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Importance of Finding Breast
Cancer Early
The goal of screening exams for early breast cancer detection
is to find cancers before they start to cause symptoms. Screening refers to
tests and exams used to find a disease, such as cancer, in people who
do not have any symptoms. Early
detection means
using an approach that allows earlier diagnosis of breast cancer than
otherwise might have occurred.
Breast cancers that are found because they are causing
symptoms tend to be larger and are more likely to have already spread
beyond the breast. In contrast, breast cancers found during screening
exams are more likely to be smaller and still confined to the breast.
The size of a breast cancer and how far it has spread are some of the
most important factors in predicting the prognosis
(outlook) of a woman with this disease.
Most doctors feel that early detection tests for breast cancer
save many thousands of lives each year, and that many more lives could
be saved if even more women and their health care providers took
advantage of these tests. Following the American Cancer Society's
guidelines for the early detection of breast cancer improves the
chances that breast cancer can be diagnosed at an early stage and
treated successfully.
What Are the Risk Factors for
Breast Cancer?
A risk factor is anything that affects your chance of getting
a disease, such as cancer. Different cancers have different risk
factors. For example, exposing skin to strong sunlight is a risk factor
for skin cancer. Smoking is a risk factor for cancers of the lung,
mouth, larynx (voice box), bladder, kidney, and several other organs.
But having a risk factor, or even several, does not mean that
you will get the disease. Most women who have one or more breast cancer
risk factors never develop the disease, while many women with breast
cancer have no apparent risk factors (other than being a woman and
growing older). Even when a woman with breast cancer has a risk factor,
there is no way to prove that it actually caused her cancer.
There are different kinds of risk factors. Some factors, like
a person's age or race, can't be changed. Others are linked to
cancer-causing factors in the environment. Still others are related to
personal behaviors such as smoking, drinking, and diet. Some factors
influence risk more than others, and your risk for breast cancer can
change over time, due to factors such as aging or lifestyle changes.
Risk Factors You Cannot Change
Gender
Simply being a woman is the main risk factor for developing
breast cancer. Although women have many more breast cells than men, the
main reason they develop more breast cancer is because their breast
cells are constantly exposed to the growth-promoting effects of the
female hormones estrogen and progesterone. Men can develop breast
cancer, but this disease is about 100 times more common among women
than men.
Aging
Your risk of developing breast cancer increases as you get
older. About 1 out of 8 invasive breast cancer diagnoses are among
women younger than 45, while about 2 out of 3 women with invasive
breast cancer are age 55 or older when they are diagnosed.
Genetic Risk Factors
About 5% to 10% of breast cancer cases are thought to be
hereditary, resulting directly from gene changes (called mutations)
inherited from a parent.
BRCA1 and BRCA2: The most common inherited mutations are
those of the BRCA1 and BRCA2 genes. Normally, these genes help to
prevent cancer by making proteins that keep cells from growing
abnormally. However, if you have inherited a mutated copy of either
gene from a parent, you are at increased risk for breast cancer.
Women with an inherited BRCA1 or BRCA2 mutation have up to an 80%
chance of developing breast cancer during their lifetime, and when they
do it is often at a younger age than in women who are not born with one
of these gene mutations. Women with these inherited mutations also have
an increased risk for developing ovarian cancer. Although BRCA
mutations are found most often in Jewish women of Ashkenazi (Eastern
Europe) origin, they are also seen in African-American women and
Hispanic women and can occur in any racial or ethnic group.
Other genes have been discovered that might also lead to inherited
breast cancers. These genes do not impart the same level of breast
cancer risk as the BRCA genes, and are not frequent causes of familial
(inherited) breast cancer.
ATM: The ATM gene normally helps repair damaged DNA.
Certain families with a high rate of breast cancer have been found to
have mutations of this gene.
CHEK2: The CHEK2 gene increases breast cancer risk about
twofold when it is mutated. In women who carry the CHEK2 mutation and
have a strong family history of breast cancer, the risk is greatly
increased.
p53: Inherited mutations of the p53 tumor suppressor gene
can also increase the risk of developing breast cancer, and several
other cancers such as leukemia, brain tumors, and/or sarcomas (cancer
of bones or connective tissue). The Li-Fraumeni syndrome,
named after the 2 researchers who described this inherited cancer
syndrome, is a rare cause of breast cancer.
PTEN: The PTEN gene normally helps regulate cell growth.
Inherited mutations in this gene cause Cowden syndrome, a rare disorder
in which people are at increased risk for both benign and malignant
breast tumors, as well as growths in the digestive tract, thyroid,
uterus, and ovaries.
Genetic testing: If you are considering genetic testing,
it is strongly recommended that first you talk to a genetic counselor,
nurse, or doctor qualified to explain and interpret the results of
these tests. It is very important to understand and carefully weigh the
benefits and risks of genetic testing before these tests are done.
Testing is expensive and is not covered by some health insurance plans.
There have been concerns that people with abnormal genetic test results
might not be able to get life insurance or that coverage may only be
available at a much higher cost, but many states have passed laws that
prevent insurance companies from denying insurance on the basis of
genetic testing.
For more information, see the separate American Cancer Society
document, Genetic Testing: What You Need to Know.
You may also want to visit the National Cancer Institute Web site (www.cancer.gov/cancertopics/Genetic-Testing-for-Breast-and-Ovarian-Cancer-Risk)
for information about genetic testing and breast cancer. To learn about
state laws against genetic testing discrimination, you may want to
visit the Web site of the National Conference of State Legislatures (www.ncsl.org/programs/health/genetics/ndishlth.htm).
Family History of Breast Cancer
Breast cancer risk is higher among women whose close blood
relatives have this disease.
Having 1 first-degree relative (mother, sister, or daughter) with
breast cancer almost doubles a woman's risk. Having 2 first-degree
relatives increases her risk about 5-fold. Although the exact risk is
not known, women with a family history of breast cancer in a father or
brother also have an increased risk of breast cancer. Overall, about
20% to 30% of women with breast cancer have a family member with this
disease. (It's important to note this means that 70% to 80% of women
who get breast cancer do not have a family history
of this disease.)
Personal History of Breast Cancer
A woman
with cancer in one breast has a 3- to 4-fold increased risk of
developing a new cancer in the other breast or in another part of the
same breast. This is different from a recurrence (return) of the first
cancer.
Race
White women are slightly more likely to develop breast cancer
than are African-American women. However, African-American women are
more likely to die of this cancer. At least part of this seems to be
because African-American women tend to have more aggressive tumors,
although the reasons for this are not known. Asian, Hispanic, and
Native American women have a lower risk of developing and dying from
breast cancer.
Abnormal Breast Biopsy Results
Some types of
benign breast conditions are more closely linked to breast cancer risk
than others. Doctors often divide benign breast conditions into 3
general groups, depending on how they affect this risk:
non-proliferative lesions, proliferative lesions without atypia, and
proliferative lesions with atypia.
