Not long after Teresa Brown turned 40, she had her first mammogram at her doctor’s suggestion. She didn’t suspect anything—this was, after all, a routine test for a 40-year-old woman, based on generally accepted medical guidelines. The results, however, called for further investigation. Brown’s doctor referred her to a specialist, who performed a biopsy. The next day, Brown, now 46, found out that she was in the early stages of breast cancer. Fortunately, it was caught in time, and she had a lumpectomy to remove the growth.
Unfortunately, another lump appeared three years later. This time, Brown elected to have the lymph nodes on her right side removed in an attempt to keep the cancer from appearing there. “It was totally my decision,” she says. “The doctors said that sometimes the cancer comes back into your lymph nodes. I was scared, but I wanted to live for my kids.”
The surgery left Brown with painful swelling in her right arm, which kept her from being able to complete normal activities—she even had to resign from her job because of it. She also endured uncomfortable chemotherapy and radiation treatments. Now, however, Brown says she’s doing fine. “It did stress me out at first,” she says. “I was taking medication for depression.”
Brown’s story is not unlike those of the nearly 200,000 American women—including 20,000 black women—diagnosed each year with breast cancer (the second most common cancer, following skin cancer, among women).
While over 41,000 women die of breast cancer each year annually, women’s odds of surviving are improving, mainly because more are getting regular mammograms, which increase the likelihood their cancer will be diagnosed early, when it is still treatable, as Teresa’s was.
Recently, though, the American Cancer Society (ACS) made the somewhat controversial decision to change its diagnostic guidelines. The ACS now recommends that highly sensitive Magnetic Resonance Imaging (MRI) be employed for women with higher-than-average prospects for developing breast cancer. The ACS recommends an MRI, in addition to mammograms, for these women starting at age 30. Previously, the ACS had only suggested that higher-risk women get additional testing, such as more frequent mammograms or MRIs. The catch: Most of the million or so American women at high risk of developing breast
cancer don’t know it.
How high is high?
Women with an increased risk of breast cancer have odds that are 20 to 25 percent higher—or roughly a 14 to 15 percent chance—of developing the disease over their lifetime than the average woman, whose risk is about 12 percent. Typically, women defined as high-risk include those:
• whose tests indicate genetic mutations such as BRCA1 or BRCA2. Women who come from families with strong histories of cancer, particularly at young ages, should get tested for these and other mutations;
• who are first-degree relatives (the parent, sibling or child) of women who carry those mutations;
• whose first-degree relatives developed cancer before menopause;
• whose chests received radiation between the ages of 10 and 30, typically for other cancers such as lymphoma.
The ACS now advises these high-risk women to get mammograms and MRIs once a year starting at age 30. For women whose risk is average, the guidelines have not changed—you should get your first mammogram at age 40 and annually thereafter. Multiple websites offer probability scores for those concerned that they may carry the BRCA1 or BRCA2 gene (try http://astor.som.jhmi.edu/BayesMendel/brcapro.html). However, do any risk assessment with a health care professional to ensure your results are interpreted properly.
The short end of the stick?
What these new guidelines mean for black women is unclear.While we suffer from breast cancer less frequently, we tend to be diagnosed when our cancer is much more advanced and, consequently, die of it more often. According to the National Breast Cancer Coalition, about 77 percent of black women diagnosed with breast cancer survive for five or more years, compared to 90 percent of white women. While the likelihood that we’ll overcome breast cancer has improved dramatically over the years—in part because more sisters are getting mammograms—our survival rate has not increased proportionately for reasons experts struggle to find. Many suspect environmental and socioeconomic factors.
Facing our fatalism
MRIs may improve some women’s chances of detecting cancer early. An MRI is more sensitive than a mammogram in picking up abnormal breast tissue. But Harold Freeman, MD, surgeon and medical director of New York City’s Ralph Lauren Center for Cancer Care, questions whether adding MRIs to the screening process is economically feasible for individuals, hospitals or the insurance industry. A breast MRI can cost over $2,000, and it is unclear whether insurance companies will pay for them. There are neither enough MRI machines to accommodate the potential increase in procedures nor qualified radiologists to read them. In addition, radiologists often disagree on what is considered abnormal.
For Freeman the more important factor is whether a woman receives treatment after her breast cancer diagnosis.
“I have heard many women ask: ‘Why should I get a test that may give me a result that I can’t do anything about because I can’t afford the treatment?’ ” says Freeman, who also serves as associate director of the National Cancer Institute. After diagnosis, a woman has to face the possibilities of surgery, radiation, chemotherapy and/or medications such as tamoxifen. These expenses can be daunting, and especially so if the illness and subsequent treatment forces you to leave your job, as it did for Teresa Brown. After having to resign, Brown applied for disability and was denied; she’s now fighting that decision. However, having a strong network around to help can prove invaluable.
“I got through this with the support of my family,” says Brown, who left Columbus, Ohio, to move back to Detroit to be with the rest of her family. “I’d been feeling a little uncomfortable about the breast thing. Now I can talk about it. I’m a breast cancer survivor.”
