Friday, September 22, 2006

Breast Cancer

Y'all know I'm helping write a book. Well, recently we got the news from our editor that they want a book half the size we thought we were writing. As a result, we've had to make some adjustments, some cuts, etc. Rather than just file my drafts in the back of a drawer to collect dust, I thought I'd at least share them here. This was going to be one on breast cancer, from a chapter called "Spurn Your Bra."

spurn bra – breast cancer DRAFT

In a chapter about bras and breasts, what is a responsible doc going to talk about? What else but that ghastly goblin lurking in the heart of every woman, that most feared of diagnoses – breast cancer. If your pulse rate just went up, count yourself normal.

By the time you’re fifty, I’d lay a confident bet that all of you have known (or been) someone with breast cancer. I can think of seven that I’ve known well, and that isn’t counting patients. One woman died from it, one died from something else, three are survivors and two are still in treatment. It’s a sobering, all-too-common reality.

But guess what? It isn’t all bad news. You’ve probably heard the statistics, the ominous “one in seven” that certainly lodged itself in my brain the minute I heard it years ago. Well, it turns out that is an exaggeration. That “1 in 7” is what’s called an “average lifetime risk.” It means that one of every seven baby girls born today would statistically get breast cancer by the time she is 70. But not all those baby girls live to be 70. Some die of other things. And some of those who died of, say, a car crash or a heart attack were counted as that one in the 1 in 7 who was supposed to get breast cancer. If you’re saying, “Huh?” by now, don’t worry. You’re not dumb. It’s the statistics that are confusing. (I had open book exams in that class in college and I still barely passed!)

More meaningful are statistics that give you your age-specific risk. In other words, given the age you are now, what is your likelihood of developing breast cancer? That’s what we all want to know, right? Here are the numbers:

A woman’s chance of being diagnosed with breast cancer is:

  • from age 30 through age 39 . . . . . . 0.44 percent (often expressed as “1 in 229”)
  • from age 40 through age 49 . . . . . . 1.46 percent (often expressed as “1 in 68”)
  • from age 50 through age 59 . . . . . . 2.73 percent (often expressed as “1 in 37”)
  • from age 60 through age 69 . . . . . . 3.82 percent (often expressed as “1 in 26”)

See, it’s not quite as big a goblin as you thought.

Still, it deserves some attention in our lives, and more as we get older. So what advice do you think I have for you? Right. Get your mammograms! Or perhaps I should say, “Get your breasts studied!” The field of breast diagnostics is changing rapidly. By the time this book comes out, some other technology may have replaced the annual mammogram. Some exciting techniques in the works already are MRI, ultrasound, digital mammography, PET scans, Electrical Impedance Scanning and Ductal lavage PAP smears. Hey, some day they’ll be able to just run a whatchacall – that thing from Star Trek – tricorder down the air in front of our body –“bleep, bleep, bleep” – diagnosing and treating in one fell swoop! But for the present, we’re stuck with mammograms.

You’ll hear different recommendations from different experts about how often you should have a mammogram, from yearly to every other year. Me, I squeeze it into my schedule (pun intended) every year, and advise my patients to do the same. I’d rather risk a few extra rays to catch that sucker when it’s still tiny and operable.

There’s also the infamous “self breast exam” which can seem impossibly technical in the exam room brochures, but really is just about getting to know your breasts with your hands. By now you’re either in the habit of this or not, but one of the basic tenets of this book is that it is possible to teach an old dog new tricks, so if you’re not in the habit, get in the habit! Put it on your calendar, make it part of your monthly “hair, nails and breasts” day, whatever works. Get help. I’ll lay another bet that your intimate partner would be delighted to assist you with a frequent breast exam. Sharing a shower is a great way to save water, get a thorough breast exam, and end up with squeaky clean breasts in the process! Men, this means you too. Guys can get breast cancer, so soap up!

And thirdly, two simple (I didn’t say easy) steps you can take to decrease your breast cancer risk: exercise more, and limit your alcohol intake.

Back to the mammogram for a minute. If you’re like me, one mammogram was one too many. But hey, sometimes we gotta suffer for the greater good, right? Given that, here, from a mammogram survivor (too)many times over, are a couple basic tips.

