B
H
A
Preface
_______________________________________________________________________
This resource manual is designed by American Cancer Society volunteers to provide
information and guidelines for health care professionals who will serve as Breast Health
Awareness Faculty.
Our special thanks to the volunteers who developed and revised this resource.
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Table of Contents
I.
Developing a Program Outline ..................................................................... 4
II.
Instructor Criteria and Expectations ............................................................ 5
III.
Course Objectives ....................................................................................... 5
IV.
What Is Breast Cancer ................................................................................. 6
V.
Anatomy and Physiology ............................................................................ 9
VI.
Benign Breast Conditions .......................................................................... 15
VII.
Breast Self Examination ............................................................................ 21
VIII.
Methods of Detection ................................................................................ 25
IX.
Methods of Diagnosis ................................................................................ 28
X.
Pathology .................................................................................................. 30
XI.
Pathologic Staging of Breast Cancer ........................................................ 31
XII.
`Prognostic Factors ................................................................................... 31
XIII.
Treatment ................................................................................................. 32
XIV.
Quality of Life Issues ............................................................................... 33
XV.
Insurance and Medicare ............................................................................ 35
XVI.
Teaching Tips for Lay Audiences ............................................................ 36
XVII.
Suggested Outline for Lay Programs ........................................................ 38
XVIII. Translating Information into Behavior Change Using Tell-A-Friend ...... 39
XIX.
Research Program of the American Cancer Society ................................ 41
XX.
American Cancer Society Breast Health Awareness Resources ............... 44
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I. Developing a Program Outline
The Table of Contents in this manual should serve as your program outline. In preparing the
specific content for a program, consider that breast health care professionals represent diverse
backgrounds (e.g., nurses, certified mammography technologists, health educators, etc.).
Therefore, the level of content should reflect the specific backgrounds and special needs of
each audience.
Also, contact the ACS for appropriate material, or visit the ACS Breast Cancer Resource
Center at www.cancer.org.
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II. Instructor Criteria and Expectations

Instructors are identified as persons delivering a message about the triad of breast
health: screening mammography, clinical breast exam, and breast selfexamination.

Instructors include registered nurses, certified mammography technologists, and
health educators.

Instructors who attend and successfully complete a training course will be
awarded an American Cancer Society certificate.

Instructors are expected to present a minimum of three programs per year to
health care professional or lay audiences.

Instructors who wish to become faculty to teach the Instructor Course should
discuss this with their ACS staff.
III. Course Objectives
Audience: This course is designed for registered nurses, certified mammography
technologists and health educators who are responsible for teaching
breast health awareness to the lay public.
At the completion of the Breast Health Awareness Training Course, participants will
be able to:
1. Discuss breast cancer risk factors and epidemiology.
2. Describe the structure of the breast, chest wall, and lymphatic system.
3. Discuss the theoretical and clinical implications of breast physiology and
pathology.
4. Identify the signs and symptoms of breast cancer.
5. List the American Cancer Society’s current breast screening recommendations
for asymptomatic women.
6. Describe procedures used to diagnose breast cancer.
7. Discuss methods for management of breast cancer.
8. Discuss psychosocial concerns and barriers associated with screening, diagnosis,
and treatment.
9. Identify educational resources available through the American Cancer Society.
Review American Cancer Society resources, references, and research updates
available.
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IV.
What is Breast Cancer?
A. Breast Cancer Statistics
1. Breast cancer is the most frequently occurring cancer in American
women*. The American Cancer Society estimates that there will be
182,800 new cases of breast cancer diagnosed in women during 2000. An
additional 1,400 will be in men** each year through the 1990s.
2. Breast cancer incidence rates have increased about 4% a year since 1980.
Some of this increase is due to the aging of the female population but have
recently leveled off at about 110 per 100,000. Other influences on this
increase, especially environmental factors, have not been substantiated.
CANCER INCIDENCE AND MORTALITY BY SITE ---- 2000
INCIDENCE
MORTALITY
Breast
Lung & Bronchus
Colon & Rectum
Uterine Corpus
Ovary
Non-Hodgkin’s
Lymphoma
Melanoma of the
Skin
Urinary Bladder
Pancreas
Thyroid
All Sites
23,200
Lung &
Bronchus
Breast
Colon & Rectum
Pancreas
Ovary
Non-Hodgkin’s
Lymphoma
20,400
Leukemia
9,600
14,900
14,600
13,700
Uterine Corpus
Brain
Stomach
6,500
5,900
5,400
187,800
74,600
66,600
36,100
23,100
600,400
All Sites
67,600
40,800
28,500
14,500
14,000
12,400
268,100
3. The American Cancer Society estimates that 41,200 deaths from breast
cancer will occur during 2000. Breast cancer is the second most common
cause of cancer deaths in women, surpassed only by lung cancer**.
4. After increasing about 4% per year in the 1980s, breast cancer incidence
rates have leveled off in recent years, and mortality rates continue to
decline.
*Excluding skin cancer.
**Statistics are updated annually. Please refer to current American Cancer Society Cancer Facts and Figures.
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Probability of Developing
Breast Cancer by Different Ages
14
12
10
8
6
NOTE: About 76% of women
who have had a mammogram,
said their physician
recommended it1, yet only 35%
of Texas physicians
recommended a mammogram2.
The probability of a woman
over 59 getting a mammogram
is only 12% despite the fact that
breast cancer risk increases
with age. (1 The Wirthlin
Group/Jacobs Institute Study,
1992 and 2 Leiberman Researc,
1994)
4
2
0
30
40
50
60
70
80
85
95+
Each bar represents the percent of women expected to develop breast cancer by the noted age. There is a 1 in 8
lifetime risk of developing breast cancer. Prepared by the American Cancer Society from incidence and
mortality rates 1987-1988, SEER areas.
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B.
How Cancer Develops
Most cancers are due to an interaction between what an individual inherits and what that
individual is exposed to from the environment. Only about 5-10% of all breast cancers are due
solely to what one inherits. Approximately 85-90% of all breast cancers occur in women without
a family history of the disease.
C.
Risk Factors
1.
2.
3.
4.
5.
6.
7.
8.
The most proven and significant risk factors for breast cancer are being a woman and
getting older.
Having a personal history of breast, colon, ovarian, or endometrial cancer can also increase a
woman’s risk of developing breast cancer.
A family history of breast, colon, ovarian, or endometrial cancer may prove to be a risk factor
for some women. However, the vast majority of breast cancers occur in women without a
family history.
Research has shown that high dose radiation exposure to the area of the breast during younger
years increases risk for some women. The following radiation exposures are included in this
category: diagnostic radiation for scolosis, radiation of an enlarged thymus, radiation for
pneumothorax, and fluoroscopy for tuberculosis.
a. There is a problem in evaluating studies assessing radiation and breast cancer occurrence
because other studies are not reliable or comparable.
b. In general, most women who had radiation exposure in the area of the breast do not get
breast cancer. Mammograms and dental or chest x-rays have not been proven to be risk
factors for breast cancer.
Research on heart disease and colon cancer has shown dietary associations. Although
research linking breast cancer and diet is, to date, not as strong, similar findings are consistent.
Specifically, increased breast cancer risk appears to be associated with a diet low in fiber and
high in fat. Current research in this area may provide more conclusive information.
The most recent evidence appears to show that birth of a first child after age 30 may increase
risk for those women who have a family history of breast cancer. This increase risk applies
only in breast cancers appearing to have an inheritable base. Age at menarche and menopause
do not appear to have a significant effect on risk as once thought.
Many other factors are mentioned as increasing risk for breast cancer which include alcohol
consumption, smoking, stress, depression, oral contraceptives, hormone replacement therapy,
trauma to the breast, body height, body weight and body shape. Although none of those
appear to raise a woman’s risk of developing breast cancer, research is ongoing in many of
these areas.
Most benign breast conditions do not increase a woman’s risk of developing breast cancer,
however, a small percentage of lesions are classified as “atypical hyperplasia.” Biopsied
lesions, thus classified, increase a woman’ risk of developing breast cancer.
Until the genetics of breast cancer is understood, it will be difficult to conclusively delineate breast cancer risk
factors.
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V. Anatomy and Physiology
To evaluate problems of the breasts, health care professionals need to understand the
anatomy, pysiology, and pathophysiology of the breasts. An awareness of the cyclical
changes and the effects of the aging process is critical for proper assessment and
evaluation of the breasts.
A.
Introduction
The breast is an anatomical organ unique to mammals. The female breast is
distinguished from the male breast by growth and development. Interestingly, the
breast is the only anatomical organ that does not develop embryologically.
B.
Anatomy
1.
