most important issue is lumps.
While younger women are advised not to get routine screening mammograms, they are also, happily, less apt to acquire breast cancer. However, those who do find suspicious lumps are under more pressure to act quickly.
On the other hand, by age forty, women have crossed a line that divides “younger” from “older” women. While X-ray diagnosis is no longer a safety issue, the possibility of developing breast cancer is high enough to justify the expense and inconvenience of screening mammograms.
This section outlines what can be expected in women’s breast history from newborns through the years until the woman turns forty. In each age group, a discussion of possible breast concerns is followed by recommended treatment options.
NEWBORNS
Breast Lumps
Breast lumps are common in newborns. They are almost always benign and related to maternal hormones encountered in the womb. In some cases, milk can be expressed from the nipple. The effect is short-lived and the breast soon returns to normal. Referral to the pediatrician is indicated if symptoms persist after several weeks. In the rare case in which the baby has a fever and the breast is red and swollen, the pediatrician should be contacted immediately.
PRE-TEENS
Breast Lumps
Pre-teen girls usually develop a button-like prominence directly below the nipple. At first, the lump may be evident on one side only. This is a common finding in young women entering puberty. The “lump” is referred to as a breast bud. Observation is all that is required. When we see this type of lump in our office we simply inform the parents to return in one to two months if they still have any questions or concerns. Surgical removal of the breast bud will result in the failure of breast development.
Lumps that aren’t breast buds in pre-teens are unusual and require the attention of a physician. An ultrasound is the diagnostic procedure of choice for any persistent lump in this age group. An experienced surgeon, preferably a pediatric surgeon, should be involved in the decision- making process.
In select cases a needle biopsy should be performed to establish a diagnosis. Follow-up treatment will be based on the results of the needle biopsy.
Asymmetry
It is common for one breast to develop faster than the other. In most cases, reassurance is all that is required. An exam by the pediatrician is sufficient to reassure the patient and her family that all is well.
Breast Infections
Breast infections are rare in this young age group, and typically respond to antibiotics. Cases that are recurrent or unresponsive to therapy should be referred to a breast surgeon.
PUBERTY TO TWENTY
Breast Pain
Breast development and the onset of the menstrual cycle are indicators of early puberty. The pediatrician easily manages most issues of breast care in this age group. Issues such as cyclic breast pain are best handled with reassurance. In some cases, anti-inflammatories or caffeine restriction is advised (see chapter six).
Breast Lumps
Breast lumps are still unusual for this age group, but any such lump should be reported to the pediatrician. Although breast cancers are rare in teenagers, they do occur, and diagnostic delays must be avoided. Again, ultrasound is the diagnostic procedure of choice and mammograms are rarely indicated. A needle biopsy is usually needed to make the final diagnosis. Surgical removal should be considered only after an accurate diagnosis.
Breast Infections
Though infections are unusual in this age group, they are now being seen with increasing frequency as a result of nipple piercings. These infections usually respond to antibiotics. However, we’ve had cases in which the infection did not go away, requiring removal of the nipple ring. In some cases, the infection can lead to a disfiguring scarring of the nipple. Any sign of redness, pain, or swelling should be reported immediately and treated aggressively with antibiotics.
Radiation Exposure
It is well established that the developing breast is very sensitive to radiation exposure. Studies of women who, when they were teens, were treated for scoliosis (curvature of the spine) and had frequent chest X-rays to evaluate the progression of their disease show them to be at increased risk of developing a future breast cancer. X-rays cause direct damage to the DNA in the cells of the developing breast, an onslaught that sets the stage for future development of an early-onset breast cancer.
Now every effort is made to avoid X-ray exposure to the breasts of young women. When such treatment is required, the breasts are shielded with lead drapes. The dangers of radiation slowly diminish with the years, and by age thirty the risk is reduced to the point that it is safe to do a diagnostic mammogram when cancer is strongly suspected.
Young women who have had chest radiation for other malignancies are also at risk for early-onset cancer. The most common incidents are in girls who, during their teens or early twenties, receive chest wall radiation for the treatment of Hodgkin’s disease.
Such women are often unaware of their risks and fail to follow early detection guidelines. Those who have been exposed to therapeutic radiation for Hodgkin’s disease or other malignancies should be followed by experienced physicians, preferably in clinics that manage patients who are at increased risk of tumors. In addition to twice-yearly exams by an experienced physician, yearly MRI screening should start as early as age twenty-five. Yearly screening mammography should start as early as age thirty.
