Why Screening for Breast Cancer Is Important

Paige Heitman, director of marketing, and Kayla Marsala, marketing assistant, talk with Tiffany Henry, RN, Comprehensive Breast Center coordinator at Phelps Health, about the importance of mammograms in preventing breast cancer, on the Ask the Professionals radio show.

Paige Heitman: Good morning and welcome to our Phelps Health Ask the Professionals show. I'm your host, Paige Heitman, co-hosting with my colleague, Kayla Marsala.

Kayla Marsala: Good morning, everyone.

Paige: Today, we have Tiffany Henry, the Phelps Health Comprehensive Breast Center coordinator, back on our program.

Tiffany Henry: Good morning.

Paige: We usually don't get the luxury of having you until October, so thank you for coming early. Tiffany, can you explain your role at Phelps Health? This will be a great segue into today’s topic.

Tiffany: I am the Breast Center coordinator. I'm a nurse, and I work in the Breast Center with the radiologist and the technologist to make sure everything's running smoothly and that patients get the care they need. That's the long and the short of it.

Kayla: That brings us to what we're going to be talking about today, which is breast cancer and the importance of being screened. So, Tiffany, first, what is breast cancer?

Tiffany: Breast cancer is the rapid division of cells and abnormal cell growth [in breast tissue].

Kayla: Do you know how many women will get breast cancer in their lifetime?

Tiffany: Breast cancer is one of the most-frequently diagnosed cancers in women. About one in eight women, or 13 percent, will develop breast cancer in their lifetime. And it's estimated [that] about 30 percent of newly-diagnosed cancers in women will be breast cancer.

Kayla: Wow, so what are the different types of breast cancer?

Tiffany: There are several different types of breast cancer. Your most common ones are going to be your ductal cancers. [From there,] those [ductal cancers] are divided into ones that have remained within the duct, so your non-invasive and very-easy-to-treat cancers; or those that have evaded outside of the duct, requiring more extensive treatment. Another type is lobular carcinoma, occurring in the lobules instead of the ducts. The lobules are the milk-producing [glands, and cancers originating in these glands] are a little more difficult to identify. There's also inflammatory breast cancer. When people think of breast cancer symptoms, this is typically what comes to mind, the very red inflamed breast, the orange skin, which is dimpling; and the overall inflammation in the breast. But it's [inflammatory breast cancer] actually a lot less common type of breast cancer. [There is also] Paget's disease, which a lot of people don't know about. It involves some crusting of the nipple, or a lesion. And there are other types, but these are the ones most commonly discussed.

Kayla: Thank you, Tiffany. What are some of the risk factors somebody might have for developing breast cancer?

Tiffany: Your number-one risk factor is going to be that you're a woman. So, gender. Only about one percent of males develop breast cancer, but it can still happen. So men, if you feel lumps, come in and have evaluations, too. [Secondly,] Genetics: Having a genetic mutation, such as [the commonly-known] BRCA1, BRCA2 and CHEK2 mutations, [will make you more predisposed.] There are many, many different mutations that you can have. Age [is another risk factor.] As we age and get older, we are more likely to develop breast cancer. [Finally,] family history is another risk factor. However, one thing we commonly hear is, "I don't have any family history, so I don't need to come in and get my mammogram." But I'd like to dispel that [myth] because about 80 percent of women diagnosed with breast cancer have no family history, so you should still come in and get that mammogram.

Kayla: Now, for women who don't have a familial history of breast cancer, at what age should they start getting screened? Should they be doing screenings yearly at their annual wellness exams?

Tiffany: Yes, yearly [beginning] at age 40, is typically what we recommend for normal-risk women. If you're at a higher risk for breast cancer, [per se] you have a first-degree family relative, a mother, sister, daughter, father, brother; we typically recommend screening 10 years before your relative was diagnosed. So, say your mom was diagnosed at age 40, you would start at age 30, but not before age 25. [At that age,] your tissue is so dense that it's very difficult to identify anything, so we would just do problem-solving, in that case. If you should feel a lump at age 25, however, you should come in for an ultrasound.

Paige: So, it’s important to communicate with your primary care provider regarding your family and medical history.

Tiffany: Yes, that is very important. A primary care provider can order a screening mammogram for you and follow up with test results. Then, should you need to have any additional imaging, you're not scrambling to find a provider to order and manage that for you.

Paige: It sounds like the process becomes fairly seamless once you have one.

Tiffany: Yes, absolutely.

Paige: You had mentioned genetics and the BRCA genes one and two; is that something that Phelps Health can test for?

Tiffany: Absolutely. Your primary care providers can do that. OB/GYNs are very good at ordering that kind of testing. We also have a genetic counselor who comes once a month, and you can also make an appointment with her. It’s a very detailed appointment, where she will go over all [of] your family history, and make recommendations based on that. And [then] you can do your [genetic] testing.