Gross Anatomy: (Diagram #1)
a. Nipple: Pigmented, cylindrical structure located at the fourth intercostal
space.
b. Areola: Pigmented, circular area surrounding the nipple.
c. Tubercles or Glands of Montgomery: Also called areolar glands. Tiny
sebaceous glands located within the areola that aid in lubrication of the
nipple during lactation.
Diagram #1
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2.
Structure: The breasts are composed of three types of tissue:
a.
Glandular Tissue: (Diagram 2) The glandular tissue is concentrated in the upper,
outer quadrants. It is arranged in 15 to 20 lobes that radiate around the nipple
and beneath the areola. Each lobe is composed of 20 to 40 lobules containing the
milk-producing cells (alveoli cells or acini) that empty into the lactiferous ducts.
Lactiferous ducts drain milk from the lobe onto the surface of the nipple.
Diagram #2
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b.
Fibrous Tissue: (Diagram #3) Fibrous tissue bands (suspensory ligaments or
Cooper’s ligaments) are attached to the chest wall musculature and provide
support to each breast. These ligaments extend from the connective tissue layer,
through the breast, and attach to underlying muscle fascia. (Clinically,
suspensory ligaments are important because of the connection between the breast
tissue and the skin. Both benign and malignant lesions can affect these
ligaments, resulting in skin retraction or dimpling of the breast.)
Diagram #3
c. Fatty Tissue (Diagram #4) Subcutaneous and retromammary (behind the mammary
gland) fat surround the glandular tissue and compose the bulk of the breast. There is
no fat immediately beneath the areola and nipple.
Diagram #4
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d. The amounts of glandular fibrous and fatty tissue in the breast are a dynamic process.
The proportions of each of the component tissues vary with age, nutritional status,
pregnancy, lactation and genetic predisposition.
3. Lymph Nodes (Diagram #5): The breast contains a lymphatic network that drains the
breast radially and deeply into underlying lymphatics. The lymphatics flow from much of
the breast toward the axilla. Superficial lymphatics flow from the skin, and deep
lymphatics flow from the mammary lobules. It is important to palpate both axillary
and clavicular nodes during breast examination. It is believed that breast cancer can
metastasize via lymphatics to infraclavicular or superaclavicular nodes, nodes deep
in the chest or abdomen and to the opposite breast.
Diagram #5
4. Inframammary Ridge: This is a firm ridge of tissue like a “shell” in the lower curve of
each breast. It is more prominent in women with large breasts.
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C. Physiology (Diagram #6): Normal physiologic changes in the female breast occur at
the onset of puberty, during the menstrual cycle, pregnancy and lactation, and as a
woman ages.
1.
Onset of Puberty: Breast development is usually the first sign of puberty in the
female. The breasts develop at different rates resulting in asymmetry. Full
development of breast tissue is mediated by a variety of hormones, including
estrogen and progesterone. Estrogen initiates growth of the breasts and the
extensive milk-producing system. It is also responsible for the characteristic
external appearance of the mature female breast. Progesterone promotes
development of the lobules and alveoli, causing the alveolar cells to proliferate
and become secretory.
Diagram #6
2.
Menstrual Cycle (Diagram #7): During each menstrual cycle, the breast tissue
undergoes a series of changes in response to stimulation by estrogen and progesterone.
Three to seven days prior to menses, the breasts become engorged due to the influences
of progesterone. Breast engorgement or increased fullness of the breasts is characterized
by an increase in breast size, density, physiologic and nodularity, and increased
sensitivity or tenderness. With the sudden decrease in progesterone at the onset of
menses, breast discomfort usually subsides. This is the rationale for performing breast
self-examination at the end of menstrual flow when physiologic changes are minimal.
Diagram #7
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3. Pregnancy and Lactation: During pregnancy, glandular tissue displaces connective
tissue and the breasts become softer and looser. The areola becomes more deeply
pigmented and the diameter increases. The nipple becomes more prominent and
darker, and mammary vascularization increases. A crust caused by dried colostrums
may be present on the nipple.
4. Aging Process: Before menopause there is a moderate decrease in glandular tissue and
loss of alveolar and lobular tissue. After menopause, glandular tissue gradually
decreases and is replaced by fatty tissue. The form of the breasts may become less
conical and appear flattened, elongated, and pendulous with thickening of the
inframmary ridge. Suspensory ligaments relax causing breasts to hang more loosely
on the chest wall. The nipple and areola become less pigmented and are less
prominent. On palpation, tissue feels less firm or nodular and feels somewhat “stringy
or grainy.” Women taking hormone replacement therapy may have hormonal
stimulation of the glandular tissue and may not experience the typical post-menopausal
changes of the breast.
Diagram #8
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VI. Benign Breast Conditions
Benign breast conditions encompass a mixed group of lesions that present as clinical,
radiographic, or pathological abnormalities. Benign breast conditions are significant because
they need to be distinguished from breast carcinomas.
A. Fibrocystic Changes (A Non-Disease) (Diagram #9)
1. This is an imprecise term applied to a variety of changes that occur in the breast,
including lumpiness, tenderness, swelling, changes on the mammogram or
ultrasound, or pathological changes identified by a breast biopsy. Fibrocystic
changes are also called chronic cystic mastitis and mammary dysplasia.
2.
Clinically, fibrocystic breast changes may be interpreted as palpable areas, with or
without pain and tenderness, which fluctuate with the menstrual cycle. Fibrocystic
changes are usually found in premenopausal women, or post-menopausal women
who are taking replacement hormones and represent the response of the breast
parenchyma to estrogen and progesterone. Clinical evidence of fibrocystic changes
is present in approximately 50% of women.
3.
Pain is one of the most common symptoms of clinical fibrocystic changes. The pain
may be unilateral/bilateral or cyclical/non-cyclical. Heaviness or aching are words
that may describe breast sensations. Pain may radiate to the axillae or to the
ipsilateral arm.
4.
Fluid-filled cysts originate in the lobules of the breast tissues and represent dilated
acini or terminal ductules. Cysts may vary in size from 1 mm to several cm. and
may be present as a solitary nodule or multifocal changes. Cysts may be evident as
palpable lumps or as changes on the mammogram or sonogram. Breast ultrasound
(sonography) is an accurate method used to diagnose breast cysts.
5.
Pathologically, fibrocystic changes represent a variety of changes in the breast
tissue, including nonproliferative lesions, proliferative lesions without atypia, and
atypical hyperplasia. Fibrocystic changes do not represent a significant risk factor
for breast cancer, except for those women who have a diagnosis of atypical
hyperplasic obtained as the result of a biopsy.
Diagram #9
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6. Treatment:
a.
Breast Pain: Pain should be evaluated carefully to distinguish cyclical from noncyclical, identify focal areas, exclude pain arising from sites outside the breast,
and rule out a mass as the source of pain. Pain should be assessed by character,
location, intensity, and duration. Additional assessment information should
include relationship to the menstrual cycle, new medications, changes in
emotional stress and lifestyle, and patterns of physical activity, e.g., lifting
weights (muscular pain may mimic breast pain). Careful physical assessment,
diagnostic imaging studies, and a complete history are necessary. If clinical and
diagnostic exams (mammogram and sonogram, if indicated) are negative, most
patients can be reassured that the pain is not related to a breast malignancy.
Common therapies such as diuretics, vitamins A, B, and E supplement, and total
elimination of methyl xanthine (caffeine) from the diet may relieve symptoms.
Although caffeine restriction is widely recommended, research studies have not
proven this to be effective in reducing fibrocystic changes. Evening of primrose
oil has been used to treat breast pain but it is not regulated by the FDA. Breast
massage may relieve symptoms by improving lymphatic drainage.
Breast cysts: Cyst aspiration (needle aspiration of cystic fluid) may be
performed for diagnostic or therapeutic reasons. Aspiration may be performed
by palpation or with sonographic guidance. Cytologic analysis of cyst fluid is
not routinely recommended.
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B. Fibroadenoma (Diagram #10)
1. Most common solid lesion found in the
breast. Fibroadenomas may occur at any age,
but they are more common in younger
women and may occur bilaterally. Clinically,
fibroadenomas usually present as discrete,
smooth, mobile, non-tender, round or
lobulated lesions with a firm to rubbery
texture. At biopsy, fibroadenomas are found
to be pseudoencapsulated and are sharply
delineated from the surrounding skin.
Fibroadenomas may grow during pregnancy
Diagram #10
and contain estrogen and progesterone
receptor cells. Fibroadenomas may be diagnosed by fine needle aspiration, core
biopsy, or open biopsy.
Key Points
 Fibrocystic changes are a non-disease.
 Fibrocystic changes may present as a palpable finding on a breast exam,
changes on the mammogram or ultrasound, or pathological changes.