The non-proliferative lesions (those
without any overgrowth
of breast tissue) do not seem to affect breast cancer risk, or if they
do it is to a very small extent. They include:
- fibrosis
- cysts
- mild hyperplasia
- adenosis (non-sclerosing)
- simple fibroadenoma
- phyllodes tumor (benign)
- a single papilloma
- fat necrosis
- mastitis
- duct ectasia
- other benign tumors (lipoma, hamartoma, hemangioma,
neurofibroma)
The proliferative lesions without atypia
(those with
excessive growth of cells in the ducts or lobules of the breast tissue)
seem to raise a woman’s risk of breast cancer slightly (1 ½ to 2 times
normal). They include:
- usual ductal hyperplasia (without atypia)
- complex fibroadenoma
- sclerosing adenosis
- several papillomas or papillomatosis
- radial scar
The proliferative lesions with atypia
(those with excessive
growth of cells in the ducts or lobules of the breast tissue, and in
which the cells no longer appear normal) have a stronger effect on
breast cancer
risk, raising it 4 to 5 times higher than normal. They include:
- atypical ductal hyperplasia (ADH)
- atypical lobular hyperplasia (ALH)
Women with a family history of breast cancer and either
hyperplasia or atypical hyperplasia have an even higher risk of
developing a breast cancer.
Menstrual Periods
Women who started menstruating at an early age (before age
12) or who went through menopause at a late age (after age 55) have a
slightly higher risk of breast cancer. This may be related to a higher
lifetime exposure to the hormones estrogen and progesterone.
Previous Chest Radiation
Women who as children or young adults had radiation therapy to the
chest area as treatment for another cancer (such as Hodgkin disease or
non-Hodgkin lymphoma) are at significantly increased risk for breast
cancer. This varies with the age of the patient at the time of
radiation. If chemotherapy was also given, the risk may be lowered if
the chemotherapy stopped ovarian hormone production. The risk of
developing breast cancer appears to be highest if the breast was still
in development (during adolescence) when the radiation was given.
Diethylstilbestrol (DES) Exposure
From the 1940s through the 1960s some pregnant women were
given an estrogen-like drug called DES because it was thought to lower
their chances of losing the baby (miscarriage). Studies have shown that
these women have a slightly increased risk of developing breast cancer.
Recent findings have also suggested that women whose mothers took DES
during pregnancy may have a higher risk for breast cancer. For more
information on DES see the separate American Cancer Society document, DES
Exposure: Questions and Answers.
Lifestyle-Related Factors and
Breast Cancer Risk
Not Having Children, or Having Them Later in Life
Women who have not
had children, or who had their first child after age 30 have a slightly
higher breast cancer risk. Having multiple pregnancies and becoming
pregnant at an early age reduces breast cancer risk.
Oral Contraceptive Use
It is still not certain what part oral contraceptives (birth control
pills) might play in breast cancer risk. Studies have suggested that
women now using oral contraceptives have a slightly greater risk of
breast cancer than women who have never used them, but this risk seems
to decline once their use is stopped. Women who stopped using oral
contraceptives more than 10 years ago do not appear to have any
increased breast cancer risk. When thinking about using oral
contraceptives, women should discuss their other risk factors for
breast cancer with their health care team.
Postmenopausal Hormone Therapy or Hormone
Replacement Therapy
Postmenopausal hormone therapy, also known as hormone replacement
therapy (HRT), has been used for many years to help relieve symptoms of
menopause and to help prevent osteoporosis (thinning of the bones).
Earlier studies suggested it might have other health benefits as well,
but these have not been found in more recent, better designed studies.
There are 2 main types of PHT. For women who still have a uterus
(womb), doctors generally prescribe estrogen and progesterone (known as
combined PHT). Because estrogen alone can increase the risk of
developing cancer of the uterus, progesterone is added to help prevent
this. For women who no longer have a uterus (those who've had a
hysterectomy), estrogen alone can be prescribed. This is commonly known
as estrogen replacement therapy (ERT).
Combined PHT: It has become clear that long-term use
(several years or more) of combined postmenopausal hormone therapy
increases the risk of breast cancer, and may also increase the chances
of dying of breast cancer. Several large studies, including the Women's
Health Initiative (WHI), have found that there is an increased risk of
breast cancer related to the use of combined PHT. Combined PHT also
increases the likelihood that the cancer may be found at a more
advanced stage, possibly because it reduces the effectiveness of
mammograms.
The increased risk from combined PHT appears to apply only to current
and recent users. A woman's breast cancer risk seems to return to that
of the general population within 5 years of stopping combined PHT.
ERT: The use of estrogen alone does not appear to
increase the risk of developing breast cancer significantly, if at all.
But when used long term (for more than 10 years), ERT has been found to
increase the risk of ovarian and breast cancer in some studies.
At this time there appear to be few strong reasons to use
postmenopausal hormone therapy (combined PHT or ERT), other than
possibly for the short-term relief of menopausal symptoms. Along with
the increased risk of breast cancer, combined PHT also appears to
increase the risk of heart disease, blood clots, and strokes. It does
lower the risk of colorectal cancer and osteoporosis, but this must be
weighed against the possible harms, and it should be noted that there
are other effective ways to prevent osteoporosis. While ERT does not
seem to have much effect on the risk of breast cancer, it does increase
the risk of stroke.
The decision to use PHT should be made by a woman and her doctor after
weighing the possible risks and benefits (including the severity of her
menopausal symptoms), and considering her other risk factors for heart
disease, breast cancer, and osteoporosis.
Breast-feeding
Some studies suggest that breast-feeding may slightly lower
breast cancer risk, especially if it is continued for 1½ to 2 years.
But this has been a difficult area to study, especially in countries
such as the United States, where long-term breast-feeding is uncommon.
The explanation for this possible effect may be that
breast-feeding reduces a woman's total number of lifetime menstrual
cycles. This may be similar to the reduction of risk due to starting
menstrual periods at a later age or due to early menopause, which also
decrease the total number of menstrual cycles.
Alcohol
Use of alcohol is clearly linked
to an increased risk of developing breast cancer. The risk increases
with the amount of alcohol consumed. Compared with non-drinkers, women
who consume 1 alcoholic drink a day have a very small increase in risk.
Those who have 2 to 5 drinks daily have about 1½ times the risk of
women who drink no alcohol. Alcohol is also known to increase the risk
of developing cancers of the mouth, throat, esophagus, and liver. The
American
Cancer Society recommends limiting your consumption of alcohol.
Being Overweight or Obese
Being overweight or obese has been found to increase breast
cancer risk, especially for women after menopause. Before menopause
your ovaries produce most of your estrogen, and fat tissue produces a
small amount of estrogen. After menopause, once the ovaries stop making
estrogen, most of a woman's estrogen comes from fat tissue. Having more
fat tissue after menopause can increase your estrogen levels and
thereby increase your likelihood of developing breast cancer.
The connection between weight and breast cancer risk is complex,
however. For example, risk appears to be increased for women who gained
weight as an adult but may not be increased among those who have been
overweight since childhood. Also, excess fat in the waist area may
affect risk more than the same amount of fat in the hips and thighs.
