With breast disease, best to be proactive


If there is a woman who has never worried about the health of her
breasts, chances are no one among her family or friends has had
breast cancer. Chances are, too, she has never been told after a
mammogram that her breasts are cystic or dense and difficult to
examine, or that they contain tiny calcium deposits that are usually
harmless but bear watching.

The reality is that symptoms of breast disease are much more
common than the occurrence of cancer, and knowing when to treat can
be difficult. But in most cases, the proactive approach is the best
one.

This is the story of one concerned reader who wrote to me:

"Five years ago, calcium deposits showed up on a mammogram; a
biopsy gave a negative result. Two years ago, a small mass of
calcium deposits showed up in another area. The radiologist urged
further examination, and my M.D. referred me to a surgeon who
strongly encouraged another biopsy, though she stated that there was
an 80 percent chance that the calcifications were benign. Through
benign neglect, I decided to let matters stand and assume that I
would fall into the 80 percent category."

Although this woman has still never received a breast cancer
diagnosis, her assumption of infallibility could have been a big
mistake.

Enough is known about the significance of different patterns of
calcifications that when a biopsy is recommended by a knowledgeable
physician, the wisest course is to have it done, sooner rather than
later. If the biopsy is negative, that would lift the burden of
concern. If it is positive, quick action to remove the cancer can be
life-saving and often breast-saving.

Figuring that you are protected against breast cancer, as this
reader did, because you are healthy and strong, eat right and
exercise regularly, is wishful thinking. No woman is immune, and
taking early action can make all the difference.

*

CHOOSING NOT TO WAIT

Kerry Herman of Brooklyn, New York, took the opposite path from
the reader above, and it clearly paid off.

Knowing that her mother had breast cancer at age 49, she had her
first mammogram at 38, just before her first full-term pregnancy.
She was told her breasts were cystic and very dense but otherwise
healthy.

When Herman stopped nursing her daughter, she had a second
mammogram, at 41, then annually thereafter.

Herman was in her early 50s when the mammograms started to show
calcifications. By then sonograms were readily available to
supplement her breast exams. At age 55, her annual mammogram
revealed a different pattern of calcifications in her left breast.
Though the radiologist and surgeon told her they did not think this
was worrisome, a biopsy was recommended and done in three locations.
It revealed very early cancer called ductal carcinoma in situ, or
DCIS.

Faced with removal of the left breast and biopsies of the right,
Herman said in an interview: "I decided to be more proactive. After
consulting my husband, who said he was more concerned about my
health than my breasts, I had a bilateral mastectomy and
reconstruction."

"I have never regretted my decision," she said. "For me, having
to go through this every year and wondering if I would beat the Grim
Reaper was agony."

A friend of hers with the same findings chose to wait and see,
Herman said. She ended up with an invasive cancer that had spread
beyond the breast by the time of her next exam.

*

WHAT'S NORMAL, WHAT'S NOT

Many women have symptoms of breast disease, but few have cancer,
as an educational article in the Cleveland Clinic Journal of
Medicine in 2002 noted.

"Yet these symptoms are understandably a source of great concern
for women," said the article, titled "Benign Breast Disease: When to
Treat, When to Reassure, and When to Refer." "The challenge for
physicians is to distinguish between benign and malignant lesions,
and to know when prompt referral to a surgeon or other specialist is
necessary."

The article explained that during their reproductive years, just
before menstruating, many women experience swelling and tenderness
in their breasts, and some develop lumpiness and pain, all of which
goes away after their periods. This is normal and not a cause for
concern.

But if lumpiness or thickening occurs in only one breast and
persists between periods, further examination by mammography (or if
a woman is under 35, by sonography) and referral to a breast
specialist for a possible biopsy is needed.

Women are told that breast pain is not a symptom of cancer. But
if pain occurs in only one breast in a specific area and, in a
premenopausal woman, does not subside after her period ends, a
mammogram, sonogram and visit to a breast specialist are in order.

A decade ago, this course of action saved my left breast and
perhaps my life. My mammogram was negative but a sonogram of the
area that hurt was not, and while I could feel no lump, a biopsy
revealed an early cancer treatable with lumpectomy and radiation.

Breast lumps are common, and most are benign. But those that are
firm with irregular borders and attached firmly to the skin or soft
tissue are more likely to be malignant. Even if a mammogram is
negative in such cases, a biopsy is needed, since about 15 percent
of cancers are missed by mammography.

Herman and I both benefited from the fact that we saw the same
radiologists year after year, doctors who knew our breast history
and had records of previous exams available for comparison. If you
go to a new mammographer, bring your earlier films.

*

UNDERSTANDING CALCIFICATIONS

Calcium deposits in the breast are common, especially after
menopause, and can result from several noncancerous causes: calcium
in the fluid of a benign cyst; a result of inflammation in or injury
to the breast; prior breast radiation; calcium deposits in a dilated
milk duct or an artery; dermatitis; or a residue of powders,
ointments or deodorant.

They do not, however, come from calcium in the diet or calcium
lost from bones. But tattoo pigments on the breast can produce a
misleading picture of calcifications.

Breast calcifications come in two forms. Large, or coarse,
calcifications appear as single white dots on a mammogram. They are
most common and nearly always benign. Smaller ones, called
microcalcifications, look like tiny white specks. If they are
scattered, they bear watching but are also usually benign.

When microcalcifications are numerous and clustered, further
testing is needed. The radiologist may call for a magnification
mammogram and, even if no lump is apparent, a needle biopsy or
stereotactic core biopsy of the suspicious area. If instead of a
biopsy you are told to return in six months or a year for another
mammogram, you'd be wise to seek a second opinion.


(C) 2008 International Herald Tribune. via ProQuest Information and Learning Company; All Rights Reserved

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