 Most fibrocystic changes are not a risk factor for breast cancer.
 Breast pain should be carefully evaluated, particularly when the pain is focal
and non-cyclical.
 Fibroadenomas are the most common benign solid tumor of the breast
C. Intraductal Papilloma
1. Lesion (tumor) of a lactiferous duck, usually occurring in a single duct,
unilaterally.
2. The period of greater incidence is between ages 35 to 55.
3. Clinically, lesions usually present with bloody discharge, often in one breast and
from a single duct. A palpable mass may be present.
4. Mammography and galactography may be utilized for evaluation.
5. Treatment is total duct excision if the affected duct can be identified.
D.
Mammary Duct Estasia and Periductal Mastitis
1. Mammary duct estasia refers to dilated, thinned, secretion-filled ducts. Periductal
mastitis refers to an inflammatory process around the ducts. These conditions
commonly occur together.
2. The period of greatest incidence is in women from ages 40 to 49 although it has
been shown in women from ages 80 to 90 years and also in men.
BHA - 17
3. Clinical presentation may include profuse, variable-colored discharge from several ducts in
one or both breasts. Subareolar tenderness, nipple retraction or inversion, presence of a hard
mass, doughy, tubular masses beneath the areola and chronic or recurring abscesses and
fistulas from dilated ducts to the skin.
4. Mammography may show calcifications in the lumen and walls of dilated ducts.
5. Treatment includes biopsy and excision of the dilated ducts producing the discharge.
Antibiotic administration is included in treatment due to increased risk of infection following
biopsy for this condition.
E. Mastitis
1. Infection of the breast occurring when bacteria enters the breast through the nipple. Puerperal
mastitis occurs in the lactating breast. In this instance the infection is around the ductal system
rather than within the ducts themselves.
2. The period of greatest incidence is during lactation.
3. Clinically, cellulitis occurs in a wedge-like pattern over a section of breast skin. The skin may
be red, warm and very tender. The nipple may be cracked or irritated. Fever, chills and flulike symptoms are common.
4. Treatment is antibiotic administration. In lactating women, breastfeeding or pumping of the
affected breast is encouraged to promote drainage of milk from the affected area. The
application of warmth and pressure to the affected area may decrease engorgement and speed
resolution. There are no adverse effects to the infant and the infant does not require antibiotic
treatment. If puerperal mastitis does not resolve with antibiotic treatment, abscess may be
present and incision and drainage may be necessary.
F. Male Gynecomastia
1.
Benign, usually reversible, enlargement of the male breast. It may be associated with
developmental, genetic, other organic underlying disease, or be related to medications.
2.
The period of greatest incidence is pre-pubertal boys, adolescent boys and older men, but it
can occur in any age group.
3. Clinically, the magnitude of the enlargement may range from a barely detectable mass to the
dimensions of a full female breast. It may present with a rubbery, tender, firm disc of tissue
beneath the areola and may occur bilaterally or unilaterally.
4. Mammography may be used preoperatively in older men with unilateral presentation to
differentiate from carcinoma.
5. In most cases, the condition is self-limiting and regresses spontaneously without treatment. In
persistent cases, identification of underlying cause determines treatment. Medical treatment
may include the discontinuation of medication, medications for treatment, or treatment for
underlying conditions. Surgical treatment may be used as an alternative to medical treatment
and to distinguish this condition from carcinoma.
BHA - 18
METHODS OF DIAGNOSIS
Bland, K. and E. Capland (editors), The Breast:
Malignant Disease. W. B. Saunders Company, 1991.
Comprehensive Management of Benign and
Parker S. and W. Jobe, Large-Core Breast Offers Reliable Diagnosis. Diagnostic Imaging, October
1990.
Parker, S. H. and Klaus, A.J., Performing a Breast Biopsy with a Directional Vacuum Biopsy
Instrument. Radio Graphs. 1997, 17:1233-1252.
Schmidt, R., et.al., Benefits of Stereotactic Aspiration Cytology, Breast Imaging. October 1990: 3542.
Townsend, C. Breast Lumps, Clinical Symposia, V32, No. 2, 1980.
BREAST CANCER TREATMENT
Brinker, Nancy. The Race is Run One Step at a Time. Simon and Schuster, New York, 1990.
Champion, Victoria, The Role of Breast Self-Examination in Breast Cancer Screening.
Supplement, 1992 79(7); 1985-1991.
Cancer
Harris Jay, et.al., Breast Diseases. Second Edition, J.B. Lippincott Company, 1991.
Harris, Jay, et.al., Breast Cancer, The New England Journal of Medicine, 1992, 327(6), pp. 390-398.
Love, Susan M., Dr. Susan Love’s Breast Book, Addison-Wesley Publishing Company, Inc., Reading,
Massachusetts, 1990.
Mansfield, Carl, et.al., A Review of the Role of Radiation Therapy in the Treatment of Patients with
Breast Cancer, Seminars of Oncology, Vol. 18, No. 6, pp. 525-535, 1991.
McLean, Martha. If You Find a Lump in Your Breast, Bull Publishing Co., Palo Alto, California,
1986.
White, Linda, et.al., Cancer Prevention and Detection in the Cancer Screening Clinic, University of
Texas M.D. Anderson Cancer Center, 1988.
Wilson, Pamela, and Alice Judkins, Testicular and Breast Self-Examination: Nurses’ Impact on Early
Cancer Detection, Dimensions in Oncology Nursing, 1990 4(3):32.
Winchester, David, and James Cox, Standards for Breast Conservation Treatment, CA-A Cancer
Journal for Clinicians, Vol. 42, No. 3, May-June 1992.
BHA - 19
PATHOLOGY
Brinker, Nancy, The Race is Run One Step at a Time, Simon and Schuster, New York, 1990.
Champion, Victoria, The Role of Breast Self-Examination in Breast Cancer Screening, Cancer
Supplement, 1992 79(7), 1985-1991.
Harris, Jay, et.al., Breast Diseases, Second Edition, J.B. Lippincott Company, 1991.
Harris, Jay, et.al., Breast Cancer, The New England Journal of Medicine, 1992, 327(6),
pp. 390-398.
Love, Susan M., Dr. Susan Love’s Breast Book, Addison-Wesley Publishing Company, Inc., Reading,
Massachusetts, 1990.
Mansfield, Carl, et.al., A Review of the Role of Radiation Therapy in the Treatment of Patients with
Breast Cancer, Seminars of Oncology, Vol. 18, No. 6, pp. 525-535, 1991.
McLean, Martha, If You Find a Lump in Your Breast, Bull Publishing Co., Palo Alto, California, 1986.
White, Linda, et.al., Cancer Prevention and Detection in the Cancer Screening Clinic, University of
Texas M.D. Anderson Cancer Center, 1988.
Wilson, Pamela, and Alice Judkins, Testicular and Breast Self-Examination: Nurses’ Impact on Early
Cancer Detection, Dimensions in Oncology Nursing, 1990 4(3):32.
Winchester, David, and James Cox, Standards for Breast Conservation Treatment, CA-A Cancer
Journal for Clinicians, Vol. 42, No. 3, May-June 1992.
BHA - 20
VII. Breast Self-Examination
Breast self-examination (BSE) only takes a few minutes each month. The American Cancer Society
Guidelines for Breast Self-Examination recommend that women begin to do regular BSE by age
twenty.
A.
BSE consists of inspection (looking) and palpation (feeling). With regular examination, a woman
will become aware of the normal appearance and feel of the breast so that any changes from
normal will be easily recognized.
B.
It is important to examine the following areas:
1. All of the area between the collarbone and the base of the breast, and from the breastbone to
the underarm area.
2. Lymph node areas above and below the collarbone and under each arm.
C.
Signs and symptoms to be report to a health care professional (any change from normal):
1.
Raised area on breast
2.
Sores or ulcerations not caused from injury, or sores that do not heal
3.
Dimpling, puckering, or pulling-in of the skin
4.
Veins which protrude or are noticeably larger or more prominent in one breast.
5.
Change in color
6.
Change in shape or size of either breast
7.
Change in the nipple areolar skin (thickening, scaling, crusting)
8.
Change in the direction of the nipple
9.
Change in the appearance of moles or skin
10. Presence of a lump or thickening in the breast
11. A lump or knot in the underarm area, or above or below the collarbone (if present for 2
weeks)
12. Persistent discomfort or pain in the breast
13. Change in nipple drainage: either a change in color or amount; or the presence of a
discharge when none was previously present
14. For a woman who has had surgery for breast cancer, a change in the incision area (red,
raised bump like a mosquito bite or a rash
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D. Steps of BSE:
1. Inspection of the breast (looking for change from normal):
a. Remove all clothing from the waist up, then stand facing a mirror and look directly at
the breasts. Turn from side to side in each of the following positions:
b. Rest arms at sides.
c. Place arms overhead.
d. Place hands on hips pressing down firmly to tighten the chest muscles.
e. Lean forward to allow the breast to fall away from chest.
f. Look for any drainage from the nipple.
