Screening Guidelines for Breast Cancer

Intro: MemorialCare Health System, excellence in healthcare, presents Weekly Dose of Wellness. Here is your host, Deborah Howell.

Deborah Howell (Host): Hello everybody. Welcome to the show. You're listening to Weekly Dose of Wellness brought to you by MemorialCare Health System. I'm Deborah Howell and today our guest is Dr. Angela Sie, Medical Director Breast Imaging, MemorialCare Breast Center at Long Beach Memorial. She has overseen breast imaging at Long Beach Memorial since 2001. Today we'll be discussing the screening guidelines for breast cancer. Welcome, Dr. Sie.

Angela Sie, MD: Well, hi there, Deborah.

Deborah Howell (Host): Very, very, very nice to have you on the show today. So let's kick right in. What are some of the signs of breast cancer?

Angela Sie, MD: Well, the most common sign of breast cancer is a palpable lump. And it's usually painless, but sometimes it can be painful. Other symptoms are focal pain, palpable thickening, skin dimpling, nipple changes like nipple retraction or rash, spontaneous nipple discharge, which is non-milky. Spontaneous meaning it's coming out on its own, like you find it on the inside of your bra or on your nightclothes.

Deborah Howell (Host): And what color might that be?

Angela Sie, MD: Either clear or bloody.

Deborah Howell (Host): Okay.

Angela Sie, MD: Usually green or milky discharge is not something that is worrisome. Other things are like generalized breast swelling or redness. But screening mammography is, the goal of screening mammography is to find breast cancers earlier before they cause symptoms. And that's why screening mammography saves lives.

Deborah Howell (Host): Okay. Now I want to go back to the very first symptom you spoke of. You said it may or may not be painful.

Angela Sie, MD: Yes.

Deborah Howell (Host): Can you describe what that first symptom might feel like to a person who might have it?

Angela Sie, MD: Well, many women come in with just a sort of nondescript change in their breast. They just say it just doesn't feel right in this certain spot. It's never felt like that before, it feels different to me. And sometimes we do the diagnostic workup, including a mammogram and an ultrasound, and it just looks like normal glandular tissue. Other times that can represent cancer. Usually when cancer presents as a palpable lump, it's not painful.

Deborah Howell (Host): Alright. Okay. So we know. So you said the magic word in there. What are the screening guidelines for mammograms?

Angela Sie, MD: The screening guidelines are to get a baseline screening mammogram at the age of 40 and then annually thereafter. This is the guideline for the American Cancer Society, the American College of Radiology, the American Congress of OB-GYNs, and also the National Comprehensive Cancer Network, which basically sets the guidelines for the prevention and treatment of cancer in this country. There are certain circumstances that require earlier screening.

Deborah Howell (Host): Yes.

Angela Sie, MD: For instance, if you have a family history of premenopausal breast cancer, you might start screening earlier than age 40.

Deborah Howell (Host): Right.

Angela Sie, MD: If you're known positive for breast cancer genes BRCA1 or 2, you might start screening earlier. If you had prior radiation therapy to the chest, that might warrant earlier screening.

Deborah Howell (Host): How early are we talking?

Angela Sie, MD: Well, usually when someone has a family history, mother, sister, daughter of premenopausal breast cancer, we recommend starting screening about 10 years before the cancer was diagnosed in that relative.

Deborah Howell (Host): I see. Okay, so different for each individual.

Angela Sie, MD: Yes. But if you don't have that history, it's important to get a baseline screening at 40 and then annually thereafter.

Deborah Howell (Host): Okay, now annually thereafter until what point? I mean, should women stop getting mammograms at a certain point?

Angela Sie, MD: Well, that's up to the patient and her doctor. I believe that mammograms should continue annually as long as a woman would benefit from treatment if a cancer was found. Many people feel that as long as your life expectancy is more than five years, you should continue to get screening mammograms.

Deborah Howell (Host): Okay. Now, what about clinical breast exams? There's a bit of discussion coming around about that. How old should women be to get a clinical breast exam and how often?

Angela Sie, MD: About every three years for younger women. So when you're in your 20s and 30s, you should get a clinical breast exam from your primary care doctor or your gynecologist about every three years.

Deborah Howell (Host): And could you describe what a clinical breast exam entails?

Angela Sie, MD: It entails your healthcare provider feeling your breast to detect any changes, looking at your breasts, just sitting looking at your breasts to see if there are any asymmetry or changes, bringing your arms up slowly for your healthcare provider to see if that creates any dimpling or changes in your breast shape. And feeling your axilla, feeling your armpits to see if there are any changes or palpable lumps in that area as well.

Deborah Howell (Host): I see. Okay. What about women themselves? Should they still be performing self-exams as well as those clinical ones?

Angela Sie, MD: Self breast exams?

Deborah Howell (Host): Mm-hmm.

