Category: Breast Health

by Dixie Mills, MD

The questions and answers around mammograms are muddy to say the least. The debate about their use can get quite heated and more emotional than one would think for a medical screening test. No one really gets up in arms about chest x-rays or blood draws. Unfortunately, the science around mammograms is not as straightforward or black and white as anyone would like it to be.

A study published earlier this year in a very reputable journal, the British Medical Journal, reported that mammograms are really not that helpful and do not prevent any more breast cancers in women between the ages of 40 and 59, than having clinical exams.¹  Then the next day, a rebuttal was made by other medical professionals (many radiologists and cancer specialists) that the study used out-dated equipment and was poorly designed. These conflicts in the “breast field” seem to appear in the lay press every few years and obviously confuse the majority of women as much as they are confusing to the medical professionals. Primary care doctors – many of which have never had a mammogram themselves because they are men or too young, are not sure what to recommend to their patients and organizations are trying to come up with meaningful guidelines.

Unfortunately, I think some of the sound bites we have heard over and over are not as accurate as we once thought. Let’s look at “Early Detection Saves Lives.”  Well it may for some, but the big data does not show that having annual mammograms makes as big a difference in breast cancer as we had originally hoped. I have many patients who swear they were saved by having a mammogram. Their cancers were caught when small – they were Stage 1 and they had the recommended treatments of surgery, radiation and systemic therapy and go for their follow-up mammograms on a regular basis. However, there are also women who went for their annual mammograms and their cancers were not caught early – some were hidden or missed in their mammograms, others were just fast growing tumors. Or there are the thirty something women who are too young for mammograms who get breast cancer.

And then there are women whose cancers were caught early, did all the right things and still got more cancer and their breast cancer spread. On the other side, there are the women who are sure that their cancer was caused by having too many mammograms – exposing them to too much radiation. And now, we realize that there are some breast cancers which are fairly benign, and do not kill, so there is no need to find them early.

It disturbs me to think of throwing mammograms out (and slowly that may be happening whether it is a woman’s choice or health care companies not wanting to pay for a test) – without something to take it’s place.  Ultrasounds are almost there, but whole breast ultrasound technology is not quite ready for prime time, and MRI’s are much too expensive and time consuming. So we are left with the least high tech instrument – our own fingers or our health care providers!  And mammograms themselves, while most are digital, are still just black, gray and white images.

I certainly would hope, that with all the data technology out there, that some independent group would try and answer this debate. As I have half jested in the past, I would like be a curator of a mammogram museum when I retire. However, that means that either we have found a way to prevent breast cancer so we don’t need to screen for it anymore, or someone (where are you Silicon Valley folks?) invents a better screening device – GOOGLE Mammograms, an Apple iMammo? A prize for the best name?

The medical community is trying to advocate more personalized medicine and in particular, identifying molecular markers on tumors to direct treatment. I read where Google has funded a nanoparticle pill that you swallow and it disperses though the body and can identify cancer cells. Who knows? But hopefully someday there will be a way to tell which women need to have mammograms, which need ultrasounds, and how often. Stay tuned for the next article on some tips about what you can do to take care of your breasts.

¹ Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial  BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g366  (Published 11 February 2014)

by Marcelle Pick OB/GYN NP

• Keep breathing
• Ask questions, gather information
• Find a support person to be with you

Sometimes the films just don’t come out right and they need to repeat them.
The three most common “things” that radiologists see in mammograms that they want “worked-up” are:

1. A new nodule
2. An asymmetric density — (the breast tissue doesn’t look the same in each breast)
3. A new cluster of calcifications (little white specks)

The first 2 should have an additional spot compression film to see if it is real and an ultrasound to see if the area is fluid or solid and have a better look at its shape. Nodules that are irregular or spiculated (like a star) are more worrisome.

Calcifications should have special magnification views done of them which can help determine if they are normal or worrisome. Most calcifications are normal and associated with aging — not from taking too much calcium.

If someone tells you to wait 6 months and recheck it it is usually because they think it is benign. However, if you don’t want to wait 6 months you have the right to ask for a second opinion.

If someone tells you you need to have something biopsied you should feel you have gotten your questions answered as to why, and that the mammogram has been worked up sufficiently. Someone should also examine your breasts and correlate them with the mammogram to be sure that nothing is palpable. Remember the point of getting a mammogram is to find lesions early and too small to feel.

Most breast centers today have equipment to biopsy mammographic findings with a needle and thus spare a woman a trip to the operating room. This is called a stereotactic biopsy or a mammotone-core biopsy. This type of biopsy has been shown to be as accurate as a surgical biopsy and much less invasive. I recommend you try to find a center which does these biopsies and does them frequently — our breast center does 2 to 4 stereotactic biopsies a day.

