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Family Health Magazine
WOMEN'S HEALTH

Screening for Breast Cancer
How to do a breast self-examination

Many women worry about breast cancer, both as a concern for themselves and for the increased occurrence among women in general. Fortunately there are things individual women can do to increase the chance of early detection and cure.

Although the number of women getting breast cancer each year is rising worldwide, the number of women in Canada who die from the disease has been declining since 1990. Once the most common fatal cancer in women, it has fallen to being the second most common. One reason for this change is widespread screening programs that help to pick up breast cancer early, increasing the chances of cure. If the cancer is confined to the breast at the time it is discovered, the chance of cure is 70 to 90 per cent. Improved treatments are also playing an important role in reducing deaths from breast cancer.

Who is at risk of breast cancer?

The two biggest risk factors that predict breast cancer are being female and getting older. In women younger than 30, the risk is low at 0.3 per cent (3 in 1,000). Over the age of 50 the risk increases to 2 per cent (1 in 50). By the time women are over the age of 85 the risk has risen to 10 per cent (1 in 10). The likelihood also rises when a close female relative (mother, sister or daughter) has had breast cancer or when there is a history of exposure to a high dose of radiation before the age of 30. Other conditions that increase risk slightly include a history of benign breast disease, high alcohol intake, women who have had no children or had their first pregnancy after 30, women whose first menstrual period was at a young age or whose menopause is late in life. Although hormone replacement therapy after menopause may increase the risk slightly, birth control pills have not been shown to increase the risk.

Despite all of these things that may predict a person getting breast cancer, no one is guaranteed free of risk. One in every nine Canadian women is affected over a lifetime and even men can be affected!

What about screening to detect breast cancer?

The goal of screening in healthy women is to detect cancer early to increase the chances of survival and cure.

Screening for breast cancer has three important parts: breast self examination (BSE), clinical breast examination(CBE) by your doctor and mammography (or special x-ray of the breast).

Breast self examination

What is it?

Breast self examination (BSE) is a way for you to examine your breasts routinely and methodically for changes. This is how most breast cancer was found before breast screening programs were started. In fact, 69 to 80 per cent of breast cancers are still found during self-examination.

Why do BSE?

With regular examination you will become familiar with your normal breast structure. This increases the probability of detecting a new lump when it is still small and has not spread outside the breast. If a lump is cancerous and is confined to the breast, it is much easier to treat than if it has spread to nearby lymph nodes (particularly under the armpit) or other body organs.

Scientific study has shown BSE can save lives when done properly. The value of BSE is greatly increased by proper. The three elements of successful BSE are:

1. Use the middle three fingers.
2. Use the pads of the fingers, not the tips. Examine with fingers straight, don’t bend fingers.
3. Visual inspection - look carefully at the breast. Who should do BSE and how often should it be done?
   All women over the age of 20 should do monthly self-examinations. If you are still having menstrual periods it is best to perform the examination at the time in the cycle when the breasts are least swollen, which is 10 to 14 days after the first day of a period. This way a lump may stand out more readily if it is there.

Regular, monthly BSEs can be done any day of the month if you are no longer menstruating. Some women choose to do BSE the same day each month (such as the first or last day of the month).

Many women are anxious about doing BSEs as they are unsure what “normal” breast tissue feels like. They fear they might not recognize a significant breast lump (especially women with naturally lumpy breasts). Normal breast tissue can feel soft, firm, smooth or lumpy. Because of the differences in the feel of breast tissue, it is important for you to become aware of what your breasts normally feel like. Regular self-examinations over the years will help you to be confident that you can find a worrisome change in your breast.

What if you find a lump in your breast?

If you find a lump or tender area, it should be checked by your doctor. About 85 per cent of lumps detected are benign (not cancer). They are most often fluid-filled cysts or solid lumps called fibroadenomas. They are often found on BSE and may cause pain.

Careful examination by your doctor can often given an indication of the seriousness of a lump in your breast. Sometimes further testing such as ultrasound, mammography, withdrawing fluid from the lump or a tissue sample is needed to help make a diagnosis.

Clinical Breast Examination (CBE)

Clinical breast examination follows the techniques of BSE but is done by a doctor at regular examinations or at times of concern. If you do BSE, examination by a doctor is also a “second opinion” of your own impression of your breast tissue. In either case, CBE is also an opportunity to review proper breast self examination. Regular clinical examination by your doctor is an important part of your breast cancer screening program.

Mammography

Mammography is a low dose x-ray exam of the breast. Like regular BSE and CBE, mammography is used in hopes of detecting breast cancer early.

Who should have a mammogram?

There are two types of mammograms:

1. a screening type
2. a diagnostic type

The difference between these two tests relates to their purpose. A screening mammogram is done at a particular time in a woman’s life when no abnormality is suspected. A diagnostic mammogram is ordered when a problem is suspected and it often requires a more detailed examination.

