Breasts (26 page)

Not all of my milk ducts were visible. Some, explained Wynn, had regressed with disuse. That notion made me feel like an expired dairy product. It had only been five years since I last lactated, but already my glandular cells were being replaced by fat cells. (If I get pregnant now, in my early forties, this process would quickly reverse.) This surprised me; I knew breasts grew less dense after menopause, but I didn’t realize this process would be so evident so soon. Wynn pointed to the light parts of screen. “All of this here and here and here and here and here and here is fat,” he said.

To better show me the changes in my breasts over time, he uploaded on the opposite computers the CD my doctor had sent of my previous mammograms. First he pulled up an image from my last mammogram, taken six months earlier. Here the colors were
reversed; glands are white, fat is dark. “The more white, the more dense,” he explained, pointing to a portion of the image. “The fat content in here makes up at least 75 percent of this whole area. It may look denser to the untrained eye because of superimposed parenchyma.” (A quick refresher from chapter 3: the breast is made of three major things: fat, gland, and stroma. The gland is sometimes called ductal, parenchymal, or epithelial tissue. The stroma is the extracellular universe surrounding the gland and supporting it. It includes collagen, growth factors, and proteins and also looks whitish on a mammogram.)

Because of my family history, I got my first baseline mammogram when I was just thirty-three, and got another after I turned forty and was finished with pregnancy and breast-feeding. The point of a baseline is to have something for radiologists to compare with later images. Wynn pulled up my first mammogram. It’s from an older machine, and fuzzier. “You can see there was fat then but there was a lot more white,” he said, pointing to the screen. “And so you’re progressively depositing more fat as the fibroglandular and ductal system atrophies. It’s a good thing you don’t have denser breasts now. For your age, you have tissue that’s appropriately regressing and you have progressively more fatty breast tissue.” In the early film, my ratio of fat to gland was about 40-60 whereas the ratio ten years later was the reverse. The verdict: moderately dense tissue, not high risk.

I don’t love it when people start sentences with “for your age.” But with breasts, the march of time is inexorable. Most women’s breasts are like mine, losing dense tissue as their reproductive years wane. Breasts are considered “very dense” if the gland and stroma remain, taking up 75 percent or more of the breast. No one is sure why some breasts are denser than others, but it tends to be hereditary. There’s a big search on to identify these genes in
the hopes of someday linking them to cancer and targeting them with drugs.

Women tend to have denser breasts if they’ve never had children. Hormones also influence density. Menopausal women taking hormone replacement therapy develop denser breasts almost immediately. If they take tamoxifen (an anti-estrogen drug used in cancer treatment), the mammary gland retreats and gets replaced by fat. Not everyone should start popping tamoxifen, but it proves that drugs can change your breasts, and fast. Some studies show that wine drinkers have denser breasts, as do smokers and women eating high-fat diets. These things may turn on or off genes in ways that promote inflammation, growth, or instability in glandular cells.

In this way, density stands in for breast cancer risk overall. If a woman is postmenopausal, she can reduce her risk by eating well and exercising and by not drinking excessive alcohol or smoking. Unfortunately, though, these gains are small. It appears that by the time a woman reaches menopause, her cancer destiny is mostly laid out by some mysterious combination of her genes, the pattern of growth taken by her breasts, and the accumulated damage (or lack thereof) to her cells over many decades. Menopause is simply the end zone in a long game of chicken between breasts and carcinogens. By this stage of life, it’s too late for a woman to change the things that may have set her down a particular path: the childhood exposures, her reproductive history, the hardiness of her genes. New exposures, such as to hormone therapy, may put her over the edge. But her cells will keep aging no matter what she does, and as they do, they’ll collect more mutations. Most women take hormones without a hitch. The risk—a doubling in deaths from breast cancer—sounds bad, but it is the equivalent of about two additional breast cancers per year for every ten thousand women taking hormones. It’s enough of an effect, though, that when a third of hor
mone users quit following the study results of 2003, the U.S. breast cancer rate noticeably declined.