BHA - 22
2.
Palpation (feeling for any change from normal):
a.
Using the pads of the fingers, feel all of the breast and chest area. Become familiar with
the normal feel of the breast and report any changes to a health care professional.
(1) Palpate above and below the collarbone and the underarm areas for swollen lymph
nodes.
(2) While bathing, palpate the entire breast/chest area using firm pressure in a circular
motion. Cover the areas between the collarbone and the base of the breast, and the
breast bone and the underarm.
(3) While lying down, place a towel or pillow under the shoulder on the side of the
breast being examined. Using the same firm pressure of the finger pads, examine
the entire breast/chest in the same circular motion. Be sure to include the area
directly under the nipple. Lotion, powder, or baby oil helps to increase tactile
sensitivity just as soap does while bathing.
BHA - 23
E.
Who should do BSE?
All women, by the age of 20, should do BSE every month for the rest of their lives. All women
are at risk for breast cancer.
F.
When should women do breast self-examination?
1.
Menstruating women: do BSE just as their period is ending. If on oral contraceptives, do
BSE the first day of a new pill pack.
2.
Post-menopausal women: perform BSE on the same day each month. Choose a date that
is easy to remember.
3.
Pregnant women: check breasts on the same day each month.
4.
Breast feeding mothers: check breasts on the same day each month after emptying their
breasts.
5.
Women on hormone replacement therapy: check on the same day each month. If there is a
break in hormone therapy, then BSE should be done the day hormone therapy resumes. If
estrogen is taken continuously, then BSE should be done on the same day every month.
6.
Women who have had a mastectomy, breast-conserving surgery, or reconstruction should
examine both sides of their chest every month paying particular attention to the incision. It
is important to become familiar with the appearance, texture, and feel of the scar and the
surrounding chest area. Note any differences in this area.
Breast self-examination is an important part of breast cancer detection. In fact, most lumps are found
by women. Breast self-examination guidelines are designed to help women feel confident in doing
monthly BSE.
BHA - 24
VIII. Methods of Detection
A. Screening Guidelines
1. The American Cancer Society (ACS) recommends the following guidelines* for breast cancer
screening of women without symptoms:
a.
Clinical Breast Exam by a health care professional every 3 years for women aged 20
to 39, and annually for women age 40 and over.
b.
Breast Self-Exam monthly for all women aged 20 or over.
c.
A mammogram every year for all women age 40 and over (screening may begin
earlier if clinically indicated).
*
Guidelines for screening women without symptoms of breast disease and with normal risk
for cancer. The presence of a strong family history of breast cancer or other factors may
alter these recommendations. Check with your health care provider if you have any
questions.
B. Breast Self-Examination (BSE)
1.
BSE is simple, economical, safe, and involves women in a health promoting behavior.
2.
The majority of palpable breast changes are detected by women themselves.
3. Lesions found by women who do BSE regularly are smaller than those found accidentally.
4. One of the major limitations of BSE is that the lesion must be palpable in order to be
discovered. Larger lesions are usually not associated with early stage disease.
C.
Clinical Breast Exam (CBE):
1. CBE can be performed by a physician, nurse, or other specially trained health care
professional. Patients should request that CBE be included with their routine physical exam.
2.
The exam should include both inspection and palpation of the axillary, infraclavicular and
supraclavicular lymph nodes.
3. Breast Self Exam, Clinical Breast Exam and Mammography are all necessary to achieve
maximum detection rates.
D. Screening Mammography
1.
A mammogram is a low dose x-ray of the breast taken from different angles. It is the most
sensitive screening method for the early detection of breast cancer in asymptomatic women
(without a breast problem).
BHA - 25
2. Benefits
a. Mammography combined with clinical breast exam and breast self-exam results in a
significant reduction in deaths due to breast cancer.
b. Regular annual screening rather than a single or an occasional screening is more likely to
detect breast cancer in an early stage when it is curable.
3.
Risks
a. The carcinogenic effects of radiation from mammography is minimal with the use of
dedicated equipment and more sensitive film. The average dose of radiation exposure for
screen-film mammography is about 0.3 rad per two-view exam of each breast. This is not
significant radiation exposure. Each individual in the United States receives an equal
amount of radiation to his/her entire body every year due to naturally occurring
background radiation.
4.
Regulation of Mammography
a. The Mammography Quality Standards Act (MQSA) of 1992 requires that each facility
conducting mammography in the United States (except those of the Department of
Veterans Affairs) be accredited by the Food and Drug Administration (FDA) and undergo
annual inspection. In Texas, facilities must also be certified by the Texas Department of
Health. Bureau of Radiation control certificates to this effect must be displayed where
they can be viewed by patients. Since October 1, 1994, only certified and accredited
mammography facilities can lawfully conduct mammography.
b. An important component of mammography is comparison of previous x-rays. Subtle
changes in the breast tissue can be detected when mammograms are compared. It is
important for a woman to record when and where her mammograms are done so that
comparison can be made.
E. Screening Versus Diagnostic Mammogram
1. Screening Mammogram
a. The purpose of a screening mammogram is to detect an unsuspected abnormality in an
asymptomatic woman.
b. Screening mammography should be easily accessible, inexpensive, and of good quality.
c.
Two views are done of each breast (craniocaudal and mediolateral oblique views).
d.
Screening mammograms are usually not read at the time of the procedure. If an
abnormality is detected, the woman is notified and scheduled for further studies
(additional views or other diagnostic modalities). Approximately 10% of all screening
mammograms will require further work-up.
BHA - 26
2.
Screening Mammograms for Women with Implants
a. Screening mammograms for women with implants involve four x-ray views of each
breast. This includes the usual screening views (craniocaudal and mediolateral oblique).
This procedure, referred to as the “Ecklund technique”, or “displacement films” allows for
better visualization of the breast tissue. There is additional cost for this examination
because of the specialized procedure and the complexity of the interpretation.
3.
Diagnostic Mammogram (problem-solving)
a. The purpose of a diagnostic mammogram is to evaluate a clinical breast problem such as a
breast mass. A diagnostic work-up is also done to evaluate abnormal findings detected on
a screening mammogram.
b. Diagnostic mammograms should be done under the direct on-site supervision of a
qualified radiologist.
BHA - 27
IX. Methods of Diagnosis
The only accurate method of diagnosing breast cancer is through histological (pathological)
examination of tissue. Tissue sample may be obtained by:
A. Open Biopsy
1. Needle localization for biopsy: A non-palpable lesion is localized using mammography.
Based upon the original mammogram films, a needle is introduced into the breast and directed
toward the lesion. Once the needle is positioned correctly a hookwire replaced the needle and
the patient is taken to surgery. A surgical biopsy is performed on the area localized by the
wire. A specimen radiograph is usually done while the patient is in the operating room to
ascertain if the lesion has been removed successfully.
2. Excisional biopsy: This involves the removal of all the suspicious area and a margin of
normal tissue. This procedure may be done as an outpatient using either local or general
anesthesia.
3. Incisional biopsy: This biopsy is used for larger lesions that are not amenable to the excisional
biopsy. Only a portion of the lesion is removed and sent for histologic exam. This procedure
may be done on an outpatient basis and either local or general anesthesia may be used.
B. Needle Biopsy
1. Fine Needle Aspiration Biopsy (FNA)
2.
(a)
This procedure uses a small gauge needle to obtain cells from a palpable mass for
cytologic examination. The needle is moved back and forth within the lesion while
applying full suction on the syringe.
(b)
FNA is performed on an outpatient basis with local anesthetic.
(c)
FNA results are limited. Cytology is unable to diagnose invasion in malignancies and
cannot provide a specific benign diagnosis. This is due to the small amount of tissue
obtained.
Core Biopsy
(a)
In this procedure, a large-gauge core biopsy needle is used to remove several cores of
tissue for histologic examination.
(b)
Stereotactic core biopsy is used primarily for nonpalpable breast lesions seen on a
mammogram. It combines the use of a biopsy device and a stereoscopic x-ray device.
With one type of equipment, the patient lies face down on the table and the breast drops
through an opening in the table. The x-ray machine with the biopsy device is mounted
below the table. The breast is x-rayed from two angles and a computer plots the exact
position of the suspicious area.
