Your breast cancer guide

Breast cancer is the most common cancer among women in Israel. Since October is breast cancer awareness month, here’s the information you need about risk factors, how it’s diagnosed, treatment methods and more. Early detection and diagnosis saves lives, so read this article now.

For over a year and a half, the corona cloud has hovered over us and dominated headlines worldwide, but unfortunately this virus didn’t replace diseases that were already here, but added to them. And, even though attention is constantly on corona, this can’t replace the need to be aware of cancer. Every October, there are campaigns to raise awareness about breast cancer, and now’s the time to get tested, since early detection might save your life.

Breast cancer is the most prevalent cancer among women in the Western world and in Israel, and the most common cause of death from cancer among women. Every year, more than 5,000 women with breast cancer are diagnosed in Israel. In 2018, 5,539 new patients with a breast tumor were diagnosed in Israel, and 1,042 women died from invasive breast cancer.

The cumulative risk for women in Israel to develop breast cancer during their lifetime (up to age 90) is about 12.8%  among Jewish women, and about 7% among Arab women. The incidence of breast cancer increases with age, and most cases are diagnosed after age 50.

The good news is that there has been a significant downward trend in breast cancer mortality of about 2% per year since 1996, thanks to early diagnosis and better treatment options.

What are the risk factors for breast cancer?

In most cases it’s not known which factors cause any woman to develop cancer, so they all need to be investigated. Recognized risk factors are:

1. Family history of breast cancer, especially close relatives such as a mother or sister.

2. Carrier of a genetic mutation, mainly BRCA1/2. Note that in 2020, a test to detect BRCA 1/2 was included in standard government health insurance for healthy Jewish women of Ashkenazi descent, even without a family history or prior genetic counseling.

3. Radiation therapy to the chest at a young age (10-30) due to another malignant disease, most often lymphoma.

4. Prolonged exposure to estrogen caused by a young age at the start of menstruation, first birth at the age of 30+ and hormone replacement therapy will slightly increase the risk of breast cancer.

How is breast cancer diagnosed?

Most cases of breast cancer are detected by imaging tests, usually mammograms and ultrasounds, or by self-palpation. Some tumors are detected during a standard exam by a breast surgeon. The earlier the tumor is detected, when it’s smaller and at a stage where it hasn’t spread to the lymph nodes, the better the chances of it being cured. In imaging tests such as mammography and ultrasound, a tumor can be detected even before it’s big enough to be felt or has caused other changes in the breast.

Although the effectiveness of self-examination is doubtful and there is no general recommendation for any woman to self-test, it’s recommended that women be aware of changes in the breast such as a lump in the breast or armpit, seeing the nipple turning inward, pitting of the skin, or fluid secreting from the nipple.

In Israel, as in most Western countries, a mammogram is recommended once every one or two years for every woman over the age of 50 until age 74. It should be noted that there is a constant debate by doctors and researchers whether to start screening earlier, such as at age 40 or 45. In women aged 45-49, a referral for a mammogram may be only once every two years, following a medical consultation. In practice, many doctors refer patients (even those not in the risk group) to mammography from the age of 40.

Women at risk, with a family history of breast cancer, should begin mammograms at a younger age, at least 40, and sometimes even younger if family members were in their 20s or 30s when they were diagnosed with the disease. If you’re at risk, ask your doctor for a referral to a mammogram before age 40, since the general computer system of your health fund doesn’t automatically detect women in the risk group.

Mammography

A mammogram is a non-invasive test that uses low-dose X-rays to create an image of breast tissue.

Before the test you need to remove jewelry, your shirt and bra. The technician will place the breast on an X-ray plate, then cover it with a plastic plate that presses the breast down. It hurts but is essential for the quality of the test, and it only takes a few seconds for the tech to x-ray each part of the breast.

The mammogram is not perfect and may miss tumors, especially in women with a dense breast structure. The effectiveness of mammography as a screening test for reducing breast cancer mortality stands at a rate of about 25-30%, which was proven in a number of randomized and controlled clinical trials.

Today, in many imaging institutes, mammography is performed using a technology called tomosynthesis, a type of three-dimensional mammography. This tech makes it possible to detect breast lesions without "overlapping" the nearby breast tissue as is sometimes the case with regular mammograms, and slightly improves the ability to diagnose women with dense breasts. This test is relatively new and not in the health basket yet, but several studies have shown it can highlight tumors not seen on regular mammograms.

Ultrasound

Ultrasound tests use sound waves to create an image of the tissue, similar to those performed in pregnancy ultrasound.  This test is safe and doesn’t dissipate radiation. It’s common to perform a breast ultrasound as a supplement to the mammogram in cases of thick or dense breasts, and to clarify findings seen on mammography or when there are silicone implants. In young women who have not yet had a mammogram, an ultrasound will sometimes be done as a single test and not as a supplement to the mammogram.

MRI

MRI of the breasts is the most sensitive imaging test for breast cancer. The "price" of that high sensitivity is that sometimes the MRI will find something suspicious. Yer, after further investigation and/or a biopsy a lump will be shown to be benign or insignificant. It should be noted that findings that require clarification and ultimately are not cancerous also exists in mammography and sonar tests.

Currently, in accordance with Health Ministry guidelines, a breast MRI is performed as an annual follow-up exam, usually in addition to mammography, in women at very high risk of developing breast cancer. This includes BRCA carriers and women with a significant family history in which no mutation was found, but according to a calculation by a genetic counselor) they have more than a 20% chance to develop breast cancer.  MRIs are also done in breast cancer detection to assess the extent of the disease or as a follow-up to a response treatment, or as recommended by medical staff.

In conclusion, consult a breast surgeon to determine which tests are necessary. In Israel, thousands of women have recovered from breast cancer, mainly due to early detection and quality treatment. Early diagnosis of breast cancer may save lives.

Dr. Orit Golan, Director of the Breast Health Center at Raphael Hospital, Tel Aviv and Director of the Breast Imaging Unit at Tel Aviv Sourasky Medical Center