Breastlink at Breast Care & Imaging Center of Orange County

A .Every woman is at risk for developing breast cancer. Breast cancer is the most common cancer of women, and as a woman gets older, her risk for breast cancer increases. Three-quarters of all breast cancers occur in women over age 50. Though rare, men can also develop breast cancer ( High Risk Program ).

2.Aren't there women with special risk factors?

A. Risk is somewhat higher in women whose close female relatives (i.e. mothers or sisters) have the disease. It has been observed generally that women who never have had children (or had their first child after age 30) appear to be at somewhat higher risk for breast cancer, although individual cases may vary considerably. Other possible risk factors include not having breast-fed, early menarche and late menopause, exposure to environmental carcinogens and lifestyle factors (i.e. radiation, pesticides, alcohol and tobacco use, poor diet, stress, lack of adequate sleep), obesity, exposure to hormones (i.e. hormone replacement therapy), race/ethnicity (i.e. Caucasians may have a somewhat higher risk than other races), and higher socioeconomic status.

3.What can be done to protect against breast cancer?

A. It is still not clear what causes breast cancer, or how to prevent it. The best protection against breast cancer is to detect it at its earliest stage and to treat it promptly. Researchers are investigating the possible roles of heredity, the environment, lifestyle and diet. Also, there is currently research underway to develop a breast cancer “vaccine” that can be used to prevent the onset of breast cancer (Prevention Guidelines).

4.What are the recommended guidelines for early detection of breast cancer?

A. The recommendation of the American Cancer Society and the nation's leading health organizations is this three-step early detection program:

Have regular mammograms : Screening mammograms should begin by age 40, and should continue every year up until about age 75; after this time, it will be up to the discretion of the patient and healthcare provider to either continue annual mammograms, reduce mammograms to once every three years, or to discontinue mammograms altogether based on the patient’s overall health status and co-morbidities (other diseases that might make it difficult or even impossible for the patient to receive mammograms).
See your healthcare provider for regular breast exams : This should be done at least every three years between the ages of 20 and 40, and every year starting at age 40 and beyond.
Practice monthly breast self-exam : Ask your healthcare provider to teach you the proper method for breast self-examination. Please see our schedule of free breast self-exam classes (Breast Self Exam Classes). These guidelines for early detection of breast cancer are for women who have no symptoms. They are designed to find breast cancer at the earliest stages, when there is the best opportunity to treat it successfully (Screening Guidelines).

5.What are the signs and symptoms of breast cancer?

A. The most common symptom of breast cancer is an adherent (non-mobile), either vague or discrete lump or thickening that does not go away or change, or even increases gradually in size over time. Most lumps in the breast are not cancerous; four out of five are from other benign causes. All lumps should be checked by a doctor. Other symptoms to be aware of are swelling, puckering or dimpling, skin irritation or skin changes, persistent focal pain of the breast/nipple, or nipple discharge (clear or bloody). If any of these symptoms occurs in a man, they should be checked immediately. Signs of breast cancer, especially in an asymptomatic woman who has none of the above symptoms in her breasts, can be seen on a mammogram (i.e. suspicious clusters of calcifications, changes in the density pattern of breast tissue, or a new or growing tissue mass. Link to: Making The Diagnosis).

6.What is a mammogram?

A. mammogram is an x-ray picture of the breast. Modern mammography equipment and techniques expose women to only minimal amounts of radiation (less than the cosmic radiation you might receive while on a 3-hour airplane flight). A trained radiolologic technologist positions your breast between two plastic plates that compress it, spreading the tissue out so that the x-ray can produce as precise a two-dimensional image as possible. Two x-rays are taken of each breast during mammography: One from above, and one from side to side. A specially trained physician (a radiologist / mammographer) reads the mammogram to see if any suspicious areas exist in either breast. Link to : Digital Mammography

7. What if breast cancer is found?

A. Not all breast cancers or breast cancer patients are alike. Treatments for early breast cancer can include: Lumpectomy (a limited surgery which removes the cancer, but not the entire breast), followed by radiation therapy; or mastectomy (surgical removal of the breast). Additional treatment may include chemotherapy or hormone therapy. A woman with breast cancer should fully review her treatment options with her doctor before decisions are made on a treatment program. See our section on Diagnosis and Treatment for more information.