Researchers believe that fat cells in various parts of the body have
subtle differences in their metabolism that may explain this
observation.
The American Cancer Society recommends you maintain a healthy weight
throughout your life by balancing your food intake with physical
activity and avoiding excessive weight gain.
Physical Activity
Evidence is growing that physical activity in the form of
exercise reduces breast cancer risk. The only question is how much
exercise is needed. In one study from the Women's Health Initiative, as
little as 1¼ to 2½ hours per week of brisk walking reduced a woman's
risk by 18%. Walking 10 hours a week reduced the risk a little more.
To reduce your risk of breast cancer, the American Cancer
Society recommends that you engage in 45 to 60 minutes of intentional
physical activity 5 or more days a week.
Factors with Uncertain,
Controversial, or Unproven Effect on Breast Cancer Risk
High-fat Diets
Studies of fat in the diet have not clearly shown that this is
a breast cancer risk factor.
Most studies have found that breast cancer is less common in
countries where the typical diet is low in total fat, low in
polyunsaturated fat, and low in saturated fat. On the other hand, many
studies of women in the United States have not found breast cancer risk
to be related to dietary fat intake. Researchers are still not sure how
to explain this apparent disagreement. Many scientists note that
studies comparing diet and breast cancer risk in different countries
are complicated by other differences (such as activity level, intake of
other nutrients, and genetic factors) that might also alter breast
cancer risk.
More research is needed to better understand the effect of the
types of fat eaten and body weight on breast cancer risk. But it is
clear that calories do count, and fat is a major source of these. A
diet high in fat has also been shown to influence the risk of
developing several other types of cancer, and intake of certain types
of fat is clearly related to heart disease risk.
The American Cancer Society recommends eating a healthy diet
with an emphasis on plant sources. This includes eating 5 or more
servings of vegetables and fruits each day, choosing whole grains over
processed (refined) grains, and limiting consumption of processed and
red meats.
Antiperspirants
Internet email rumors have suggested that chemicals in
underarm antiperspirants are absorbed through the skin, interfere with
lymph circulation, and cause toxins to build up in the breast,
eventually leading to breast cancer. There is very little laboratory or
population-based evidence to support this rumor.
One small study recently found trace levels of parabens (used
as preservatives in antiperspirants and other products), which have
weak estrogen-like properties, in a small sample of breast cancer
tumors. However, the study did not look at whether parabens caused the
tumors. This was a preliminary finding, and more research is needed to
determine what effect, if any, parabens may have on breast cancer risk.
On the other hand, a large population-based study found no increase in
breast cancer in women who used underarm antiperspirants or shaved
their underarms.
Bras
Internet e-mail rumors and at least one book have suggested
that bras cause breast cancer by obstructing lymph flow. There is no
good scientific or clinical basis for this claim. Women who do not wear
bras regularly are more likely to be thinner, which would likely
contribute to any perceived difference in risk.
Induced Abortion
Several studies have provided very strong data that neither
induced abortions nor spontaneous abortions (miscarriages) have an
overall effect on the risk of breast cancer. For more detailed
information, see the separate American Cancer Society document, Can
Having an Abortion Cause or Contribute to Breast Cancer?
Breast Implants
Several studies have found that breast implants do not
increase breast cancer risk, although silicone breast implants can
cause scar tissue to form in the breast. Implants make it harder to see
breast tissue on standard mammograms, but additional x-ray pictures
called implant displacement views can be used to more completely
examine the breast tissue.
Environmental Pollution
A great deal of research has been reported and more is being
done to understand environmental influences on breast cancer risk. The
goal is to determine their possible relationships to breast cancer. Of
special interest are compounds in the environment that have
estrogen-like properties, which could in theory affect breast cancer
risk. While this issue understandably invokes a great deal of public
concern, at this time research does not show a clear link between
breast cancer risk and exposure to environmental pollutants, such as
the pesticide DDE (chemically related to DDT) and PCBs (polychlorinated
biphenyls).
Tobacco Smoke
Most studies have found no link between cigarette smoking and
breast cancer. Though active smoking has been suggested to increase the
risk of breast cancer in some studies, the issue remains controversial.
An issue that continues to be a focus of scientific research
is whether secondhand smoke may increase the risk of breast cancer.
Both mainstream and secondhand smoke contain chemicals that, in high
concentrations, cause breast cancer in rodents. Chemicals in tobacco
smoke reach breast tissue and are found in breast milk.
The evidence regarding secondhand smoke and breast cancer
risk in human studies is controversial, at least in part because the
risk has not been shown to be increased in smokers. One possible
explanation for this is that tobacco smoke may have different effects
on breast cancer risk in smokers compared to those who are just exposed
to secondhand smoke.
A report from the California Environmental Protection Agency
in 2005 concluded that the evidence regarding secondhand smoke and
breast cancer is "consistent with a causal association" in younger,
mainly premenopausal women. The 2006 US Surgeon General's report, The
Health Consequences of Involuntary Exposure to Tobacco Smoke,
concluded that there is "suggestive but not sufficient" evidence of a
link at this point. In any case, this possible link to breast cancer is
yet another reason to avoid secondhand smoke.
Night Work
Several studies have suggested that women who work at night,
such as nurses on night shift, may have an increased risk of developing
breast cancer. This is a fairly recent finding, and more studies are in
progress to look at this issue. According to some researchers, the
effect may be due to disruption in melatonin, a hormone that is
affected by light, but other hormones are also being studied.
American Cancer Society
Recommendations for Early Breast Cancer Detection in Women Without
Breast Symptoms
Women age 40 and older should have a screening
mammogram every year and should continue to do so for as long as they
are in good health.
- Current evidence supporting mammograms is even stronger
than in the past. In particular, recent evidence has confirmed that
mammograms offer substantial benefit for women in their 40s. Women can
feel confident about the benefits associated with regular mammograms
for finding cancer early. However, mammograms also have limitations. A
mammogram will miss some cancers, and it sometimes leads to follow up
of findings that are not cancer, including biopsies.
- Women should be told about the benefits, limitations, and
potential harms linked with regular screening. Mammograms can miss some
cancers. But despite their limitations, they remain a very effective
and valuable tool for decreasing suffering and death from breast
cancer.
- Mammograms for older women should be based on the
individual, her health, and other serious illnesses, such as congestive
heart failure, end-stage renal disease, chronic obstructive pulmonary
disease, and moderate-to-severe dementia. Age alone should not be the
reason to stop having regular mammograms. As long as a woman is in good
health and would be a candidate for treatment, she should continue to
be screened with a mammogram.
Women in their 20s and 30s should have a clinical
breast exam (CBE) as part of a periodic (regular) health exam by a
health professional preferably every 3 years. After age 40, women
should have a breast exam by a health professional every year.
- CBE is a complement to mammograms and an opportunity for
women and their doctor or nurse to discuss changes in their breasts,
early detection testing, and factors in the woman’s history that might
make her more likely to have breast cancer.
