October is Breast Cancer Awareness month – an important reminder about the impact of breast cancer in our community and personal lives.
It is estimated that in their lifetime about one in eight American women will get breast cancer, the most common cancer among women, according to the American Cancer Society. The ACS estimates there are more than 4 million breast cancer survivors and that 42,000 women in the United States will have died from breast cancer in 2024.
Fortunately, the United States is making progress in early diagnosis and treatment for breast cancer, leading to a decrease in death rates for patients. Experts agree that it is important for women to get regular breast exams and mammograms for early detection. While many lumps in a woman's breast are benign, any lump should be checked by a medical professional to determine if it is cancerous.
Cancer rates can vary by race. Black women have a lower incidence of breast cancer than white women but a higher risk of getting breast cancer than all other races, and a higher death rate. Native American women have a lower rate of breast cancer than white women, and Asian women have a lower mortality rate than other races. Reasons for these disparities are likely multifactorial and interventions to close the gap are an ongoing area of research and policy change.
Although breast cancer is rare in men, they also should take precautions, especially if they find a lump. Men make up about 1% percent of breast cancer diagnoses. Disparities also have been observed, with Black men having a higher risk of incidence and mortality from breast cancer compared to white men.
This disease touches many lives, from patients to loved ones, yet there are common misconceptions about breast cancer. We addressed some common questions and prevention measures with two UCLA Health physicians - Mediget Teshome, MD, chief of Breast Surgery, and Cheryce P. Fischer, MD, from the UCLA Department of Breast Imaging/Diagnostic Radiology:
What causes breast cancer? Is it genetic?
In some cases there is a genetic link, Dr. Teshome said, but everyone needs to be on guard against the disease and learn about prevention approaches and strategies for early diagnosis.
"About 5 to 10% of all breast cancers are due to a hereditary cause, so it is important to know your family history. While many other risk factors for breast cancer are outside of our control, some are modifiable, such as those related to lifestyle and healthy habits," said Dr. Teshome, a member of the UCLA Health Jonsson Comprehensive Cancer Center.
"Certainly, there are populations where we would recommend genetic testing to help understand if there is that underlying genetic risk, which has implications for the treatment of the disease as well as in managing the risk of a future breast cancer and even other cancers. But outside of a genetic cause for breast cancer, there are risk factors associated with an increased chance of breast cancer, some of which we have personal control over. Some ways to reduce your risk of breast cancer are not smoking, limiting alcohol, increasing physical activity and exercise, and maintaining a healthy body weight. Obtaining a yearly mammogram can also help diagnose cancer, if it is present, at the earliest stages."
What does a breast cancer lump feel like?
Dr. Fischer, also part of the UCLA Health Jonsson Comprehensive Cancer Center, said if a breast cancer is palpable, it is most likely going to feel like a hard, fixed mass as opposed to a soft, mobile mass. However, since many cancers are not palpable, it is very important to have a yearly screening mammogram beginning at age 40 for women at average risk.
"Any new or enlarging lump should be checked, regardless of age," she said.
How is breast cancer typically diagnosed?
The leading method for detection is a mammogram, which uses the latest x-ray technology to show a lump.
"Beginning at age 40, a woman who is at average risk should have a mammogram every year. It is the best way to detect breast cancer early and get it treated successfully," Dr. Fischer said.
Dr. Teshome noted that the majority of women have no symptoms from early breast cancer, and may otherwise feel healthy, so the annual mammogram often is the key to making an early diagnosis. “Some women may have a normal mammogram and may have symptoms such as a lump, skin changes, nipple discharge or swollen lymph nodes which lead to a cancer diagnosis. The key is to reach out to your doctor if you have any questions related to your breast health.”
When is it recommended to use an MRI?
Dr. Fischer said it is case by case, but typically MRI is used for a patient with higher-than-average risk of breast cancer, or to clarify something ambiguous that shows up on a mammogram or ultrasound, especially if the breast tissue is dense. For high-risk women, doctors often will recommend a yearly MRI in between yearly mammograms. She emphasized that "a yearly mammogram is the best way" to stay on top of potential breast cancers for most women. Other indications for breast MRI are in patients with newly diagnosed breast cancer and those with a prior history of breast cancer.
The U.S. Food and Drug Administration recently updated its mammography regulations to require mammography facilities to notify patients about the density of their breasts.
Is it possible to conduct a self-examination to check for breast cancer?
Dr. Fischer said women should check regularly for any lumps in their breasts. Dr. Teshome agreed, saying "breast self-awareness is important, knowing what is normal for you and if you notice any worrisome changes in your breasts.”
