Early Detection of Breast Cancer
I am going to talk about breast cancer today. Breast cancer is a subject that everyone needs to know about. Why? One of every eight women that you know will develop breast cancer. Even some men will. The good news is that the vast majority of these people will be cured of their disease. The key to the cure is early detection. With early detection, breast cancer can be cured, in most cases.
Breast cancer is greatly feared by women. It seems to me that they fear it even more than they should. I have seen studies that analyze the perception of risk that people have. That perception of risk is all wrong. When women are asked what they perceive their risk of breast cancer to be, they will say 50 percent. When asked what their perception of heart disease is, they will say something like 10 percent. The reality is inverted. The real risk of women dying from heart disease is 50 percent. That is the same risk as men. The common wisdom that women have some kind of protection from heart disease is all wrong. Women have the same heart risk as men. That risk is 50 percent. A full half of all living women and men will die of heart disease.
On the other hand, women in general have a 12 percent chance of getting breast cancer, not 50 percent as they perceive. Since most of those women will be cured, only about three percent of women will die of their breast cancer. Thus the real risk is much lower than the perceived risk.
But many women spend much more effort on worrying about breast cancer than heart disease. If the worry effort were proportional to risk, women would have to spend about 15 fold more time worrying about heart disease than breast cancer. How can heart disease be prevented? You can hear about this every day on the news. It is a very basic list of suggested behaviors. Don't smoke, or if you do smoke, don't smoke too much. Lose weight. Exercise. Keep your LDL cholesterol down and your HDL cholesterol up. Keep your blood pressure down. Don't eat too much processed foods. Eat more vegetables and fruits, and less red meat and refined carbohydrates. Keep your stress level down. Get enough sleep. Manage depression and anxiety better. Get regular checkups. Each one of these interventions will lower your cardiac risk a certain amount.
But women do need to consider the risk of breast cancer and do some things to help protect themselves. What can women do?
First of all, women should be doing self breast examination. The studies show that it works. Almost all women complain that they don't know how to do it, and they think they will do it wrong. When they say that, I will point out to them that the studies which validated self exams were done on women very similar to themselves. All of the women in the studies started out not knowing how to do the exam. They were then briefly instructed on how to do it. Then they did it. And some of them found lumps. Self exams are cheap, easy, repeatable, and the responsible thing to do. There is no excuse for not doing it. Even the feeling of inadequacy is not any kind of excuse. Lumps found early, are much more curable, should they turn out to be cancer.
Second of all, women should be getting checkups. A physician who has palpated breast cancer in the past will have the ability to find lumps that the women may have overlooked, or missed. Gyne's, Family Doctors, Nurse Practitioners, Internists, all are capable of doing a competent breast exam.
Generally, what does breast cancer feel like? To me, the best description is that it feels bad. It really feels like it doesn't belong there. Breast cancers can be really firm, or hard. Benign lumps are soft. Breast cancers can be really bumpy, with bumps of all different sizes. Smooth lumps are usually not breast cancer. Breast cancers are asymmetrical. Benign lumps, also known as fibroadenomas, are commonly smoothly round. Breast cancers are fixed in place, maybe to the skin, maybe to the bone, maybe to other lumps. They are fixed in place with projections of growth. Benign lumps are usually mobile, not fixed to anything. Finally, breast cancers are usually big and get bigger over time. Big is usually relative, but believe me, when a women finds a scary lump, even a pea feels gigantic. Benign lumps usually attain a certain size, and then they don't grow anymore. If a women tells me that a lump has been there for years without change, it is very unlikely to be breast cancer.
Thirdly, women need to be getting their mammograms. When a women gets a mammogram, the radiologist is looking mainly for one type of finding. That finding is called clustered microcalcifications. When that mammogram finding is reported, it will be reported as a positive mammogram finding. Not positive as in certainty, but positive as in the findings suspicious for cancer are really there, and it is not a negative mammogram. The new terminology will call it BIRADS 4. BIRADS 1 is completely negative. BIRADS 2 is negative with some benign findings. BIRADS 3 is suspicious, but not positive for cancer. BIRADS 4 is likely cancer, and there are clustered microcalcifications. BIRADS 2 is the most common report I get.
A radiologist will commonly request a sonogram if there is a BIRADS 2 or 3. A sonogram will not tell us as much as a mammogram. But it will be helpful if the sonogram reports a simple empty cyst. Cysts are nearly always benign, only contain a water like fluid, and only a few will need to be drained. If the fluid that comes out is clear, then the fluid can be thrown away as it is not cancer.