- There may be some benefit in having the CBE shortly before
the mammogram. The exam should include instruction for the purpose of
getting more familiar with your own breast. Women should also be given
information about the benefits and limitations of CBE and breast self
exam (BSE). Breast cancer risk is very low for women in their 20s and
gradually increases with age. Women should be told to promptly report
any new breast symptoms to a health professional.
Breast self-examination (BSE) is an option for women
starting in their 20s.
Women should be told about the benefits and limitations of BSE. Women
should report any breast changes to their health professional right
away.
- Research has shown that BSE plays a small role in finding
breast cancer compared with finding a breast lump by chance or simply
being aware of what is normal for each woman. Some women feel very
comfortable doing BSE regularly (usually monthly) which involves a
systematic step-by-step approach to examining the look and feel of
one’s breasts. Other women are more comfortable simply looking and
feeling their breasts in a less systematic approach, such as while
showering or getting dressed or doing an occasional thorough exam.
Sometimes, women are so concerned about "doing it right" that they
become stressed over the technique. Doing BSE regularly is one way for
women to know how their breasts normally look and feel and to notice
any changes. The goal, with or without BSE, is to report any breast
changes to a doctor or nurse right away.
- Women who choose to do BSE should have their BSE technique
reviewed during their physical exam by a health professional. It is
okay for women to choose not to do BSE or not to do it on a regular
schedule. However, by doing the exam regularly, you get to know how
your breasts normally look and feel and you can more readily detect any
signs or symptoms If a change occurs, such as development of a lump or
swelling, skin irritation or dimpling, nipple pain or retraction
(turning inward), redness or scaliness of the nipple or breast skin, or
a discharge other than breast milk. Should you notice any changes you
should see your health care provider as soon as possible for
evaluation. Remember that most of the time, however, these breast
changes are not cancer.
Women at high risk (greater than 20% lifetime risk)
should get an MRI and a mammogram every year. Women at moderately
increased risk (15% to 20% lifetime risk) should talk with their
doctors about the benefits and limitations of adding MRI screening to
their yearly mammogram. Yearly MRI screening is not recommended for
women whose lifetime risk of breast cancer is less than 15%.
- Women at high risk include those who:
- have a known BRCA1 or BRCA2 gene mutation
- have a first-degree relative (parent, brother,
sister, or child) with a BRCA1 or BRCA2 gene mutation, and have not had
genetic testing themselves
- have a lifetime risk of breast cancer of 20% to 25% or
greater, according to risk assessment tools that are based mainly on
family history (see below)
- had radiation therapy to the chest when they were
between the ages of 10 and 30 years
- have Li-Fraumeni syndrome, Cowden syndrome, or
Bannayan-Riley-Ruvalcaba syndrome, or have one of these syndromes in
first-degree relatives
- Women at moderately increased risk include those who:
- have a lifetime risk of breast cancer of 15% to 20%,
according to risk assessment tools that are based mainly on family
history
- have a personal history of breast cancer, ductal
carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical
ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)
- have extremely dense breasts or unevenly dense breasts
when viewed by mammograms
- If MRI is used, it should be in addition to, not instead
of, a screening mammogram. This is because while an MRI is a more
sensitive test (it's more likely to detect cancer than a mammogram), it
may still miss some cancers that a mammogram would detect.
- For most women at high risk, screening with MRI and
mammograms should begin at age 30 years and continue for as long as a
woman is in good health. But because the evidence is limited regarding
the best age at which to start screening, this decision should be based
on shared decision making between patients and their health care
providers, taking into account personal circumstances and preferences.
- Several risk assessment tools, with names such as BRCAPRO,
the Claus model, and the Tyrer-Cuzick model, are available to help
health professionals estimate a woman's breast cancer risk. These tools
give approximate, rather than precise, estimates of breast cancer risk
based on different combinations of risk factors and different data
sets. As a result, they may give different risk estimates for the same
woman. Their results should be discussed by a woman and her doctor when
being used to decide on whether to start MRI screening.
- It is recommended that women who get screening MRI do so at
a facility that can do an MRI-guided breast biopsy at the same time if
needed. Otherwise, the woman will have to have a second MRI exam at
another facility at the time of biopsy.
- There is no evidence at this time that MRI will be an
effective screening tool for women at average risk. While MRI is more
sensitive than mammograms, it also has a higher false-positive rate
(where the test finds something that turns out not to be cancer), which
would result in unneeded biopsies and other tests in a large portion of
these women.
The American Cancer Society believes the use of mammograms,
MRI (in women at high risk), clinical breast exams, and finding and
reporting breast changes early, according to the recommendations
outlined above, offers women the best chance to reduce their risk of
dying from breast cancer. This approach is clearly better than any one
exam or test alone. Without question, breast physical exam without a
mammogram would miss the opportunity to detect many breast cancers that
are too small for a woman or her doctor to feel but can be seen on
mammograms. While mammograms are a sensitive screening method, a small
percentage of breast cancers do not show up on mammograms but can be
felt by a woman or her doctors. For women at high risk of breast
cancer, such as those with BRCA gene mutations or a strong family
history, both MRI and mammogram exams of the breast are recommended.
Mammograms
A mammogram is an x-ray of the breast. A diagnostic
mammogram is used to diagnose breast disease in women who have breast
symptoms. Screening
mammograms are used to look for breast disease in women who are
asymptomatic; that is, those who appear to have no breast problems.
Screening mammograms usually involve 2 views (x-ray pictures taken from
different angles) of each
breast. Women who are breast-feeding can still get mammograms, although
these are probably not quite as accurate.
For some women, such as those with breast implants (for
augmentation or as reconstruction after mastectomy), additional
pictures may be needed to include as much breast tissue as possible.
Breast implants make it harder to see breast tissue on standard
mammograms, but additional x-ray pictures with implant displacement and
compression views can be used to more completely examine the breast
tissue. If you have implants it is important that you have your
mammograms done by someone skilled in the techniques used for women
with implants.
Although breast x-rays have been performed for more than 70
years, modern mammography has only existed since 1969. That was the
first year x-ray units dedicated to breast imaging were available.
Modern mammogram equipment designed for breast x-rays uses very low
levels of radiation, usually about a 0.1 to 0.2 rad dose per x-ray (a
rad is a measure of radiation dose).
Strict guidelines are in place to ensure that mammogram
equipment is safe and uses the lowest dose of radiation possible. Many
people are concerned about the exposure to x-rays, but the level of
radiation used in modern mammograms does not significantly increase the
risk for breast cancer.
To put dose into perspective, a woman who receives radiation
as a treatment for breast cancer will receive several thousand rads. If
she had yearly mammograms beginning at age 40 and continuing until she
was 90, she will have received 20 to 40 rads. As another example,
flying from New York to California on a commercial jet exposes a woman
to roughly the same amount of radiation as one mammogram.
For a mammogram, the breast is compressed between 2 plates to
flatten and spread the tissue. Although this may be uncomfortable for a
moment, it is necessary to produce a good, "readable" mammogram. The
compression only lasts a few seconds. The entire procedure for a
screening mammogram takes about 20 minutes.