Another way to biopsy is with ultrasound guidance — this is sometimes a bit easier because your breast does not have to be compressed. Most mammographic problems, except calcifications, can be identified on ultrasound. Most breast centers have accredited mammography and ultrasound units and specialized breast-imaging radiologists.

by Marcelle Pick OB/GYN NP

This is one of the most common questions I am asked. I think it is because informed women now question it’s side effects. This pill, the most widely prescribed oral medication for breast cancer, has been studied in more trials than any other drug. However, the patent for Tamoxifen is running out and there are some newer hormonal blockers. Tamoxifen has an interesting history. It is not a new drug — it was synthesized back in the 70’s to be a birth control pill. It worked that way in mice, but instead increased fertility in women. Other scientists then decided to try it on advanced breast cancer patients and it did help — extending survival by many months or years. Tamoxifen is now seen as an estrogen blocker to the breasts — it inhibits estrogen from binding to cells. However in other parts of the body, the uterus, bones, ovary, it acts like an estrogen.

We now know that Tamoxifen has some negative side effects, increasing hot flashes, mood swings, and most significantly, increasing blood clots and uterine cancer. The last two are pretty rare, but significant. When Tamoxifen is used in women with more advanced breast cancer, positive nodes or metastases, the benefits exceed these risks. However, for women with earlier stages, like DCIS or very small tumors, one does need to balance the benefits with the risks. A woman should be able to have an objective discussion with her provider about the true benefits of Tamoxifen — is it 3% or 10% improvement — and then make an informed decision. Some women want to do everything, even if the benefit is small; others do not see it that way. For some women Tamoxifen is a safety net; for others it is a poison they cannot swallow.

Tamoxifen is now FDA approved for prevention of breast cancer in women with strong family histories or with atypical biopsies or LCIS. I have found that Tamoxifen is actually best tolerated by the younger women — women from the age 35 to 45. They are still having their periods and do not have any side effects. It is recommended that they take it for 5 years (using contraception, because of potential birth defects) and that the benefits last a lifetime. I have seen perimenopausal women have the most problems with Tamoxifen, as far as aggravating the symptoms of menopause and “just not feeling right.” Some women tough it out, others stop. The recommendation is to take it for 5 years only — the most benefit comes from at least 2 years. No one has tested it for, say 3 or 4 years. I often suggest that women give Tamoxifen a try for at least 3 months and keep a diary of how they feel taking it. Belief is important here and if you don’t think it is going to work, I doubt that it will.

For post menopausal women, newer drugs called aromatase inhibitors are on the market and appear to be superior to Tamoxifen. They block the conversion of estrogen from one’s fat, cholesterol or adrenal sources. Women seem to have fewer side effects, except for joint pain, with these drugs. However, they have only been studied for the last 5 years so we don’t have long term data on them. You can also ask your doctor about ovarian suppression by surgery or pills. The benefits may be equal to chemotherapy, but also have other side effects — going into sudden menopause.

Now being tested is a tamoxifen gel to be applied topically to the breasts. The hope is that it will still have its protective effects without the downside.

Hopefully in the near future we will have a better understanding of which women need which drugs.

by Marcelle Pick, OB/GYN NP

Many women are asking this question now because they want to be proactive and often feel on shaky ground once treatment is over. This can be a difficult question that could take a lifetime to answer. Also, there are many tiers to answering it. I have found that I can provide the sources of information and let the woman delve into it as much or as little as they want. Some need a little push; some get a bit obsessed, and most find a good balance over the long haul. I have learned a lot from them and will try to share it.

I usually answer by asking a few questions —

• Can you see any meaning in this diagnosis for you?
• What would you change about your life?
• What about this diagnosis is a wake-up call?
• If this were the last year of your life what would you do differently?

In asking this question, I preface by saying I am not placing blame anywhere, that you did not do anything wrong, but there is always room for change. This can be a hard concept for some to differentiate. It is also hard for me to hear and understand, but many women tell me years later that getting breast cancer was “good,” or for some, “the best thing.” because of the changes they made.

What changes? Many women choose to make changes in their job or work environment, others in their relationships — friends or family. Some find a good support group; others use a therapist, and other women do it on their own with meditation, art or writing. A very good college roommate of mine has taught writing for many years and has a website to share her tools: www.creativechoices.net. And of course many women experiment with many new choices but settle into one or two which feels best for them.