Mana Lumumba-Kasongo, MD, MS is an emergency medicine physician in Albany, Georgia, and a nationally published writer.
BREAST CANCER SIGNS AND SYMPTOMS
Detecting breast cancer early, when it’s most treatable, can be difficult because the condition usually isn’t painful. Common symptoms may include:
- Any nipple discharge other than breast milk;
- A change in breast or nipple appearance, such as turning inward, redness, an orange tinge or a pitted surface;
- Any change in breast or nipple texture, such as a lump or thickening.
If anything about your breasts seems unusual or appears to have changed, seek medical assistance. In the meantime, follow breast cancer screening guidelines (see below).
A mammogram isn’t the test that tells you that you have cancer. It’s purpose is merely to identify the presence of unexpected kinds of breast tissue. An abnormal reading has usually just picked up a cyst, a collection of fluid which is rarely cancerous; a fibroadenoma, a type of benign tumor; or calcifications, small mineral deposits.
About 90 percent of the time, doctors will monitor these benign conditions by ordering follow-up mammograms, typically within six months. Less than 10 percent of the time, the tissue also needs to be biopsied, usually using a needle that is guided by ultrasound. Good news: tissue biopsies turn out to be benign 80 percent of the time. And out of every 1,000 mammograms, only one or two detect an abnormality that turns out to be cancer.
EARLY DETECTION BY THE NUMBERS
According to the American Cancer Society, regular screenings are the best way for most women to detect breast cancer early, when the disease is confined to breast tissue and less likely to have spread. Follow these guidelines:
In your 20s
Begin performing a monthly breast self exam (BSE), which will help you become more familiar with the pattern and texture of your breast tissue, better preparing you to identify abnormalities should they develop.
Every three years, obtain a clinical breast exam (CBE) from a health professional. Your CBE offers you a chance to discuss any changes you may notice in your breasts, as well as you personal and family health histories, which will help your doctor determine whether you’re at higher risk.
In your 30s
Continue performing monthly BSEs and obtaining CBEs every three years. If you have a higher-than-average breast cancer risk, get a mammogram every year, along with an MRI.
In your 40s and beyond
If your risk is low or normal, begin getting yearly mammograms at 40. But know that mammograms can miss some cancers and may detect other noncancerous tissue abnormalities, resulting in false-positive results, follow-up tests and understandable anxiety if it happens to you. If your risk is high, talk to your doctor about getting regular MRIs.
Is Breast Cancer Really More Deadly in Black Women?
A new study may explain why breast cancer kills disproportionate numbers of black women. The research, published in the June 2006 issue of the Journal of the American Medical Association, looked at 496 North Carolina women diagnosed with cancer between 1993 and 1996. Then, the annual breast cancer death rate among premenopausal black women was about 15 deaths per 100,000, versus 9 deaths per 100,000 for white women. Of the study participants, 39 percent of the premenopausal black women with breast cancer appeared to have a particularly dangerous strain called basal-like breast tumor, significantly higher than the 16 percent seen in non-African-American women.
Unfortunately, there are no targeted treatments addressing the basal-like type of cancer. However, researchers found that even when the basal-like subtype was removed from the equation, black women’s breast cancer death rates were still higher than white women’s. S. David Nathanson, MD, surgical oncologist at Detroit’s Henry Ford Health System and author of Ordinary Miracles: Learning From Breast Cancer Survivors, says, “We suspect that [the reasons behind] black women’s higher breast cancer mortality may not be biological, but socioeconomic.”
Scientists have known for years that carcinogens are produced when meats are cooked at high temperatures, as often happens during grilling. So is it possible that barbecue causes breast cancer? Susan Steck, PhD, a professor and epidemiologist at the University of South Carolina in Columbia, led a study of roughly 3,000 women and found that postmenopausal women who consumed smoked, grilled or barbecued meat more than once a week had a 47 percent higher incidence of breast cancer. “We do not know if it is the cooking method or the overall intake of meat over a lifetime that is the main cause of increased risk. It is possible that high intake of grilled/barbecue meat is just a marker for some other risk factor for breast cancer, such as high fat intake,” Dr. Steck says.
To reduce your cancer risk, eat more fruits and vegetables that are high in antioxidants, including broccoli, carrots, spinach, strawberries and tomatoes.
Breast self-exam (BSE)
A monthly hand inspection of your breasts and underarms that you perform at home to detect early tumors.
Clinical breast exam (CBE)
A routine checkup performed in a medical office by a health care practitioner.
Film screen mammogram (FSM)
A breast X-ray that is examined by a radiologist—an X-ray interpreter—for abnormalities.
A digital image of the breast that is viewed on a televisionlike monitor.
An additional mammogram performed to inspect breast lumps or abnormalities already identified by a FSM or digital mammogram.
Magnetic resonance imaging (MRI)
A noninvasive procedure that allows doctors to detect smaller tumors.
An invasive procedure to remove suspicious cells or tissues to determine whether cancer is present.