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 doctor 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.
Kerry Herman of Brooklyn, New York, took the opposite path from the reader above, and it clearly paid off.
CHOOSING NOT TO WAIT
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 (which is why you are told not to use deodorant on the day of your mammogram).
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.
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