Angela Sie, MD: Absolutely. Absolutely. But one other thing, Deborah, I was mentioning that about every three years for younger women in their 20s and 30s, they should get a clinical breast exam. But after 40, just like a mammogram, you should have an annual clinical breast exam.

Deborah Howell (Host): I see. Okay. Interesting. Alright. From your primary or from your gynecologist?

Angela Sie, MD: Yes.

Deborah Howell (Host): Or both? Can't hurt.

Angela Sie, MD: Well, no, just one. Just one. Most women, I think, get them from their gynecologist.

Deborah Howell (Host): Okay.

Angela Sie, MD: Regarding self-breast exams, I believe they're helpful. The American College of Radiology recommends self-breast exams because it's important for women to know how their breasts normally look and feel so that they can detect any changes easily and promptly report them to their primary care doctor.

Deborah Howell (Host): And in your opinion, when should they do them?

Angela Sie, MD: In their 20s. Again, women should start self-breast exams in their 20s, and about once a month is good, right after their period.

Deborah Howell (Host): Okay, that's important, because they're going to feel a little bit different.

Angela Sie, MD: Yes, absolutely. Because of the hormonal changes of the menstrual cycle, breasts are going to be tender and maybe more engorged right before their period.

Deborah Howell (Host): Right.

Angela Sie, MD: And then after their period, they tend to be the most quiescent.

Deborah Howell (Host): Right. So say your period ends on the first of the month, then maybe five or six days after that on a monthly basis. Just kind of put it on your calendar, right?

Angela Sie, MD: Exactly, exactly.

Deborah Howell (Host): Alright, now the guidelines for getting mammograms keep changing, and why do you think that is?

Angela Sie, MD: Well, you know, the guidelines of many important healthcare organizations actually have never wavered from their recommendations of annual mammography beginning at age 40. For instance, the American Cancer Society, American College of Surgeons, American College of Radiology, they've always recommended annual mammography at age 40. What happened was several years ago in December of 2009, the U.S. Preventive Services Task Force came out with different guidelines based on an analysis of many different breast cancer studies. The problem with those recommendations was that a number of the studies that they used were severely flawed in their design, either by economic bias or they were not blinded, they were not randomized properly. And so those studies that were included that had corrupt data, so to speak, they had actually very little to do with the type of screening mammograms that we offer today.

Deborah Howell (Host): I see.

Angela Sie, MD: And another thing was that none of the task force members were breast cancer specialists. Which means that none of them have any understanding of the prevention, diagnosis, or treatment of breast cancer, at least in a specialized setting.

Deborah Howell (Host): Ah, I see. Okay.

Angela Sie, MD: So I think they came to an erroneous conclusion that can unfortunately be very dangerous for women in this country and could lead to more deaths from breast cancer.

Deborah Howell (Host): Okay. So stick with the original. Start at 40 if you have no immediate family concerns in sister, mother, or daughter.

Angela Sie, MD: Having breast cancer could prompt a high-risk evaluation. If you have a relative who's had premenopausal breast cancer, it may warrant a high-risk evaluation and you should ask your doctor for a referral for a high-risk clinic. One thing I wanted to get back to regarding the guidelines, according to the National Cancer Institute data, since mammography screening started in this country in the mid-1980s, the breast cancer death rate has dropped more than 30%.

Deborah Howell (Host): That's excellent.

Angela Sie, MD: Before the 1980s, before there was screening, it had remained unchanged for 50 years.

Deborah Howell (Host): Wow.

Angela Sie, MD: So screening mammography really does save lives. And one of the largest randomized studies regarding breast cancer with the longest follow-up, 29-year follow-up in Swedish counties, showed that there was a 30% reduction of mortality in women who underwent screening mammography.

Deborah Howell (Host): That is definitely worth taking note of. And just to be crystal clear, and some people may have joined us a little bit later, so let's just underline it again, what does the MemorialCare Breast Center recommend for screening?

Angela Sie, MD: Annual screening beginning at age 40.

Deborah Howell (Host): Okay. Alright. Let's hear it, ladies. Every single year after 40. And where should listeners go to get more information about the MemorialCare Breast Center?

Angela Sie, MD: Well, they can go to our website. It is www.memorialcare.org/lbbreast. And the phone number is 562-933-7880. Other resources for ladies who want to find out more about breast cancer in general, the Society of Breast Imaging has a wonderful website. Their website is www.sbi-online.org. And the American Cancer Society, which is www.cancer.org/cancer/breastcancer.

Deborah Howell (Host): Great. Lots of resources, no excuses. Thank you so much, Dr. Sie, for spending some time with us this afternoon. It's been great to have you on the program today.

Angela Sie, MD: Thank you, Deborah. You have a good day.

Deborah Howell (Host): You too. And to listen to the podcast or for more info, please visit memorialcare.org. That's memorialcare.org. I'm Deborah Howell. Join us again next time as we explore another Weekly Dose of Wellness brought to you by MemorialCare Health System. Have a fantastic day and get that screening.