FAULKNER HOSPITAL Breast Care and You Your guide to preventive steps, risk factors and screenings for breast cancer FAULKNER HOSPITAL 75 Francis Street Boston, MA 02115 www.brighamandwomens.org 1153 Centre Street Boston, MA 02115 www.faulknerhospital.org 1-877-BWF-5773 5K(3/04)
WWhile breast cancer is the second leading cause of cancer death in American women, exceeded only by lung cancer, the promising news is that most women diagnosed with the disease do survive and continue to live normal lives. It is projected that in 2004 alone, almost 217,400 women in the United States will have been diagnosed with the disease that is one every three minutes. Breast cancer will take the lives of 40,500 women within the year. Fortunately, detecting the disease in its earliest stages can frequently be accomplished through regular clinical breast exams by your doctor, obtaining a mammogram as needed, and performing your own breast self-exam every month. This guide is intended to provide you with the information you need to know about your risk for breast cancer and how it is detected. What is breast cancer? A cancer is named based on where it first develops. Breast cancer begins in the breast tissue, eventually forming a mass of cancerous cells called a tumor. Cells from that tumor can break away and spread (called metastasis) to other organs of the body such as the bones, lungs and liver where they can multiply in number. Even though the causes of breast cancer are not known, early detection and newer treatments are leading researchers toward a cure. Researchers have identified certain risk factors that have been associated with breast cancer - knowing these and determining your risk are the first steps toward protecting yourself from the disease. What is your risk for breast cancer? It is almost impossible to predict whether or not a woman will be diagnosed with breast cancer some women can have all the risk factors and never develop the disease while other women develop the disease and do not have many of the known risk factors. As with all diseases, there are certain factors that place you at higher risk for breast cancer than the average person some you can control while others you cannot. Breast cancer risk factors that you cannot control, are: Your sex - Being a woman is the leading risk factor for breast cancer primarily because of the complex hormonal changes that occur to a woman throughout her lifetime. It is believed that normal monthly hormonal fluctuations contribute to the development of breast cancer. Men are also diagnosed with breast cancer, but it is rare. Your age - As you age, your chance of developing breast cancer increases. By age 40, 1 in 200 women are diagnosed with breast 1 2
cancer; by age 50, 1 in 50; by age 60, 1 in 25; by age 80, 1 in 10; and by age 85, 1 in 9. Breast cancer is uncommon in women under the age of 35. As the majority of our population ages, we can expect to see more women diagnosed with the disease. Family history - If you have a family history that includes close blood relatives who have had the disease, you are at increased risk. If your mother, sister or daughter has had breast cancer, you are at almost double the risk. Reproductive health history - If you had your first period before age 12 or reached menopause after age 55, you are at higher risk for breast cancer because of your longer-term exposure to ovarian hormones, which increases your risk of breast cancer. Ethnic or racial background - Not all groups of women in the United States are equally susceptible to breast cancer. Caucasian women have the highest risk, followed by African- American and Hawaiian women. Hispanic-American and Asian-American women appear to have the lowest risks. Hereditary breast cancer - Between five to 10 percent of women diagnosed with breast cancer have been found to have an inherited breast cancer genetic mutation. When a woman has inherited one of the breast cancer susceptibility genes, called the BRCA-1 and BRCA-2 genes, it increases her risk of both breast and ovarian cancers. By age 50, the average woman has a two percent risk of having been diagnosed with breast cancer. In women who carry a BRCA-1 or -2 mutations, the risk of breast cancer can be as high as three percent by age 30, 20 percent by age 40, 50 percent by age 50, 55 percent by age 60, and 85 percent by age 70. Higher than most ethnic backgrounds, women of Eastern European Jewish decent (Ashkenazi Jewish) have a two percent chance of carrying a mutation on the BRCA-1 or -2 genes. 3 Previous findings - If you have had a previous breast biopsy that showed irregular changes, you may be at increased risk for breast cancer and require close monitoring. There are three such changes: lobular carcinoma in situ (LCIS); atypical lobular hyperplasia (ALH); and atypical ductal hyperplasia (ADH.) None of these are breast cancer or necessarily develop into breast cancer. They are the equivalent of red flags and indicate that a woman with one of these changes has a higher risk of developing breast cancer than the average American woman. Close annual monitoring is recommended for such women. Women who previously have been treated for breast cancer before have an increased risk of developing a new, second cancer of the breast compared to women of the same age. There are no specific health hazards strongly linked to breast cancer, as smoking cigarettes is to lung cancer. Yet there are breast cancer risk factors that can be controlled. Breast cancer risk factors that you can control, include: Hormone replacement therapy - The use of hormone replacement therapy in the form of estrogen and progesterone for longer than five years places you at a slightly higher risk for breast cancer. In addition, there are increased risks of heart attacks, strokes, and blood clots to the lungs, and decreased risks of colon cancers and hip fractures. Currently, most physicians believe that HRT can be used for a period not to exceed five years to control the quality-of-life symptoms associated with menopause. If you are on HRT, or are considering starting, speak with your doctor about its benefits and potential risks to your personal health. Not having children or having children later in life - If you never have given birth or have delivered your first child after age 30, you are at increased risk. Doctors speculate that when a woman brings a child to term it results in a locking in of breast DNA making it more resistant to future changes, including the development of breast cancer. In women who do not have children and those who have their children later in life, it is believed that the years of uninterrupted menstrual cycles increase the potential for breast cancer. 4