It is currently recommended that all women between the ages of 50 and 69 have screening mammograms every two years (along with annual CBE and monthly BSE).

There remains much controversy about doing screening mammograms in women from 40 to 49 years old. At the moment, however, it is not recommended in Canada.

For women under the age of 50, there may be some benefit to screening mammograms if certain risk factors are present. If there is a strong family history of breast cancer, for instance, screening mammograms should start five to 10 years earlier than the age at which the youngest family member was diagnosed. Again, it is important that this screening be done in collaboration with regular BSE and CBE. If you are in this risk group, a personalized breast care schedule should be discussed with your family doctor. Women who decide to screen before age 50 are usually advised by their doctor to have a yearly mammogram.

A diagnostic mammogram may be necessary when a lump is detected, by whatever method, or if there are symptoms such as breast pain, nipple discharge or skin abnormality.

Mammography does help to detect cancers early but it is not a perfect test. Sometimes it suggests cancer when it is not there and sometimes it does not pick up cancer in the breast of those who have the disease. These are important reasons to limit screening of women at higher risk and the age groups of women for whom routine mammography has been proven to be beneficial. This approach helps to minimize misdiagnosis and anxiety related to the test.

What is involved when someone goes for a mammogram?

The screening mammogram takes about 10 minutes and is done by a trained technologist. The breasts are x-rayed one at a time. After proper positioning of the breast, it is compressed to spread out the breast tissue. In this way, small lumps can be detected more easily. The compression only lasts a few seconds, but it may cause some discomfort.

Once the films are taken, a radiologist (an x-ray specialist) reviews the films and compares to previous mammograms, if they are available. Further x-rays may be suggested if an area of concern needs to be examined more closely.

What about radiation from the x-rays?

Given that radiation exposure is a risk factor for developing cancer, many patients worry about radiation received during a mammogram (a woman may have several screening mammograms in her lifetime). In women over 40 years there appears to be no increased risk and it is very small for women in their 20s and 30s. Its use in young women and children is reserved but it is considered a safe test in women over 40.

Other methods of detection

Genetic testing is being studied and may be able to identify women at risk for certain types of breast cancer. This research is ongoing and this type of testing is not yet generally available.

Research continues in the area of breast cancer screening and treatment. This research provides women with information and tools to deal with the many areas of breast disease. A good relationship with a family doctor, regular visits and patient education are important steps in the prevention of breast cancer and for the best chances of survival if it is found.

Key Points

• Widespread screening of selected women including mammography seems to be detecting more breast cancer at an earlier stage in the disease increasing the likelihood of successful treatment.
• The number of women dying from breast cancer is decreasing.
• For women between the ages of 50 and 69, it is important to follow the three steps of:
  1. regular monthly self-examination (BSE)
  2. regular yearly examination by a doctor (CBE) and,
  3. screening mammography in order to maximize the chance of detecting breast cancer early.
• More women in the 50-69 age group need to take advantage of breast cancer screening. Many provinces have government-run early detection programs that offer the high quality and consistency of care making these clinics an excellent resource for women.
• For a woman younger than 50, regular BSE may help in early detection and a personalized breast care plan should be discussed with her doctor based on an “individual” risk for getting breast cancer.
• If you find a lump or a change in your breast, have it checked as soon as possible by your doctor.
• Proper technique for BSE is very important and it should be reviewed if you have any concerns. Three characteristics of effective BSE are: using the flat part of the fingers, the middle three fingers and careful visual inspection.
• Additional information about assessing and reducing your risk for breast cancer can be obtained through your family doctor, local health unit or the Canadian Cancer Society. With practice you can see or feel changes in your breast.

1.Visual Check

• Stand in front of a mirror and look at your breasts carefully - first face forward and then turn slowly side to side.
• Lift your arms above your head and behind your ears. If you have pendulous breasts you may need to lift them up to see the lower halves.
• Lower your hands part-way and squeeze your palms together.

2. Hand Check

Standing

Use the opposite hand for each breast.

• Use a flat hand. Bend your wrist, not your fingers, to go over curves. Apply moderate pressure and keep constant contact with your skin.
• Move back and forth across the breast in a straight line pattern, making constant small circles. Slide your hand down one finger width for each pass. Cover the full area indicated.
• Check the area under your arm. Relax your arm, place your hand under it, making the same small circular movements as before.

3. Hand Check -Lying Down

• In the last steps of BSE, lie down on a firm surface. Use exactly the same steps used when standing. It is not necessary to check your underarm while lying down.

What are you checking for? If you feel anything that is a different texture or movement than what you have felt before, consult your doctor. Remember that it may be normal for your breasts to be lumpy - you’re checking for something that wasn’t there last month.