8.What is lobular carcinoma in-situ (LCIS)?

A. Despite its frightening name, lobular carcinoma in-situ is not a “true” cancer. It does not have the ability to invade tissue or spread beyond the breast at this point in time. Even when closely monitored for many years, cancer does not develop in the majority of cases.

LCIS originates in the breast lobules, the part of the breast which produces milk. LCIS does not show up on the mammogram, and does not produce a lump; therefore, it is usually only discovered incidentally when a biopsy has been done for some other reason, such as to evaluate a palpable lump or abnormal mammogram. Previous studies have demonstrated that when LCIS is present in one part of the breast, it frequently can be found in multiple spots in the breast.

LCIS is sometimes confused with ductal carcinoma in-situ (DCIS), which is another type of non-invasive breast cancer; however, the two behave quite differently. When a patient with LCIS develops invasive lobular cancer, it usually does not develop at the site of the original LCIS biopsy. It is just as likely to occur at any other place within either breast.

However, when a patient with DCIS develops invasive ductal cancer, it is almost always found at the site of the original biopsy. Also, when a patient with LCIS develops an invasive cancer, it is more likely to be of the ductal type rather than the lobular variety. When a patient with DCIS develops invasive cancer, it is virtually always of the ductal variety. Thus, LCIS is considered a high-risk tissue marker for the future development of invasive breast cancer (either lobular or ductal), and DCIS is considered to be an actual pre-cancerous condition.

9.How does LCIS develop?

A. woman's breast contains numerous milk-producing lobules and milk-carrying ducts, which connect the lobules to the nipple. LCIS starts in the breast lobules. A normal lobule is lined with small, rectangular cells with a small, discrete central nucleus. An early step in the development of LCIS is hyperplasia, in which these normal cells increase in number and pile up upon themselves in the lobules. When the lobules become filled with abnormal cells that have changed in cellular structure (i.e. enlarged, irregularly-shaped cells with large, diffuse nuclei), the condition is labeled LCIS. In the final step, the abnormal cells break through the lining of the lobules and invade into the breast tissue. This process is called invasion, and has the potential to spread beyond the breast.

10. Q. What is my risk for developing invasive cancer from LCIS?

A:. The risk of a woman with LCIS developing invasive cancer is in the range 1-2% per year; thus, the maximum risk after 10 years of follow-up would be as high as 20%. This risk is increased in the presence of other risk factors, such as family history of breast cancer or hormone replacement therapy use.

11.What are your choices if you have LCIS?

A: If LCIS is diagnosed, you do not have a true cancer, but you are at increased risk for developing future cancer. The Breast Care Center recommends the following schedule for monitoring most women diagnosed with LCIS:

Every month: Breast self-examination.

Every 6 months: Physical examination by a healthcare provider experienced in breast health and breast diseases.

Every Year: High-resolution digital diagnostic mammogram, and possibly a diagnostic breast MRI every 1-2 years.

When appropriate: Risk-factor analysis; genetic testing for BRCA 1 or BRCA 2 mutations; biopsy of any suspicious lesions seen on imaging studies; discontinuation of hormone replacement use.

Should you have other risk factors (such as a strong family history, or if you have already had breast cancer before), the our providers will help you evaluate your personal risk. We will outline a personalized plan that offers the best opportunity for early detection and cure. And, we direct our efforts and expertise to provide you with careful monitoring to detect any breast changes at the earliest possible stage.

Women diagnosed with LCIS who are young, apprehensive, or who have unusual risk factors (i.e. an extremely strong first-degree family history of breast cancer; documented BRCA 1 or BRCA 2 gene mutation) may consider a more aggressive approach. In consultation with The Breast Care and Imaging Center team, a woman may decide to have a bilateral mastectomy with or without immediate breast reconstruction. Women who choose this option are often surprised at how natural their bust-line appears after surgery. Aesthetics aside, a high-risk woman who chooses surgery almost completely eliminates the threat of developing breast cancer in the future.