 Most women also know that their nutrition hasn’t been right for awhile and want to know what to eat. This topic could obviously fill another whole website, so I will try to be brief and to the point.

I have not found one eating plan that works for everyone. I have found that there are certain points within many diets which are the same, and which I think everyone (with cancer or not) should try to follow. To summarize:

• Decrease portion size
• Eliminate the “whites” — white sugar, white bread and rice. Use honey, maple syrup, “date sugar” or Stevia
• Avoid hydrogenated fats with trans-fatty acids (read labels), most processed foods — i.e., donuts, bakery sweets. Butter in moderation; olive oil is best
• Use alcohol and caffeine in moderation — teas are better options
• Increase the use of washed organic fruits and vegetables and organic chicken, red meats and fish
• Take a good multivitamin without iron and with lots of folic acid, and add extra omega 3 fatty acid (fish oil) supplement
• Add flax in ground seed form or oil — increases fiber (other fiber sources essential also)
  
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by Marcelle Pick, OB/GYN NP

This question has intrigued me now for over 10 years. In fact when I was in Boston, a nutrition colleague and I wrote a large grant to identify causes and treatments. We also wanted to see if there was an association between women who had tender breasts and those that got breast cancer. Unfortunately it was not funded because breast pain did not and still doesn’t have a high priority among funding groups. I kid with my patients that this is because men just don’t “get it”— because, first, they don’t really have breasts so don’t get breast pain, and second, most do not identify with the anxiety that happens to women when they experience breast pain.

In a day in my office, at least a quarter of my new consults are for breast pain or mastalgia — the fancy medical word for pain. The majority of these women, no matter how well-educated or health savvy, are sure that something terrible is wrong. We are taught that pain is a symptom of something wrong — a sprained muscle, a stress headache, an upset stomach. But what is the cause of breast soreness? I hear women tell me that sometimes the pain wakes them up at night, sometimes it is sharp and burning, often it radiates to the nipple.

Several years ago I wrote an article about solving the mystery of breast pain. The points of that article are still true today. While very few complaints of breast pain are actually breast cancer, women should see their health providers to rule this out. A breast exam needs to be done to be sure there is no lump; an ultrasound should be preformed to be sure there is nothing hidden; medications and diet should be addressed. For many women, especially those in their 40’s and perimenopausal, linking their cycles and other symptoms of hormonal imbalance is very useful. It is unusual for post menopausal women to have breast pain (one of the benefits of menopause) and this symptom should be addressed in women over 50.  Hormonal replacement pills in to high doses can cause breast swelling and pain.

In addition, when given the opportunity and the space, many women will also recognize some form of stress, usually a relationship at work or home, that may also be contributing.

Other treatments that I recommend include:

• A healthy diet
• A good multivitamin with extra B’s
• A digestive cleanse/ fast or detox to remove excessive estrogens or hormonal disruptors
• Progesterone cream

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Some new therapies I’ve been recommending are topical iodine and lymphatic massage. Topical (meaning used on the skin, not taken by mouth) iodine can be bought over the counter in the grocery or drugstore usually for less than a dollar and painted in a quarter size area once a night on the breast until the brown spot persists overnight or for one month. I will admit that I cannot explain exactly how this works, but the iodine seems to adjust the hormones just enough to keep the swelling down or perhaps it is treating some subclincal virus or bacteria. Most of our diets today do not have the same amount of iodine in them that our ancestors did. This use of iodine does not seem to affect thyroid function.

If you can find a therapist trained in lymphatic massage he or she can be very helpful in treating some types of breast pain. You do not have to have lymphedema or arm swelling for them to help lymph flow and treat the pain. You can try some breast massage techniques on yourself first if you want. Breast oils and creams are available in Europe and women use them like face and body lotions to keep the skin moisturized — not necessarily to enhance the size.

While some cause of breast pain may still remain a mystery, no woman should remain in a prolonged anxiety state about it. Find someone who will listen to you and offer some reassuring solutions not just tell you to grin and bear it or make you feel it is all in your head! It isn’t!

by Marcelle Pick, OB/GYN NP

First take a deep breath and keep breathing. Most women seem to find a breast lump just by chance or something draws them to it — an itch, a pull or a pain. The point of doing breast self exams is to know what is normal so that when you feel a “lump” – you will know it is different. Most women and doctors can find many normal or benign lumps in breasts. I’ve found that most breasts are lumpier than not lumpy. It is a rare woman whose breasts are lump-free. However most of these “lumps” are normal fatty, fibrous, cystic breast tissue.

