Читать книгу Prevent, Survive, Thrive - John G. West - Страница 13
ОглавлениеTHERE IS OBVIOUS OVERLAP when treating breast symptoms in the various age groups. For example, the care of symptomatic women in their thirties is nearly identical to what is offered for patients in their forties. To avoid repetition, we have simply summarized basic treatment in this and the previous chapter. A more detailed discussion of common breast problems is provided in Section II.
However, women in their forties should be aware of these concerns in particular:
Breast Lumps
Any new breast lump in a woman over forty merits concern. The older she is, the higher the probability of cancer. In menstruating women, breast lumpiness is common, but any nodule that persists after completion of a menstrual period requires medical attention. An ultrasound is often the only test needed to determine the nature of the lump. However, if doubt remains, a diagnostic mammogram is the next step. When findings on the mammogram or ultrasound are worrisome, a core needle biopsy (see page 48) will establish an accurate diagnosis.
If all diagnostic studies are negative, a further, two-month re-evaluation is still important, both to reassure the patient and to guard against a possible missed diagnosis of malignancy.
Abnormal Mammograms
The second most common breast problem in this age group is an abnormal screening mammogram. In most cases, additional imaging will eliminate concerns and the woman can return to routine yearly screening.
In the event of a positive finding, a core needle biopsy (see page 47) will provide an accurate diagnosis. If the biopsy is benign, the patient returns to regular screening. However, if the biopsy proves positive, the patient is referred to a breast surgeon.
Nipple Discharge
Nipple discharge is common in over-forty age groups, and squeezing the nipples is the primary cause. It is normal for breast ducts to contain fluid, and it is common for the breast, when squeezed, to produce a drop or more of yellow, green, or white fluid from the nipple. Although this discharge is not worrisome, women are advised not to squeeze their nipples.
However, discharge that occurs spontaneously requires medical attention—though in most cases the event is not related to a hidden breast cancer. Still, we are concerned when the fluid is either clear or bloody. If the discharge is suspicious enough to warrant a biopsy, it usually turns out to be benign, or associated with small, potentially curable breast cancers. For a more detailed discussion, see chapter nine.
Breast Pain
Breast pain is one of the most common symptoms that send women to a breast care center. While it is unusual for a breast cancer to cause pain, it can be the first indicator of an underlying malignancy. Pain that is centered in one specific area and becomes more intense in a matter of weeks merits the attention of a specialist. For further details, see chapter six.
Breast Infections
Breast infections are relatively common in nursing women, an issue covered in chapter four.
In non-lactating females such infections are rare but require immediate medical attention. With most patients, the inflammatory process responds to standard antibiotics. After treatment, an attempt should be made to determine the root cause. Infections that don’t respond to antibiotics, or episodes that recur, should be referred to a breast care specialist.
MAMMOGRAMS
One of the biggest breakthroughs in the history of women’s health care was the development of screening mammography. Initial studies in the United States and Sweden demonstrated a 30 percent or greater reduction in breast cancer mortality for women undergoing screening mammography. With improvements in technology and a better understanding of who is at risk, there is now an incredible opportunity for making even more dramatic improvement in the rate of survival of this number-one cancer killer of young women.
That said, age is one of the critical factors that increases a woman’s chance of developing breast cancer. The older she gets, the greater her peril. By forty, vulnerability has reached the point where it’s appropriate to start routine annual mammographic screening—and as always, the goal is to detect small cancers before they cause symptoms or even before they grow large enough to be felt.
Despite the well-established benefits of mammographic screening, we’re seeing an increasingly strident disagreement over several issues: the best age to start, how often women should be tested, and the proper age to quit. This controversy will be explored in more detail in chapters fifteen and sixteen. It is first necessary to understand the basics of mammographic screening.
Screening vs. Diagnostic Mammogram
One of the first issues that needs clarification is the difference between a screening and a diagnostic mammogram. The screening mammogram is for women who are symptom free. They have no suspected breast lumps, no new patterns of breast pain, no nipple discharge, and basically no newly revealed breast symptoms. Diagnostic mammograms, on the other hand, are for women who have breast symptoms.