Paige: It’s fantastic to have these resources right here at Phelps Health. So before you had touched on what the symptoms of breast cancer can be… can you tell us some more symptoms that could be associated with breast cancer?

Tiffany: Most commonly, women come in reporting a lump that they felt, which isn't ideal. We want everybody to be coming in having their screening mammogram yearly, so we can detect those small changes. But if you are feeling a lump, that's definitely something you should be coming in and getting checked out. [You may also notice] swelling, redness of the skin, dimpling of the skin, a change in your breast size, where one breast suddenly becomes larger; and breast asymmetry. It is fairly common that your breasts are two different sizes. But [if] all of a sudden, one of your breasts has gotten quite a bit larger than the other, and it's noticeable to you, that is something you need to report. An itchy, scaly sore around your nipple [can possibly indicate] Paget's disease. Nipple discharge that starts suddenly or is spontaneous, is also something that you should report. New pain in one spot and a retraction of your nipple [is another symptom.] So if your nipple, like a belly button, is normally out and starts pulling in, that is something to be on the lookout for, as well.

Kayla: Tiffany, sometimes menstruation symptoms are very similar to some of these symptoms that you're describing. Given that, how do we differentiate between the two and know, this is something that is not normal during my cycle?

Tiffany: So [it’s important to] practice good breast self-awareness and do the breast self-exams. The [American] Cancer Society, and a lot of places, don't necessarily recommend the stringent breast exam anymore; they just recommend good breast self-awareness. [Ask yourself these questions:] Do I normally have a lump here during my menstruation? Is this change coming and going? Am I having pain during my hormonal cycles? And then have those conversations with your primary care provider, [or] your OB/GYN, to determine whether this is something that needs to be evaluated or not.

Paige: I think that's great advice because a lot of women may have experienced some of these symptoms. So it's not always necessarily a cause for concern, but it’s important to become familiar with your body.

Tiffany: Yes, [it’s always important to] become familiar with your body and report things that are not normal for you.

Kayla: So Tiffany, when you do reach that age, or if you find some concerning symptoms, can you explain to us what a mammogram is, and what someone can expect?

Tiffany: So a mammogram is a low-dose X-ray specialized to take pictures of your breast. Since it's a screening exam, and we do it yearly, we want there to be minimal radiation exposure. Women are often concerned about that, and so mammograms are FDA-regulated to have low-dose radiation. So it is very safe and the most effective way to detect breast cancer at this time. We take pictures from multiple views, [which normally amounts to] about four pictures of each breast for the radiologist to review. If we're doing tomosynthesis, or 3D [mammography], we will take multiple projections, as it does a complete sweep across the breast. The [result] is a book [of sorts], where you can flip through the pictures of your mammogram. It also provides a 3D-synthesized image of your breast tissue that we're able to detect small abnormalities through. So 3D [mammography] is very good for dense breasts. The exam itself takes about 15 minutes, and there is compression involved, which is probably the most common thing women complain about. [While] the compression may be somewhat uncomfortable, it is crucial to help hold the tissue still. [This allows] our radiologists to get a good, clear picture of the breasts and any abnormalities.

Paige: So you mentioned [the procedure may be] uncomfortable. Let's define that because there are women who come in and get this every day, right? So while it is uncomfortable, would you consider it manageable?

Tiffany: Manageable yes, and most women don't have too much difficulty with it. But there are some who are a little more sensitive; it just varies with each patient. There are things that you can do [to prepare.] If you know you're going to be starting your menstrual cycle, [I’d] avoid coming during that time when your breasts are more tender. [You can also] talk to your doctor about taking an NSAID [non-steroidal anti-inflammatory drug] or something a little bit beforehand to help manage that discomfort. [It’s also helpful] to work with your technologist to fine-tune the compression to a manageable level, while still providing a quality exam.

Paige: You mentioned that we can tell our X-ray technologist, “Hey, I'm uncomfortable; can we pause for a minute?” So patients really do have the ability to do that and to share their experience?

Tiffany: Absolutely. We have a really fantastic crew here. Our technologists, [all of whom] are very experienced, want you to have a great experience. They want you to have a good exam, so that you will want to come back year after year to get your mammogram. That way, we can detect any small changes. Our staff is very passionate about it [mammography]. They love what they do, and are more than happy to do whatever you need to help get you through your exam.

Paige: I think sometimes there's a misconception that, when it comes to healthcare, you can't ask questions; you can't be your own advocate. But that's changing, right?

Tiffany: Absolutely.

Paige: As healthcare moves to a consumer-based model, it really is up to the patient to advocate for themselves.

Tiffany: Absolutely, yes. We want you to participate in your exam so you can have the best exam possible.