Women need a baseline mammo at 35, then yearly after 40. There was a committee at the NIH in 2009 that declared that no mammos before age 50 were useful, and that self breast exams were not worth the stress and anxiety they caused. What ensued was a firestorm of indignation. My patients, especially the ones between 40 and 50, were outraged. The qualifications of the members of the committee were highly questioned. All of the relevant professional groups had to put out press releases decrying their wrong conclusions. Even President Obama had to have a press conference stating that no one in the government was going to change any protocols. During this whole process the giant new health care bill called Obamacare was undergoing debate, and this whole debacle strengthened the opposition to the bill. Everyone assumed that Obamacare would follow the most restrictive rules possible, in order to save money. As of now, that debate isn't done yet. I believe that the bill does empower the same committee at the U.S. Preventive Services Task Force to make binding recommendations.
See http://www.uspreventiveservicestaskforce.org/about.htm for the USPSTF.
See http://www.nytimes.com/2009/11/17/health/17cancer.html for a news story at the time.
Since then, ACOG, my professional society, has reconfirmed that yearly mammo's are required after 40 years of age. This will save lives, for sure.
So now we get to the crux of the matter: what do we do if there is a lump or a finding? The basic rule is simple, it is that all persistent new lumps need to be biopsied. Why? because the only way to be absolutely sure that any lump is not cancer is to get a piece of it into the lab. Anything short of this is taking a chance on someone's life. There are some things that one needs to be aware of when using this rule. First, cysts are not lumps, they are water, and draining them is optional. Second, a lump that goes away is not cancer, as cancer cannot go away on it's own. So, if you re-examine a lump after a menstrual cycle and it is gone or much smaller, then there is no worry. Just follow that lump over time. Third, a diagnostic mammo and sono are required, as they can give us very important info. If it is BIRADS 4, then she needs to go to the surgical oncologist now. Fourth, even BIRADS 3 is not usually cancer.
The bottom line is that too many women will get breast cancer. Of every 100 women that you know, 12 of them will get breast cancer. 3 of them will succumb to the disease. It will always be painful to them and to those around them. Every single one of them who gets breast cancer will wish with all her heart that she did something to diagnose it sooner. Because of this, failure to diagnose breast cancer is the number one malpractice loss for gynecologists in the United States. No Gyn or doctor on Earth wants to fail to diagnose it. That may be why your Gyne pushes so hard to get you to do all of those things above.
This was another very wordy blog but the material is so important that everyone should read this twice. And take my advise.
Thank you, Sincerely,
Dr John Marcus Ob/Gyn
Ridgewood NJ 07450
201-447-0077
Tomorrows post: Circumcisions? Why? Why are we cutting the little boys?
On the other hand, women in general have a 12 percent chance of getting breast cancer, not 50 percent as they perceive. Since most of those women will be cured, only about three percent of women will die of their breast cancer. Thus the real risk is much lower than the perceived risk.
But many women spend much more effort on worrying about breast cancer than heart disease. If the worry effort were proportional to risk, women would have to spend about 15 fold more time worrying about heart disease than breast cancer. How can heart disease be prevented? You can hear about this every day on the news. It is a very basic list of suggested behaviors. Don't smoke, or if you do smoke, don't smoke too much. Lose weight. Exercise. Keep your LDL cholesterol down and your HDL cholesterol up. Keep your blood pressure down. Don't eat too much processed foods. Eat more vegetables and fruits, and less red meat and refined carbohydrates. Keep your stress level down. Get enough sleep. Manage depression and anxiety better. Get regular checkups. Each one of these interventions will lower your cardiac risk a certain amount.
But women do need to consider the risk of breast cancer and do some things to help protect themselves. What can women do?
First of all, women should be doing self breast examination. The studies show that it works. Almost all women complain that they don't know how to do it, and they think they will do it wrong. When they say that, I will point out to them that the studies which validated self exams were done on women very similar to themselves. All of the women in the studies started out not knowing how to do the exam. They were then briefly instructed on how to do it. Then they did it. And some of them found lumps. Self exams are cheap, easy, repeatable, and the responsible thing to do. There is no excuse for not doing it. Even the feeling of inadequacy is not any kind of excuse. Lumps found early, are much more curable, should they turn out to be cancer.
Second of all, women should be getting checkups. A physician who has palpated breast cancer in the past will have the ability to find lumps that the women may have overlooked, or missed. Gyne's, Family Doctors, Nurse Practitioners, Internists, all are capable of doing a competent breast exam.