Women who are about to undergo their yearly screening exam should make certain they alert the technician or support staff about any recently discovered breast problems. Such symptoms will be reported to the radiologist (mammographer), who will then determine what additional procedures might be helpful to evaluate the new issues.
When to Start Screening
Despite all this recent controversy, there is a general consensus that starting mammographic screening at age forty saves lives. A government funded task force is now recommending women start mammographic screening at age fifty. However, this approach ignores an important group of women.
Approximately 20 percent—one out of five—cancers we see in our practice are in women under fifty. Patients with cancer who started mammographic screening at age forty tend to be diagnosed with small, treatable breast cancers, while most of the advanced cancers are found in patients who have never had a mammogram.
Self-proclaimed “experts” who advise that screening start at age fifty have two reasons: One is that most women in their forties have such dense breasts on mammographic imaging (see chapter fourteen) that it’s hard to find small cancers . . . and, besides, “we all know” that fewer women in their forties develop breast cancer than women over fifty. The other is the much-touted concern about the issue of false positive biopsies. When the radiologist sees a worrisome spot on the mammogram, a needle biopsy is recommended. It is well-known that many of these biopsies will prove to be benign. The chance of a false positive is higher for younger women, in large part because many of these women are receiving their first mammogram and there are no previous images to check. When previous films are available for comparison, the number of false positive biopsies drop.
As the critics of early screening point out, a great deal of anxiety occurs when a woman is told she needs a breast biopsy. They conclude that the anxiety associated with a false positive biopsy is just one more reason why starting screening at age forty is not justified.
The critics, however, are not fair and balanced. They manage to overlook the downside—the anxiety associated with a delayed diagnosis. In my experience, most women are willing to take the chance of a false positive when it’s associated with a potential for detecting a breast cancer at an earlier stage—that interval when treatment is less aggressive and the probability of survival is improved. As one of my patients noted, “Both ways it’s good news: Either my doctor caught a malignancy early, while it’s easily treatable, or I learn I don’t have cancer.”
My advice to patients: Start mammographic screening at age forty and do it yearly. This advice applies to women at normal risk for breast cancer. Those with strong family histories or others who have been exposed to radiation at a young age are followed more aggressively, which may include yearly clinical exams starting at age twenty-one, yearly MRIs starting at age twenty-five, and yearly mammograms starting at age thirty.
BI-RADS CLASSIFICATION
The American College of Radiology established a standardized reporting system called BI-RADS (or Breast Imaging Reporting and Data System) that is used by all mammography centers in the USA—a major advance, as before we had such a system screening reports were often difficult to interpret. All mammogram reports are given a final BI-RADS score ranging from zero to six.
• A category 0 report means additional imaging is required.
• Categories 1 and 2 indicate a completely normal exam. A category 2 score means something is seen on the mammogram, like a cyst, but because it is inconsequential, the exam is still considered to be normal. For both categories, a one-year follow-up is recommended.
• Category 3 indicates the presence of something that is probably benign. A six-month follow-up is indicated.
• Categories 4 and 5 indicate a cancer is suspected (more so in 5 than in 4) and a biopsy is mandatory.
• Category 6 means the diagnosis of breast cancer has been made and further treatment is required.
How Often to Do Screening
There is also ongoing controversy about how often to do mammographic screening. Some guidelines suggest every other year is sufficient. I am not convinced and will not be until there is more data to prove that this is just as safe as yearly.
When to Stop Screening
Limited data indicates that screening beyond age seventy-four saves lives. The explanation for ever selecting this particular age as an endpoint is that previous studies arbitrarily stopped with women older than seventy-four. Despite the lack of proof, I recommend that yearly screening continue as long as a woman remains in good health.
Tips for Women Undergoing Screening
The most common complaint about screening mammography is the pain that occurs when the breast is compressed. Although many women breeze through the process, there are others who dread the anticipated discomfort. A few steps can be taken to reduce apprehension.
• Menstruating women should schedule their mammogram five to ten days after the onset of their period, when the breasts are least tender.
• 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.
