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Sadia Khan

Demystify the process and importance of mammograms with Meri Sehat. Stay proactive in your breast health journey.

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Ismail Munir

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Pap Smear – A Crucial Step Towards Preventing Cervical Cancer

Introduction

After cancers of the mouth and <a href="https://merisehat.pk/disease/breast-cancer">breast cancer</a> of all age groups, cervical cancer is the third most prevalent disease in women under 50. Despite being a preventable disease, it unfortunately often does not receive due attention in Pakistan.&nbsp;Pakistan is in dire need of raising awareness in the masses on this pertinent issue while promoting screening and HPV vaccination.&nbsp; &nbsp;

This is important because invasive cervical cancer has an extremely high fatality rate. Every year, nearly 500,000 women worldwide are diagnosed annually, of which 273,000 women die.&nbsp;The majority of cervical cancer-affected females live in developing nations<a href="#accordion">[1]</a>. It&rsquo;s imperative that these countries practice the WHO policy for prevention with HPV vaccination, and set up scheduled Pap smear screening programs nationwide.&nbsp;

The Pap smear or Pap smear test, which changed how we view cervical cancer, was named after its founder Dr. Georgios Papanikolaou.

<div>&nbsp;</div>

Understanding The Importance Of A Pap Smear Test

A Pap test, also commonly known as a Pap smear, is a procedure the doctor uses to check for cervical cancer in female patients. It can also be used to check for alterations in the cervical cells that would later develop into cancer.

Your cervix&#39;s cells are gently and carefully removed during the procedure and checked for suspicious changes. This procedure takes place in a proper healthcare environment with specialized tools. Although it could be moderately painful, it typically doesn&#39;t result in any permanent pain.

&nbsp;

<ul>
	<li>You will feel more positive and reassured when the results of a Pap test are normal.</li>
	<li>By identifying cervical cell abnormalities, routine Pap screenings assist in prompt treatment and/or exploring reasons for the abnormal cell presentation.</li>
	<li>A Pap test aids in the early detection of cervical cancer before any symptoms even appear. The early detection of cervical cancer makes it more manageable to treat. Also, early diagnosis may result in fewer treatments and a quicker recovery.</li>
	<li>Your probability of survival improves with earlier cervical cancer detection. 
	&nbsp;</li>
</ul>

<ul>
	<li>A Pap test could indicate cervical cell abnormalities even though there are none. This is called a false positive.</li>
	<li>At the other end of the continuum, a Pap test might not find abnormal cervical cells even if they do exist. This is called a false negative.</li>
	<li>Some forms of cervical cancer do not result in death and they don&rsquo;t even impact the quality of life. This identification of cervical cells is called overdiagnosis.</li>
	<li>Several women with cervical anomalies might be recommended for additional examinations or treatment for a disease that might not have progressed to cancer.&nbsp;</li>
</ul>

&nbsp;

A pap smear test&#39;s primary goal is to find precancerous changes, i.e., cellular abnormalities in the cervix that might lead to cervical cancer, whereas the HPV test looks for the human papillomavirus that can cause these changes. These tests can be done separately but it is also possible to test for HPV using a sample from a pap smear. This is called co-testing.

A pap smear can identify cervical cancer cells early, so the individual can begin therapy before the disease spreads and becomes more serious. One of the leading causes of cervical cancer is HPV, which can be acquired during intercourse. While using a condom or another barrier technique when practicing intercourse reduces your risk of catching the virus, nevertheless, all sexually active women should undergo a pap smear every 3 years at least since they risk getting HPV. 
&nbsp;

A pap test shouldn&#39;t be done while you are menstruating. The accuracy of the test is impacted by severe bleeding. Ask your doctor if you can reschedule the test if your test date falls during that time of the month.

Experts advise following these measures 48 hours before your test for the most reliable Pap smear:

<ul>
	<li>Avoid lubrication.</li>
	<li>Abstain from sexual activity.</li>
	<li>Keep sprays and powders away from the vagina.</li>
	<li>Tampons, tablets, creams, suppositories, and other items must not be placed within the vagina.</li>
	<li>Avoid washing the genital region with any liquid, including water, vinegar, or alcohol (douche). 
	&nbsp;</li>
</ul>

The exam is completed at a clinic or your doctor&rsquo;s office. It takes 10-20 minutes. You won&#39;t feel pain during the Pap test, although you might feel a slight pinch or pressure.

&nbsp;

1. As you lay on a table, your feet will be firmly secured in stirrups.

&nbsp;

2. Your doctor will ask you to spread your legs&nbsp;

&nbsp;

3. Then your doctor will gently insert a metal or plastic instrument (speculum) into your vagina. This is when you might feel a sensation of pain and discomfort and it&#39;s best to relax at this stage.

&nbsp;

4. The speculum helps in keeping the walls of the vagina apart to enable a clear view of&nbsp; the cervix.

&nbsp;

5.&nbsp;Samples from your cervix will be taken and your doctor can obtain this sample in a few different ways:

<ul>
	<li>Some doctors use a spatula.</li>
	<li>Some doctors use a brush and a spatula at intervals.</li>
	<li>Some doctors use a cytobrush, which combines the functions of a spatula and a brush.</li>
	<li>Some doctors use a swab.</li>
</ul>

&nbsp;

6. You might experience a small push and discomfort during the sampling.

&nbsp;

7. Your cervix&#39;s sample of cells will be kept intact and transported to a lab to examine the presence of abnormal cells.

