Like many women, I hold my breath in for just a few more seconds than necessary every time I visit my gynecologist and she performs a manual breast examination. Ever since I turned 30, I've been cross-examining her as to why she won't give me a mammogram until I'm 40: No family history, she explains, as if that's going to quell the anxiety. In truth, breast cancer seems so prevalent (and it doesn't help that many of us are hearing about younger and younger women being diagnosed with it) that we can't help but be curious and yearn for information — if only to try and understand something we fear.
Dr. Maggie DiNome is the director of the Margie Petersen Breast Center at John Wayne Cancer Institute at Providence Saint John's Health Center in Santa Monica, California. Her clinical expertise is on cancer surgery — in other words, she knows her stuff. Because knowledge is power, or at the very least, has the power to temper some of our unease when thinking about cancer, she graciously explains how breast cancer is generally diagnosed. And she answers other questions you've always had about the diagnosis process.
For starters, if you are 40, you should be receiving regular mammograms because DiNome says the majority of breast cancer cases in women 40 and older are detected via the examination. Since it is a screening — and, by definition, a screening implies the patient feels nothing abnormal — DiNome says most women are shocked when they find out a tumor has been detected in their breast.
"Once a woman feels a mass, sees a retraction, etc., the test is no longer a screening test and it's diagnostic. The cancers are generally larger than when they are found on routine screening and that's why getting that screening test just because you're over 40 is so important. Waiting to feel something is not the right time to find a cancer."
DiNome puts it into perspective: A cancer the size of a period contains 1,000 cancer cells, so a 1 centimeter cancer already has 1 billion cancer cells. "Most cancers that are felt are already close to 2 centimeters," she says. "Screening can help us find cancers 1 centimeter or less. The smaller we can find a cancer through routine and enhanced screening methods, the greater chance we have of curing that cancer with less aggressive treatment options."
What about women younger than 40? You probably guessed it: Most approach their doctors because they felt a lump at home while performing a self-examination. Yet another crucial reason to learn how to give yourself a breast exam in the privacy of your own bathroom.
The second after a lump is detected, DiNome says a breast surgeon will take a comprehensive personal and family history and then do a thorough exam of both breasts and the lymph node basins that drain the breasts. Remember: There are plenty of benign tumors as well as malignant ones. This means, it may seem like the end of the world to you in that moment and you may yearn for immediate answers, but a doctor has to be sure she is dealing with cancer before that next step can be taken. Depending on a patient's age and the clinical suspicion of the "lump," DiNome says, diagnostic imaging might be ordered.
Based on the results from the diagnostic imaging, a doctor may order a biopsy, which is when tissue is removed from the breast so that it can be inspected. The length of time between the moment a doctor detects a lump and a biopsy may vary, but DiNome says patients at her breast center can have a complete exam, including imaging studies and a biopsy, done in one day.
You often hear about different stages of cancer — stages 0-4 — each is staged by something called the AJCC staging system and varies for each cancer type, DiNome says. "For breast cancer, it is based on the size of the cancer in the breast, whether and how many lymph nodes are involved, and whether there is any evidence of disease in other organs outside of the breast," she says.
Once cancer is detected, it's time to discuss treatment options, which are not necessarily made based on the stage of cancer, but more on tumor biology and are highly specified to fit the needs of each individual patient, DiNome says. What works for one woman with stage 1 cancer may not be the winning recipe for another. "An early stage 1 cancer may require surgery, chemotherapy, antibody therapy, hormone blocking therapy and radiation therapy for one patient and then only surgery and a hormone-blocking pill for another patient of similar age also with stage 1 cancer," DiNome says. "What we know now is that there are several different types of breast cancer and treatment recommendations are now individualized to both patient and tumor characteristics."
Most people have heard of chemo and radiation, but aren't sure why one may be used instead of other — or why both are necessary at times. Radiation therapy is local and uses X-rays to kill cancer cells wherever the radiation beams are targeted. Chemotherapy, a medication that can be delivered into the blood stream through an IV or taken in pill form, travels throughout the body, killing any cancer cells that may be in the blood or in other organs. "Chemotherapy is considered 'systemic' therapy. Meaning that it is treating other systems in the body and not just the site where the cancer started," DiNome says.
When you're talking about breast cancer, DiNome says radiation is often recommended to reduce the risk of the cancer coming back in the breast and/or lymph nodes, but as far as ridding the blood stream of tumor cells that may already be circulating in the blood, it can't help. That's where chemo comes in. "Chemotherapy will be recommended if the physician believes that the likelihood of circulating tumor cells existing in the blood is high enough to warrant treatment with this medication because once a cancer shows up in another body part outside of where it started, it is considered metastatic disease and no longer curable," she says. "We want to intervene and treat cancers at a stage when the tumor load is low enough that the cancer is not detectable on routine imaging but we are fairly certain that cancer cells exist in the blood."
Unfortunately, technology does not yet exist to give doctors a reliable marker in the blood that can indicate whether cancer cells are in the blood so the recommendation for chemotherapy will be made based on "surrogate markers," which include the size of the cancer and its aggressiveness, as well as whether they have spread to the lymph nodes — those that do have a higher chance of being in the blood, DiNome says.
It's rarely a comfortable topic to discuss or even contemplate, but rate of survival after a breast cancer diagnosis is something you can't help but think about. The type of tumor one has influences a person's survival rate more than the cancer stage, according to DiNome. Giving ballpark figures, DiNome provides the following stats for breast cancer survival: over 90-95 percent survival for stage 1, over 85 percent for stage 2, over 75 percent for stage 3.
Thanks in part to celebrities like Angelina Jolie, awareness about mastectomies has spread in recent years, but there still may be some confusion as to when a doctor might endorse a mastectomy. "A mastectomy is generally recommended for medical reasons if the patient is a BRCA genetic carrier, has a very large invasive cancer or extensive pre-invasive cancer called DCIS occupying a large part of the patient's breast, or has two or more cancers in separate quadrants of the same breast," DiNome says.
If a patient elects to have a mastectomy as a precaution, DiNome says she feels it's her decision to do so and would support her, but that she also makes sure they understand that it may not impact survival or obviate the need for certain therapies and the patient is made aware of the recovery time, potential complications and short- and long-term implications.
Perhaps the most beautiful takeaway from DiNome's interview is this: Life continues after breast cancer treatment. Unless a patient has had a mastectomy, she can still breastfeed her baby. Hair grows back. Life marches on. Being equipped with knowledge about your body, how to protect it and what your options are if you are ever diagnosed with breast cancer gives you the power to fight it.
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