There is more advanced breast cancer in women 25 to 39 years of age than 30 years ago [click here for recent television report]. Most often this means that the cancer was missed at an earlier stage.
The most common scenario for delayed diagnosis is that a young woman feels a mass, her doctor orders a mammogram, the mammogram does not show cancer, everyone feels reassured, nothing else is done, but the cancer is still there.
Learning from studying delay.
Several years ago, a colleague and I looked at all the steps in diagnosis of over 400 breast cancers [click here].
Young women under 50 years of age were twice as likely to find their own cancer by feeling the lump themselves than by any other method. Five percent of these women had delayed diagnosis for the reasons just described, i.e. they were misled by a falsely negative mammogram.
We also found that delayed diagnosis was three times more likely when the woman found the mass herself compared to her doctor or a mammogram finding the lump. It seems, unfortunately, that doctors are more willing to dismiss what a woman feels, than what they or the radiologist finds. For this reason, you have to insist on a thorough evaluation and not accept the first reassurance that may be offered.
From this study of delay, we can also say that if you are a young woman – and you develop cancer – the person most likely to find your cancer first, will be you. So, if you find a mass, you need to be certain it is fully evaluated.
How do you keep from being another statistic?
The best way to avoid becoming a statistic of delayed diagnosis is to know what to expect from your doctor if you find a mass.
Your history may be interesting, but that’s all it tells you.
Your doctor will ask about your general health, pregnancies, what your periods are like, hormones or birth control pills, and your family history. These are usual things put in your record, but not one of these factors is helpful to decide if the mass you feel is cancer.
Breast examination is more than just a quick touch.
Your doctor should examine your breasts.
A lot has been said about looking at the visual appearance of your breasts and feeling your nodes, but unless that is where the mass is located, the most important part of your examination is palpation of your breasts while you are lying down.
Several years ago, I and several colleagues evaluated the diagnostic tests for 1400 cancers and found that only one cancer would have been missed if the doctor only palpated the woman’s breast while she was lying down [click here]. The other cancer was picked up by a mammogram. For this reason, your doctor can safely skip looking at your breasts and feeling your nodes. Those steps are getting information for the chart, but they are little help to diagnose what you have felt.
What a mass feels like is not a reliable way to know if it is cancer. Specifically, even for the best experts, palpation is not a reliable way to determine if a mass is cancer. The only thing the doctor learns from the examination is whether you have a mass.
Expect your breast exam to take a few minutes.
Experts disagree on how long a thorough breast exam should take, but two minutes is pretty much the minimum. Two minutes sounds short, but very few clinicians actually take that much time [click here to see what a 2 minute breast exam is like] www.2minutebreastexam.com].
In addition to what you have felt, your doctor should examine all of the rest of both breasts and also feel both breasts at the same time to assess if your breasts are symmetric (about 60 percent of women have some asymmetry, but only 10 percent are aware of that asymmetry unless they have checked). Focal asymmetry in only one part of your breast can be the only sign of cancer.
Mammograms have limited usefulness if you’ve already felt a mass.
Your doctor may order a mammogram and possibly an ultrasound examination. A positive mammogram can guide a biopsy if it shows a focal area of suspicion, but remember that the most common reason for delayed diagnosis of breast cancer is that the mammogram was “falsely” negative even though cancer was present.
A negative mammogram is not a diagnosis. Please, do not stop at that step!
You need a sample from the mass for a pathologist to look at with a microscope.
If you have a discrete mass that is different from the rest of the breast, some sort of biopsy should be done. But also know that lumps in the breast are fairly common, and about 7 to 8 percent of women have some sort of focal area in one breast or the other that is unusual, but not cancer.
Fortunately, fine needle aspiration (also called FNA) is a great way to diagnose most masses that you can feel. Used with physical examination and mammograms, FNA by a trained specialist is sensitive enough to identify 99 out of 100 palpable cancers
Should younger women have routine mammograms just to be sure?
To answer this question, it’s best to consider women who are 40 to 49 years old separately from women who are 25 to 39 years old.
For women 40 through 49 years of age, most leading groups such as the American College of Radiologists recommend routine mammograms. Some other groups think routine mammograms should not start until age 50.
It’s all a question of how much it costs to detect one cancer.
The difference of opinion is not about effectiveness. It’s about how much money is spent on mammograms.
The randomized trials of mammograms for women between age 40 and 49 show a survival benefit with screening mammograms. However, breast cancer is less common in women under 50 so that more mammograms have to be done to find a fewer cancers. This means that more money is spent on mammograms to find one cancer in a woman under age 50 than to find one cancer in a woman over age 50. It’s not a question of benefit, but how much money is spent to get the benefit.
In contrast, routine mammograms have not been tested in women under 40 years old, so most experts do not recommend routine mammograms for women in their 30s.
My personal opinion is to start mammograms at age 40, but remember, a negative mammogram never proves cancer is not there!