&nbsp;

8. After the exam, you might experience some minor scraping discomfort or slight cramping. Additionally, minor vaginal bleeding could occur just after the test. Let your doctor know if pain or bleeding persists beyond the test day. 
&nbsp;

Your test result will arrive at your doctor&#39;s office within a few days. It would either be negative (normal) or positive (abnormal).

&nbsp;

<h5>1. Normal Outcome</h5>

A normal outcome is actually a positive thing. According to your doctor, this indicates that there aren&#39;t any cancerous or precancerous cells on your cervix. Until your next scheduled Pap is due, you won&#39;t require another one.&nbsp;

&nbsp;

<h5>2. Abnormal Outcome</h5>

Your Pap smear test might show abnormal cells due to:

<ul>
	<li>Mild inflammation or minor cell changes (dysplasia)</li>
	<li>HPV or other infection</li>
	<li>Cancer or pre-cancer</li>
	<li>Lab test error</li>
</ul>

&nbsp;

<h5>3. Atypical Squamous Cells Of Undetermined Significance (ASCUS)</h5>

Squamous cells are thin and flat and grow on the surface of a healthy cervix. In the case of ASCUS, the Pap smear reveals slightly abnormal squamous cells, but the changes don&#39;t necessarily suggest that precancerous cells are present.

Your doctor can go for a liquid-based test to reanalyze the sample to check for the presence of viruses known to promote cancer development, such as some types of human papillomavirus (HPV). If no high-risk viruses are present, the abnormal cells found as a result of the test aren&#39;t of great concern. If worrisome viruses are present, you&#39;ll need further testing.

&nbsp;

<h5>4. Squamous Intraepithelial Lesion</h5>

This term indicates that the cells collected from the Pap smear may be precancerous. If the changes are low grade, it means that the cells&#39; size, shape, and other properties indicate that if a precancerous lesion is present, it would take years to develop into cancer. On the other hand, if the changes are high grade, there&#39;s a greater chance that the lesion may develop into cancer sooner; additional diagnostic testing would be necessary in this instance.

&nbsp;

<h5>5. Atypical Glandular Cells</h5>

Glandular cells produce mucus and grow in the opening of your cervix and within your uterus. Atypical glandular cells may appear to be slightly abnormal, but it&#39;s unclear whether they&#39;re cancerous or not. Further testing is needed to determine the abnormal cells&#39; source and significance.

&nbsp;

<h5>6. Squamous Cell Cancer Or Adenocarcinoma Cells</h5>

This result means the cells collected for the Pap smear appear so abnormal that the pathologist is almost certain a cancer is present. &quot;Squamous cell cancer&quot; refers to cancers arising in the flat surface cells of the vagina or cervix. &quot;Adenocarcinoma&quot; refers to cancers arising in epithelial cells. If such cells are found, your doctor will recommend a prompt evaluation.

&nbsp;

<h5>7. Cervical Cancer (Or Pre-Cancerous Stage) 
&nbsp;</h5>

It is important to note that not all positive tests equate to cervical cancer. Additional testing is usually done to rule out other causes before a definitive diagnosis of cervical cancer is made. For example, your doctor can decide to &quot;wait and see&quot; if you experience inflammation or moderate cell abnormalities. Or they could advise that you get a second Pap test in a few months. If the abnormal cells still exist, your doctor might suggest more tests. One of these could be a technique known as colposcopy. 
&nbsp;

A colposcopy is used to diagnose genital warts, cervicitis (inflammation of the cervix), and precancerous changes in the cervix, vulva, and vagina.&nbsp;Similar to the Pap test, a speculum is inserted into your vagina during a colposcopy by your doctor. The colposcope is used to examine the cervix. The device with its particular lens and a strong light enables your doctor to see your cervix more clearly. Your doctor then swabs your cervix with vinegar or another liquid substance, which highlights the suspicious regions. Your doctor can see them due to the colposcope&#39;s lens.

Samples are collected from these suspicious areas (biopsy) and are sent to a lab for additional analysis. Multiple biopsy samples can be taken if there are multiple suspicious areas.&nbsp;

After the colposcopy, if there&rsquo;s any bleeding then the doctor would swab your cervix with a chemical solution to limit the bleeding. 
&nbsp;

If you are anywhere between 21 and 65 years of age, the test should be taken every 3 years.&nbsp;

Starting at age 30, you can decide to get both a Pap test and an HPV test. It is recommended to repeat these combined tests every 5 years instead of 3. Alternatively, women aged 30 and above could also opt for HPV testing instead of the Pap smear, this is because HPV is a known risk factor for cervical cancer.