Whatever your decision, The Breast Care and Imaging Center of Orange County is committed to providing you ongoing, personalized medical attention and emotional support.

Patient resources :
The Breast Care Center encourages patients and their families to become better informed about breast health, disease and treatment. You may find out more by reading about our Patient Support and Wellness Program Services. .

12.What is ductal carcinoma in-situ (DCIS)?

A: DCIS is a form of breast cancer that is now diagnosed more frequently as a result of the widespread use of screening mammography. Most women with this condition have no symptoms, but are diagnosed via mammographic findings. In our experience, approximately 1 out of 5 women who require a biopsy due to suspicious mammographic findings have a positive diagnosis of DCIS. Link to: Just Diagnosed

DCIS originates near the origin of the ductal system, adjacent to the lobules. Lobules make milk, which flows along the duct to exit the nipple. Normal ducts are composed of small, even rectangular cells, with small, central round nuclei. It is thought that an early stage in the development of breast cancer is hyperplasia, in which the cells become irregular and pile up upon themselves within the duct. In DCIS, the ducts are lined by cells that are irregular in shape and tend to be larger than normal in size, and the nuclei of these cells also become enlarged and more distorted. In both hyperplasia and DCIS, the cells are confined to the ducts. In invasive ductal cancer, the cells break out of the duct and invade into the surrounding breast tissue. These invasive cells have the potential to spread to other parts of the body (metastasize).

13. How is DCIS Diagnosed?

A: In the past, most cases of DCIS were associated with an actual breast lump, and many of these lumps also contained invasive ductal cancer. Currently, most women diagnosed with DCIS have no symptoms, and are diagnosed because a screening mammogram showed a distinct cluster of suspicious calcifications.

Calcium is a normal component of bone, and often deposits in normal tissue; it has nothing to do with one’s dietary intake of calcium. Most normal mammograms have some areas of random, benign calcifications; it is only when these calcifications show certain characteristics (such as clustering, or irregularities in size or shape) that they becomes of concern.

In cases where the calcification pattern is considered suspicious, a biopsy is recommended. This is most often done as a core needle biopsy, in which the breast is anesthetized with local anesthetic, and then a thin cannulated needle attached to a vacuum source is inserted into the suspicious area of calcifications under x-ray guidance. Small cylindrical “cores” of tissue containing the calcifications are suctioned out and sent for pathologic analysis.

Occasionally, an open surgical biopsy is done to remove a larger area of calcifications in the breast, or an area of calcifications that yielded a “benign” result on a core needle biopsy, but still appear suspicious. A "needle localization" is preformed prior to this type of biopsy. This technique is used to mark the area of calcifications that appears on the mammogram, but cannot be palpated in the breast. Using x-ray guidance, a radiologist places a wire needle(s) at or around the spot(s) in question. Another mammogram confirms that the needle(s) is in position. Then the patient is brought into the operating room, where under light general anesthesia the area localized by the wire needles is removed from the breast and sent to the mammography suite, where it is x-rayed to insure that the calcifications are present in the specimen. It is then sent off for pathologic analysis.

14.What are margins? (and what do they mean?)

A: The margin refers to the distance between the tumor and the edge of the lumpectomy or mastectomy specimen. To save the breast and avoid mastectomy, the margins must be cleared. This is not as easy as it sounds. Breast cancers often have microscopic extensions beyond the obvious tumor that are not visible to the mammographer pre-operatively or to the surgeon at the time of the surgery. Immediately after the surgeon removes the tumor tissue from the breast, the pathologist color codes the surfaces of the specimen with ink, then preserves it in a solution. A few days later, the specimen is examined under the microscope. If there is wide enough area of normal tissue between the tumor and the color coded edges, the margins are considered clear. If the tumor is very near or at the edge, the margin is considered positive. If the margins are positive and the woman still desires to save as much of her normal breast tissue as possible, another re-excision surgery is required. Since the margins were color coded, the surgeon will know exactly which area is in need of further removal.

