It’s October- time for autumn colours yellow, orange, red, brown! And of course pink. October is breast cancer awareness month.

Breast cancer is the commonest cancer in the UK and 1 in 7 women will get it in their lifetime with the risk increasing with age. Breast cancer in young women although not common is not rare either. Sadly we have lost another young lady Sarah Harding to breast cancer recently. Also, although the risk is smaller for men, breast cancer can affect men too. Breast and cancer especially when viewed together are extremely emotive topics. The term ‘breast health’ is actually more appropriate.

What better time than now to bust a few myths, answer questions and look at the available guidance addressing the commonest worries women presenting with breast symptoms express. This list is by no means exhaustive but should be useful to all those who care about breast health.

The myth : ‘I eat healthy, never smoked, have only a glass of red wine on weekends and have no cancer in the family. Surely I’m protected from breast cancer!’

The truth : Sad as it is, although there is a link to obesity, excess alcohol consumption and radiation, most breast cancer occurs by chance.

Guidance : There are trials and studies looking at diet and lifestyle modification to reduce risk of breast cancer.

The myth : ‘Radiation is a risk factor for breast cancer. A screening mammogram increases  that risk. ’’

The truth :  It’s all about the risk benefit. You wouldn’t needlessly run in front of an oncoming bus but seeing your child in the middle of the road would justify the same action. Mammograms involve a radiation dose of 0.4 mSv. A return transatlantic flight exposes you to 0.1 MSv.  We are normally exposed to between 1.5 to 3.5 mSv of radiation per year depending on where we live. This is due to the radon in the air, cosmic rays of the sun and the geological make up of the earth where we live. Radiation from a whole body CT scan for trauma involves 12 mSv. Also, radiation affects the most rapidly dividing tissues the most. Hence mammograms are not routinely performed in women below the age of 40 and those who are pregnant or lactating.

Early detection of cancers saves lives and hence the screening programme in most developed countries such as the UK.

Guidance: Justification for a radiological procedure should always precede the procedure. Radiological equipment records doses delivered during each investigation and this is quite strictly monitored. Every department has a Radiation protection officer and incidents of unnecessary radiation should be investigated thoroughly.

The myth : ‘I’m not medically qualified. I’m no good at breast self examination. Why can’t I get my GP to do this?’

The truth : Self examination of the breast is just another term for ‘knowing your breasts’. There is no wrong way of doing it. I would equate it to knowing perhaps your personal space in the work place or kitchen, dressing table or study. Most of us just ‘know’ when something has been moved. Examine the breasts with a bit of soap on the palms of the hands examining both breasts and axillae while you are in the shower. This should preferably be done a few days following your periods in menstruaters. If you are interested, there are various YouTube videos demonstrating routine st self examination.  Any change that has persisted needs a visit to the GP. You are not expected to diagnose the pathology. Even your experienced GP may only be able to go so far as to say – there is a lump palpable. That lump maybe a cyst, a lymph node, a cancer or something else. That can only be decided with further evaluation which includes tests such as mammogram,  ultrasound or a combination of the two.

Guidance : The GP should refer patients to a breast unit on an urgent 2 week wait pathway if the patient or they have felt a breast lump.

The myth : ‘I’ve been recalled following a screening mammogram and told I am to undergo an exam called a tomosynthesis. This I’ve been told is a different type of mammogram with a higher radiation dose. This could be dangerous.’

The truth : A tomosynthesis is a 3 dimensional X-ray of the breast (mammogram). It gives more detail and allows the doctor to decide if an area is normal or suspicious, therefore worthy of further investigation.

Guidance : The dose is still smaller than a CT scan and the additional information makes it worth it.

The myth : ‘My friend was recently diagnosed with an aggressive breast cancer. She was told her screening mammogram was normal 18 months ago. Surely this is a case of a cancer missed?’

The truth : The mammogram is a good screening tool but cannot be expected to pick up all cancers. There may be various reasons for this. These reasons include that the cancer may have developed in the interval since the previous mammogram or that the cancer was really subtle and merged with background tissue making it impossible to distinguish. Another reason that a cancer may not be picked up on a mammogram is that it may have been partly hidden by breast implants. Implant density hides the detail on breast tissue during a mammogram. Of course, it is still possible that the cancer was truly ‘missed’.

Guidance : The NHS breast screening programme provides very strict guidance to breast units in the respect of all cancers in screening age women that occur as ‘interval’ cancers. These are reviewed by a panel of breast radiologists who independently assess whether something was missed. There should be open discussion with a patient in whom this may have happened.

Guidance : Patients should be thoroughly counselled and given information prior to cosmetic breast implant insertion. This includes the reduced sensitivity of mammogram at picking up a breast abnormality due to overlap with the implant.

The myth : ‘If mammograms do not pick up cancer in all cases, I would rather undergo an MRI scan. MRI doesn’t have any risks as it does not involve radiation!’

The truth : MRI does not utilise radiation, true. However, the use of Gadolinium contrast essential for this type of scan is contraindicated in  pregnancy and poor renal function.  More importantly though, although an extremely sensitive exam, it  suffers from a lack of specificity. An MR study is likely to indicate non specific areas with the risks of over investigation and unnecessary worry.

Guidance : The Royal College of Radiology and NICE have guidance on indications for use of MRI in breast disease. Experts within a breast cancer multidisciplinary team help guide the most appropriate investigation.

The myth : ‘I’m convinced I’ve got breast cancer. I’ve got pain in the left breast and it goes all the way down my arm and up into my neck.’

The truth : Breast pain is not normally an indicator of cancer. More often than not pain is related to either hormonal changes, breast cysts or wear and tear of the muscles and bones of the chest wall. Most times this pain responds to anti-inflammatory medication. You may also find that an up to date bra fitting helps with easing pain. Localised pain in the breast may sometimes be due to an infection (mastitis) – infections are more common in pregnancy and lactating breasts. Another cause for mastitis occurring around the nipple is smoking which causes what is called ‘peri-dúctal mastitis’.

The myth : ‘I’m forever forming cysts. These need follow up. What if one  of these turns into a cancer?’

The truth : Cysts are innocent and do not turn into cancers. Some cancers may masquerade as cysts but an ultrasound can usually clarify this. It is not possible to be sure if a lump is a cyst entirely by the way it feels. A new lump therefore needs further evaluation and you should make an appointment with your GP.

Guidance : Cyst aspiration is a minor and relatively painless procedure that can easily be performed in the out patient setting. It is routinely offered to symptomatic women. Not  all cysts need drainage and a cyst per se is not an indication for surgery.

The Summary:

Know your breasts – Perform regular breast self examination. Remind your family and friends to do this.

Early diagnosis saves lives – Do participate in the screening programme

Talk about breast health – Ask questions and stay informed.

Most important,  may the sun always shine in your smile while you enjoy this autumber!

About the Author:

Dr Trupti Kulkarni is a Consultant Radiologist Specialist in Breast and Head and Neck at University Hospital of South Manchester and Trust Specialty Tutor for Radiology at Manchester University Hospitals.

Dr Kulkarni specialises in Breast Imaging, General Radiology, Head & Neck Radiology and Stroke and can be contacted for all medico-legal work and to request her CV at truptikulkarni@inneg.co.uk