&nbsp;

Your doctor could advise more frequent Pap tests if you have certain health issues, including:

<ul>
	<li>A diagnosis of cervical cancer or an abnormal Pap smear result&nbsp;</li>
	<li>&nbsp;HIV infection</li>
	<li>&nbsp;A weakened immune system due to chemotherapy, organ transplant, or chronic use of corticosteroids</li>
	<li>&nbsp;Exposure to diethylstilbestrol (DES) before birth</li>
</ul>

Note: Inform your doctor of any of the above conditions when considering getting a Pap smear test done.&nbsp; 
&nbsp;

Pap tests are quite precise. Routine Pap tests decrease the incidence of cervical cancer and associated mortality by at least 80%. Although it could be difficult initially, your health will benefit from the short-time pain you endure during the procedure. The Pap smear process is safe and reliable. However, it&#39;s possible that some aberrant cells or cervical malignancies could be missed by the test (false negative).&nbsp;

Note: Discuss getting a Pap smear test done at your next visit with the doctor.&nbsp;&nbsp;

<div>&nbsp;</div>

<ul>
	<li>In addition to your yearly gynecological checkup, you can schedule a Pap smear separately by calling your gynecologist. Most insurance plans cover Pap smears, but you might have to make a co-payment.</li>
	<li>Your doctor might want to reschedule your Pap smear if you are menstruating on the day of the test because then the results would not be as reliable.</li>
	<li>The day before your test, try to avoid having sex, douching, or using spermicidal products as these could affect your results.</li>
	<li>A Pap smear is typically safe to have in the first 24 weeks of pregnancy. It becomes difficult after that. Additionally, you ought to hold it off until 12 weeks after giving birth to improve the accuracy of your findings.</li>
	<li>Maintaining your composure and breathing throughout the Pap smear procedure is crucial since your body will function more efficiently if you are comfortable.</li>
</ul>

&nbsp;

You and your doctor can mutually decide to discontinue Pap smears.

<ul>
	<li>Ask your doctor if you need to continue obtaining Pap smears after a total hysterectomy, which involves the surgical removal of the uterus and the cervix.</li>
	<li>You might be eligible to stop getting Pap smears regularly if your hysterectomy was done to treat uterine fibroids or another non-cancerous condition.</li>
	<li>However, your doctor could advise continuing routine Pap tests if your hysterectomy was performed because of a precancerous or cancerous disease of the cervix.</li>
	<li>Doctors generally concur that if a woman&#39;s previous tests for cervical cancer were negative, she could think about quitting regular Pap tests when she turns 65.</li>
	<li>Together, you may determine what is best for you based on your risk factors. Your doctor might advise continuous Pap testing if you engage in sexual activity with many partners. 
	&nbsp;</li>
</ul>

Cervical cancer can be screened safely by using a Pap smear. A Pap smear is not 100% accurate, though. False-negative results are possible, which means that even though you have abnormal cells, the test shows no abnormality. False-negative results don&#39;t necessarily indicate that something went wrong.

&nbsp;

The following variables can result in a false-negative outcome:

<ul>
	<li>An Inadequate Collection Of Cells: An insufficient amount of collected cells may give false results.</li>
	<li>A Small Number Of Abnormal Cells: Sometimes a doctor is unable to conclude the results because of an insufficient quantity of collected abnormal cells.</li>
	<li>Blood Or Inflammatory Cells Obscuring the Abnormal Cells: Unknown inflammatory conditions and blood accumulation may cause hindrances in identifying results.</li>
</ul>

&nbsp;

Note: Please remember that if one test doesn&#39;t detect the abnormal cells, the next test most likely will. Hence repeated testing is necessary so that if abnormal cells go undetected in the first test, they will most likely be detected in any of the subsequent tests. Repeated testing is also necessary since cervical cancer takes several years to develop and regular pap smear tests allow for early intervention. 
&nbsp;

Conclusion

The incidence of cervical cancer in Pakistan is lower than in other western countries, but the mortality rate is high due to scarcity of awareness, unavailability of Pap smear tests, lack of follow-up, and late presentation of cervical cancers.To curb the late-stage presentation of the disease, implementation of the screening program on the national level is imperative. This would reduce the burden of disease on the health care sector while saving the lives of countless Pakistani women.Even though some specific dos and don'ts must be followed, Pap smear is still a valuable procedure. Healthcare experts must also encourage patients to take the test by alleviating their fears and anxiety associated with the procedure.&nbsp;

Key Points

<ul><li>The Pap smear test is a quick and effective way to test for cervical cancer in women&nbsp;</li><li>Although the procedure is short, Pap smears can be a little painful and tricky.</li><li>This procedure takes place in a proper healthcare environment with specialized tools.</li><li>Pap tests decrease at least 80% of cervical cancer incidence and mortality.</li><li>Women between 21 and 65 years of age are advised to go for a pap smear every 3 years. However starting from age 30 and onwards, it is possible to get either a combined Pap smear and an HPV test OR HPV testing every 5 years.</li><li>It is important to note that not all positive tests equate to cervical cancer. Additional testing is usually done to rule out other causes before a definitive diagnosis of cervical cancer is made. </li></ul>

[1] Syeda Asma Batool (Department of Zoology, L. C. f. W. U. L. P.)., 2017. JPMA. [Online]

[2] WHO, 2003. WHO. [Online]

Neelam Asad

Humza Khizer

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How Can I Better Support A Breast Cancer Survivor?