BHA - 28
After local anesthetic is injected, the physician advances the needle. Specimens are
obtained from several areas of the lesion and sent for histologic evaluation. Another set
of films is obtained to verify that the needle has transverse the lesion.
(c)
Ultrasound-guided core biopsy uses continuous ultrasound to guide the needle to the
suspicious lesion. Local anesthetic is injected. A technique using a coaxial system
allows multiple samples to be obtained with a single pass through the breast tissue,
thereby minimizing trauma to the breast and decreasing procedure time. Specimens are
sent for histologic evaluation.
(d)
Both stereotactic and ultrasound-guided core biopsy may be considered as an alternative
to open biopsy for the purpose of obtaining a diagnosis. Core biopsy is cost effective,
expedient and safe. Follow-up to check for stability of a lesion is required if a benign
diagnosis is obtained.
C. Other Imaging Procedures
1. Ultrasound: Ultrasound uses sound waves to produce an image of the breast. It is most useful
as an ancillary procedure to mammography in differentiating fluid-filled form solid masses.
2.
MRI: Magnetic Resonance Imaging uses magnetism and radio waves in combination with
computer analysis to create pictures of the breast. MRI is NOT used as a screening procedure.
It may be helpful in situations where conventional diagnostic methods cannot provide a
diagnosis. It may also be used in evaluating dense breasts, silicone injected breasts, or breast
implants.
3. Ductogram: Ductography is a safe, simple technique for visualization of the ductal system in
women with spontaneous nipple discharge. Indications for a ductogram depend on the
medical history, type of discharge, physical findings, and age. The most significant discharges
are those that are bloody, serious, or serosanguinous. Intraductal papilloma is the most
common source, but should be identified and evaluated histologically. A very small percent of
nipple discharge results in a diagnosis of cancer. To perform a ductogram, the patient is
placed in supine position. Using a blunt needle, a radiopaque contrast material is injected into
the discharging duct. Mammogram films are taken immediately after injection of contract
material. Ductography may locate the original of the discharge for biopsy.
BHA - 29
X. Pathology
A. In Situ – Histologically, two types are recognized ductal and lobular. The latter has a slightly
higher tendency to occur in both breasts.
B. Invasive or Infiltrating – The cancer has grown outside the duct or lobule into surrounding
tissue. The majority of invasive breast carcinomas are ductual *80%). Approximately 10%
are lobular. Other less common types of breast carcinomas include:

Tubular: Cancer cells look like little tubes. 1-2% is cancer. Usually less aggressive.

Mucinous: type of infiltrating ductal carcinoma that makes mucus and is usually less
aggressive. Approximately 3% of all breast carcinomas.

Papillary: Has cells that stick out in little papules, or fingerlike projections, usually less
aggressive.

Other: Sarcomatoid Carcinoma, Squamous Carcinoma, and Spindle Cell Carcinoma.
C. Paget’s Disease – Carcinoma of the nipple which resembles eczema or scaliness. Type of
ductal carcinoma which accounts for less than 1% of breast cancer. Paget’s disease can be in
situ or invasive.
BHA - 30
XI. PATHOLOGIC STAGING OF BREAST CANCER
Staging of breast cancer refers to the classification of breast cancer by anatomic extent. The premise
that underlies staging is that breast cancer progresses anatomically in an orderly manner and that the
extent of disease is related to prognosis. In addition, staging is a determining factor in selecting
treatment for breast cancer.
A.
Carcinoma in Situ or Localized Cancer: Very early breast cancer which is present only in the
immediate area in which it began, with no evidence of tissue invasion.
B.
Stages:
1. Stage I: The tumor is no larger than 2 centimeters in diameter and has not
metastasized
to the lymph nodes under the arm.
2. Stage II:
The tumor is from 2-5 centimeters and/or has metastasized to the lymph nodes
under the arm.
3. Stage III: The tumor is larger than 5 centimeters and involves the underarm lymph nodes
to a greater extent and/or has spread to the lymph nodes or other tissues near the
breast.
4. Stage IV: The tumor has metastasized to other organs of the body, most often the lungs,
bones, liver, or brain. Skin involvement is automatically classified as Stage IV.
Axillary lymph node status is important in identifying the extent of disease as well as those patients
who should be considered for adjuvant therapy.
XII. PROGNOSTIC FACTORS
In addition to staging there are other factors that affect the patient’s prognosis and treatment plan.
1.
Tumor size. Tumors less than or equal to 1 cm. have a particularly good prognosis. In general,
the risk of recurrence increases with increasing tumor size.
2.
Nuclear grade. Nuclear grade refers to the degree of tumor cell differentiation determined by
histology. Poorly differentiated cancers are more aggressive than well differentiated cancer and
area associated with higher rate of relapse. There are many grading systems used. A frequently
used system, Black nuclear grading, is reversed system. On a scale of one to three, grade one is
poorly differentiated and grade three is well differentiated.
3. Estrogen and Progesterone Receptor Status. Estrogen and progesterone receptor status is a test
done on the biopsy specimen to decide if the cancer is receptor positive or negative. Patients with
positive tumors respond to hormonal therapy and have a better prognosis than those with receptor
negative tumors.
4. DNA Ploidy and Proliferative Activity. Measurement of DNA ploidy and proliferative activity are
measured using a variety of techniques. Cancer with low proliferative rates is less aggressive than
those with high proliferation activity.
BHA - 31
5. Other factors. The identification and evaluation of a variety of serum markers continue to be
an area of research. Rapid tumor growth is associated with a less favorable prognosis and is
measured by a short net doubling time, a high mitotic index, and a high S-phase fraction.
Abnormally high numbers of HER-2/neu gene receptors are also an indicator of rapid growth.
Other tests may be performed. However, none of these factors have proved to be as accurate
as tumor size and nodal status in predicting outcomes.
XIII. Treatment
Taking into account the medical situation and the patient’s preference and general health status,
treatment may involve lumpectomy (local remove of the tumor) or mastectomy (surgical removal of
the breast), radiation therapy, chemotherapy, or hormone manipulation therapy. Often, two or more
methods are used in combination.
Each patient should discuss with her physician possible options for the best management of her
disease.
Treatment is divided into two categories: local (treatment of the breast itself) and systemic (treatment
for the entire body).
A. Local Treatment
1. Surgery: The aim of surgery is to remove the tumor with a border of normal tissue around it.
The goal is to stop the growth of the disease before it spreads.
a. Radical Mastectomy: Removal of the breast, fat, axillary nodes, and chest muscles.
Seldom performed unless the breast cancer has spread to the muscles.
b. Modified Radical Mastectomy: the same procedure as the radical mastectomy except the
chest muscles are left intact.
c. Local excision with radiation: Simple excision of the tumor. The general public may use
the term “lumpectomy” for this category. This procedure is usually followed with
radiation therapy.
d. Partial Mastectomy. Segmental mastectomy with radiation, Wide Local Excision:
removal of the tumor plus a portion of the unaffected surrounding tissue. Often includes
removal of some of the axillary lymph nodes.
2.
Radiation Therapy: High energy x-rays are used to destroy cancer cells. It can be used to
cure primary breast cancer. It is also used to slow down the progress of metastatic cancer by
shrinking the cancer. Radiation therapy is most often used in conjunction with surgery.
3.
Reconstruction: Is an option to rebuild the breast, the nipple areolar complex, or both. The
decision to have reconstruction is a personal choice and depends on many factors such as age,
general health, and attitude. Reconstruction should be discussed with the surgeon prior to the
initial surgery. The breast mound can be reconstructed by using an implant or by using tissue
from the patient’s own body (autogeneous tissue).
BHA - 32
Immediate Reconstruction: Is performed at the time of mastectomy. A surgeon removes the
cancer and a plastic surgeon reconstructs the breast.
Delayed Reconstruction: Is performed months or years after the mastectomy. Almost all
women can choose to have reconstructive surgery. A plastic surgeon should be consulted to
explore options for reconstruction.
B. Systemic Treatment
1. Chemotherapy: Treatment of cancer with cytoxic drugs. There are many different drugs
used in various combinations to treat breast cancer. Chemotherapy can be given by
infusion (I.V.), injection or orally. The goal is to kill cancer cells or prevent them from
growing.
Side Effects/Complications: Loss of hair, nausea, vomiting, susceptibility to infection,
fatigue, mouth ulcers, rashes, and possible lung and heart damage.
2. Hormone Therapy: Type of therapy for women with hormone receptor positive tumors.
Hormone therapy can be accomplished by surgical removal or radiation of the ovaries, or
by giving drugs that are hormone blockers.
Side Effects/Complications: Less severe than chemotherapy because they affect only
hormonally sensitive tissue. Side effects may include hot flashes, facial hair growth,
weight gain, rash, initial nausea that abates within 1-2 months, and vaginal spotting.