The x-ray machine for mammography
The procedure produces a black and white image of the breast
tissue either on a large sheet of film or as a digital computer image
that is "read," or interpreted, by a radiologist (a
doctor trained to interpret images from x-rays, ultrasound, MRI, and
related tests.)
The doctor reading the films will look for several types of
changes:
Calcifications
are tiny mineral deposits within the breast tissue that
appear as small white spots on the films. They may or may not be caused
by cancer. Calcifications are divided into 2 types:
-
Macrocalcifications are coarse (larger) calcium deposits
that most likely represent degenerative changes in the breasts, such as
aging of the breast arteries, old injuries, or inflammation. These
deposits are associated with benign (non-cancerous) conditions and do
not require a biopsy. Macrocalcifications are found in about half the
women over the age of 50, and in about 1 in 10 women younger than 50.
-
Microcalcifications
are tiny specks of calcium in the breast. They may
appear alone or in clusters. Microcalcifications seen on a mammogram
are of more concern, but do not always mean that cancer is present. The
shape and layout of microcalcifications help the radiologist judge how
likely it is that cancer is present. In most instances, the presence of
microcalcifications does not mean a biopsy is needed. Instead, a doctor
may advise you to have a follow-up mammogram within 3 to 6 months. In
other cases, if the microcalcifications look more suspicious a biopsy
is needed.
A mass,
which may occur with or without calcifications, is another important
change seen on mammograms. Masses can be due to many things, including
cysts (non-cancerous, fluid-filled sacs) and non-cancerous solid tumors
(such as fibroadenomas). However, they may be cancer and usually should
be biopsied.
- A cyst cannot be diagnosed by physical exam alone, nor can
it be diagnosed by a mammogram alone. To confirm that a mass is really
a cyst, either breast ultrasound or removal of fluid (aspiration) with
a thin, hollow needle is needed.
- If a mass is not a simple cyst (that is, if it is at least
partly solid), then you may need to have more imaging tests. Some
masses can be watched with periodic mammograms, while others may need a
biopsy. The size, shape, and margins (edges) of the mass help the
radiologist to determine whether cancer may be present.
If your prior mammograms are available, they may help show
that a mass has not changed for many years, which would mean that the
mass is likely a benign condition and help avoid an unnecessary biopsy.
Having your prior mammograms available to the radiologist is very
important.
A mammogram may show something suspicious, but by itself it
cannot prove that an abnormal area is cancer. If a mammogram raises a
suspicion of cancer, a small amount of tissue must be removed and
examined under a microscope. This procedure is called a biopsy. For
more information on the see the American Cancer Society document, For
the Woman Facing a Breast Biopsy.
Tips for Having a Mammogram
The following are useful suggestions for making sure that you
receive a quality mammogram:
- If it is not posted in a place you can see it near the
receptionist's desk, ask to see the FDA certificate that is issued to
all facilities that meet high professional standards of safety and
quality. The FDA requires that all facilities meet high professional
standards of safety and quality in order to be a provider of
mammography services. Without certification, a facility may not provide
mammography.
- Use a facility that either specializes in mammography or
does many mammograms a day.
- If you are satisfied that the facility is of high quality,
continue to go there on a regular basis so that your mammograms can be
compared from year to year.
- If you are going to a facility for the first time, bring a
list of the places, dates of mammograms, biopsies, or other breast
treatments you have had before.
- If you have had mammograms at another facility, you should
make every attempt to get those mammograms to bring with you to the new
facility (or have them sent there) so that they can be compared to the
new ones.
- Try to schedule your mammogram at a time of the month when
your breasts are not tender or swollen to help reduce discomfort and
assure a good picture. Try to avoid the week right before your period.
- On the day of the exam, don't wear deodorant or
antiperspirant. Some of these contain substances that can interfere
with the reading of the mammogram by appearing on the x-ray film as
white spots.
- You may find it more convenient to wear a skirt or pants,
so that you'll only need to remove your blouse for the exam.
- Always describe any breast symptoms or problems that you
are having to the technologist who is doing the mammogram. Be prepared
to describe any pertinent medical history such as prior surgeries,
hormone use, and family or personal history of breast cancer. Also
discuss any new findings or problems in your breasts with your doctor
or nurse before having a mammogram.
- If you do not hear from your doctor within 10 days, do not
assume that your mammogram was normal. Call your doctor or the
facility.
What to Expect When You Get a
Mammogram
- Having a mammogram requires that you undress above the
waist. A wrap will be provided by the facility for you to wear.
- A technologist will be present to position your breasts
for the mammogram. Most technologists are women. You and the
technologist are the only ones present during the mammogram.
- To get a high-quality mammogram picture, it is necessary to
flatten the breast slightly. A technician places the breast on the
mammogram machine's lower plate, which is made of metal and has a
drawer to hold the x-ray film or the camera to produce a digital image.
The upper plate, made of plastic, is lowered to compress the breast for
a few seconds while the technician takes a picture.
- The whole procedure takes about 20 minutes. The actual
breast compression only lasts a few seconds.
- You may feel some discomfort when your breasts are
compressed, and for some women compression can be painful. Try not to
schedule a mammogram when your breasts are likely to be tender, as they
may be just before or during your period.
- All mammogram facilities are now required to send your
results to you within 30 days. Generally, you will be contacted within
5 working days if there is a problem with the mammogram.
- Only 2 to 4 screening mammograms of every 1,000 lead to a
diagnosis of cancer. About 10% of women who have a mammogram will
require more tests, and most will only need an additional mammogram.
Don't panic if this happens to you. Only 8% to 10% of those women will
need a biopsy, and most (80%) of those biopsies will not be cancer.
If you are a woman and age 40 or over, you should get a mammogram every
year. You can schedule the next one while you're there at the facility.
Or, you can ask for a reminder to schedule it as the date gets closer.
For more information on mammograms and other imaging tests for early
detection and diagnosis of breast diseases, refer to the American
Cancer Society document, Mammograms
and Other Breast Imaging Procedures.
Signs and Symptoms of Breast Cancer
Although widespread use of screening mammograms has increased the
number of breast cancers found before they cause any symptoms, some
breast cancers are not found by mammograms, either because the test was
not done or because even under ideal conditions mammograms do not find
every breast cancer.
The most common sign of breast cancer is a new lump or mass. A mass
that is painless, hard, and has irregular edges is more likely to be
cancerous, but some rare cancers are tender, soft, and rounded. For
this reason, it is important that any new mass, lump, or breast change
is checked by a health care professional with experience in diagnosis
of breast diseases.
Other possible signs of breast cancer include:
- swelling of all or part of a breast (even if no distinct
lump is
felt)
- skin irritation or dimpling
- breast or nipple pain
- nipple retraction (turning inward)
- redness, scaliness, or
thickening of the nipple or breast skin
- a discharge other than breast milk
Sometimes a breast cancer can spread to underarm lymph nodes and cause
a lump or swelling there, even before the original tumor in the breast
tissue is large enough to be felt. Swollen lymph nodes should also be
reported to your doctor.