In 2020, <a href="https://merisehat.pk/disease/breast-cancer">breast cancer</a> accounted for 28.7% of new cancer cases in Pakistani women of all ages<a href="#accordion">[1]</a>. With the highest incidence in Asia, the country continues to struggle with increasing morbidity and mortality rates, especially among young females<a href="#accordion">[2]</a>.&nbsp;

As per a Pakistani study, 89% of breast cancer patients are diagnosed at a later stage while 59% present at an advanced stage<a href="#accordion">[3]</a>. This delay in diagnosis can reduce survival rates and cause an increased mortality rate among patients. Researchers believe that a lack of awareness and a combination of sociocultural and personal factors contribute to the delay. Furthermore, a delayed diagnosis also translates into a poor prognosis and the need for more aggressive treatments.&nbsp;

Treatments such as chemotherapy, radiation, and mastectomy can affect an individual&#39;s physical and mental health. The fear of side effects of chemotherapy such as loss of hair and eyebrows often causes women to delay seeking help. Moreover, mastectomy is often associated with body image issues that can be extremely challenging in a world where a woman&#39;s attractiveness is solely based on her physical appearance.&nbsp;

However, <a href="https://www.merisehat.pk/disease/breast-cancer">breast cancer</a> can have an implication on the lives of both survivors and their friends and family. Thus, it is important to identify the challenges they face and effectively address them to improve their overall quality of life.&nbsp;

&nbsp;

Understanding How To Support A Breast Cancer Survivor

A UK study looked at more than 50,000 breast cancer survivors and a control group consisting of over 200,000 women with no history of cancer. The results revealed a higher risk of anxiety, depression, fatigue, pain, and sexual dysfunction among the survivors<a href="#accordion">[4]</a>. This is similar to the results of a Pakistani study in which 74% of survivors reported feeling varying levels of anxiety. Moreover, 83% complained of fatigue, 75% of body pain or headache, 77% had reduced appetite, 63% had weight loss, and 77% reported sleep disturbances<a href="#accordion">[5]</a>. The fear of the recurrence of cancer is believed to further add to the anxiety. Thus, breast cancer can take a physical and psychological toll on the survivors.

In a society where physical beauty is often given preference over everything else, it is no surprise that breast surgery can elicit depression and anxiety in breast cancer patients. Across all cultures and countries, including Pakistan, a woman&#39;s breasts are considered a symbol of femininity, sexual beauty, and motherhood. Thus, the physical change associated with breast surgery or mastectomy can significantly lower a woman&#39;s self-esteem<a href="#accordion">[5]</a>. They may develop a negative image of their bodies, leading to lowered self-confidence and mental health problems. Furthermore, hairlessness, loss of eyelashes and eyebrows, and skin discoloration associated with cancer treatment also take a toll on the person&#39;s mental health.&nbsp;

The combination of all these factors may lead to the survivors feeling stigmatized. This can lead to many women never seeking help or talking about their concerns and self-isolation in some cases.&nbsp;

&nbsp;

The following are some of the ways one can help breast cancer survivors with their physical and mental health:

<ul>
	<li>
	<h5>Breast Reconstructive Surgery </h5>
	</li>
</ul>

Many women opt for reconstructive surgery following mastectomy or lumpectomy. A plastic surgeon may use an implant, a flap tissue from another part of the patient&#39;s body, or both to create a breast shape. However, if you don&#39;t want to go for reconstructive surgery, there are other options such as a breast form or prosthesis that one can wear under the bra.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Wigs And Accessories</h5>
	</li>
</ul>

​​​​​​​Women dealing with hair loss can wear a wig, hat, or scarves while they wait for the hair to grow back. Or you may feel comfortable flaunting the baldness which is just a reminder of the challenges you&#39;ve overcome as a survivor.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Cognitive Behavioral Therapy (CBT) </h5>
	</li>
</ul>

​​​​​​​CBT can prove beneficial in treating mental disorders among breast cancer survivors. It can also help them deal with the fear of recurrence.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Acceptance And Commitment Therapy (ACT)</h5>
	</li>
</ul>

​​​​​​​Unlike CBT which aims to change one&#39;s unhealthy thoughts and feelings, ACT teaches skills that help people accept their realities and live with them.

&nbsp;

<ul>
	<li>
	<h5>Mindfulness-Based Therapy</h5>
	</li>
</ul>

​​​​​​​Mindfulness meditation helps people become aware and accepting of their thoughts and feelings, without any judgment. In breast cancer survivors, it can help improve fatigue, stress, and symptoms of depression and anxiety.

&nbsp;

<ul>
	<li>
	<h5>Medication</h5>
	</li>
</ul>

​​​​​​​Some patients may also benefit from anti-anxiety pills and anti-depressants. However, professional help should be sought before starting any medication.