3. Bone Marrow Transplant: Investigational treatment currently used in patients with
advanced breast cancer. In this procedure, bone marrow cells are collected and stored.
The patient receives high doses of chemotherapy to kill the cancer. After chemotherapy,
the stored bone marrow cells are infused to restore the bone marrow that was damaged by
the large doses of chemotherapy. This allow for more aggressive chemotherapy treatment.
XIV. Quality of Life Issues
A. Quality of life is a concept which changes over time. The initial diagnosis of breast cancer
generates great emotional turmoil. The word “cancer’ and the thought of potentially
mutilating surgery evoke strong emotions. The effect on the women who is asymptomatic and
is not prepared to cope with a life threatening condition is even more pronounced. Within a
relatively short period of time a woman is forced to deal with unfamiliar information which
may be overwhelming. She may receive conflicting information from an array of physicians
which increases confusion. This takes place at a time when both she and her significant
supports may be filled with uncertainty, anger, and fear. The diagnostic period of time, from
the moment the woman learns that she may have cancer until she receives the confirming
diagnosis, has been found to be one of the most stressful times a woman faces.
BHA - 33
Following diagnosis, women may deal with many issues that affect quality of life. Among
these concerns may be the following: alteration in body image and issues of sexuality, fear of
loss of health, fear of loss of employment or insurance benefits, and withdrawal of family or
friends who cannot deal with the diagnosis of cancer. Later, women may be concerned about
the risk of recurrence or a second malignancy, and the development of lymphedema.
B. Resources for Women with Breast Cancer
1.
American Cancer Society Resources
a. Reach to Recovery: This is a one on one program which has been successful in
providing information and support for women with the diagnosis of breast cancer.
Women who have been treated successfully are trained to visit women newly
diagnosed with breast cancer. These volunteers provide information on exercises and
rehabilitation, provide a temporary bra and more important, bring moral support.
b. I Can Cope: This is an educational program for patients and family members that
offer information on cancer, treatment of cancer and ways of coping with the physical
and emotional effects of the disease. This program is often held at hospitals and
treatment centers and is facilitated by health care professionals.
c. Coping With Breast Cancer: This is an educational and support group facilitated by
healthcare professionals which provides women with the opportunity to share
concerns and feelings about their cancer experience.
In additional to these groups which provide information through fellow survivors and health
care professionals, the American Cancer society web site is a resource for current information
about both breast health and breast disease. This can be accessed by the public at
www.cancer.org. A wide range of topics is covered which can help women to make informed
decisions about breast cancer treatment. Among the topics are breast cancer overview, breast
cancer treatment, breast reconstruction, breast cancer dictionary, survivorship issues and many
others. For women who cannot access the web site, this information can be obtained by
calling the American Cancer Society at 188-ACS-2345 which is available 24 hours a day.
2.
Other Resources
a. Health professionals such as nurses, social workers, clergy, psychologists and
psychiatrists
b.
Supportive family and friends
c.
Local resources such as churches and the YWCA
BHA - 34
XV. Insurance/Medicare
Texas law requires that any life or health insurance company licensed in Texas to sell health insurance
must cover mammography screening in the same way diagnostic radiology is covered. The exception
is with a Single Employer Plan that is fully self-funded paying health benefit claims directly from a
trust, pool, or similar arrangement. This plan may be administered by an insurance company, but the
insurance company writes no policy and accepts no actual risk. ERISA is the federal law providing
this exemption. It is important to understand that there are three types of employer plans overseen by
ERISA, however, only the Single Employer Plan described above is exempt. It is therefore essential
for consumers to understand what type of plan their employer carries.
What does Medicare pay for?
Medicare pays for 80% of the cost of a screening mammogram each year for beneficiaries aged 40 and
older, every 365 days. There is no deductible requirement for this benefit, but beneficiaries are
responsible for a 20% co-payment of the Medicare-approved amount. If there is supplemental
insurance, such as a Medigap policy, or Medicaid, there may be no out-of-pocket costs.
BHA - 35
XVI. Teaching Tips for Lay Audiences
As an instructor you are responsible to use this manual as your teaching guide. This
manual is updated every 5 years. For the most current version, call your local ACS.
The purpose of these teaching tips is to provide a guide and frame of reference for Breast
Health Awareness faculty who present programs to both professional and lay audiences.
A. Planning a Program
Programs can be arranged by the faculty or may be scheduled through the American
Cancer Society. The ACS will provide materials and audiovisual aids.
B. Teaching Aids
Numerous resources are available through the ACS at no charge. Recommended items
are: Mammograpy & You video, code BV81, Take Charge of Your breast Health, code
B549, and Fibrocystic Breasts, code B534. The Bingo-Loteria game is an easy way to
cover the entire spectrum of breast health in a fun, relaxed way. This is an excellent
method to present information to older women. The video “Keep in Touch” is another
teaching tool that covers breast health with particular emphasis on older women. The
BHA flit chart is useful when presenting to groups of less than ten participants.
C. Teaching Tips
1.
Use the manual as a resource to prepare for your program.
2.
The minimal time for a program is 20 minutes. Refer to the suggested Program
Outline, page 33, in the manual.
3. Order material you need from the American Cancer society well in advance of the
program.
4. Arrive at the teaching site early. Check any equipment you plan to use (e.g., have it
properly focused and the volume set before the start of the program).
5. Know your audience:
a.
Many older person associate cancer with death. This is a high risk group for
breast cancer. Emphasize physical fitness and health.
b.
Teens and young adults are concerned about body image. Be sure to answer their
questions no matter how trivial. Young adults are concerned about family and
children. Emphasize the limited amount of time it takes to do BSE. Emphasize
wellness and health.
BHA - 36
c. Do not use medical jargon. Use language and terms that can be easily understood
by a general audience.
d. Some women, because of their ethnic or cultural background, may not feel
comfortable looking at or touching their breasts. For these women, it may be more
appropriate to sue the bingo-loteria game.
6.
Greet people at the door. This takes the audience more receptive.
7.
At start of program, give a short introduction. Tell a little something about yourself,
who you are, and why you are a volunteer.
8. Show your enthusiasm and try to generate the same enthusiasm in members of the
group. Create a positive feeling. Present with skill and confidence. Use good eye
contact and speak distinctly and loudly enough so that everyone can hear.
9. At the end of the program, summarize the most important points: mammography,
clinical breast exam, and BSE.
10. Finally, offer an opportunity to ask questions, publicly or privately. Repeat questions
asked publicly so that everyone hears them. If they do not ask questions, try to
encourage some type of group discussion.
11. Never be reluctant to admit you do not know the answer to particular questions,
especially the questions dealing with diagnostic exams, treatment, radiation doses,
chemotherapy, etc. You may refer the women to:






Private physician
Local American Cancer Society
www.cancer.org or 1-800-ACS-2345
Local health department
Local hospital
Cancer Information Service at 1-800-4-CANCER
12. Return borrowed materials and report the number of program participants to the
American Cancer Society office within a week after your presentation.
BHA - 37
XVII. Suggested Outline for Lay Programs
I. Welcome and Introductions
II. Introduce and Show Breast Health Awareness Video or Play Bingo Game
III. Summarize Key Points
A. Who is at risk for breast cancer?
1. A woman’s risk increase with age.
2. The majority of women with breast cancer do not have a family history.
B.
What can women do for themselves?
1.
Screening Mammography
Every year for all woman age 40 and over. (screening may begin earlier
if clinically indicated).
2.
Clinical Breast Exam by a Health Care Professional
a. Every 3 years between age 20 and 39.
b. Every year beginning at age 40
c. A small number of breast cancers are not found by mammography, but
are detected during a clinical breast exam. It is very important that a
woman have a clinical breast exam near the time of her mammogram.
3.
Monthly BSE.
a. By 20 years old, become familiar with the normal appearance and feel
of the breasts so that any change from normal will be detected early.
IV. Questions and Answers (optional)
A. Do not try to answer questions you are not professionally qualified to answer.
Recommend that the individual check with her health care professional, the
local American Cancer society, health department, or hospital.
BHA - 38
XVIII. Translating Information into Behavior Change by Using
Tell-A-Friend
The following is a program in which you can encourage others to be involved. To volunteer,
women and men can call the local ASC.
What is Tell-a-Friend?
Tell-A-Friend is an American Cancer Society (ACS)
Program conducted among friends, family and
acquaintances. Trained volunteer callers contact
five friends or other women they know to
encourage them to get a mammogram. This
strategy is called “peer counseling” because the
volunteers are contacting other women much like
themselves. It is also a strategy that has been
tested and shown to work!