Kayla: So while getting a mammogram can be uncomfortable, and no one probably wants to do it, can you explain why it's so important? I know we've touched on it a little bit.

Tiffany: [Screening is important] because breast cancer is most easily treatable when detected early. So if you're coming in yearly and getting a breast exam, we can detect these small changes years before you would ever feel them. Mammograms can detect abnormalities up to two years before you would ever feel something, so when it's very treatable and hasn't evaded outside the duct, your treatment should be much more manageable. Ideally, this is how we like to detect breast cancers, so that you can have the least amount of treatment and resume your normal life.

Kayla: Can you remind us again when we should start getting screened?

Tiffany: Yearly, after age 40, is what the American College of Radiology recommends. There are a lot of conflicting guidelines, but you're going to find that most breast centers are very passionate about the yearly [screening] after age 40, and that's what we recommend. But [we encourage you to] speak to your doctor about your personal risk factors and go with what is comfortable for you.

Kayla: So before age 40, you mentioned doing breast self-exams. At what age should a woman start doing those herself?

Tiffany: I think that you should start becoming familiar with your breasts as soon as you start developing them.

Paige: So moms and grandmas, have conversations with your kids or grandkids.

Tiffany: Yes, absolutely, make it comfortable, because we still have a lot of women who are very uncomfortable with doing a self-exam. I [would also encourage women to] have those conversations with their primary care provider about the importance [of doing these exams].

Kayla: Say, we have a mammogram, and a potential problem shows up…what are the next steps, and what does that look like?

Tiffany: If you come in for a screening mammogram, and the radiologist notices something on your exam and wants you to come back, the next step would be a diagnostic mammogram, or a breast ultrasound. [With] a diagnostic mammogram, you would come back in, and we would take some additional diagnostic views, different from the traditional views of a screening mammogram. These views are specifically targeted to the issues that you're having. A radiologist would then review this mammogram the same day, consult with you about your symptoms and determine what's going on. Additional testing, such as an ultrasound, may need to be done. After that, our radiologists will discuss your results with you. [They will] decide whether you need to have a biopsy, or if a follow-up in three or six months is warranted. [The best-case scenario] is that you can return to a routine-screening mammogram, if the findings are deemed normal.

Kayla: Tiffany, are diagnostic mammograms more or less painful [than routine mammograms], and do they take about the same amount of time?

Tiffany: With the diagnostic mammogram, the pictures take about the same amount of time, [roughly] 15 minutes. It [a diagnostic mammogram] is a little more of a time investment, and a lot of women aren't always prepared for that. Because your images are being reviewed that day, there's a radiologist on site, looking at them, talking with our technologists, consulting and seeing if we need to take more pictures. If additional pictures are needed, you could have an ultrasound, so we like to tell patients [to] expect an hour-and-a-half to two hours for a diagnostic work-up. We will discuss your problem with you, make sure you are really comfortable with what we have done and the care that you received and [ensure that] you feel confident in what the provider has discussed with you. You are then ready to go on to the next step.

Paige: Would you say this process gives patients peace of mind? Personally, whenever I undergo a test like this, I am always waiting with bated breath to hear the results.

Tiffany: Absolutely. Having the radiologist on site talking with the patients and discussing the diagnostic test results really helps the patient. You will know right then and there what the next steps are, and you can have confidence that the providers have done a good job, reviewed everything with you, and you can participate in the options to proceed with care. It’s really nice for the patient to not have to go home and wait on a letter or a phone call they might miss.

Kayla: In the event that a patient does get the devastating news that they do have breast cancer, what resources does Phelps Health offer?

Tiffany: So we have the Delbert Day Cancer Institute, where we offer...oncology services, [by medical and radiation oncologists and providers]. We also have social workers and a fantastic nurse navigator, named Jennifer [Gerlemann,] who does a fantastic job helping guide patients through the process. There is, like I mentioned, the genetic counseling, and we have wonderful, award-winning dietitians here at Phelps Health, who can help support you through your [journey]. Cancer can cause some issues with nutrition, and they [our dietitians] help support you and consult with you. We have physical rehabilitation, and we even have a lymphedema care clinic, which is really fantastic, especially for breast cancer patients who may have had several lymph nodes removed. It's less common now that we do the full-axillary node dissections, but it can cause some disruption in the lymph flow in the arms, and they can really work with you on that. [Finally,] we have top-notch surgeons on staff who can perform breast surgeries and consult with you.

Paige: Yes, we have a comprehensive care team similar to what you would get in St. Louis, Springfield or Kansas City. But the best part of this is, if you do get a cancer diagnosis, or someone you love gets a cancer diagnosis, you don't have to drive up there for all-day treatment, drive back and then be sick or uncomfortable.