The reason that the margin issue is so important is that breast cancer recurrence rates are much higher if the margins are not adequately cleared. How much clearance is necessary is controversial. In our practice, we prefer ideally 5 mm of margin clearance for both invasive cancers and for DCIS. If a woman is not planning on doing radiation after surgery, we prefer 10 mm of clearance for DCIS; radiation is always required after a diagnosis of invasive cancer (no matter how generous the margin clearance), unless a mastectomy was performed. With this aggressive approach, we have a 10-year local DCIS recurrence rate of less than 2%, which is very low as compared to national standards.

A common problem facing a woman who has recently been diagnosed with DCIS is that her margins are positive after the area of calcifications has been completely removed. The most common reason why this occurs is because much of the DCIS in the affected area of breast does not actually contain calcifications. For this reason, it cannot be seen on the mammogram and cannot be felt by the surgeon. Residual DCIS at or close to the margins is usually not found until 4-5 days after the surgery, when the pathologist examines the slides under the microscope.
Link to: Understanding Path Report

15 .What are my choices if I have DCIS?

A: If all the margins are clear, a mastectomy can usually be avoided. Small, non-aggressive forms of DCIS may be safely treated with lumpectomy and subsequent careful observation and follow-up. However, in extensive or more aggressive forms of DCIS, radiation therapy is always required to lower the rate of future local recurrence. Even cases with involved margins can often be treated with breast conservation surgery (lumpectomy), as long as the margins can be cleared with a subsequent re-excision surgery.

In cases where the DCIS is found to be more extensive, or when re-excision margins are again involved, mastectomy with or without reconstruction is usually the treatment of choice.

Conclusion:
The most important point to remember is that DCIS is 100% curable! If diagnosed early, the breast can be preserved with a good cosmetic result, and most (if not all) women can continue to live happy and productive lives.

Patient resources:
The Breast Care Center encourages patients and their families to become better informed about breast health, disease and treatment. You may find out more by reading about our Patient Support and Wellness Program Services.

16. What do the numbers on a mammogram reading refer to?

A: The numbers are a standardized classification of mammogram results which tells the physician what to do with the results. This classification is called BIRADS. The following is a generalized description of what is meant by each number:

I. Normal mammogram, no significant findings.

II. Benign finding(s) within the breast, nothing to worry about.

III. Probably benign finding within the breast, with a less than 2% chance that this is a cancer; however, it is advised that a mammogram should be repeated on the specified breast in 6 months.

IV. Worrisome, indeterminate, or suspicious finding indicative of a possible cancer; consult a surgeon for biopsy.

V. Highly suspicious finding indicative of cancer; consult a surgeon for immediate biopsy.

VI. Assumed breast cancer until proven otherwise.

17. What are calcifications, and what do they mean on a mammogram?

A. Calcifications are visible as discrete, white spots seen on the mammogram; these represent calcium deposits / calcium salts, and may appear as randomly scattered grains of coarse-ground salt, clustered together as fine grains of salt of various shapes and sizes, as larger grains of gravel, or even as round, distinct white densities over the mammogram film. Calcium is a by-product of breast tissue metabolism and cell turnover due to reproductive and hormonal changes throughout a woman’s life. A vast majority of these changes are not cancer. The radiologist can describe which ones are not worrisome (benign) and which ones need to be biopsied to see if they are associated with a cancer.

18. I feel a breast lump, but my mammogram was negative. Do I need to see a specialist?

A. Mammograms are falsely negative (meaning, they give a result that is normal or benign, even if a cancer is actually present) 10-15% of the time in post-menopausal women, and 25% of the time in pre-menopausal women. If a woman still has a lump or breast mass that still persists, even after having a normal mammogram, she should still have additional workup to have her lump evaluated. LInk to: Breast Lumps