Alcohol consumption - Drinking wine, beer and hard liquor have been shown to elevate the amount of estrogen in a woman s blood. Anything that increases your long-term exposure to estrogen increases your risk of breast cancer. While studies including the Nurses Health Study have shown that consuming one drink of alcohol per day increases the risk of breast cancer, it has also been shown to have a positive effect on heart health. Speak with your doctor about alcohol and your level of risk for breast cancer, heart disease and any other conditions it affects so that you both can make the best decision for your good health. Being overweight - Depending on several other factors, having excess weight can increase your risk of breast cancer. The Nurses Health Study at Brigham and Women s Hospital studied the association between weight and breast cancer risk. Women who had gone through menopause (postmenopausal), and had never used hormone replacement therapy (HRT), had a moderately increased risk of breast cancer linked to obesity. Gaining weight, say researchers, is yet another matter. In the study, weight gain was linked to an increased risk of breast cancer for all postmenopausal women. Women who since age 18 gained more than 45 pounds had an increased risk for the disease and the more weight that was gained, the more the risk. Those women in the Nurses Health Study who gained more than 45 pounds and never used HRT had double the risk. Researchers think that being overweight increases a postmenopausal woman s risk of breast cancer because it increases her levels of estrogen. The Nurses Health Study showed that the more weight gained after menopause, the more estrogen is produced by the body therefore placing a woman at higher risk for breast cancer. No matter what your risk factors are, you should still practice healthy breast care. Additional steps to reduce your risk There are several ways that you can adjust your lifestyle to reduce your risk of breast or other cancers. They include: Cancer experts recommend eating a balanced diet that includes plenty of fruits and vegetables and is low in saturated fats. The Nurses Health Study has shown that a higher consumption of fruits and vegetables results in a lower rate of different cancers. Of all the nutrients studied, folic acid appears to be the most protective, but the findings are preliminary and research on a variety of foods and nutrients is ongoing. If you drink alcohol every day, speak with your doctor about your personal risk for breast cancer and your heart health. If you are on hormone replacement therapy, or are considering taking it, ask your doctor to assess your level of risk. If you have been on HRT for greater than five years, speak with your doctor about discontinuing this medication. Avoid weight gain, particularly if you have gone through menopause. Exercise to maintain a healthy weight. Nurses Health Study Research findings of the Nurses Health Study at Brigham and Women s Hospital have revealed extensive information on major women s health concerns, including breast health. Considered the most comprehensive study of women s health in history, the Study has followed 121,700 nurse participants between the ages of 30 and 55 since 1976. It began as a study of the relationships between the use of oral contraceptives and smoking and the risks of major illnesses and has expanded to evaluate the implications of lifestyle factors such as exercise and diet on women s health. Conducted at Channing Laboratory a multidisciplinary research division of Brigham and Women s Hospital and Harvard Medical School researchers have identified several lifestyle modifications that have been associated with improved health in women. Visit www.nurseshealthstudy.org for more information on the Nurses Health Study and to learn more about the latest findings. 5 6
If you are at high risk for breast cancer based on family history or results from a previous breast biopsy, or have several of the other risk factors, you should: Speak to your doctor about the best schedule of clinical breast exams and mammograms for you, and whether a comprehensive evaluation at a breast health center is appropriate for you. Perform your monthly breast self-exam. Early detection provides a better chance for survival reg- mam- The keys to excellent breast care are to be sure to have your ularly scheduled breast health screenings, including mograms, and to perform breast self-exams every month. Mammography and breast exams A low-dose x-ray of the breast, called a mammogram, can reveal a breast cancer years before it can be felt. Between 85 and 90 percent of all breast cancers can be detected through mammography. Physicians at Brigham and Women s/faulkner Hospitals recommend that every woman age 40 and over have a mammogram yearly. You should begin sooner if you have specific risk factors. For example, if your mother, sister or daughter developed the disease prior to menopause, you and other first degree female relatives should begin annual mammography 10 years before the age at which your relative was diagnosed. It is also important to have your breasts examined by your doctor every year or as frequently as needed. Breast self-exams While annual mammography is crucial, 10 to 15 percent of breast cancers are not detected by the test and additional breast cancers may also become detectable between routine mammograms. That is why it is important for every woman in addition to