Tiffany: Absolutely. It's very convenient and close to home for patients.

Paige: Yes, that's a great way to describe that. So, what are some other services offered at the Comprehensive Breast Center? I know that your team does mammograms, but you do so much more than that.

Tiffany: Absolutely, we do. So, comprehensive means that we can take you from screening to diagnosis, and then we also can offer some services for surgery. So we do screening mammograms and diagnostic work-ups including breast ultrasounds, [which we touched on earlier.] We [also] offer stereotactic biopsies, ultrasound-guided breast biopsies and needle localization. Needle localization is needed for surgery to assist the surgeon in removing a benign or cancerous areas, or for a galactogram.

Paige: OK, so what's a galactogram? Because it sounds like something from “Space Force.”

Tiffany: [Yes, you can think of it as being in a] galaxy far, far way...so a galactogram is a work-up for nipple discharge. Patients really want these. They're actually very interesting, and there's some really fascinating imaging involved with these. So basically, they are for women who are having discharge that we determine to be suspicious. We basically thread a tiny little catheter into the patient's nipple duct, inject contrast and take mammography pictures. The contrast fills the duct, and we can see if there's a papilloma, [which is a non-cancerous lump], something [else] blocking the duct or another abnormality that could be causing the nipple discharge. So, it's [a galactogram] a way to evaluate nipple discharge. If you should need or want to have surgery to remove the issue, it [this work-up] helps guide the surgeon.

Kayla: Do you perform those types of imaging often at Phelps Health?

Tiffany: Yes, we do. We also offer bone density testing, which goes hand-in-hand with the Women's Health Center, especially for post-menopausal women.

Paige: Onto my next question: I've seen a ton of anecdotal evidence about breast implants and how they can potentially cause issues long-term. Can you offer any feedback or opinions on that? Is there enough research for us to even know?

Tiffany: Good question. There is some research out there. We do see women who have kind of vague symptoms, and they relate them back to their breast implants. There is some type of lymphoma, I believe, that's linked to breast implants. So there is some evidence out there that they [implants] can cause some issues for some women.

Paige: Tiffany, can you speak to what the hospital is doing to increase access to some of these potentially life-saving services that Phelps Health offers?

Tiffany: So, the [Phelps Health] Foundation, which is the hospital's philanthropic arm, is very good about supporting women's health in this area. There are funds available for women who are uninsured in our community to get screening and diagnostic mammograms.

Paige: Now, is that only during the month of October, or if somebody comes in today with a need, is there a way for us to support those patients?

Tiffany: Yes, there is a way for us to support those patients any time of the year.

Paige: So don't wait to get the services.

Tiffany: Correct. But, in October, we do promote it. There's a day that we do 50 free mammograms. We don't require income guidelines during that time; you just have to be uninsured. There is that small gap of people who are uninsured, because they don't quite meet the requirements to get Medicaid, so we have that time of the year for women like that, that need to get a mammogram, because it's important.

Kayla: It is important, absolutely. So, if someone does need to get a mammogram, how can they make an appointment with you?

Tiffany: Simply call Centralized Scheduling for a screening mammogram. You do not have to have an order; you just need to have a provider that we can send the results to, so a primary care provider or an OB/GYN are going to be your most common doctors that you would send those results to. Simply call Centralized Scheduling and tell them, "Hey, I need to schedule my screening." Please make sure that you're not having any symptoms, when you're calling in. If you do have symptoms, [first contact your primary care provider.] [They will then] determine whether you need to have a diagnostic work-up. But [if you are symptom-free], just call Centralized Scheduling at (573) 458-7737, and they will be happy to set you up with an appointment. You can also self-schedule through MyChart.

Paige: Fantastic.

Tiffany: So, if you have the MyChart app, you can get in and schedule yourself an appointment when it's convenient for you, and you don't have to use the phone.

Paige: OK, before we wrap-up, I have one more question about MyChart. For patients who get mammograms or whatever type of support services they might need, do those results show up in MyChart so they can track them over time?

Tiffany: Absolutely they do, and it's actually very quick. When our radiologist signs off on them [the results], normally they will be available to view in about 24-48 hours. Patients really like that.

Kayla: So you can take any questions you may have ahead of time to ask your provider.

Tiffany: And you don't have to wait for that letter in the mail now. We do still send the traditional letters in the mail for patients who prefer that, but it does take about five to 10 business days to arrive, whereas in MyChart, it’s immediate.

Paige: So, today, we've been speaking with Phelps Health Comprehensive Breast Center Coordinator Tiffany Henry. Tiffany, thanks so much for being here today. We're glad to have you on with us outside of October.

Tiffany: Yes, absolutely.

Paige: If you missed part of the show or would like to listen to it again, please visit our Phelps Health Podcast and Radio page.