I was increasingly learning that the whole blame-your-lifestyle approach to understanding breast cancer is problematic. In a way, it presents an excuse not to probe into the deeper reasons for disease. As environmental historian Nancy Langston put it, “Traditional medicine and public health practices have been reductive, focused on individual risk factors for disease.” Instead, she argues, we need a more ecological understanding that explores how genes and the environment interact to compromise our immune system in the first place. Ultimately, we should be asking and answering,
Why
do some women have dense breasts? Is there anything we can do to prevent or lessen the impact once it kicks in?

In lieu of that understanding safeguarding our breasts any time soon, I figure knowing our tissue density can at least help us make more informed decisions about the choices we have left in middle age, but with the knowledge that those choices are imperfect. Women with very dense breasts might want to avoid taking additional hormones if the benefits aren’t worth it for them. They might want to lobby their insurance companies so they can get screened more often, using a greater variety of technologies like the 3-D machine to boost their odds of catching problems. Mammograms might work pretty well for most older women, who tend to have low-density breasts and slow-growing tumors. Even in this group, however, the benefits of early detection are debatable, because it’s likely that many of these tumors would not be lethal. The statistics get more depressing on the effectiveness of mammograms for women between the ages of forty and fifty, who often have more aggressive, fast-growing tumors that are harder to spot. Recall the enormous flare-up in 2009, when the U.S. Preventive Services Task Force reviewed the data and recom
mended against the decades-old policy of women under fifty getting routine mammograms (later, the panel backpedaled to say screening decisions should be made by patients and their doctors).

Here’s the sorry and under-sung fact: mammograms for my age group are lousy. Thanks to time spent in Wynn’s flight deck, I now know why: we still have too much white stuff (the dense glands) that X-rays can’t see through. A 20 percent failure rate is just not good enough. But what especially rankled the task force were the costly false-positives. Better to do none at all, it implied, until your breasts fatten up. That recommendation wasn’t the only blow the task force dealt. There was another that drew far less attention: women should no longer be taught how to perform breast self-examination, known as BSE. Equally disheartening, the task force went on to say there wasn’t even enough evidence to recommend clinical breast examination, the kind performed by your doctor during an annual checkup.

Like many women, I wasn’t liking the options left by the task force. We’ve all heard that early detection can be the key to surviving this disease, at least for some if not all tumors. But how, in women under fifty, is a growing tumor supposed to be detected without mammography or people looking for it? Where I live in Colorado, fully one-third of all breast cancers occur in women under fifty. Put together, these two recommendations meant that we might as well just take up voodoo and buy a Magic 8 ball.

As blogger Leigh Hurst put it, “Wow—are you kidding me? How can this be? A BSE is what saved my life.” Hurst found her tumor when she was thirty-three and has gone on to promote breast self-awareness through a hip website called Feel Your Boobies. It’s a well-recognized fact that most breast cancers are found by women themselves, not by mammograms. Often, this happens by accident, not during a formal search-and-destroy mission.

I learned that the task force’s BSE guidelines were based on two large studies, one in China and one in Russia. Those studies compared women who were taught how to do BSEs and did them, with women who did nothing, and found discouragingly similar death rates from breast cancer. At the same time, the women who performed BSEs found more false lumps.

But a number of other experts have criticized those two studies as flawed, saying, for example, that the women in China received inadequate training and that the Russian study ran out of money for follow-up. Other studies modestly support BSE, including one in Canada, which did find a lower death rate in women who were well trained. A recent study from Duke University found that mammograms, MRIs, and BSEs were equally effective in finding tumors in high-risk women. For women at highest risk of breast cancer, mammography may actually be hazardous, since faulty BRCA genes make breast cells more sensitive to the damage caused by radiation used in the procedure. For these women, BSE might actually be their best option.

The strongest argument against BSE is that it’s difficult to do properly and requires training. For a large population, it’s simply unrealistic, according to Dr. Russell Harris, who served on the U.S. task force and supports the recommendation. But for a motivated individual, BSE could be your best friend. As Lee Wilke, a breast surgeon and the author of the Duke study, told me, “BSE turns out to be only as good as the person doing it.”