Clinical Breast Exam
A clinical breast exam (CBE) is an examination of your
breasts by a health professional, such as a doctor, nurse practitioner,
nurse, or physician assistant. For this exam, you undress from the
waist up. The health professional will first look at your breasts for
abnormalities in size or shape, or changes in the skin of the breasts
or nipple. Then, using the pads of the fingers, the examiner will
gently feel (palpate) your breasts.
Special attention will be given to the shape and texture
of
the breasts, location of any lumps, and whether such lumps are attached
to the skin or to deeper tissues. The area under both arms will also be
examined.
The CBE is a good time for your health professional to
teach
you how to be aware of changes in your breasts and to teach breast
self-exam (BSE) techniques if you wish to do BSE. Ask your doctor or
nurse about how to be aware of breast changes and to teach you and
watch your technique.
Breast Awareness and
Self-Exam
Beginning in their 20s, women should be told about the
benefits and limitations of breast self-exam (BSE.) Women should be
aware of how their breasts normally look and feel and report any new
breast change to a health professional as soon as they are found.
Finding a breast change does not necessarily mean there is a cancer.
A woman can notice changes by being aware of how her breasts normally
look and feel and feeling her breasts for changes (breast awareness),
or by choosing to use a step-by-step approach and using a specific
schedule to examine her breasts.
Women with breast implants can do BSE. It may be useful to have the
surgeon help identify the edges of the implant so that you know what
you are feeling. There is some thought that the implants push out the
breast tissue and may make it easier to examine. Women who are pregnant
or breast-feeding can also choose to examine their breasts regularly.
If you choose to do BSE, the following information provides a
step-by-step approach for the exam. The best time for a woman to
examine her breasts is when the breasts are not tender or swollen.
Women who examine their breasts should have their technique reviewed
during their periodic health exams by their health care professional.
It is acceptable for women to choose not to do BSE or to do BSE
occasionally. Women who choose not to do BSE should still be aware of
their breasts and report any changes without delay to their doctor.
How to Examine Your Breasts
This procedure for doing breast self-exam is different than
previous procedure recommendations. These changes represent an
extensive review of the medical literature and input from an expert
advisory group. There is evidence that this position (lying down), area
felt, pattern of coverage of the breast, and use of different amounts
of pressure increase ability of the test to find abnormal areas.
Newer Technologies for
Breast
Cancer Screening
Mammography is the current standard test for breast
cancer
screening. MRI is also recommended along with mammograms for some women
at high risk for breast cancer. Other tests, such as ultrasound, are
now being studied as well.
Magnetic Resonance
Imaging (MRI)
For certain women at high risk for breast cancer, screening
MRI is recommended along with a yearly mammogram. MRI is not generally
recommended as a screening tool by itself, as it may miss some cancers
that mammograms would detect.
MRI uses magnets and radio waves, instead of x-rays, to produce very
detailed, cross-sectional images of the body. The most useful MRI exams
for breast imaging use a contrast material (gadolinium DTPA) that is
injected into a small vein in the arm before or during the exam. This
improves the ability of the MRI to clearly show breast tissue details.
MRI scans can take a long time -- often up to an hour. You have to lie
inside a narrow tube, which is confining and may upset people with
claustrophobia (a fear of enclosed spaces). The machine makes loud
buzzing and clicking noises that you may find disturbing. Some places
provide headphones with music to block this out. MRIs are also
expensive, although insurance plans generally pay for them in some
situations, such as once cancer is diagnosed.
Just as mammography uses x-ray machines designed
especially
to image the breasts, breast MRI also requires special equipment.
Higher quality images are produced by dedicated breast MRI equipment
than by machines designed for head, chest, or abdominal MRI scanning.
However, many hospitals and imaging centers do not have dedicated
breast MRI equipment available. It is important that screening MRIs are
done at facilities that are capable of performing an MRI-guided breast
biopsy at the time of the exam if anything abnormal is found.
Otherwise, the scan will need to be repeated at another facility at the
time of the biopsy.
MRI is also more expensive than mammography. Most major
insurance companies will likely pay for these screening tests if a
woman can be shown to be at high risk, but it's not yet clear if all
companies will. At this time there are concerns about costs of and
limited access to high-quality MRI breast screening services for women
at high risk of breast cancer.
Breast Ultrasound
Ultrasound, also known as sonography, is an imaging method in
which high-frequency sound waves are used to look inside a part of the
body. For this test, a small, microphone-like instrument called a
transducer is placed on the skin (which is often first lubricated with
oil or ultrasound gel). It emits sound waves and picks up the echoes as
they bounce off the organs. The echoes are converted by a computer into
a black and white image that is displayed on a computer screen. You are
not exposed to radiation during this test.
Breast ultrasound is sometimes used to evaluate breast
problems that are found during a screening or diagnostic mammogram or
on physical exam. Breast ultrasound is not routinely used for
screening. Some studies have suggested that ultrasound may be a helpful
addition to mammography when screening women with dense breast tissue
(which is hard to evaluate with a mammogram), but the use of ultrasound
instead of mammograms is not recommended.
Ultrasound is useful for evaluating some breast masses
and is
the only way to tell if a suspicious area is a cyst (fluid-filled sac)
without placing a
needle into it to aspirate (pull out) fluid. Cysts cannot be accurately
diagnosed by physical exam alone. Breast ultrasound may also be used to
help doctors guide a biopsy needle into some breast lesions.
Ultrasound has become a valuable tool to use along with
mammograms because it is widely available, non-invasive, and less
expensive than other options. However, the effectiveness of an
ultrasound test depends on the operator’s level of skill and
experience. Although ultrasound is less sensitive than MRI (that is, it
detects fewer tumors), it has the advantage of being more available and
less expensive.
Ductogram
This test, also called a galactogram, is sometimes helpful in
determining the cause of nipple discharge. In this x-ray procedure, a
thin plastic tube is placed into the opening of the duct at the nipple.
A small amount of contrast material is injected that outlines the shape
of the duct on an x-ray image and shows if there is a mass inside the
duct.
Ductal Lavage and Nipple
Aspiration
Ductal lavage is an experimental test
developed for women who have no symptoms of breast cancer but are at
very high risk for breast cancer. It is not a test to screen for or
diagnose breast cancer, but it may help give a more accurate picture of
a woman's risk of developing it.
For this test, gentle suction is used to help draw tiny
amounts of fluid from the milk ducts up to the nipple surface. The
fluid droplets that appear help locate the milk ducts' natural openings
on the surface of the nipple. A tiny tube is then inserted into an
opening on the nipple. Saline (salt water) is slowly delivered through
the tube to gently "rinse" the duct and collect cells. The fluid is
then withdrawn through the tube and sent to a lab, where the cells are
viewed under a microscope.
Ductal lavage is much more useful as a test of cancer risk
rather than as a screening test for cancer. It is not considered
appropriate for women who aren't at high risk for breast cancer. It is
not clear whether it will ever be a useful tool. The test has not been
shown to detect cancer early, nor have there been any studies to show
that this approach prevents the development of breast cancer or death
from breast cancer. More studies are needed to better define the
usefulness of this test.