It’s personal
communication. You
deal with people you
already know. I think
it shows your friends
or associates that you
Why is Tell-A-Friend Important?
care about them.
Breast cancer is the second leading cancer-related
death among women in the United States (after
Tell-A-Friend
lung cancer), and the most frequently diagnosed
Volunteer
non-skin cancer among US women. Finding breast
cancer early is currently the best way to control
it, and a mammogram can find a cancer several years
before it might be discovered by a woman or her health care provider. Many women age 40
or older have still not ever had a mammogram, and many more do not get them every year, as
recommended by the American Cancer Society. These women need encourage- ment and
support to get screened. Tell-A-Friend programs provide this kind of support.
Tell-A-Friend Works!
Tell-A-Friend uses a proven intervention (peer counseling) that involves one-on-one efforts
by volunteers to encourage friends and family to have a mammogram. This special effort by
someone she knows may convince a woman to get a mammogram, or it may bring her closer
to making that decision in the future.
BHA - 39
Tell-A-Friend: The Basics
Program Goal and Objectives
The goal of Tell-A-Friend is to increase the number of women in the US who receive regular
mammograms in accordance with American Cancer Society guidelines. Specific program
objectives are:

To increase the number of women who (1) obtain mammograms for the first time and
(2) obtain regular mammograms.

To focus program efforts on those women identified through community needs
assessments, which are most likely to need the support provided by Tell-A-Friend in
order to get a mammogram.
Essential Elements
All five of these essential elements must be present for a program to be
called Tell-A-Friend:





Recruitment of appropriate volunteers to reach those women at risk
who are least likely to be getting regular mammograms;
Trained volunteers to conduct one-on-one “peer” counseling;
Multiple contacts with each woman counseled (at least three if
necessary to achieve screening);
Identification of resources and referral services for women
contacted;
Tracking/monitoring of program results (number of women
contacted; number who obtained mammograms following Tell-AFriend contacts).
Measuring the Success of Tell-A-Friend
The measure of the success of Tell-A-Friend is the number of women who actually obtain a
mammogram following contact by an ACS volunteer caller. Because Tell-A-Friend
focuses on behavior change, its success is measured in smaller numbers than those associated
with large-scale, awareness-building efforts.
However, the outcome being measured –
mammography screening – is one that is known to be effective in detecting breast cancer at
an early stage, and thus improving a woman’s chances for long-term survival.
BHA - 40
XIX. Research Program
Cancer research findings from across the country are routinely shared with the media. Some
of the researches findings are accurate and scientifically based some are not.
This section of your manual is designed to help keep you informed of current breast cancer
issues that appear in the media or in publications. Please use this section as your “personal
file” and add information as appropriate.
If you have questions, need additional information, or come across controversial emails,
rumors or information that needs clarifications, please contact your local American Cancer
Society at 1-800-486-2345 or visit our website at www.cancer.org.
Breast Cancer Research
Background
As the nation’s largest private, not-for-profit source of research funds, the American Cancer
Society focuses its funding on investigator-initiated, peer-reviewed proposals. This process
ensures that scientists propose project they believe are ready to be tackled with the available
knowledge and techniques, rather than working on projects designed by administrators who
are far removed from the front lines of research. This intellectual freedom encourages
discovery in areas that scientists believe are most likely to solve the problems of cancer.
Breast Cancer Funding
Since 1972, the Society has awarded over $140,000,000 in grants for breast cancer research.
The figure for FY98-99 was $16.4 million, or almost 19% of the total research grant dollars
awarded. As of January 1, 2000 we had 150 grants totaling approximately $41,266,750 which
include multiple year awards, pertaining to breast cancer.
The Society spends more on breast cancer than on any other solid tumor site. However,
84% of the research we supported in 1999 was basic science that may have relevance to many
kinds of cancer, including breast.
The Society awards grants in the following areas: basic research grants in genetics,
hormone action, diagnostics (imaging and biomarkers), drug development; and preclinical,
clinical and epidemiological studies in prevention, diagnosis, therapy, rehabilitation and
quality of life.
Breast cancer research is not in competition with research on other cancers. Similar
abnormalities of molecular behavior on the genetic level initiate cancer in many different
tissues. It is important to understand the factors that determine the similarities as well as the
differences. Growth factors, oncogenes, suppressor genes – these are common to all cancers;
hormones are involved in breast, prostate, and other cancers.
BHA - 41
There are some organizations that support only breast cancer research. Many of the
agencies dedicated solely to breast cancer support the same types of basic cancer research
projects as the Society does, because they also recognize that researchers never know where
the answers will come from. The Society could easily classify all of its basic cancer
research projects (75%-85% of the projects) as having potential benefit for breast
cancer. The Susan G. Komen Foundation funded approximately $18 million in research
projects in 1999, and the Breast Cancer Research Foundation approximately $6 million. The
National Cancer Institute estimates they spent $388 million on breast cancer in 1999; the
Department of Defense allocated $135 million to breast cancer in 1999.
Significant
Accomplishments of Society-supported Breast Cancer Researchers.
Learning that there are special proteins in breast cells called estrogen receptors, into which
estrogen fits like a key in a lock. The binding of estrogen to its special receptor stimulates the
growth of breast cancer cells.
Showing that the anti-estrogen drug tamoxifen can fit into the estrogen receptor and prevent
stimulation of breast tumors by estrogen. Tamoxifen can also prevent a second breast cancer
in some women who have already had the disease.
Demonstrating that tamoxifen can reduce the incidence of breast cancer by 45% in certain
high-risk women.
Showing that the estrogen receptor modulator, raloxifene, may reduce the incidence of
estrogen receptor positive breast cancer by 76% in normal risk women.
Finding that limited surgery (lumpectory) plus radiation is just as effect as removal of the
entire breast (mastectomy) in treating certain breast cancers.
Developing the technique for human bone marrow transplantation.
Discovering BRCA1, a gene for inherited susceptibility to breast cancer.
Identifying the association of breast cancer susceptibility in mothers of ataxia-telangiectasia
patients (ATM gene). Cloning and sequencing the ATM gene, a prelude to identifying
carriers in the population.
Identifying the first inherited cancer, the Li-Fraumeni syndrome, where family members
develop breast, endometrial, lung, and other cancers because of an inherited mutation in the
p53 gene.
Successfully prolonging survival in patients with Stage IV breast cancer with a combination
of chemotherapy and Herceptin, a monoclonal antibody directed at the Her2/neu
receptor.
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Showing that variations in estrogen-metabolizing genes can lead to early menarche and an
increased breast cancer risk.
Showing that high fat intake does not increase breast cancer risk as long as the woman
maintains a normal weight, but that alcohol use does increase risk. Other risk factors
identified by Society-supported researchers are high birth weight and factors that reflect the
concentration of estrogen in utero.
Showing that regular exercise reduces the risk of breast cancer when the exercise begins at
puberty and continues throughout life.
Showing that women who die of breast cancer before the age of 60 are more likely to have
had a family history of breast cancer than women who die of breast cancer after the age of
60.
Showing that current cigarette smoking is associated with fatal breast cancer, possibly
because smokers are less likely to get mammograms than nonsmokers.
Showing that a woman’s risk of fatal breast cancer is reduced by 16% if she has ever used
estrogen, perhaps because estrogen users are more health conscious and participate in regular
screening.
Demonstrating the feasibility of developing small peptide estrogen receptor antagonists for the
treatment of tamoxifen-resistant or refractory breast cancers.
Clinical Trials and Breast Cancer
The American Cancer Society does not support large-scale clinical trials, although we do
support early human testing and studies that “piggy-back” onto ongoing trials. The National
Institutes of Health sponsor numerous trials of experimental therapies for breast cancer. A
clinical trial to compare the two anti-estrogen drugs, tamoxifen and raloxifene, for decreasing
the risk of breast cancer in high-risk women, has just begun to enroll 22,000 women.
Individuals can obtain information about enrolling in clinical trials by calling the National
Cancer Institute at 1-800-4-CANCER. Information can also be found on the following web
sites:
http://www.nabco.org/trials/
http://cancertrials.nci.nih.gov/
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XX. American Cancer Society Breast Health Awareness Resources
The following is a selection of useful American Cancer Society breast Health Resources available at
no charge. Check with your local American Cancer Society staff for the most current or additional
resources. All programs must be reported to the American Cancer Society. Useful and current
information, including information about research, email rumors and news items, is also available at
http://www.cancer.org, http://www.asc-txcancer.org, and 1-800-ACS-2345, seven days a week,
twenty-four hours a day.
