Breast Cancer Risk Types

Women can be segregated into two distinct risk categories and different screening tests available to facilitate the detection of breast abnormalities.

1. Average-risk women have:

• No symptoms
• No history of invasive breast cancer, ductal or lobular carcinoma in situ, or atypia, also known as atypical hyperplasia. 
• No family history in a first-degree relative (parent or sibling), or no suggestion/evidence of a hereditary syndrome
• No history of mantle radiation

2. Above-average risk women have any of the following:

• Family history of breast cancer (i.e., one first-degree relative – a parent or sibling – who had breast cancer)
• Diagnosis of atypia, aka atypical hyperplasia (benign breast disease), or lobular carcinoma in situ
• History of having been treated with mantle radiation before the age of 32

Breast cancer screening involves a number of different types of examinations, namely:

1. Breast Self Examination
During a breast self-examination (BSE) , a woman checks herself for any irregularities, which may include lumps, changes in breast size or shape, nipple discharge, or irregular tissue thickening. To date, no study has shown a statistically significant reduction. Hence BSE is no longer aggressively encouraged nor is any woman actively discouraged from performing regular BSE.
2. Clinical Breast Examination
A clinical breast examination (CBE) is an examination of the breast performed by a health professional who is fully competent in performing such an examination. In clinical studies where CBE was performed along with mammography, the reduction in deaths from breast cancer was similar to the reduction in those women who received mammography alone. This suggests that CBE adds little to mammography in reducing breast cancer deaths.
3. Mammography
Mammography is the diagnostic examination of the breast using low-dose x-rays. Annual mammogram screenings have been shown to reduce significantly the number of women dying from breast cancer in the age group 40 years and older. Until fairly recently, all mammograms used the conventional film-based technique. Today, digital mammography uses x-rays but captures the image on a computer database, where the resultant image can be viewed and manipulated for better contrast and analysis. This is becoming the standard. Although no significant difference between the two techniques when applied to the general population and for most women over 50, studies show that digital mammograms detected more cancers in three specific groups: women under 50, women with dense breasts, and women before menopause.
4. Ultrasound
Breast ultrasound is the alternative modality to evaluate breast abnormalities that are found during mammography or a clinical breast exam. The accuracy of breast ultrasound is highly operator dependent, thus creating an increased risk of false positives that requires follow-up and biopsy. This often leads to unnecessary anxiety for the patient. Again to date, there is no data to establish that annual screening with ultrasound will reduce breast cancer mortality. For the subpopulation of high-risk women with dense breasts in whom the benefits outweigh the risks, there is an ongoing multi-centre study evaluating the use of ultrasound in this group. Currently, it is not the standard of care to offer or perform an ultrasound as a routine screening examination. 
5. Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is an expensive diagnostic procedure that uses a magnetic field and requires the injection of intravenous contrast dyes. Recent studies of women with an inherited risk of breast cancer have shown that MRI has a higher sensitivity in detecting breast cancers than other screening methods. However, there are no study data showing that MRI will reduce the number of deaths.

Breast screening recommendations varied worldwide, and if you belong to the average risk group, you may refer to the recommendation below for reference.

Breast Cancer Screening Recommendations for Women at Average Risk

You can focus on looking for the signs and symptoms of breast cancer in the breast, nipple and armpit through observation, standing and lying down self-check.

Breast self-check steps 1,2,3
Observation	Standing	Lying-down

1) Observation (face the mirror)

• With your shoulders straight and your arms on your hips, observe the size, shape and colour of the breast, including skin rash, an inverted nipple, etc
• raise your arms and look for the same changes (look for any signs of fluid coming out of one or both nipples)

2) Standing (can have standing self-check during shower) 

• Use your right hand to feel your left breast and then your left hand to feel your right breast.
• Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, about the size of a quarter. Cover the entire breast from top to bottom, side to side — from your collarbone to the top of your abdomen, and from your armpit to your cleavage.

3) Lying-down

• Use the same method as standing to check each part of the breast.

If you’ve noticed unusual changes like any of the below, please don’t hesitate to call your doctor for further checking.

• Breast: any lump(s), change in breast size and shape, dimpling or puckering of the skin
• Nipple: retraction of the nipple, secretion or bleeding
• Armpit: swelling of the lymph glands in the armpit

If you suspect yourself having any breast cancer symptoms or being worried, please don’t hesitate to discuss with your doctor for further checking.

1. Myth: I’ve already had my breasts examined during the whole body check-up/gynaecological check-up, so I don’t need to join any other breast screening programme.
   Truth: An effective and comprehensive breast health check-up exercise should include Self-Breast Examination, Clinical Breast Examination and Mammography Screening. A general body check-up or gynaecological check-up package may not necessarily include these three modalities. Recommend individuals to have regular breast screening to safeguard breast health.
2. Myth: Mammography screening isn’t safe
   Truth: In fact, the radiation risk is very low, with a dose of about 0.36 millisieverts per test, which is equivalent to one-eighth of the radiation absorbed annually from natural background radiation, or the radiation exposure from four round-trip flights between Hong Kong and London. (Source: Radiation Health Unit of the Department of Health)
3. Myth: Ultrasound imaging could substitute for mammography screening
   Truth: No. The principles and functions of the two imaging methods are different. They cannot replace each other but are mutually complementary. Ultrasound imaging can distinguish between a substantial tumour and a cyst, but mammography screening can detect a tumour which has not yet fully developed and cancerous cells in the micro-calcification.
4. Myth: My doctor recommends me for an ultrasound, does that mean I am likely diagnosed with breast cancer?
   Truth: Indeed, there are different reasons that your doctor arranges an ultrasound for you, including:
   • The image of dense tissues may sometimes be unclear on a mammogram. A doctor generally uses ultrasound imaging to examine the breasts of those whose breast tissue is generally higher in density.
   • If a mass is detected in a breast through palpation, but no images are shown in the mammogram, the doctor will use ultrasound imaging.
   • If a mass is detected in a mammogram, the doctor may use ultrasound imaging to determine whether the mass is a hard substance or a cyst.
   • During the extraction of tissue from a mass for tests, the doctor sometimes uses ultrasound imaging as a tool to identify the location.

If you suspect yourself having any breast cancer symptoms or being worried, please don’t hesitate to discuss with your doctor for further checking.

References

1. Clinical guidelines for breast cancer screening assessment. Published June 2010 (3rd Edition) | ISBN 978-1-84463-068-4