&nbsp;

<h4>"Supporting cancer survivors can lower their stress levels. Head on over to the <a href="https://www.merisehat.pk/page/sehat-scan/" target="_blank">sehat scan</a> to monitor your stress level today!" </h4>

While cancer is a challenging time for the patient, it also takes a toll on one&#39;s family and friends who are helping them through the disease. Moreover, it can often put a strain on people&#39;s relationships with their partners. According to research, anxiety, and depression more commonly affects long-term cancer survivors and their spouses compared to healthy controls<a href="#accordion">[6]</a>.&nbsp;

If a friend or family member is a breast cancer survivor, the following can help you deal with the emotional and psychological toll:

<ul>
	<li>Support Groups - Online or in-person support groups can help people realize that they are not alone. It allows you to talk about your feelings in a safe space and trade advice with others going through similar experiences. There are also many support groups for family members of survivors on social media.&nbsp;</li>
	<li>Couples Therapy - Cancer can often affect one&#39;s personal relationships. Many partners may benefit from couple&rsquo;s therapy to improve their family and marriage relationships.&nbsp;</li>
</ul>

&nbsp;

While a cancer diagnosis and going through treatment is emotionally and physically exhausting, the post-cancer period is often what really tests the person. Both cancer survivors and their family members go through a period of psychological distress. Therefore, there is a need for programs and interventions that target both patients and their caretakers and family. Moreover, early screening breast cancer patients for mental health disorders can also help provide timely intervention and reduce the disease burden.

<ul>
	<li>A combination of physical, cultural, and social factors contributes to a delayed diagnosis of breast cancer among women. This leads to a poor prognosis and the use of aggressive treatments.</li>
	<li>Breast cancer survivors often report fatigue, pain, sleep disturbances, <a href="https://merisehat.pk/disease/depression">depression</a>, and <a href="https://merisehat.pk/disease/anxiety">anxiety</a>. Moreover, post-mastectomy or breast surgery, women report lower self-esteem and body image issues as breasts are considered a symbol of femininity, beauty, and womanhood.&nbsp;</li>
	<li>Breast reconstructive surgery, cognitive behavioral&nbsp;therapy, mindfulness meditation, acceptance and commitment therapy, and medications can help breast cancer survivors improve their overall quality of life.</li>
	<li>Partners of breast cancer survivors also report similar levels of anxiety and depression as them. Therefore, there is a need for effective programs that target both survivors and their families to help provide them timely support.&nbsp;</li>
</ul>

&nbsp;

[1] International Agency for Research on Cancer, 2021. Pakistan Globocan 2020. [Online]

[2] Sohail, S. & Alam, S. N., 2007. Breast cancer in pakistan - awareness and early detection. Journal of the College of Physicians and Surgeons Pakistan, 17(12), pp. 711-2.

[3] Gulzar, F. et al., 2019. Identifying the reasons for delayed presentation of Pakistani breast cancer patients at a tertiary care hospital. Cancer management and research, Volume 11, pp. 1087-1096.

[4] Carreira, H. et al., 2021. Associations between breast cancer survivorship and adverse mental health outcomes: A matched population-based cohort study in the United Kingdom. PLOS Medicine, 18(1).

[5] Azam, M. et al., 2021. An empirical study on quality of life and related factors of Pakistani breast cancer survivors. Scientific Reports, Volume 11.

[6] Mitchell, A. J. et al., 2013. Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis. The Lancet Oncology, 14(8), pp. 721-732.

Nimrah H. Sattar

Medilink Consultant clinic

ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Menopause And Breast Cancer

According to research, in all of Asia, Pakistan has the highest rate of <a href="https://merisehat.pk/disease/side-effects-of-breast-cancer-treatment">breast cancer</a>, with 1 in 9 women at risk of getting diagnosed with breast cancer<a href="#accordion">[7]</a>&nbsp;<a href="#accordion">[6]</a>. This is usually because of the myths associated with the condition. Delayed screening means the cancer is diagnosed when it has advanced and there is little chance of survival.

Understanding the link between Menopause and Breast cancer

Age is one of the major risk factors for developing breast cancer. The likelihood of being diagnosed with a malignant tumor in the breast is greatest between the ages of 45 and 55. Unless an individual has previously undergone chemotherapy, surgeries such as hysterectomy or oophorectomy, or possesses a genetic predisposition to experience early menopause, this is when a natural decline in hormone levels occurs.

The decreased production of estrogen and progesterone leads to irregular menstrual periods before they eventually cease. During this phase, one may experience hot flashes, sexual difficulties, insomnia, memory problems, osteoporosis, and anxiety.

However, menopause itself is not our concern here. Menopause itself is not related to a higher risk of getting cancer. It&rsquo;s the fact that 1 out of 8 cases of breast cancer occur during their lifetime, mostly in women over 50, that&rsquo;s worrisome<a href="#accordion">[8]</a>. This is why the age factor is important &ndash; a girl who starts menstruating before 12 and/or experiences menopause after 55 will have an increased number of ovulations and, thereby, increased exposure to hormones like estrogen.