Generally, what does breast cancer feel like? To me, the best description is that it feels bad. It really feels like it doesn't belong there. Breast cancers can be really firm, or hard. Benign lumps are soft. Breast cancers can be really bumpy, with bumps of all different sizes. Smooth lumps are usually not breast cancer. Breast cancers are asymmetrical. Benign lumps, also known as fibroadenomas, are commonly smoothly round. Breast cancers are fixed in place, maybe to the skin, maybe to the bone, maybe to other lumps. They are fixed in place with projections of growth. Benign lumps are usually mobile, not fixed to anything. Finally, breast cancers are usually big and get bigger over time. Big is usually relative, but believe me, when a women finds a scary lump, even a pea feels gigantic. Benign lumps usually attain a certain size, and then they don't grow anymore. If a women tells me that a lump has been there for years without change, it is very unlikely to be breast cancer.
Thirdly, women need to be getting their mammograms. When a women gets a mammogram, the radiologist is looking mainly for one type of finding. That finding is called clustered microcalcifications. When that mammogram finding is reported, it will be reported as a positive mammogram finding. Not positive as in certainty, but positive as in the findings suspicious for cancer are really there, and it is not a negative mammogram. The new terminology will call it BIRADS 4. BIRADS 1 is completely negative. BIRADS 2 is negative with some benign findings. BIRADS 3 is suspicious, but not positive for cancer. BIRADS 4 is likely cancer, and there are clustered microcalcifications. BIRADS 2 is the most common report I get.
A radiologist will commonly request a sonogram if there is a BIRADS 2 or 3. A sonogram will not tell us as much as a mammogram. But it will be helpful if the sonogram reports a simple empty cyst. Cysts are nearly always benign, only contain a water like fluid, and only a few will need to be drained. If the fluid that comes out is clear, then the fluid can be thrown away as it is not cancer.
Women need a baseline mammo at 35, then yearly after 40. There was a committee at the NIH in 2009 that declared that no mammos before age 50 were useful, and that self breast exams were not worth the stress and anxiety they caused. What ensued was a firestorm of indignation. My patients, especially the ones between 40 and 50, were outraged. The qualifications of the members of the committee were highly questioned. All of the relevant professional groups had to put out press releases decrying their wrong conclusions. Even President Obama had to have a press conference stating that no one in the government was going to change any protocols. During this whole process the giant new health care bill called Obamacare was undergoing debate, and this whole debacle strengthened the opposition to the bill. Everyone assumed that Obamacare would follow the most restrictive rules possible, in order to save money. As of now, that debate isn't done yet. I believe that the bill does empower the same committee at the U.S. Preventive Services Task Force to make binding recommendations.
See http://www.uspreventiveservicestaskforce.org/about.htm for the USPSTF.
See http://www.nytimes.com/2009/11/17/health/17cancer.html for a news story at the time.
Since then, ACOG, my professional society, has reconfirmed that yearly mammo's are required after 40 years of age. This will save lives, for sure.
So now we get to the crux of the matter: what do we do if there is a lump or a finding? The basic rule is simple, it is that all persistent new lumps need to be biopsied. Why? because the only way to be absolutely sure that any lump is not cancer is to get a piece of it into the lab. Anything short of this is taking a chance on someone's life. There are some things that one needs to be aware of when using this rule. First, cysts are not lumps, they are water, and draining them is optional. Second, a lump that goes away is not cancer, as cancer cannot go away on it's own. So, if you re-examine a lump after a menstrual cycle and it is gone or much smaller, then there is no worry. Just follow that lump over time. Third, a diagnostic mammo and sono are required, as they can give us very important info. If it is BIRADS 4, then she needs to go to the surgical oncologist now. Fourth, even BIRADS 3 is not usually cancer.
The bottom line is that too many women will get breast cancer. Of every 100 women that you know, 12 of them will get breast cancer. 3 of them will succumb to the disease. It will always be painful to them and to those around them. Every single one of them who gets breast cancer will wish with all her heart that she did something to diagnose it sooner. Because of this, failure to diagnose breast cancer is the number one malpractice loss for gynecologists in the United States. No Gyn or doctor on Earth wants to fail to diagnose it. That may be why your Gyne pushes so hard to get you to do all of those things above.
This was another very wordy blog but the material is so important that everyone should read this twice. And take my advise.
Thank you, Sincerely,
Dr John Marcus Ob/Gyn
Ridgewood NJ 07450
201-447-0077
Tomorrows post: Circumcisions? Why? Why are we cutting the little boys?
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