I SUDDENLY WANTED TO BE VERY GOOD AT IT. THERE WOULD BE
no more half-assed shower gropings. I was going to learn to do it properly. I bought a fake, silicone boob (forty-eight dollars from
Amazon.com
) and considered where best to stick it on my chest. It wasn’t just any fake boob; this one came with lumps and bumps designed to mimic the nodularity of real breasts. It also came embedded with a number of “tumors,” or harder bits of plastic of various sizes and at various depths. It felt almost disturbingly real, with a squishy nipple and smooth skin. Manufactured by a company called MammaCare, this model was designed to teach women how to perform “tactually accurate” BSEs.

Per the instructions, I lay down and placed the cool falsie below my collarbone, which made me feel like a multi-teated mammal. I popped the accompanying DVD into my laptop, which I perched on my stomach, and prepared to enter the world of low-tech, lastresort cancer detection.

MammaCare is considered the Harvard of BSE trainers. Its squishy silicone booblets are used in the Mayo Clinic and in medical schools throughout the country. Company cofounder Dr. Mark Goldstein told me they were designed in a university lab after almost laughably painstaking research into “pressure load curves of the human breast.” Goldstein is considered a sensory scientist, a man who believes that we can train and use our senses to work like finely calibrated machines. He told me his father ran a metal fabrication company and could judge the correct width of sheet metal within a hundredth of an inch, using his fingertips. One night this man happened to detect a three-millimeter tumor in the breast of his wife (Goldstein’s mother). Most tumors are ten times that size by the time a woman or her partner finds them. Goldstein wanted to create a training program that was simple, thorough, and effective, and that ordinary women could use. He said BSE, performed right, is as accurate as mammography, especially in women under fifty.

“We can take someone who can’t find a marble on a table and teach them to detect a three-millimeter tumor inside a breast,” he said.

I was ready. I pressed play. A no-nonsense woman with an early-1990s hairstyle introduced the concept of the “vertical strip” search pattern. Goldstein calls this “mowing the lawn.” The circles of yesteryear are clearly no longer in favor. Following along with the video, I proceeded to feel up my model along these lines, using the fat pads on my three middle fingers to create a small dime-sized zone. I dutifully applied three pressure depths—surface, medium, and deep—at each spot on the grid. I immediately detected two small, hard “tumors” on the left side and one on the right. During the review a few minutes later, though, I found out that I missed two others, including a big one deep under the nipple. To feel those, I had to press down much more firmly. If my model had been a water balloon, I’d have popped it. I was unsure whether I’d have the guts to press that hard on the real deal, and I was right.

When it was time to trade the model for my own breasts, I could tell right away that things are much more complicated in flesh and blood. If the model represented the geography of rolling tundra, my body felt more like the great Himalayan upthrust, complete with granite, lakes, ice, snow, and the occasional civil war. It was harder to tell what was going on or where a cancer might lurk. And it was harder (and painful) to push down very far through all my natural ropy tissue. If I were to develop cancer, I’d have to hope for shallow tumors. Also, I have to admit, it’s frightening as hell. What
are
all these bumps? And the exam takes some time, about seven glacial minutes per breast when you’re starting out. Discouraged, I called Goldstein to ask for tips. He told me that the more I practice BSE, the better I’ll get at telling what’s normal and what isn’t,
especially if I do the exam at the same time every month, ideally at the beginning of my cycle before the late-month progesterone-hit makes things even knottier in there. “The fingers remember,” he reassured me. “They operate brilliantly, but they need to be used. You can’t sit down at the piano and start playing Mozart.” He also reminded me that having my breasts squished between mammography glass hurts even more. Good point.

I believe Goldstein; I believe that it’s possible and important to learn to do this well. I would like to think I will do BSEs, if not every month, then at least a few times between mammograms. But I also have to acknowledge I was never great at practicing piano, and I recognize I might not be destined for BSE virtuosity. I called William Goodson, a San Francisco–based breast cancer surgeon and researcher and another proponent of BSE. He told me that just getting to know one’s own breast geography is a major accomplishment. For women who can’t bring themselves to conduct the full-on regular BSE, just better breast awareness is a big step. No one knows your breasts like you do. “It’s useful to have a woman become familiar with her breasts, to be aware of any changes. You’ve got to sit down and look at them. And don’t only look for lumps. Many cancers feel like a more irregular area, where the skin doesn’t move right or feel quite right.”