Breast cancer screening 101
Cancer screening is recommended for women without breast symptoms. Screening can often detect tumors before they spread, which increases the probability of successful treatment. The Affordable Care Act mandates mammograms at no cost.
- Have clinical breast exams — exams by a health professional — at least once every three years starting in your 20s and 30s.
- Become familiar with how your breasts normally feel so you can detect changes.
- Initiate yearly mammograms and clinical breast exams at the age of 40.
- Get a yearly MRI as well as mammogram if you are at very high risk for breast cancer.
- Establish a screening schedule with your doctor that accommodates your personal risk. Some people may start screening before the age of 40.
Source: American Cancer Society
Early detection still key to beating the odds
Ellvera Nusum was diagnosed with inflammatory breast cancer, a rare but aggressive type of cancer. (Photo courtesy of Ellvera Nusum)
Ellvera Nusum, 56, had her routine down pat. She religiously underwent yearly mammograms and checked her breasts monthly for any changes. She even timed her self-exams correctly — a few days after her period — when her hormone level was lower.
After all, she was always taught that breast cancer begins with a lump. The fact that both her maternal grandmother and aunt were diagnosed at a young age and eventually died of breast cancer kept her vigilant.
But in July 2010 she observed changes in her breast. At first she paid little attention. She had seen this before.
When she breast-fed her children years ago she sometimes noticed similar symptoms. Back then she had mastitis, an inflammation of the breast tissue, which occurs most commonly in women who are breast-feeding. The symptoms eventually subsided.
But not this time. The changes escalated. When her breasts became two different sizes, making it difficult to wear a bra, she knew something was wrong.
She visited her doctor. Without even a physical examination, the doctor came right to the point. “I know exactly what this is,” he said, and referred her for a biopsy.
Nusum had inflammatory breast cancer (IBC), a rare but very aggressive form of breast cancer that tends to strike women younger than the typical age of onset and is seen more frequently in black women, according to the American Cancer Society.
“I had never heard of IBC,” she said. “I had no idea there was more than one type of breast cancer.”
She is not alone. Contrary to common beliefs, breast cancer is not just one disease; it’s an umbrella of many different cancers, some of which may differ considerably. As in the case of Nusum, many women initially ignore the symptoms of IBC, attributing the changes to a mosquito bite, a bruise or a transient infection.
Breast cancer is the most common cancer in women and the second most deadly, trailing only lung cancer. And race matters. While the median age of diagnosis is 61, incidence rates in women under the age of 45 are higher among African Americans than whites.
In addition, breast cancers diagnosed in black women are more likely to be advanced or aggressive, resulting in a poor prognosis.
Overall, the incidence of breast cancer is highest in white women, but black women die of it at a greater rate. According to statistics from the National Cancer Institute, between 2004 and 2008, the U.S. death rate from breast cancer in black women was 32 per 100,000 women versus 23 per 100,000 in white women, a difference of 39 percent.
Yet, many surveys indicate that black women have a high rate of breast cancer screening. For instance, the Behavioral Risk Factor Surveillance System, a survey conducted by the Centers for Disease Control and Prevention, indicates that in 2008, over 87 percent of black women in Massachusetts aged 40 and older said that they had a mammogram within the past two years as compared to 85 percent of white women.
Dr. Beth Overmoyer (left) is the director of the Inflammatory Breast Cancer Program at Dana-Farber Cancer Institute. (Photo courtesy of Dana-Farber Cancer Institute)
The type of cancer is not the only factor that may contribute to poor outcomes. Disparity can be attributed to a gap between screening and follow-up for suspicious results. Researchers from the University of Alabama cited seven major barriers to following up on abnormal mammograms by black women: emotional, financial, social, religious, lack of transportation and even the vagaries of the healthcare system. But the most cited was lack of awareness or understanding of the disease itself.
Regardless of the reason, survival rates differ significantly. The five-year relative survival rate of breast cancer is 90 percent for white women and 77 percent for black women.
All females are at risk for breast cancer, and with each passing year, the risk increases. That’s why early detection is key. The American Cancer Society recommends that “women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health.”
Women of very high risk, for instance, those with genetic mutations, are advised to get an MRI as well as a mammogram. In addition, yearly breast examinations by a health professional are recommended for all women.
Though it’s not possible to absolutely fend off the disease it is possible to reduce its risk by monitoring three factors — weight, physical activity and alcohol consumption.
Fat produces estrogen and many breast cancers are estrogen-based. Keeping a healthy weight thereby reduces a woman’s exposure to the hormone. The 2008 Physical Activity Guidelines for Americans recommend 150 minutes of moderate activity, such as walking, every week. Physical activity not only improves cardiovascular health, it keeps the pounds from adding up.
Too much alcohol was found to be another culprit. In a recent study published in the Journal of the American Medical Association, the researchers found an increased risk of breast cancer with consumption of just three to six drinks a week.
In addition, women should consider the increased risk of breast cancer associated with combined estrogen and progestin menopausal hormone therapy use when evaluating treatment options for menopausal symptoms.
For her part, Nusum keeps a positive attitude. Her 21-year-old daughter accompanies her for her treatments in Boston — visits that Nusum has called their “Boston Boob Adventure.”
Nusum was referred to Dr. Beth Overmoyer, the director of the Inflammatory Breast Cancer Program at Dana-Farber Cancer Institute, and has undergone a very aggressive treatment regimen that consisted of chemotherapy, surgery, radiation and hormonal treatment. The cancer has metastasized but is responding to therapy.
Overmoyer is no stranger to IBC. “It’s known by its very rapid onset,” she explained. “Usually three to six months.” Or even overnight. The breast becomes enlarged and red, and the skin of the breast thickens, she added.
Usually there is no mass, which causes it to escape a mammogram’s detection. “A better imaging tool is the MRI,” she said. But she admits that a good old fashioned physical examination works well. “You can see it,” she explained.
While other types of cancers can affect one section of the breast allowing the possibility of breast-conserving surgery, IBC encompasses the entire breast. It enters the lymph vessels of the breast, which empty into the lymph nodes, allowing quick and ready access to the rest of the body. That’s how cancer cells spread. That also explains why once IBC is detected, it has progressed to Stage III or Stage IV, indicating that it has moved beyond the confines of the breast.
IBC constitutes no more than 5 percent of all breast cancers, but, according to Overmoyer, its numbers are increasing. The problem of detecting IBC is two-pronged. Women have been educated to look for lumps — not physical changes in the breast itself. Unfortunately, because of its rarity, many doctors often do not recognize it either.
Courtesy of Dana-Farber Cancer Institute
There is some good news. A change in order of treatment strategy has increased survival rates. When chemotherapy precedes surgery, followed by radiation and hormone treatment, the five-year survival increased from about 10-15 percent to over 50 percent, according to Overmoyer.
And that is what Nusum is counting on — good news. But she is practical as well. “I put my will in order and divided up the house and jewelry,” she said. But she is not letting her IBC to get the better of her.
“I survived two divorces,” she said. “I will survive this.”