Along with its enormous cosmetic and functional importance, the breast has great consequence to a woman's general health. Breast cancer is second only to cancers of the skin in incidence among women, and it kills more individuals than any malignancy save lung cancer. These realities mean that preventive breast care for women is central to any wellness program.

Breast Self Examination (BSE)

Breast self-examination is a technique that all adult women should learn. Although it is not a substitute for physical exam by the physician, it is a helpful part of a woman's preventive health program. Through monthly self exam, a woman can become more aware of the nature of her breast tissue than any other person. If she establishes this habit pattern, she may find small changes if they should occur and bring these to the attention of her doctor. She should check monthly for any lumps or thickenings in the breast tissue. Although most of these will not prove to be cancerous, early detection and action are critical to a happy outcome for those lumps that are. The breast should be checked once each month about 1 week after completion of the menstrual period.

The steps to follow in BSE are as follows:

• Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.
  • Look for: visible distortion or swelling, dimpling or puckering, nipple changes, redness or rash.
• Step 2: Raise your arms and look for the same changes.
  
• Step 3: While still at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (milky or yellow fluid or blood).
• Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together.
  • Cover the entire breast—from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. Be sure to feel all the breast tissue: just beneath your skin with a soft touch and down deeper with a firmer touch.
• Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower.

See an interactive BSE demonstration from Susan B Komen

Breast Self Awareness

The American Cancer Society (ACS) and some institutions have begun to de-emphasize BSE, making a shift to what is called "breast self-awareness," (BSA). This has been done for several reasons:

• BSE confused women and many did not practice it at all
• Research has not shown a benefit in finding breast lumps by using a certain technique.
• Oncologists saw that most of their patients found a breast lump or other symptom of breast cancer when they were going about every day activities, such as showering or dressing.

BSA does not require special training – women just need to know their own bodies. It is recommended that women continue to touch or feel their breasts to be familiar with their look and feel – but there is no right or wrong way to do that.

Although women commonly wonder if they would recognize a breast change, those who are simply self-aware generally will. For premenopausal women, the best time to touch the breasts is right after a menstrual period when the breast tissue is softer and less tender.

If a woman notes any of the following, she should tell her doctor immediately.

• Lump or mass in the breast
• Enlarged lymph nodes in the armpit
• Changes in breast size, shape, skin texture or color
• Skin redness
• Dimpling or puckering
• Nipple changes or discharge
• Scaliness
• Nipple pulling to one side or a change in direction

Commonly Recommended Screening Guidelines for Breast Cancer

Between ages 20 and 39 – Clinical breast exam (an examination of your breasts by your doctor) every one to three years.

Age 40 and older – Yearly mammograms and clinical breast exams, continuing for as long as you are in good health.

Women at increased risk of breast cancer (e.g., family history, genetic predisposition) should talk to their doctor about the benefits of starting mammograms earlier or having additional tests such as breast ultrasound or MRI.

 

A mammogram is a set of pictures of your breast taken with a low dose X-ray machine. It's the most effective and widely used examination for early detection of breast cancer. There are two types of mammography exams known as "screening" and "diagnostic."

A routine screening mammogram is performed when the patient has no symptoms and involves two views of each breast. Starting at age 40, the American Cancer Society recommends an annual screening mammogram for every otherwise healthy woman. A diagnostic mammogram is performed if there is concern regarding the breasts or if a screening mammogram is inadequate and requires additional images.

While you don't need to prepare for a mammogram, you may be asked not to wear deodorant on the day of the study because such products may show up on the films. Also, it's best to schedule an exam during the week following the menstrual period, when the breasts may be less tender.

When you reach the exam room, you'll be asked to stand in front of the mammography unit, which can move up and down and side to side. The technologist positions the breast between two firm surfaces that compress the breast as flat as possible. Compression is necessary to spread the breast tissue and eliminate motion. It may be uncomfortable but shouldn't hurt. During the 20 to 30 seconds of compression, an X-ray beam comes from above, creating the X-ray image on a film cassette that is located below the breast. Denser tissue, including cancerous tumors, appears bright and white, whereas less dense tissue, such as fat, appears dark or gray.

The film is then processed and made available for interpretation. Based on what the radiologist sees on the screening, one may be asked to return for a diagnostic mammogram. In some cases, special images known as cone views with magnification are also used to make a small area of abnormal breast tissue easier to interpret.

A diagnostic mammogram may show that a lesion is likely to be benign (not cancer). In these cases, it is common to ask the patient to come back sooner than usual for another study, (usually in 4 to 6 months). If the study shows that the abnormality is not at all worrisome, the woman can return to routine yearly mammograms. Lastly, the mammogram might suggest that a biopsy is needed to rule out cancer. (N.B. Even when mammograms show no tumor, if a mass can be felt, then a biopsy will generally be needed. An exception exists if an ultrasound exam finds that the lump is a fluid-filled sac, (cyst).

Full-field digital mammogram, (or just "digital mammogram") is similar to a standard mammogram, but is different in the way an image is recorded, viewed and stored. While standard mammograms are recorded on photographic film, digital studies are recorded and stored on a computer. The doctor can look at them on a computer screen and adjust the image size, brightness, or contrast to see certain areas more clearly. Digital mammograms cost more than standard mammograms, so studies are being done to determine which form of mammogram will benefit more women. Some studies find that women who have a FFDM return less often for additional imaging tests and that a FFDM is more accurate in finding cancers in women younger than 50 and with dense breast tissue.

