Breast cancer is a relatively common cancer, representing about 30% of all cancers in women. In broad terms, treatment is successful in about 3 out of 4 patients in controlling or eliminating the cancer. In about one out of four, the cancer proves fatal.

The risk of developing breast cancer increases steadily with increasing age. It is rare among women under age 25 but affects nearly one in nine of those women reaching age 90.

A number of factors are associated with an increased of developing breast cancer, including:

• Strong family history of breast cancer
• Menopause after age 55
• No term pregnancy prior to age 35

Despite the increased risk, most (about 80%) of breast cancer occurs in women not at increased risk for developing breast cancer. For that reason, efforts at early detection are not focused just on those with somewhat increased risks, but on all women.

Assumptions

The underlying assumption of all breast screening programs is that if we can detect a breast malignancy when it is very small, then the outcome will be better for the patient than if we discover the problem when it is bigger. Just how true that assumption is and the exact parameters of that truth are still under debate, as is the effectiveness of any of the breast cancer screening programs in improving outcome for women with breast cancer.

Strategy

The primary strategy has involved a three-armed effort: Periodic (annual) professional breast examination, self-breast examination, and mammography at appropriate intervals.

Studies on the clinical utility and effectiveness of each of these screening techniques has yielded conflicting results. Consequently, the best use of each of these techniques remains controversial.

One commonly used approach for women at low or average breast cancer risk is:

• Routine screening mammogram every 1-2 years starting by age 40 to 50 and continuing until at least age 75.
• Annual Professional Breast Exam.
• Breast Self-Exam or Breast Awareness on a case by case basis.

Professional Breast Examination

Once a year, a woman’s breasts should be evaluated by a qualified health professional. Any significant abnormalities in texture, contour, skin, any palpable masses, retractions, dimpling or nipple discharge will require followup appropriate for the abnormality. Professional breast exams are felt to be about 80% reliable in detecting significant breast abnormalities.

Self Breast Examination

Once a month, a woman should examine her own breasts, looking for changes in appearance, texture, or nipple discharge that was not previously present. Examination technique is not obvious, but is a skill to be learned (and taught). Any new findings should be promptly reported to the woman’s physician or other qualified healthcare provider. Most breast cancers are first noted by the patient herself.

Critics of self breast exams have observed that they may cause more problems than they solve. Most of the self-discovered breast lumps are benign and do not represent a threat. Nonetheless, they are often subjected to investigation, including biopsy and excision. Further, by the time a breast cancer is large enough for the woman to feel herself, it is not likely to be “early.”

However, as the American College of Obstetricians and Gynecologists point out: (https://www.acog.org/womens-health/faqs/mammography-and-other-screening-tests-for-breast-problems)

Breast cancer often is found by a woman herself. This happens in almost one half of all cases of breast cancer in women aged 50 years and older. In women younger than 50 years, more than 70% of cases of breast cancer are found by the women themselves.

Mammography

The goal of mammography to to detect very early cancers or pre-cancerous changes before they have a chance to develop into a more advanced and dangerous stage. Mammography is felt to be about 80% effective in detecting significant breast abnormalities, but many of the ones that are missed by mammography can be detected by examination.

There is controversy over how frequently mammograms should be performed. If there is a clinical abnormality, mammograms can be used to gain additional information about the abnormality (a “diagnostic” mammogram). Many physicians recommend that “screening:” mammograms be performed every other year between ages 40 and 50, and annually thereafter. Some physicians dispute the usefulness of mammograms prior to age 50. Some physicians recommend mammograms more often if there is a strong family history of breast cancer. Some physicians dispute the value of screening mammograms after age 75 or 80. Some physicians dispute the value of screening mammograms at any time.

Breast Ultrasound

Breast ultrasound is used in some countries (although not commonly in the United States) to screen for breast cancer. It has the advantage that it is relatively inexpensive, quick, painless, and uses no radiation. It is particularly good at detecting cystic masses (better than mammograms). In skilled hands, it does a fair job of detecting malignancies.

Unfortunately, it is not as good at detecting malignancies as mammograms and so it is not usually used for primary screening in the U.S. It is commonly used in the U.S., however, as an adjunctive method to evaluate abnormalities palpated by the examiner or identified on mammograms.

Thermography

Thermography is a means of looking at the breast with an infrared (heat-sensitive) imaging device. It relies on the principle that cancers have increased metabolic activity, generating more heat, that can be detected with a thermographic process. While this has some theoretical advantages over other imaging techniques, in practice, thermography has not been demonstrated to be effective in early detection of significant lesions, and so is not generally used as a primary screening technique.

3-D Mammography (Digital Breast Tomosynthesis), MRI (Magnetic Resonance Imaging) of the breast, and other imaging modalities

These techniques are not useful in mass screening of low to average risk populations, but may be very useful in:

• Screening of high risk individuals.
• Obtaining different types of information on previously identified abnormalities.
• Helping clarify ambiguous findings from other studies.