Breast Cancer; A month in its name

October is breast cancer awareness month!

During this time period many nonprofit organizations, hospitals, healthcare workers, celebrities and social media tend to promote for breast cancer awareness and to shed the light on the value of earlier detection and treatment?
This propaganda indirectly hints on the importance of this disease and the value of its awareness. How scientifically true is that?

How common is Breast Cancer?

Breast cancer is the most commonly diagnosed cancer worldwide (after non-melanomatous skin cancers) with a woman’s lifetime risk for developing breast cancer of 12%. This means that 1 in 8 women will develop breast cancer during their lifetime. This high incidence is similar across all countries (with minimal differences), and across different cultures and ethnicities.
Nowadays, almost every person knows someone who was diagnosed with breast cancer, and with time, every family is expected to witness such a disease.

What are the risk factors for developing breast cancer?

I will be discussing the most commonly encountered risk factors for breast cancer development.

Age is the single most important risk factor for breast cancer that is less frequently encountered before the age of 40. As per the American statistics, the risk for developing breast cancer before the age of 30 is 0.4%, by the age of 40-50 it is 1.5%, and after the age of 60, the risk increases further to 3.6% meaning that 1 in 28 women aged 60-70 will develop breast cancer. 

Female gender is another important risk factor however, breast cancer cases have been diagnosed in males as well. Actually 1% of all diagnosed breast cancer cases are seen in males. 

Even though breast cancer is common across all races and ethnicities, however white women were shown to be at a slightly higher risk for developing breast cancer, yet black women were more likely to present with more advanced stages of the disease and unfortunately scored higher mortality rates. This ethnic variation in breast cancer incidence and presentation can be explained by genetic, lifestyle and socio-demographic discrepancies among races.

Obesity and high body mass index have been linked to a higher incidence of breast cancer. This association was shown to be true only in post-menopausal women. Studies have shown that excessive weight or new weight gain at the time or menopause (around age of 50) was associated with a higher breast cancer rate. However, this weight-cancer link was not found to be true among pre-menopausal women. Actually, obese pre-menopausal women were shown to have a lower risk for developing early onset breast cancers (this counterintuitive correlation is poorly understood till today). 

Unlike weight, height was associated with a higher risk for developing breast cancer in both pre and post-menopausal women! The body of evidence we have showed that women who were >175 cm tall had a 20% higher lifetime risk for developing breast malignancies compared to those <160 cm tall.

Early menarche and late menopause have also been associated with a higher incidence of breast cancer, and this can be explained by prolonged estrogen exposure duration. Studies have shown that girls who have their menarche after the age of 15 were less likely to develop breast cancer compared to those who hit menarche before the age of 13.

Nulliparity (having no kids before) and late age for first pregnancy were also linked to breast malignancies. Actually nulliparous women have the same risk for breast cancer development as women who have their first full term pregnancy after the age of 35.

Exposure to therapeutic radiation since an early age has been linked to breast cancer too. This risk is routinely discussed with patients with childhood or early adulthood malignancies (such as lymphomas) requiring chest irradiation.

Lifestyle factors that were shown to be associated with breast cancers are excessive alcohol consumption and smoking! As I always tell you, quit (or at least limit consumption) as long as you can.

Finally, and most importantly, having a personal or family history of breast, ovarian or colon cancer increases your chance for developing breast cancer. Hence, I always encourage you to talk to your health care providers about your detailed personal and family histories as your risk assessment highly depends on them. Some breast and ovarian cancers are hereditary and thus run in families, therefore helping your provider to elucidate these diseases is of utmost value as the follow-up, management and counseling differs from that of the general population.

What are the protective factors?

Two of the most important protective factors against breast cancer are breastfeeding and exercise.
Women who breastfed their infants have a lower incidence of breast cancer, and this association was highly dependent on the duration of breastfeeding in addition to the confounding parity of the mother (discussed above). Moreover, physical activity was linked to a lower chance for developing breast cancer in both pre-menopausal and post-menopausal women via a healthier hormonal profile in physically active women compared to those with a sedentary lifestyle.

 

What are the symptoms of breast cancer?

Nowadays, with the routine use of screening modalities for the earlier detection of breast cancer, most cases are diagnosed on mammography. However, 15% of breast cancer cases are not seen on mammography and another 30% of cases are diagnosed in between routine mammograms. Moreover, women below the age of mammography are diagnosed with breast cancer based on their presenting symptoms.