I encourage women to get to know their breasts — they should feel comfortable touching themselves all over. I do not think there should be a strict way to examine your breasts. A woman should just feel good about knowing her breasts and realize that at different times of the month they may be lumpier than other times. Usually the week before one’s period they get more swollen, tender and lumpier and the week after they are less.

However if you do find something that feels different, after breathing, and remembering where you are in your cycle, I recommend making an appointment with your provider as soon as possible. Most practices try to accommodate women quickly. Some women are comfortable waiting through a cycle and seeing if the lump goes away or gets smaller — cancers won’t. Women should be able to obtain an ultrasound of the lump also in a timely fashion. An ultrasound will be able to tell if the lump is a fluid filled cyst, something solid, or more likely breast tissue. A mammogram may also be helpful if one hasn’t had one recently. Mammograms are less useful in younger women, less than 35 or 40 years old. I would not rely on a mammogram only however. I have seen too many women who present with breast cancer after having been told their mammograms were normal.

If the ultrasound is solid or questionable, a woman should be seen by a provider who specializes in breast problems. He or she can then decide if the lump should be tested with a tissue sample. This can be done usually at the same visit with a fine needle aspirate or a core needle aspirate. These tests done in experienced hands are quite accurate. I personally have not seen needles tract or spread cancer except in rare cases of a rare type of breast cancer called colloid cancer.

Results of these tests should be available in 24 to 48 hours. Women should not be subjected to unnecessary delays. All breast lumps do not have to be surgically excised. The decision to remove a breast lump should be made with as much information as possible, i.e. ultrasound, mammogram, a woman’s and her doctor’s input. If a woman wants a breast lump removed this wish should be respected.

Likewise no woman should be rushed into having a lump removed if she isn’t comfortable with that decision- she has the time to contemplate it or get a second or third opinion.

• Breathe and breathe again
• Find a support person
• Ask questions
• Sleep on any decision

by Marcelle Pick, OB/GYN NP

Again it is important to keep breathing! Find your support system. Realize that life has changed but not ended! A diagnosis of breast cancer is not a death sentence and it is not an emergency. A woman has time to find out as much as she wants to know about her diagnosis. I tell women it is like going back to school in a class you never wanted to take but you will pass.

I would first recommend that a woman or her partner find the nearest Breast Center — most cities or universities now have one, if not several. These centers, however, need to be more than imaging centers and should have multidisciplinary teams of breast surgeons, oncologists and radiation specialists. www.breastcare.org. If you are unable to find a breast center, it is important that you have confidence in your surgeon, usually the person that first diagnosed you, and that she/he has contacts with medical and radiation oncologists. There are websites of breast surgeons also – www.breastsurgeons.org . However, some people choose not to belong, or cannot afford the membership fees to all these organizations, so the fact that your surgeon does not belong does not mean that she/he is not good. However, all surgeons should be board certified. Many surgeons are now choosing to specialize in breast and have practices where they only do breast surgery. If you want this type of care you should be able to find it. www.womensurgeons.org/CDR/Breast. There are several websites that cover the basics and overview of breast cancer treatment options.

Here are my favorites —

• www.cancer.gov/cancertopics/types/breast – The National Cancer Institute’s site
• dslrf.org/actwithlove/
• www.imaginis.com/
• www.breastcancer.org/
• www.nationalbreastcancer.org/

There is a lot of information on these sites, and many diagrams and search functions. Some of the sites also have subscription newsletters and links to other sites. 

Also, now there are many books on the topic. My favorite still remains one of the first — Dr. Susan Love’s Breast Book. A Breast Center should also have a library of information, pamphlets, brochures, videos and check lists — www.educareinc.com/patient. 

 A woman is usually referred first to a surgeon. Again, most general surgeons are trained in breast surgery, but there is a growing specialty of breast surgeons who see and operate only on breasts.

Many women prefer to see a specialist. A woman, however, should feel comfortable with her surgeon and get as many opinions as she wants to find this person who often is the “captain” of her team.

 A woman and her support team should be provided with the “standard of care” for breast cancer. This standard usually includes surgery, radiation and some type of systemic or total body care.

 Surgery in 2003 should include a choice between a lumpectomy and mastectomy. Women should understand that both types of surgery can offer the same long term survival. www.healthandage.com. Both usually are accompanied by a relatively new procedure called sentinel node biopsy. www.cancernews.com. Sentinel node biopsies in breast cancer have become standard-of-care in 2003, and a woman should request that it be done. There are only very few cases where it cannot be done. Sentinel node biopsies reduce the time of surgery and most of the post operative complications for many women. The surgical experience can be made into a very positive one instead of a frightening trip if one wants to use some new techniques. www.healfaster.com