And then there&rsquo;s the issue of medications or treatments like hormone replacement therapy one may be taking to manage the menopausal symptoms, which increases the risk of breast cancer. 
&nbsp;

While menopause is a risk factor for breast cancer, interestingly, breast cancer can also induce menopause. Treatments like chemotherapy, ovarian suppression (through surgery, hormone therapy, or radiotherapy), and hormone therapy (e.g., anastrozole, exemestane, letrozole, and tamoxifen) cause menopausal symptoms<a href="#accordion">[9]</a>.&nbsp; While each woman reacts differently to therapy, premature menopause due to breast cancer may be permanent (rather than temporary) if they&rsquo;re closer to the natural age of experiencing it. 
&nbsp;

Menopausal signs that are frequently experienced include:

<ul>
	<li>Joint pain</li>
	<li>Night sweats</li>
	<li>Anxiety and irritation</li>
	<li>Mood change</li>
	<li>Heart palpitations</li>
	<li>Change in libido</li>
	<li>Hot flushes</li>
	<li>Changes to hair and skin</li>
	<li>Weight gain, especially around our waist</li>
	<li>Difficulty sleeping</li>
	<li>Memory issues</li>
	<li>Vaginal dryness 
	&nbsp;</li>
</ul>

The onset of these symptoms can be gradual or sudden. It is worth mentioning that not all individuals experience all the listed symptoms, and the severity of symptoms can vary among individuals. 
&nbsp;

The estrogen-driven breast cancers, also known as estrogen-receptor-positive cancers, are a more common occurrence than aggressive cancers. They tend to develop gradually and have a lower mortality rate. In other words, they require less aggressive therapy and have a better outlook and reduced chance of recurrence.

According to studies, if you&rsquo;re overweight or obese post-menopause, you have a 20-60% greater risk of developing breast cancer than those who are lean<a href="#accordion">[10]</a>. This extra fat is the main source of estrogen at that time. It also produces proteins that increase inflammation throughout the body, which causes breast cancer to recur. 
&nbsp;

<h5 style="text-align:justify">Medications</h5>

There are two distinct kinds of drugs, and they both function differently. Aromatase inhibitors (AIs) reduce or halt the body&#39;s production of estrogen, which causes the tumors to die. Tamoxifen prevents estrogen from acting on breast cancer cells.

Both tamoxifen and an aromatase inhibitor can be used to treat postmenopausal individuals with estrogen-positive breast cancer. However, aromatase inhibitors are generally more effective and do not increase the risk of blood clots or uterine cancer<a href="#accordion">[10]</a>. 
&nbsp;

Exercising, a balanced diet, quitting smoking (including avoiding passive smoking) and drinking alcohol, and relieving stress can help breast cancer patients deal with the symptoms. 
&nbsp;

Menopause can be a risk factor for breast cancer and vice versa. However, you can overcome both issues with a balanced diet, a healthy lifestyle, proper checkups, and the right therapy.

[1]Sohail S, Alam SN. Breast cancer in Pakistan-awareness and early detection.

[2] Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. International journal of cancer. 2010 Dec 15;127(12):2893-917

[3] Clemons M, Simmons C. Identifying menopause in breast cancer patients: considerations and implications. Breast cancer research and treatment. 2007 Aug;104:115-20.

[4] Biglia N, Bounous VE, Sgro LG, D'Alonzo M, Pecchio S, Nappi RE. Genitourinary syndrome of menopause in breast cancer survivors: are we facing new and safe hopes?. Clinical Breast Cancer. 2015 Dec 1;15(6):413-20.

[5] De Villiers TJ, Pines A, Panay N, Gambacciani M, Archer DF, Baber RJ, Davis SR, Gompel AA, Henderson VW, Langer R, Lobo RA. Updated 2013 International Menopause Society recommendations on menopausal hormone therapy and preventive strategies for midlife health. Climacteric. 2013 Jun 1;16(3):316-37.

[6] Academic.oup.com.

[7] Khan NH, Duan SF, Wu DD, Ji XY. Better Reporting and Awareness Campaigns Needed for Breast Cancer in Pakistani Women. Cancer Manag Res. 2021;13:2125-2129. Published 2021 Mar 2. doi:10.2147/CMAR.S270671

[8] NHS choices.

[9] Menopausal symptoms and breast cancer. Breast Cancer Now.

[10] Stepko B, En español , español E, 03 O. Dealing with breast cancer after menopause. AARP

Syeda Qurat-ul-Ain

Obesity And Breast Cancer

However, the relationship between <a href="https://merisehat.pk/disease/obesity">obesity</a> and breast cancer is not straightforward. Research indicates that gaining weight as an adult increases the risk, but being overweight since childhood does not have the same effect. Additionally, excess fat around the waist will pose a greater risk than having it around the hips or thighs<a href="#accordion">[1]</a>. 
&nbsp;

Understanding of the link between Obesity and Breast Cancer

A study using BMI and cancer incidence data found that around 37,670 new cases of cancer in men and 74,69 new cancer cases in women between 2011 and 2015 were due to excess body weight (i.e. overweight, obese, or morbidly obese)<a href="#accordion">[2]</a>.

The percentage of cases due to excess weight varied across different types of cancer, with the highest number of cases of liver/gallbladder and endometrial cancers in women and esophageal adenocarcinoma in men. 
&nbsp;

Obesity is a well-established risk factor for various cancers in women. For instance, obese women are at a high risk of developing breast cancer. Moreover, they experience different treatment outcomes due to their body weight.