Nipple aspiration also looks for abnormal
cells from the ducts. The device for nipple aspiration uses small cups
that are placed on the woman's breasts. The device warms the breasts,
gently compresses them, and applies light suction to bring nipple fluid
to the surface of the breast. The nipple fluid is then collected and
sent to a lab for analysis. As with ductal lavage, the procedure may be
useful as a test of cancer risk but is not appropriate as a screening
test for cancer. The test has not been shown to detect cancer early,
nor have there been any studies to show that it prevents the
development of breast cancer or death from breast cancer.
Full-field Digital Mammograms
(FFDM)
A full field digital mammogram (or just "digital mammogram")
is similar to a standard mammogram in that x-rays are used to produce
an image of your breast. The differences are
in the way the image is recorded, viewed by the doctor, and stored.
Standard mammograms are recorded on large sheets of photographic film.
Digital mammograms are recorded and stored on a computer. After the
exam, the doctor can view them on a computer screen and adjust the
image size, brightness, or contrast to see certain areas more clearly.
Digital images can also be sent electronically to another site for a
remote consult with breast specialists. While many centers do not offer
the digital option at this time, it is expected to become more widely
available in the future.
Because digital mammograms cost more than standard
mammograms, studies are now under way to determine which form of
mammogram will benefit more women in the long run. Some studies have
found that women who have FFDM have to return less often for additional
imaging tests because of inconclusive areas on the original mammogram.
A recent large study from the National Cancer Institute found that FFDM
was more accurate in finding cancers in women younger than 50 and in
women with dense breast tissue, although the rates of inconclusive
results were similar between FFDM and film mammography. It is important
to remember that standard film mammography also is effective for these
groups of women, and that they should not miss their regular mammogram
if digital mammography is not available.
Computer-aided Detection and
Diagnosis (CAD)
Over the past 2 decades, computer-aided detection and
diagnosis (CAD) has been developed to help radiologists detect
suspicious changes on mammograms. This is done most commonly with
screen-film mammograms and less often with digital mammograms.
Computers can help doctors identify abnormal areas on a
mammogram by acting as a second set of "eyes." For standard mammograms,
the film is fed into a machine, which converts the image into a digital
signal that is then analyzed by the computer. Alternatively, the
technology can be applied to an image captured with digital
mammography. The computer then displays the image on a video screen,
with markers pointing to areas it "thinks" the radiologist should check
especially closely.
It's not yet clear how useful CAD is. Some doctors find it
helpful, but a recent large study found it did not significantly
improve the accuracy of breast cancer detection. It did, however,
increase the number of women who needed to have breast biopsies.
Further research of this approach is needed.
Scintimammography
In scintimammography, a radioactive tracer is injected into a
vein to detect breast cancer cells. The tracer attaches to breast
cancers and is detected by a special camera. This is a very new
technique and is still considered experimental. It may or may not be
helpful in evaluating abnormal mammograms.
Talk to Your Doctor
If you think you are at higher risk for developing breast
cancer, talk to your doctor about what is known about these tests and
their potential benefits, limitations, and harms. Then make a decision
together about what is best for you.
For more information on imaging tests for early detection and
diagnosis of breast diseases, refer to the American Cancer Society
document, Mammograms
and Other Breast Imaging Procedures.
Paying for Breast Cancer Screening
This overview provides a snapshot of laws assuring coverage
for private health plans, Medicaid, and Medicare coverage of early
detection services for breast cancer screening.
State Efforts to Ensure
Coverage of Mammography for Private Health Insurance
Many states ensure that private insurance companies, Medicaid, and public employee health plans provide coverage and reimbursement for specific health services and procedures. The American Cancer Society (ACS) supports these kinds of patient protections, particularly when it comes to evidence-based cancer prevention, early detection, and treatment services.
The only state without a law ensuring that private health plans cover or offer coverage for screening mammograms is Utah (see table below). Of the remaining 49 states that have enacted either assured benefits or ensured offerings for mammography coverage, many states do not conform to ACS guidelines and are either more or less "generous" than ACS recommendations. Some states like Rhode Island, however, specifically state in their legislative language that mammography screening should be covered according to the ACS guidelines.
State Mammography Screening
Coverage Laws
| State |
Frequency
and Age Requirements |
| Alaska |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Alabama |
Every 2 years for 40s or physician recomendation;
each
year for 50+, or physician reccomendation |
| Arkansas |
Insurers must offer coverage
for
baseline for ages 35-39, every 2 years for 40s, each year 50+, or
physician reccomendation |
| Arizona |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| California |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Colorado |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Connecticut |
Baseline for ages 35-39, every year 40+
(Under a law that took effect Oct. 1, 2005, individual and group
insurers are also will required to provide coverage for a comprehensive
ultrasound screening of the entire breast if it is recommended by a
physician for a woman classified as a category 2, 3, 4 or 5 under the
American College of Radiology's Breast Imaging Reporting and Data
System.) |
| District of Columbia |
Coverage |
| Delaware |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+ |
| Florida |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Georgia |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Hawaii |
Annual for 40+, or physician reccomendation |
| Iowa |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Idaho |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Illinois |
Baseline for ages 35-39, annual for 40+ |
| Indiana |
Annual for 40+, or physician reccomendation |
| Kansas |
Covered in accordance with American Cancer Society
guidelines if insurers provide reimbursement for lab and X-ray services |
| Kentucky |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+ |
| Louisiana |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Massachusetts |
Baseline for ages 35-39 and annual for 40+ |
| Maryland |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Maine |
Annual for 40+ |
| Michigan |
Insurance must offer or include
coverage of baseline for ages 35-39, annual for 40+ |
| Minnesota |
If recommended |
| Missouri |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Mississippi |
Insurance must offer
annual for
ages 35+ |
| Montana |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| North Carolina |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| North Dakota |
Baseline for ages 35-39, annual for 40+, or
physician
reccomendation |
| Nebraska |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| New Hampshire |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+ |
| New Jersey |
Baseline for ages 35-39, each year for 40+ |
| New Mexico |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Nevada |
Baseline for ages 35-39 and annual for 40+ |
| New York |
Baseline for ages 35-39, every year for 40+, or
physician reccomendation |
| Ohio |
Baseline for ages 35-39, every 2 years for 40s,
every
year if a woman is at least 50 but under 65, or physician
reccomendation |
| Oklahoma |
Baseline for ages 35-39 and annual for 40+ |
| Oregon |
Annual for 40+, or by referral |
| Pennsylvania |
Annual for 40+, physician rec. for under 40 |
| Rhode Island |
According to ACS guidelines
(Also requires individual and group insurers to provide coverage for 2
screening mammograms
per year for women who have been treated for breast cancer within the
past 5 years or who are at high risk for developing cancer due to
genetic predisposition, have a high-risk lesion from a prior biopsy or
atypical ductal hyperplasia.) |
| South Carolina |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation., in accordance with American
Cancer Society guidelines |
| South Dakota |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Tennessee |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+, or physician reccomendation |
| Texas |
Annual for 35+ |
| Utah |
None |
| Virginia |
Baseline for ages 35-39, every 2 years for 40s,
each
year 50+ |
| Vermont |
Annual for 50+, physician reccomendation. for under
50 |
| Washington |
If recommended |
| Wisconsin |
2 exams total for ages 45-49, each year 50+ |
| West Virginia |
Baseline for ages 35-39, every 2 years for 40s |
| Wyoming |
Covers a screening mammogram and clinical breast
exam
along with other cancer screening tests; however, the health plan is
responsible only up to $250 for all cancer screenings |
Sources:
- Health Policy Tracking Service, "Mandated Benefits:
Breast
Cancer Screening Coverage Requirements," 4/01/04; CDC Division of
Cancer Prevention and Control, “State Laws Relating to Breast Cancer:
Legislative Summary, January 1949 to May 2000.”