Breast mass is the most common presenting symptom for breast cancer. The typical suspicious mass is a hard, immobile, fixed, single and irregular mass. But keep in mind that many similar masses turn out to be benign. So, do not freak out, and always follow with your provider in the setting of any breast masses. 

Other findings (more commonly seen in more advanced stages of breast cancer), include axillary lymphadenopathy (lymph node swelling in your underarm area) and skin changes of the breast (peau d’orange [orange peel like skin], nipple retraction, redness or thickening of the skin).

Some women’s presenting symptom can be in the form of a new nipple discharge. Here again, not all nipple discharges are secondary to malignancies since many benign conditions are associated with unilateral (1 sided) or bilateral (2 sided) nipple discharges. Worrisome discharges are those that are clear, unilateral and associated with an existing breast lump. So, here again, in the setting of any new nipple discharge, follow with your provider but do not panic!

How to screen for breast cancer?

Before addressing the guidelines for breast cancer screening, we should determine the individual risk for developing breast cancer. Many risk prediction models have been created in order to stratify patients according to their overall lifetime risk for developing breast malignancy, and this is divided into average, moderate and high risks. The majority of the population lies in the average risk group (with around 12-13% lifetime risk for developing breast cancer), and a smaller percentage of women lie in the moderate and high risks groups with lifetime risks for developing breast cancer of 15-20% and >20% respectively.
In summary, the factors that put a women into the high risk groups are (personal or family histories of breast, ovarian, tubal or peritoneal cancers, known genetic mutation associated with breast cancer [BRCA1/2…], or a history of therapeutic chest irradiation between the ages of 10-30…)
In this article I will not touch upon the screening and follow-up plans of moderate and high risk women, instead I will be focusing on the age-stratified screening modalities in the average risk women.

Ages between 21-39

In this age category, all medical societies agree that women are at an overall low risk for breast cancer development and thus screening mammography is not indicated in this age group. However women are always encouraged to do monthly self breast examination and yearly examination by a professional. To note that clinical and self breast exams are no endorsed by all societies (for a high false positive rate) and thus should never substitute routine screening methods in the advanced age group population. The World Health Organization encourages clinical and self breast examination with the condition that women are taught by a professional on how to perform a proper self breast examination to increase its sensitivity.

Ages between 40-49

Some societies recommend starting with the screening mammography as of the age of 40, while others shy away from screening this age group unless coinciding with other risk factors. However I personally follow the American College guidelines and recommend the initiation of breast cancer screening with yearly mammography as of the age of 40.

Ages between 50-74

All medical societies agree that screening should be routinely performed in all women after the age of 50, however here again discrepancies arise among different medical guidelines as some recommend annual screening while others endorse screening to be done every 2 years. Again, I am a strong advocate for the yearly mammography screening and not the one done every 2 years as up to 30% of breast cancers are diagnosed in between mammograms (interval diagnosis of breast cancer) and thus increasing the inter-mammography interval further is not wise.

After the age of 75

Here individualization of the screening method should be implemented. Mammography should be done every 1 to 2 years in women aged 75 or more only if their life expectancy is 10 years or more!

Anything other than mammography?

MRI and ultrasound have been used in the diagnosis and further characterization of a breast lesion, however they are not approved to be part of the routine average risk population screening for breast cancer (you can discuss with your physicians the value of these imaging modalities)

 

Breast cancer is suspected on clinical and imaging grounds; however the only definitive diagnosis is based on a tissue biopsy. So, if you are experiencing a new lump, nipple discharge, breast skin changes, underarm swelling or had abnormal mammography results follow immediately with your physician for further investigation. Moreover, do not hesitate to talk to your physician about your personal and family histories of malignancies (breast, ovarian, colon…) for better risk assessment and screening plan.
Breast cancer is indeed the most commonly diagnosed cancer worldwide (after non-melanomatous skin cancers), however lower mortalities rates have been observed over the past few years. This lower death rate is secondary to better screening modalities, earlier detection and more advanced therapy plans.
Stay informed, don’t ignore your symptoms and always seek professional help when in doubt

Don’t hesitate to email me or direct message me on https://www.instagram.com/online_women_health1/?hl=en for further concerns.
Questions related to breast implants, history of breast surgery/reconstruction, history of breast cancer and screening of high risk population can be discussed privately. 

 

Karam