  1. Schedule your mammo for a midcycle time. If you’re still menstruating, with roughly predictable cycles, don’t plan to get your breasts squashed like pancakes when they’re at their most swollen and tender. In other words, NOT when you’re premenstrual. That should be a no-brainer, but I’ve goofed on it before. Ouch!
  2. Keep quiet. I’m one of those patients that tends to be chatty and friendly with medical staff, because I think it’s common courtesy, plus it makes the medical experience more palatable overall. But this is one procedure during which I just shut my yappy trap. The mammographer has a job to do, and the more you don’t distract her, the quicker she’ll get it done. And you DO want it done quickly, trust me. Listen to her instructions, follow them exactly, and keep your mouth shut. And just when you think you can’t stand the pressure one more nanosecond, it’s over.
  3. Practice. Lie down in the driveway and have your spouse run over your – I’m kidding! You’ve all seen those mammogram practice jokes running around the internet I’m sure. Hilarious, right? NOT! Once a year is bad enough.

Finally, a few words about genetics. You’ve probably heard about the “breast cancer gene” and might have wondered about getting tested for it. The bare facts are these: We all have genes called BRCA1 and BRCA2. Some of us have mutations in these genes that make us more susceptible to breast cancer and other cancers. If several women in your family (close blood relatives) have had breast cancer, or both breast and ovarian cancer, or if your heritage is Ashkenazi Jewish, you might want to talk to your doctor about BRCA testing. But I recommend a dose of caution before heading into this particular morass. It’s not a straight-over, one on one correlation here. In other words, if you have the dreaded BRCA1 or BRCA2 mutation, that doesn’t guarantee that you will get cancer, nor will the absence of the mutation guarantee that you won’t. If you do have the mutation, you have to decide what you’re going to do about it, if anything. Some women have had both their breasts removed, for prevention. No breasts, no breast cancer, right? But that is major surgery that carries major risks, and it turns out that most times a mastectomy leaves some breast tissue behind. You only need one cell to develop cancer. On the other hand, it might be worth the risk to have the peace of mind. Only you can decide, and I’m just suggesting you look and think before you leap into the bottomless BRCA pit.


The National Cancer Institute of the US National Institutes of Health

The U.S. Preventive Services Task Force (USPSTF)


Bardiac said...

Nice post! I really found the way you set out the odds by decade interesting.

I get confused by the ways information about false negatives is presented. Care to take that up, maybe side by side with the decade information? It seems like that might be a balancing point for women to decide which risk level they're willing to accept or not.

difficultpt said...

I just had the dreaded mammogram last week. I thought it was interesting that you mentioned men--the mammographer shared that a man was in the same morning as I. She also said that when men notice a lump, they often put off having it checked out until it is a major problem.

I blogged about my mammogram at

dr peg said...

Bardiac - Good question about the false negatives. I'll look into it.

Difficultpt - When I walked in the Komen race last year, there was a man who was something like a 12 year survivor of breast cancer there. It was a good reminder.

Giovanni said...

I appreciate your casual, personal and friendly way of sharing important information.

Here's a little boy question: Do some men get mamograms too? We certainly are enjoined to palpate our testicles for tumorous growth; but our breasts? Seems like a stretch for a lot of men. I think I'll look into that.

Hope your book is going well. Keep us updated.


dr peg said...

Giovanni - Men don't get routine mammograms like women do, but if they find a lump in their breast, a mammogram will help diagnose whether it is cancer or not, just like for women. It's not a common cancer in men, but it is possible.

And yes, you can fit a male breast into a mammogram machine!

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Emma said...

What a wonderful post!

I work as a mammographer, and I agree with your comment about keeping quiet during a mammogram 100%. I know I'm female, but I'm hopeless at multitasking - the patients that I get chatty with are the ones I end up making mistakes on. Simple ones, like not labelling a film correctly, or double exposing a cassette, because I'm not totally concentrating.

Plus, the conversation usually starts with either 'a man must have invented this machine' or 'is this all you do all day?', which, frankly, I'm running out of answers to.

You have a fantastic, empathetic writing style - I know no one enjoys mammograms, but you have a spot on attitude, and empathetic writing style.

(And I'm only 12 months late with a reply to this post...)

Peg Spencer, MD said...

Emma - thanks so much for reading this and for your nice comment. Great to have feedback from a real mammographer! Only part of this post made it into the book we wrote, but it does include the part about keeping quiet.

Take care!


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