While an annual mammogram is essential for women older than 40, Dr. Teshome also said a woman should see a doctor about any unusual symptoms, especially those which persist, from a lump to skin changes or nipple discharge.
What is the fatality rate for breast cancer?
While fatalities have been reduced in recent decades, one in 40 women still die from breast cancer in the United States, making it second only to lung cancer.
"Treatments have improved as well as our understanding of the disease as comprised of different subtypes," Dr. Teshome said. "There is not a one-size-fits all approach to treatment, but rather this is targeted to the subtype of the tumor and based on the stage of disease. We have known for many years it is best to treat breast cancer as a team. With the patient at the center, surgical oncologists, medical oncologists, radiation oncologists, plastic surgeons, radiologists, pathologists, genetic counselors and others, working together to create a treatment plan to maximize the patient’s outcome and goals for treatment.”
The major reason for declining death rate is most likely early detection with tests such as mammograms, and advances in systemic therapies. Breast cancer survival is greatly influenced by the stage at presentation. Dr. Teshome said if the cancer is contained within the breast, the survival rate for women with breast cancer is about 99%. Overall, the U.S. five-year survival rate from all stages of breast cancer is about 91%, she says.
One concern for Dr. Teshome and other oncologists is the survival rate disparity by race and ethnicity. She said Black women are 40% more likely to die from breast cancer than other races. Dr. Teshome said this is likely related to many factors including age and stage at presentation, higher prevalence of more aggressive tumor subtypes and access to medical care and other societal factors.
"We hope that we will be able to implement interventions to eliminate these disparities across the cancer continuum but especially in treatments received and clinical outcomes," Dr. Teshome said. "While there has been a lot of progress in our understanding and management of breast cancer, persistent challenges remain to achieving equity. There is a lot of work going into trying to understand these disparities more fully, and to identify approaches to reduce and eliminate them."
What stage of breast cancer requires a mastectomy?
"The decision for a mastectomy is more dependent on the extent of disease in the breast," Dr. Teshome said. Doctors recommend mastectomy when the cancer is more extensive in the breast, if the cancer has recurred after breast-conserving treatment, or when the patient cannot receive radiation, she said. This may also be recommended for women with a genetic predisposition to breast cancer as an approach to reduce their risk of a future breast cancer.
Doctors typically try to preserve the breast if possible and in line with the patient’s goals, but sometimes if the cancer is too large, mastectomy may be the only option, she said.
What are the options for breast reconstruction or implants following a mastectomy?
"There are many options for breast reconstruction after mastectomy including implant-based reconstruction or autologous tissue reconstruction. This can be performed at the time of the mastectomy or in a delayed fashion depending on the patient’s goals and treatment plan. These decisions can be very individualized and based on a variety of factors," Dr. Teshome said. "If a woman is considering reconstruction, she should discuss the optimal timing, type of reconstruction and how this fits within her cancer treatment plan with her breast cancer surgeon and the plastic surgeon."
In some cases, Dr. Teshome said, "we are able to offer nipple-sparing mastectomy, preserving the nipple, the areola, the skin of the breast, achieving a more natural aesthetic. Sometimes that is not possible based on the tumor location and extent. In those cases, we are often able to preserve the breast skin, with nipple reconstruction performed in the future. In cases where we are not able to do skin or nipple-sparing mastectomy, a traditional mastectomy is performed. In these cases, aesthetics are still important and it can be beneficial to have a flat aesthetic closure. Women may then be fitted for a special breast prosthesis and post-mastectomy bra, as an alternative to reconstruction."
Dr. Teshome said the federal Women's Cancer Rights Act requires insurance companies in most cases to cover breast reconstruction surgery following breast cancer treatment.
How can individuals stay healthy and prevent breast cancer?
Dr. Teshome emphasized the best ways to reduce one's risk of breast or any cancer is to avoid smoking, moderate alcohol consumption, exercise and maintain a healthy body weight.
Since as many as 10% of breast cancers are genetic, it is a good idea to know one's family history, from both sides of your family, if possible, she said.
"Understanding your family history of cancer is important to understand if there is a genetic risk and also a higher-than-average risk of the disease. It is helpful to share with your doctors if you have a history of breast cancer, or any cancers, in your family," Dr. Teshome said.
Dr. Fischer agreed, adding that while cancer can strike the healthiest person, being healthy is the best way a person can take control of increasing their odds of avoiding cancer.
"Maintain a healthy lifestyle with exercise and healthy weight, avoid smoking and limit alcohol, and you improve your odds," Dr. Fischer said. She also said women should discuss hormone replacement therapy with their doctors, and how that can affect cancer risks.