- Health Policy Tracking Service, “Overview: Health
Insurance
Access and Oversight,” 6/20/05
- Netscan’s Health Policy Tracking Service Health
Insurance
Snapshot, 8/8/05
- Netscan’s Health Policy Tracking Service, “Mandated
Benefits: An Overview of 2006 Activity,” 4/03/06
Updated 9/14/06; National Government Relations Department
Other State Efforts and
Self-Insured Plans
Other types of health coverage also provide screening
mammograms. Public employee health plans are governed by state
regulation and legislation, and many cover screening mammograms. ERISA,
or self-insured plans, are not regulated at the state level and,
therefore, women in these plans do not necessarily get screening
mammogram benefits, even if there are laws in the state to cover such
benefits. Self-insured plans are typically large employers. Women who
have self-insured-based health insurance should check with their health
plans to see what breast cancer early detection services are offered.
Medicaid
All state Medicaid programs plus the District of Columbia cover screening mammograms. This coverage may or may not conform to American Cancer Society Guidelines. State Medicaid offices should be able to provide screening-coverage information to interested individuals. The Medicaid programs are governed by state legislation and regulation, so assured coverage is not always apparent in legislative bills.
In addition, all 50 states plus the District of Columbia have opted to provide Medicaid coverage for all women diagnosed with breast cancer through the Centers for Disease Control and Prevention's (CDC's) National Breast and Cervical Cancer Early Detection Program (see next section), so that they may receive cancer treatment. This option allows states to receive significant matching funds from the federal government. States vary in the age, income and other requirements that women must meet in order to qualify for treatment through the Medicaid program. (All 50 states, 4 U.S. territories, the District of Columbia, and 13 American Indian/Alaska Native organizations participate in the National Breast and Cervical Cancer Early Detection Program.)
National Breast and
Cervical
Cancer Early Detection Program
States are making breast cancer screening more available
to
medically underserved women through the National Breast and Cervical
Cancer Early Detection Program (NBCCEDP). This program provides breast
and cervical cancer screening to low-income, uninsured, and underserved
women for free or at very low cost. The NBCCEDP attempts to reach as
many women in medically underserved communities as possible, including
older women, women without health insurance, and women who are members
of racial and ethnic minorities. Age and income requirements vary by
state.
The program provides both screening and diagnostic
services,
including:
- clinical breast exams
- mammograms
- Pap tests
- surgical consultations
- referrals to treatment
- diagnostic testing for women whose screening results
are
abnormal
Though the program is administered within each state, tribe, or territory, the Centers for Disease Control and Prevention (CDC) provide matching funds and support to each program. Since 1991 when the program began, it has provided more than 6.9 million screening exams to underserved women and diagnosed over 29,000 breast cancers, over 94,000 pre-cancerous cervical lesions, and over 1,800 cervical cancers. Now that the program is firmly established, doctors are detecting new cancers at their earliest stages, leading to longer-term survival. These accomplishments demonstrate a truly nationwide effort. Unfortunately, however, due to limited resources, only about 1 in 5 eligible women aged 50 to 64 is served nationwide.
Each state's Department of Health will have information on how to contact the nearest CDC screening and early detection program in your area. For more information, please contact the CDC at 1-888-842-6355 or through their Web site at www.cdc.gov/cancer
Medicare
Since 1998, Medicare has covered mammograms once every 12
months for all women with Medicare aged 40 and over. (Women are
eligible for Medicare if they are age 65 and older, are disabled, or
have end-stage renal disease.) Medicare also pays for a clinical breast
exam once every 24 months along with a pelvic exam. These benefits are
not subject to the usual Medicare Part B deductible, but the standard
20% copay applies.
As of January 1, 2005, Medicare covers an initial
preventive
physical exam for all new Medicare beneficiaries within 6 months of
enrolling in Medicare. The "Welcome to Medicare" exam includes
measurements of height, weight, and blood pressure, in addition to
referrals for prevention and early detection services already covered
under Medicare, such as mammograms.
Additional Resources
More Information From Your
American Cancer Society
The following information may also be helpful to you.
These
materials may be ordered from our toll-free number, 1-800-ACS-2345
(1-800-227-2345), or found on our Web site, www.cancer.org.
National Organizations and
Web
Sites
In addition to the American Cancer Society, other sources
of
patient information and support include*:
Centers for Disease Control and Prevention (CDC)
Cancer Prevention and Control Program
Telephone: 1-800-232-4636
Internet Address: http://www.cdc.gov/cancer
Information about the National Breast and Cervical Cancer Early Detection Program.
National Cancer Institute (NCI)
Telephone: 1-800-4-CANCER (1-800-422-6237)
Internet Address: http://www.cancer.gov
General breast cancer information.
*Inclusion on this list does not imply
endorsement
by the American Cancer Society.
The American Cancer Society is happy to address any
cancer-related topic. If you have any more questions, please call us at
1-800-ACS-2345 at any time, 24 hours a day.
References
American Cancer Society. Detailed Guide: Breast Cancer. 2007. Available at: http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=5. Accessed September 10, 2007.
Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program. Available at: http://www.cdc.gov/cancer/nbccedp/about.htm. Accessed September 10, 2007.
Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005;353:1773-1783.
Saslow D, Boetes C, Burke W, et al for the American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75-89.
Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society guidelines for breast cancer screening: Update 2003. CA Cancer J Clin. 2003;53:141-169.
Revised: 09/17/2007
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Lie down on your back and
place your right arm behind your head. The exam is done while lying
down, not standing up. This is because when lying down the breast
tissue spreads evenly over the chest wall and is as thin as possible,
making it much easier to feel all the breast tissue.
Use 3 different levels
of pressure to feel all the breast tissue. Light pressure is needed to
feel the tissue closest to the skin; medium pressure to feel a little
deeper; and firm pressure to feel the tissue closest to the chest and
ribs. A firm ridge in the lower curve of each breast is normal. If
you’re not sure how hard to press, talk with your doctor or nurse. Use
each pressure level to feel the breast tissue before moving on to the
next spot.
Move around the breast in an up-and-down
pattern starting at an imaginary line drawn straight down your side
from the underarm and moving across the breast to the middle of the
chest bone.(sternum or breastbone). Be sure to check the entire breast
area going down until you feel only ribs and up to the neck or collar
bone (clavicle). 