Over the past 20 years, "computer-aided detection and diagnosis" (CAD) has been developed to help radiologists detect suspicious changes on mammograms. This is done most commonly with screen-film mammograms, but also with digital mammograms. For standard mammograms, the film is converted into a digital signal that is then analyzed by the computer and then displayed on a video screen with markers pointing to areas that the radiologist should check.

Mammography and Breast Implants

Women with breast implants must consider two important issues with regard to mammography.

• Mammography may be less effective in detecting cancer in women with breast implants. To mitigate this risk, individuals with implants must be prepared to accept additional mammographic views and the need for other additional surveillance studies
• Mammography may damage implants and lead to premature failure

In order to deal with both of these concerns, radiologists should perform a different sort of mammography on women with implants. "Screening" studies are never sufficient for implanted patients who should always have multi-view diagnostic studies. These studies will include oblique views designed to project breast tissue off the implant. Also, and importantly, so called "displacement" views are needed to get breast tissue away from the implant .

Displacement views separate the breast tissue from the implant, and by so doing, help to protect the device and improve the view of the breast tissue. When breast augmentations are soft, such views can ordinarily be obtained regardless of implant position (subglandular or submuscular). If the patient suffers from significant capsular contracture, this may make displacement impossible and render mammography nearly useless.

Ultrasound, also called "sonography," uses high-frequency sound waves to outline structures within the body. A breast ultrasound can show all areas of the breast, including the area closest to the chest wall, which is hard to see on a mammogram. Ultrasound is perhaps most helpful in women with dense breasts (particularly those under age 40). Among the common uses for breast ultrasound are the following:

• Check a breast lump found on physical examination or mammogram to see whether it is fluid-filled (a cyst) or a solid lump. A lump that has no fluid or that has fluid with floating particles may need more tests.
• Look at the breasts in younger women because their breast tissue is often more dense, and a mammogram may not show as much detail.
• Guide the placement of a needle or tube for drainage of an abscess
• Guide a needle used for a biopsy
• Guide the placement of a needle to drain a cyst.
• Check your breasts if you have silicone breast implants or dense breasts
• Check the integrity of your breast implants

To perform the test, a small, microphone-like instrument is placed on the skin which is lubricated with gel. This "transducer" emits sound waves and picks up the echoes as they bounce off the tissues within the breast. The echoes are converted into an image that is displayed on a computer screen. There is no exposure to radiation from this test.

Ultrasound quality is quite "operator dependant," so having an experienced radiologist or technologist is important. It has become a valuable tool because it is widely available and less expensive than other tests such as MRI. Ultrasound is useful for evaluating the implanted breast because:

• it does not threaten the implant by compressing it as with mammography
• it may see lumps that xrays might miss because of the implant
• it is a more sensitive test for implant rupture than mammogram

Some studies suggest that ultrasound may be a useful primary screening tool, particularly in those with dense breast. Dense breast tissue is hard to distinguish from cancers on mammography, and the ultrasound is sometimes better able to differentiate between these two. However, there is no unanimity of opinion as to the role of ultrasounds as a primary screening tool, and it is not recommended as a replacement for mammography.

As a breast and implant examination tool it is both less expensive and less sensitive than MRI.

MRI scans use radio waves and strong magnets to view inside the body, (there is no radiation as with xrays or CT scan). The radio wave energy is absorbed and then released in a pattern determined by the type of body tissue. A computer then translates the pattern into a very detailed image. For evaluation of breast tissues, a contrast material called gadolinium is injected into a vein before the scan to better reveal tissue detail.

During an MRI of the breast, the patient lies on her stomach on the scanning table. Each breast hangs into a hollowed out area in the table that contains coils that detect the magnetic signal. The table is then moved into a tube-like machine that houses a powerful magnet. After an initial series of images has been taken, the patient is then given the contrast agent. This material is not radioactive, but can concentrate within tumors and improve their visibility.

MRIs can be extremely sensitive tools, seeing details that would never appear on mammogram or even ultrasound. However, their very sensitivity can be a problem by leading to what doctor's call "false positives," (things that look suspicious, but that turn out after more testing or surgery not to be significant). Also, and like ultrasound, MRIs do not see microcalcifications as a mammogram can. Since such calcifications can be an important marker for cancer (particularly DCIS, or ductal carcinoma in-situ), the MRI does not substitute for mammogram.

New MRI systems equipped with "computer-assisted diagnostics" (CAD) appear to provide extraordinary capability for detecting cancer in the breast. These detailed studies can be helpful in deciding if a breast conserving operation like lumpectomy is a viable treatment option. They can also provide valuable followup for patients undergoing radiation of chemotherapy treatments.

MRI can be used along with mammograms for screening women who are at high risk for cancer, particularly young women with strong family history and dense breasts. However, it is most often used to further examine suspicious areas found by mammogram.

MRI and Breast Implants

MRI has emerged as the best test for silicone gel breast implant integrity. Many plastic surgeons recommend today that patients choosing gel implants plan to have an MRI 3 years after implantation and every 2-3 years thereafter. Although it is not a substitute for regular clinical exam by the plastic surgeon, MRI can often detect "silent" ruptures for which there is no clinical evidence. If the plastic surgeon is strongly suspicious of rupture on physical exam it is usually best to obtain MRI as confirmation, as well as to better understand the anatomy of the rupture, (intra- vs. extracapsular rupture). This will equip him/her to design the most appropriate surgical treatment plan.

When used as a test of implant integrity, MRI does not require use of contrast material. However, since the MRI's view of the breast is unimpeded by the presence of implants, it may be well for women to also have contrast views when implant surveillance is done so that double benefit can be derived. The integrity of the implant and the health of the breast can both be assessed.