Both pre-and postmenopausal women are at an increased risk of developing breast cancer due to increased body weight. However, it is believed that this risk may be lower in very young premenopausal women who have no family history of breast cancer and live in developed countries. Nevertheless, obese women, regardless of age, generally have poorer survival rates. 
&nbsp;

Obesity increases the risk of some cancers in the following ways<a href="#accordion">[2]</a>:

<ul>
	<li>Fat tissue produces excess estrogen, which is associated with increased risks of breast, endometrial, ovarian, and some other cancers.</li>
	<li>Obese people usually have increased blood levels of insulin and insulin-like growth factor-1, which is responsible for the development of colon, kidney, prostate, and endometrial cancers.</li>
	<li>Obesity combined with chronic inflammatory conditions, such as gallstones or non-alcoholic fatty liver disease, can cause oxidative stress and increase the risk of the biliary tract and other cancers.</li>
	<li>Fat cells produce hormones called adipokines that can stimulate or inhibit cell growth, with high levels of leptin promoting aberrant cell proliferation and low levels of adiponectin having antiproliferative effects that protect against tumor growth.</li>
	<li>Obesity increases risk through impaired tumor immunity and changes in the mechanical properties of the scaffolding tissue that surrounds developing tumors.</li>
	<li>A poor diet is also linked to obesity since it lacks essential nutrients for maintaining healthy cells and preventing cancer.</li>
	<li>Sedentary behavior and lack of physical activity are associated with an increased risk of obesity and breast cancer.</li>
	<li>Certain genetic factors make individuals more susceptible to obesity and breast cancer.</li>
	<li>Obesity can lead to difficulties in cancer screening and management. For instance, screening for cervical cancer is not very effective in obese women. 
	&nbsp;</li>
</ul>

Note: While obesity is a risk factor for breast cancer, not all obese individuals develop breast cancer. Other factors, such as age, family history, and lifestyle choices, can also influence an individual&#39;s risk of breast cancer. 
&nbsp;

Observational studies suggest that obese people losing excess weight can reduce the risk of certain types of cancer, such as breast, endometrial, colon, and prostate cancers. However, these studies cannot prove that obesity causes cancer, and caution should be exercised in interpreting their findings.

In a study of postmenopausal women, intentional weight loss of more than 5% of body weight was associated with a lower risk of obesity-related cancers, especially endometrial cancer. 
&nbsp;

Bariatric surgery among obese people, particularly women, was associated with reduced risks of cancer overall, hormone-related cancers, and obesity-related cancers such as postmenopausal breast cancer, endometrial cancer, and colon cancer.

Nevertheless, more research is needed to fully understand the relationship between weight loss and the risk of cancer among obese people<a href="#accordion">[2]</a>. 
&nbsp;

Losing weight can improve overall health:

<ul>
	<li>Reduces risk of chronic diseases, such as type 2 diabetes, heart disease, and certain types of cancer</li>
	<li>Lowers blood pressure and improves cholesterol levels</li>
	<li>Decreases strain on joints, hence, reducing pain and improving mobility</li>
	<li>Improves sleep quality and reduces the risk of sleep apnea</li>
	<li>Improves mood and decreases risk of depression and anxiety</li>
	<li>Increases energy levels and improves physical performance</li>
	<li>Reduces risk of pregnancy complications and infertility</li>
	<li>Improves immune function and reduces inflammation</li>
	<li>Improves brain function and cognitive performance 
	&nbsp;</li>
</ul>

An effective way to reduce weight includes a combination of a healthy diet, regular exercise, and lifestyle changes. Here are some specific tips that can help<a href="#accordion">[3]</a>:

Eat A Balanced And Nutritious Diet: It&rsquo;s important to eat a balanced diet, which includes plenty of fruits and vegetables, whole grains, lean proteins, and healthy fats. Avoid processed and high-calorie foods.

Control Portion Sizes: Use smaller plates and cups, and measure the portions to avoid overeating.

Stay Hydrated: Drink plenty of water and avoid sugary drinks.

Exercise Regularly: At least 30 minutes of moderate-intensity exercise every day, such as brisk walking, cycling, or swimming, is recommended.

Be Active: Find ways to stay active throughout the day. For instance, take the stairs instead of the elevator or walk during lunch breaks.

Get Enough Sleep: Aim for at least 7-8 hours of sleep every night, as lack of sleep can affect weight loss.

Manage Stress: Stress can contribute to weight gain, so find ways to manage stress, such as meditation or deep breathing exercises.

Seek Support: A registered dietitian or a personal trainer can help develop a personalized weight loss plan and provide support and accountability. 
&nbsp;

Obesity has been linked to an increased risk of breast cancer in postmenopausal women. This is thought to be because adipose tissue produces estrogen, which can promote the growth of estrogen-sensitive breast cancer cells. Additionally, obesity can lead to chronic inflammation and insulin resistance; both increase the risk of breast cancer. 
&nbsp;

However, the relationship between obesity and breast cancer is complex and not fully understood. Other factors, such as age, family history of breast cancer, and hormone therapy use, can also affect a woman&#39;s risk of developing breast cancer. Therefore, women should maintain a healthy weight and engage in regular physical activity to reduce their risk of breast cancer and other health problems. Additionally, regular breast cancer screening, such as mammograms, can help detect breast cancer early when it is most treatable. 
&nbsp;

