11 Things Experts Wish You Knew About Breast Cancer and Screening

[Originally published: Oct. 11, 2017. Updated: Aug. 20, 2021.]

Breast cancer affects 1 in 8 women—mothers, daughters, sisters, wives and friends—and causes a lot of worry for women in general. 

“Fortunately, so many women are diagnosed with breast cancer at a very early stage, that it is curable and treatable,” says Rachel Greenup, MD, MPH, chief of Breast Surgical Oncology at the Breast Center at Smilow Cancer Hospital.  

But, it’s important to know that this cancer—which is the most common cancer for women after skin cancer—does not discriminate. “All women are at risk for breast cancer. It doesn’t matter whether or not they have a close relative with breast cancer or what their race is, if they have dense breasts, have breastfed, or had multiple pregnancies,” says radiologist Regina Hooley, MD, vice chair for clinical affairs for Radiology & Biomedical Imaging. “All women should consider beginning screening for breast cancer at age 40.”

With that in mind, we asked leading experts what they often tell their own patients and what they wish every woman knew about breast cancer. 

“The majority of breast cancers are diagnosed in women without any known risk factors—other than being a woman,” says Dr. Hooley.  

However, more and more data are emerging about the importance of genetic information and genetic testing in certain higher risk populations, so screening and treatment recommendations can be personalized, adds Maryam Lustberg, MD, MPH, director of the Breast Center at Smilow Cancer Hospital and chief of Medical Oncology at Yale Cancer Center.

The American Cancer Society no longer recommends that women do breast exams, says Dr. Hooley. She is one of many physicians who aren’t sure they agree. 

“So, maybe women don't have to stress about doing a monthly breast exam, but it is good to have ‘self-breast awareness,’ and contact your physician if a change is noted in the breast, including if a new palpable lump is found,” says Dr. Hooley. 

Mammography remains the standard of care for diagnosing breast cancer, but there are new technologies that are more advanced than the traditional 2D or “2View” mammography, says Mehra Golshan, MD, MBA, a breast cancer surgeon and deputy chief medical officer for Surgical Services at Smilow Cancer Hospital and director of the Breast Cancer Program. 

“With what’s called tomosynthesis, you get multiple images of the breast to be able to find the cancer or abnormality at a much earlier or smaller stage,” Dr. Golshan says.   

It also helps characterize lesions better, preventing unnecessary biopsies, says Yale Medicine’s Liane Philpotts, MD, a radiologist at the Breast Center at Smilow Cancer Hospital. 

“To the patient, 3D mammography will feel exactly the same as 2D, and is done at the same radiation dose,” Dr. Philpotts says. 

There's also breast MRI, which is a technique where a woman gets multiple images of the breast before and after getting what's called contrast with gadolinium, Dr. Golshan points out. “Usually we use that in high-risk women with breast cancer or at risk of developing breast cancer,” he says. 

Connecticut law requires that women be told if their mammograms show they have dense breasts, a term that reflects the amount of fibrous and glandular tissue compared to fatty tissue (as seen on a mammogram). About half of women have dense breasts. 

Dense breasts are perfectly normal, but it is more difficult to detect breast cancer in women with dense versus fatty tissue. Yale Medicine radiologists also make it their policy to tell women when they’re not “dense,” so they don’t have to wonder. If you have dense breasts, schedule an ultrasound at the same time as your annual mammogram, so you get the most accurate reading you can, says Dr. Hooley.

Called a screening ultrasound, Connecticut is unique in that state law mandates insurance coverage for the procedure, Dr. Golshan points out. 

A mastectomy is not the only way to remove breast cancer. A lumpectomy is an option for many early-stage patients, Dr. Greenup says. “The breast cancer itself is removed and the residual remaining breast tissue is treated with whole breast radiation,” she explains. “Increasingly, for older women with small, favorable breast cancer types, we can even consider foregoing radiation in some cases.”

A mastectomy can be done with or without reconstruction. “If reconstruction is an option, women can potentially save the skin and/or the nipple-areolar complex, with the breast reconstructive surgeons placing either an implant or using a woman's own tissue to reconstruct the breast mound,” Dr. Greenup says. 

Autologous or "flap" reconstruction transfers excess skin and fat from one part of your body (usually your belly) to create a breast. “Every patient has input on her final breast size and it can be larger or smaller than her pre-surgical size if she desires,” says Michael Alperovich, MD, a Yale Medicine plastic surgeon.

“Fat injections can cause scarring inside the breast which may make mammographic interpretation more difficult,” says Dr. Philpotts. Also, implants obscure some portions of the breast tissue on mammography. “While most of the time these augmentation methods are not problematic, sometimes they make mammograms less accurate or may lead to additional testing,” she says.

If only the cause of breast cancer was clear—but it's not. 

“The way in which a cancer develops is a very complex process and is almost never caused by exposure to one specific factor. It most often takes multiple exposures over a long period of time before a normal cell becomes a cancer,” explains Meena Moran, MD, chief of Breast Radiation Oncology and professor of therapeutic radiology at Yale School of Medicine. 

What researchers have learned is that smoking, having had radiation therapy at a young age (such as lymphoma patients who have received chest radiation in childhood) or having prolonged unopposed estrogen exposure have all been found to increase the risk of developing breast cancer, she says. 

Prior to beginning your course of treatment, you may have consultations with multiple physicians, including a medical oncologist, surgeon, and a radiation oncologist. You may also be referred to other care providers such as a plastic surgeon or genetic counselor. 

“In some cases, the process of seeing all of the physicians in your care team may take several weeks,” says Susan A. Higgins, MD, a radiation oncologist who specializes in treating breast cancer. “However, this is a normal part of multidisciplinary care that is now the standard for breast cancer.”

In fact, this is a benefit to coming to Yale, Dr. Greenup says. “We have subspecialists in surgery, medical oncology, radiation oncology, pathology, breast imaging, and breast reconstruction,” she says. “We also have social support services through Smilow Cancer Hospital that really provide tailored care to women with breast cancer. The literature is quite clear that treatment at a high-volume center does improve patient outcomes and the quality of treatment women have along the way.”

Pick your care team carefully. Ask how many cases of breast cancer your doctors treat a year. Studies have shown that the more experience your doctors have specifically diagnosing and treating breast cancer, the better the outcomes. Make sure your doctors are affiliated with a reputable institution and are board certified. Consider doing an online search to see if your doctors have published research papers on breast cancer in medical journals; it is an indicator of a higher level of expertise and knowledge.

Breast cancer in men accounts for 1% of all breast cancer diagnoses, says Dr. Golshan. 

“Most of the time, palpable breast lumps are benign and due to a condition called gynecomastia,” says Dr. Hooley. Although breast cancer in men is rare, they can sometimes be carriers of pathogenic gene mutations for breast cancer such as the BRCA genes. 

So, she suggests that if a man has multiple first-degree relatives (sisters or mother) with a history of pre-menopausal breast cancer or who are known carriers of the BRCA gene, consider genetic counseling and undergo breast cancer screening, if indicated.

With breast cancer, early detection is key. Many patients will want to begin screening mammography in their 40s. You should discuss this with your health care provider.