The Breast Cancer Surgery Center is pleased to present this next installment of our continuing series on breast health. In the last article we presented some basic statistics on the incidence of breast cancer in women. We also discussed calculating your individual risk for developing a breast cancer. We utilized the "Gail Model" developed by the National Cancer Institute. Women whose risk is above the average for their age are considered high risk. (Some investigative and/or treatment decisions are altered if your risk is 1.5 times the average, and one other decision is impacted whenever your 5-year risk becomes > 1.70 %.)

      In this issue we will discuss how knowing your statistical risk enables you to utilize "selective screening" and other risk management strategies which include not only increased surveillance, but also chemoprevention, and prophylactic surgery. Women who are at high risk should increase cancer surveillance. One basic intervention is two care-giver exams per year instead of one. This was discussed briefly in the last issue of Women's I.

      Mammography would still be done yearly. All mammograms are given a risk-rating called a BiRads classification. Although not quite this simple, a rating of "BiRads 1" is a "normal" mammogram; a "2" means there is an abnormality which is clearly benign and does NOT need increased watching; a "3" means that it is probably, but not definitely, benign, and a repeat mammogram should be done in 4 - 6 months to detect any changes; a "4" means that either there is an increased suspicion for cancer, or that the abnormality would not be expected to change much in 6 months and, therefore, a biopsy is recommended now; a "5" means that enough malignant characteristics are present that it is quite probably a cancer.

      These classifications are made without knowledge of your individual risk, i.e. for the general screening population. If your mammogram shows a BiRads 3 lesion, and your Gail Model risk is more than 1.5 times the average, you will want to consider having a biopsy. This decision is made by comparing the benefits of the procedure versus its risks, e.g. how deep the lesion is, if you smoke or have other medical conditions such as taking a blood thinner, and whether the biopsy can be done with a needle under local anesthesia rather than a larger incision.

      Any masses (lumps) found in the breast should be evaluated with ultrasound, even if your mammogram is normal. The Breast Cancer Surgery Center can perform this right in our facility. This exceedingly valuable technique can tell whether a palpable (able to be felt) mass is fluid-filled (cystic) or solid, guiding your diagnostic care plan.

      Women at high risk, whose mammograms show an increased density of the glandular breast tissue, can be evaluated by an MRI (magnetic resonance imaging) scan. This imaging technique employs somewhat different characteristics of human tissue to display the structures within the breast. It is an imaging exam, but not an X-ray exam.

      A promising new technique, called ductal lavage, is employed in high-risk women to pick up both cancer and cancer-precursors much earlier than mammography. Some studies have shown that these changes can be identified up to 3 years before a lesion is visible on your mammogram. During this test, the nipple is nesthetized and a small plastic catheter is passed through the natural duct opening in the nipple. Small volumes of sterile salt water are rinsed through the ductal system, collected and sent to a laboratory.

      Thousands of cells are obtained via this technique. They are analyzed under a microscope to give a very accurate picture of the activity within the breast. A benign condition, termed atypical ductal hyperplasia, is a warning that cancer is likely to develop within the next five years. When cancers are picked up using this technique, they are generally 100% curable.

      If your Gail Model risk is greater than 1.7%, and you are past child-bearing, you will want to consider chemoprevention, or taking a medicine to reduce your breast cancer risk. The medicine which has been utilized the longest and studied the greatest is called tamoxifen. This medication blocks the effects of estrogen in the body including those effects on early cancer cells. A 44% reduction in the incidence of cancer can be achieved by taking tamoxifen for 5 years.

      However, if your Gail risk is less than 1.7%, the risks of the treatment outweigh the benefit. The major risks are a SLIGHT risk of developing uterine cancer (which is zero if you have had a hysterectomy) and a risk of blood clots in the legs (phlebitis) seen mostly in smokers. Non-smoking women who have no uterus benefit if their Gail Model risk is above 1.5%.

      A second medication has recently been utilized towards the same goal. It is called anastrozole. This medication actually limits the production of estrogens in the body. Women should remember that estrogens are produced not just in the ovaries but also in the adrenal glands and in the subcutaneous fatty tissue. Women who have had their ovaries removed, especially if overweight, still have circulating levels of estrogen which may be modulated to reduce your breast cancer risk. Other medicines are in trial stages and should be available within a few years.

      Lastly, some women at extremely high risk may choose the route of prophylactic mastectomy (removal of the breasts) to absolutely minimize the risk of breast cancer. Breast cancer can develop in the skin cells from the collar bone to the bottom of the ribs. Since much of this skin is "left behind" in these operations, the risk is reduced close to, but not equal to, zero. For some women, nipple sparing mastectomy is an option. This reduces the risk significantly while preserving sensation in this important area.

      Our next article, to be available in a future issue of Women's I, will deal with genetic testing for breast cancer. We will explain what testing is, how a woman knows if she is a candidate for testing, how the test is performed, and how a woman utilizes the results of the test to create a risk-reduction care plan to enhance personal safety.