Radiation associated with cell phone exposure is an issue of recent controversy. See chapter seventeen to learn more about this debate.
WOMEN TWENTY TO THIRTY
Breast Lumps
Breast cancer is unusual in this age group. It does occur, however, and because of its rarity, diagnostic delays are common. The breasts in young women tend to be lumpy and tender, anyway, and most such women are not confident in doing breast self-examination.
A diagnostic ultrasound—the extreme value of which is described at length in chapter fourteen—is particularly accurate in defining the nature of a breast lump at any age. It works with sound waves, which are completely safe, as compared to X-rays employed by mammograms. It is also painless and inexpensive.
In most cases of concern about a potential breast lump, a normal ultrasound along with a negative breast exam is all that is needed. However, if symptoms persist, the patient should be referred to a surgeon with experience in caring for young women with breast problems.
Nipple Discharge
As will be discussed in chapter nine, nipple discharge that occurs on its own, without squeezing, requires medical attention, as it could be an early sign of cancer, except in the case of pregnant women or women who have just given birth.
OTHER BREAST PROBLEMS, such as pain and infection, are treated much the same in all age groups.
The key point to remember is that any new breast change that persists after a woman has completed her menstrual cycle should be reported to her physician. If her doctor is unresponsive to her concerns, she should seek a second opinion, preferably from a breast surgeon.
WOMEN THIRTY TO FORTY
Breast Lumps
Though breast lumps are common in women in their thirties, the good news is most prove to be benign. However, differentiating between benign and malignant can be challenging—generally because breasts in this age group, as with younger women, tend to be lumpy under normal circumstances.
Here, the menstrual cycle plays a role, adding both lumpiness and tenderness just before the onset of menstruation. That said, the best time to do a breast exam or evaluate a lump is five to ten days after the onset of the period.
And the best way to evaluate the seriousness of a nodule is with an ultrasound. If the diagnosis still remains sketchy, a diagnostic mammogram can be both helpful and safe.
This focused mammogram, covering a specific worrisome area, can be distinguished from a screening mammogram, which is done on women forty and over who have not experienced symptoms.
Breast Pain
Though breast pain is common in this age group, it’s rarely associated with an underlying malignancy. Most such pain can be alleviated with over-the-counter anti-inflammatories, as well as caffeine restriction. Pain that is localized in one spot and increases in intensity over one or two menstrual cycles merits medical attention.
Breast Infections
Breast infections in this age group are typically associated with lactation, discussed in chapter four. Infections in non-lactating women usually respond well to antibiotics. Those that don’t, or that recur after initial treatment, should be seen by a breast care specialist.
SCREENING MAMMOGRAMS FOR WOMEN UNDER FORTY
Compared to younger age groups, women in their thirties do have a somewhat higher occurrence of breast cancers. Since their breasts still tend to be dense, small malignancies don’t show up well on mammograms.
For all these reasons, routine screening mammograms are not recommended, and a diagnostic ultrasound remains the first line of defense.
However, there are exceptions: Mammographic screening in this age group is restricted to women who have a first-degree relative (mother or sister) who was diagnosed with breast cancer under the age of fifty. Screening for those women should start ten years earlier than the age at which the relative was diagnosed. For example, if the mother was found to have a malignancy at age forty-five, the daughter would start yearly screening at age thirty-five.
In addition, very high-risk women, such as Angelina Jolie, who had multiple family members with breast and ovarian cancers and who tested positive for the BRCA gene mutation, require more aggressive screening. We follow these women twice yearly in our high-risk clinic, and we start yearly MRI screening at age twenty-five and yearly screening mammograms at age thirty.
Most of these women are also encouraged to consider risk assessment counseling, and in some cases, genetic testing (see chapter eighteen).
OTHER SYMPTOMS in this age group, such as nipple discharge, are managed in much the same manner as with younger women.
WHAT I’D TELL MY DAUGHTER
• The vast majority of breast problems in this age group (birth to forty) will be associated with non-cancerous conditions.
• Still, breast changes merit attention. Persistent or progressive changes need a timely answer.
• When in doubt, get an opinion from a breast care specialist.