mammography and clinical breast exams to perform her own breast self-exam every month. The best time for a breast self-exam is roughly seven days after the beginning of your monthly menstrual cycle this is when the hormone levels from the ovaries are at their lowest and your breasts are least likely to be tender or swollen. Women who have gone through menopause should examine their breasts the same day each month, such as the first day of the month. When performing a breast self-exam, you should first check the appearance of your breasts in a mirror. Pay close attention to any noticeable changes including dimpling of the skin, changes in the nipple or any redness or swelling. Then, either lying down or standing in the shower, examine your breasts for bumps, lumps and any thickening. Place one arm behind your head and, with your opposite hand holding fingers flat, examine all areas of the breast. First press lightly, then a bit more firmly and then very firmly in each area (the three-layer cake technique). You should then drop the arm, place the opposite arm behind your head and examine your other breast in the same way. If you have questions about how to perform a thorough breast self-exam or need instruction, speak with your doctor or health care provider. Most often, lumps felt in the breast turn out to be benign cysts, which are harmless fluid-filled sacks. Still, it is important to go see your doctor who can fully evaluate the area of concern. 7 8
Breast care at Brigham and Women s/ Faulkner Hospitals At Brigham and Women s Hospital and our community partner Faulkner Hospital women can receive the best care for breast health. We have joined the many resources of Brigham and Women s Hospital one of the country s leading academic medical centers with those of Faulkner Hospital, one of the area s finest community teaching hospitals, to provide our patients with the most comprehensive care in convenient settings. There are three stages of breast care at Brigham and Women s/ Faulkner Hospitals: routine breast exams and mammography, evaluation and if necessary treatment. Brigham and Women s/faulkner Hospitals provide routine mammography services in three convenient locations. For diagnosis, each hospital has a Center that provides comprehensive care in the evaluation of breast health concerns. At Brigham and Women s Hospital s Comprehensive Breast Health Center and Faulkner Hospital s Faulkner-Sagoff Breast Imaging and Diagnostic Centre and Faulkner Breast Centre, world-class physicians and health care professionals are able to promptly serve women who have breast conditions. Continuum of Breast Care at Brigham and Women s/faulkner Hospitals Routine Mammography All women age 40+ as needed Brigham and Women s Hospital 75 Francis Street, Boston, MA 02115 (617) 732-6248 850 Boylston Street, Chestnut Hill, MA 02467 (617) 278-0560 The Faulkner-Sagoff Breast Imaging and Diagnostic Centre 1153 Centre Street, Boston, MA 02130 (617) 983-7272 Diagnostic Services Women needing special evaluation Services include initial evaluations and state-of-the-art diagnostic procedures including stereotactic core needle biopsy, ultrasound guided core needle biopsy, fine needle aspiration biopsy and breast MRI (magnetic resonance imaging.) Brigham and Women s Breast Imaging and Diagnostic Center 75 Francis Street, Boston, MA 02115 (617) 732-8525 The Faulkner-Sagoff Breast Imaging and Diagnostic Centre 1153 Centre Street, Boston, MA 02130 (617) 983-7272 Surgical Evaluation Brigham and Women s Comprehensive Breast Health Center 75 Francis Street, Boston, MA 02115 (617) 732-8111 The Faulkner Breast Centre 1153 Centre Street, Boston, MA 02130 (617) 983-7777 9 10
At Brigham and Women s Hospital and Faulkner Hospital, patients have access to the most advanced breast care and state-of-the-art diagnostic procedures if necessary. Diagnostic procedures include: Stereotactic Core Needle Biopsy - This biopsy may be employed when a physician can see an abnormality on a mammogram but cannot feel it with a breast exam. With this procedure, the mammogram guides the radiologist in precisely locating the area to be biopsied with a core needle. Ultrasound Guided Core Needle Biopsy - This technique is utilized when a mass is either felt or unable to be felt and can be visualized on ultrasound. The ultrasound assists the radiologist in precisely confirming the location for biopsy with the core needle. Additional information If you would like more information on breast care or to make an appointment with a physician for routine breast care, mammogram or further evaluation, call 1-877-BWF-5773. Call 1-877-BWF-5773 for free copies of our booklets on the Comprehensive Breast Health Center at Brigham and Women s Hospital and Faulkner Hospital s Faulkner-Sagoff Breast Imaging and Diagnostic Centre and Faulkner Breast Centre. Also, go on-line at www.brighamandwomens.org and www.faulknerhospital.org for more information on the breast health services each hospital provides. Fine Needle Aspiration Biopsy - This can be performed when a breast mass is easily felt by the breast surgeon and can be done in the office. A slender needle is inserted into the area of concern and either fluid from a cyst is aspirated, or a small amount of tissue is extracted for microscopic evaluation. Magnetic Resonance Imaging (MRI) - A breast MRI is a high-tech way of visualizing the breast without radiation and can be used when there is suspicion of a tumor that is difficult to assess by physical exam and mammography or to determine the size and extent of a known tumor. During the procedure, a dye is injected into the patient through a vein in her arm. The dye makes a tumor much brighter than the surrounding breast tissue and therefore visible on the MRI scan. Ductogram - This technique is utilized to evaluate patients with nipple discharge. A tiny catheter is placed in the discharging breast duct through which dye is injected to outline the duct. This allows for the identification and localization of duct abnormalities. 11 12
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