Quantity
Code
Title/Description
________
BV81
Mammography and You 1999. This 7 minute, 30 second video
emphasizes mammography and ACS screening guidelines. Highly
recommended as one of the lead videos for breast health. All
audiences can benefit.
________
B549
Take Charge of Your Breast Health. (Pamphlet) Promotes the
ACS three-part message on breast health, mammography, clinical
breast examination and breast self examination.
_________
B543
No Simple Solutions, No Easy Answers. This pamphlet describes
the advantages and disadvantages of genetic testing for the breast
cancer gene. May be used to promote use of the related video,
“Informed Consent: Should You Be Tested for the Breast Cancer
Gene” (video Code P-45)
_________
BV45
Informed Consent: Should You Be Tested for the Breast Cancer
Gene? (Video 16:45 min) This video addresses the advantages of
testing against disadvantages; no clear simple solutions, anxiety, cost,
false negatives, potential discrimination. Examines the issues one can
consider for particular situation. A related pamphlet “No Simple
Solutions, No Easy Answers,” Code B543 is also available.
________
BV83
Keep in Touch Mammography and BSE. This video is about the
three-part message on breast health, mammography, clinical breast
examination and breast self examination. Very helpful for outreach to
African American Women.
________
BN3035
Being There! (Pamphlet) Address the breast health concerns of
African-American women, importance of routine mammograms and
breast self-examination, and how African American women can take
charge of their own health.
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Quantity
Code
Title/Description
_________
BV167
Fibrocystic Breasts: A Non Disease. (9 min video) This public
and patient education video stars Linda Carter as narrator and
includes a doctor patient question answer format to explain
fibrocystic breast changes, the importance of BSE, mammography,
and breast health care. Recommend distributing related pamphlet,
(code 534) to program participants.
________
BV167-S
Spanish Fibrocystic Breasts: A Non Disease. (Video 14 minutes)
_________
B501
Breast Health Awareness Training Guide and Flip Chart. This
guide contains resources designed to help individuals present breast
health awareness programs. It is usually usually given out at breast
health awareness training workshops. Includes manual for lay
audience presenters. (See Code B501.01)
_________
B501.02
Certificate: The Texas Breast Health Awareness Training
Program. This 8” x 11” certificate should be given to all who attend
and participate in the Texas Breast Health Awareness Training
Program. “Certificate Awarded To (Name)” qualifies the participant
to present breast health awareness programs to the public
________
B5101.01
Breast Health Awareness Manual for Lay Audience Presenters.
This 23-page manual provides guidance for lay audience presenters
of breast health awareness programs. Manual is provided at time of
training to qualified program presenters.
Not for general
distribution. Includes program content and teaching tips for lay
audiences; resource lists.
________
B506
Breast Health Awareness Bingo Game. A teaching game in
English and Spanish with instructions for presenters and rules for
players. Contains 24 picture cards with health messages to be read
for all to hear. Also contains 20 bingo playing cards. Pre/post
evaluations prove game to be an effective teaching tool.
________
BN8610.97 Breast Cancer Facts and Figures. A useful data resource to be
used by breast cancer detection volunteers and staff.
_________
B1209
Breast Health Awareness Training Course. (Limited to ACS
Trainings for Health Care Professionals) This book is provided to
help prepare health care professionals in teaching other faculty about
breast health. To be distributed to health care professionals at
training workshop; topics include epidemiology and risk factors
associated with breast cancer, anatomy and physiology of the breast,
common benign breast conditions, signs and symptoms of breast
cancer, methods to teach, etc.
________
LB1948.03
Breast Cancer – Early Detection is Worth its Weight in Golden
Years. (Poster) This colorful 18” x 24” poster features multi-ethnic
older women; urges mammography, professional breast exam, and
self-examination. Use to target older audiences.
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Quantity
Code
Title/Description
_________
B517
Questions and Answers about Mammography.
(Bilingual
Pamphlet) Answers questions about mammography and details the
current ACS screening guidelines)
________
B534
Fibrocystic Breasts: A Non-Disease. (Pamphlet) This patient
education pamphlet describes the causes of fibrocystic changes and
addresses the confusion arising out of the condition and how to
distinguish the difference between normal lumps and those that must
be evaluated by a physician. Treatment is explained.
_________
B534-S
Spanish Fibrocystic Breasts: A Non-Disease (Pamphlet)
________
BV208
Teaching Breast Model. This lifelike, hand-held teaching breast
model is available to facilitators for use in teaching breast selfexamination techniques to program participants. The model contains
“lumps” to help participants learn what to be alert for when
performing BSE. It may be ordered on short term loan for scheduled
programs (D208.01 Brown color models)
_________
BV2675.05 Three Ways to Take Special Care of Your Breasts. (Bilingual
Breast Health Card) Highly illustrated educational tool shows how to
do breast self-examinations, urges readers to see a doctor or nurse for
a breast exam, and emphasizes the importance of mammography to
find cancer early.
_________
BN8616
The American Cancer Society’s Commitment to Breast Cancer
Research. This attractive pamphlet explains accomplishments and
highlights key breast cancer research being supported by the
American Cancer Society. Useful for prospective donors.
________
BN3477
8 Things to Expect When You Get Mammogram. This wallet size
card contains a list of practical tips when getting a mammogram,
getting results of the mammogram, and utilizing the Medicare
benefit.
________
B506
Bingo-Loteria Game. A teaching tool designed for use in small
groups (up to 20) to teach breast health awareness, importance of
mammography, clinical examination, and regular breast selfexamination. In bilingual Spanish/English format. (Limited to one
per location)
________
B509
Learn to Give Yourself Breast Self-Examination. This bilingual
pamphlet illustrates the procedures for breast self-examination before
a mirror, lying down, and in the shower. Contains most common
questions/answers about self-examination.
________
B517
Questions and Answers about Mammography. This pamphlet
contains the A-C-S screening guidelines for mammography, answers
key questions: what a mammogram is, benefits, risks, and cost.
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Quantity
Code
Title/Description
________
BN2123
Physician’s Wall Chart on BSE. Highly illustrated 6” x 24 ½”
poster showing the steps to breast self-examination: (1) in the
shower, (2) before a mirror, and (3) lying down.
________
B533
Mamma’s Worst Fear-Fotonovela. Mamma’s worst fear is that
she might have breast cancer. Created to offer cancer prevention and
early detection information to a wide Hispanic audience it is
presented in a Spanish storyboard format and includes discussion
questions.
________
B534
Fibrocystic Breasts: A Non-Disease. This patient education
pamphlet describes the causes of fibrocystic changes and addresses
the confusion arising out of the condition and how to distinguish the
difference between normal lumps and those that must be evaluated
by a physician. Treatment is explained. (B534-S Spanish Version)
________
B540
Breast Cancer Facts Figures. This 12 page booklet is a factual
resource for program planners. Contains information on incidence
trends, mortality trends, demographics, relative survival rates, risks,
how breast cancer is treated and a section on current research. For
limited distribution to program planners/presenters.
________
P45
Informed Consent: Should You Be Tested for the Breast Cancer
Gene? This 16:40 minute video explains advantages of testing,
opportunities for risk management, relief of anxiety balanced by the
disadvantages of testing. No clear simple solutions for one with a
positive test result, cost, potential discrimination.
________
P70
Quality Mammography Can Save Your Life. (Video – 9 min)
This video features easy to follow demonstrations and use of 3-D
graphics and women of a variety of ages and ethnic backgrounds.
Stresses importance of regular mammography as part of 3-part
program for early detection of breast cancer.
________
P33
Keep in Touch. (Video – 11 min) Features an African American
mother/daughter team who discuss the unique breast health needs
and concerns of this target audience. Mammography, clinical breast
examination, and BSE are discussed and demonstrated.
________
P167
Fibrocystic Breasts: A Non-Disease. (Video – 8 min) This public
and patient education video starts Linda Carter as narrator and
includes a doctor/patient using a question/answer format to explain
fibrocystic breast changes, the importance of BSE, mammography,
and breast health care. Recommend distributing related pamphlet
(code B534) to program participants. (Spanish version, PS167, 12
minutes)
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PLEASE COMPLETE THE FOLLOWING INFORMATION AND RETURN WITH
YOUR ORDER TO YOUR AMERICAN CANCER SOCIETY:
Organization: _____________________________________________________________
Contact Person: ___________________________________________________________
Address: ________________________________________________________________
City: _____________________________________ Zip: __________________________
Daytime Telephone: (_____)_________________________________________________
E-mail Address: __________________________________________________________
Date of Program: ___________________________ Expected Audience: ______________
Will you pick up the material? ______ Yes ________ No
Note: Mail orders are shipped fourth class and will take approximately 10–14 days to arrive.
BHA - 48