Key Takeaways

<ul>
	<li>Obesity is a major risk factor for breast cancer, especially in postmenopausal women.</li>
	<li>Excess body fat can cause hormonal imbalances that increase the risk of breast cancer.</li>
	<li>Obesity can also lead to inflammation, which can promote the development of breast cancer.</li>
	<li>Obese women are more likely to have larger tumors and more aggressive forms of breast cancer.</li>
	<li>Obesity can reduce the effectiveness of breast cancer treatment and increase the risk of recurrence.</li>
	<li>Losing weight can reduce the risk of developing breast cancer in postmenopausal women.</li>
	<li>Maintaining a healthy weight through a balanced diet and regular exercise can reduce the risk of breast cancer.</li>
	<li>Obese women may have difficulty detecting breast cancer through self-examination or mammography.</li>
	<li>Breast cancer survivors who are overweight or obese have a higher risk of recurrence and lower survival rates.</li>
	<li>Addressing obesity through lifestyle changes and medical interventions can improve overall health and reduce the risk of breast cancer. 
	&nbsp;</li>
</ul>

[1] How your weight may affect your risk of breast cancer. American Cancer Society.

[2] Obesity and cancer fact sheet. National Cancer Institute.

[3] Health effects of overweight and obesity. Centers for Disease Control and Prevention.

[4] Clinics in oncology research article.

Sarah Mhowwala

Is A Family History Of Ovarian Cancer A Risk Factor For Breast Cancer?

Inherited mutations in the BRCA1 and BRCA2 genes are known to increase the risk of both breast and ovarian cancers. About 3% of breast cancers and 10% of ovarian cancers are caused by inherited mutations in these genes1. Other inherited mutations can also increase the risk of developing breast and ovarian cancers, but BRCA1 and BRCA2 are the most common.

Even though breast cancer is more common in women, men with these mutations are also at an increased risk of developing breast cancer. Additionally, BRCA mutations can also increase the risk of pancreatic cancer and, in men, high-grade prostate cancer.

Genetic counseling and testing can help you determine if you are at increased risk for these cancers and allow you to take steps to prevent them or detect them earlier when they are more treatable.

This article explores the link between breast and ovarian cancer, and how your family health history can help you assess your risk for these cancers. 
&nbsp;

Understanding the link between Ovarian Cancer and Breast Cancer

Ovarian cancer is a term used to describe a group of diseases that begin in the ovaries, fallopian tubes, or the peritoneum, which is the lining of the abdominal cavity.

In women, the reproductive system includes two ovaries in the pelvis, one on each side of the uterus. Ovaries don&rsquo;t just produce eggs. They are also responsible for the female sex hormones estrogen and progesterone, which play an important role in the development of female reproductive organs and the regulation of the menstrual cycle.

Ovarian cancer affects their ability to function properly and causes a range of symptoms, including abdominal pain, bloating, and changes in bowel habits. Successful treatment and survival depend on early detection and treatment of cancer. 
&nbsp;

Hereditary Breast and Ovarian Cancer (HBOC) is a genetic condition that is passed down from one generation to another within a family. It is caused by mutations in two genes, called BRCA1 and BRCA<a href="#accordion">[2]</a>. 
&nbsp;

These genes play a crucial role in regulating the growth and repair of cells in the body, including breast and ovarian cells. Women who carry a harmful mutation in either BRCA1 or BRCA2 have an increased risk of developing breast and ovarian cancers during their lifetime.

The risk of developing breast cancer is estimated to be between 40-85% for women with a BRCA1 mutation. BRCA2 carriers have about the same risk of breast cancer<a href="#accordion">[2]</a>. The risk of developing ovarian cancer is 39-44% for BRCA1 mutations and 11-17% for BRCA2 mutations<a href="#accordion">[3]</a>. 
&nbsp;

HBOC is usually considered in case of a personal or family history of any of the following:

<ul>
	<li>Women diagnosed with breast cancer at the age of 45 or younger</li>
	<li>Women diagnosed with breast cancer at the age of 46-50 or younger, along with at least one close blood relative with breast cancer at any age or limited family history</li>
	<li>Women diagnosed with triple negative breast cancer at the age of 60 or younger</li>
	<li>Men diagnosed with breast cancer at any age</li>
	<li>Individuals diagnosed with ovarian, fallopian tube, or primary peritoneal cancer</li>
	<li>Individuals diagnosed with cancer in both breasts</li>
	<li>Individuals diagnosed with pancreatic cancer or <a href="https://merisehat.pk/disease/prostate-cancer">prostate cancer</a> with a Gleason score of 7 or higher</li>
	<li>Individuals with a family history of breast, ovarian, pancreatic, or prostate cancer among multiple blood relatives</li>
	<li>Individuals with Ashkenazi (Eastern European) Jewish ancestry</li>
	<li>Individuals with a known BRCA mutation in the family 
	&nbsp;</li>
</ul>

Individuals at high risk should consider genetic counseling and testing to determine if they carry a harmful mutation in one of these genes, and to explore options for managing their cancer risk, such as increased surveillance or risk-reducing surgeries. 
&nbsp;

Yes, women with a family history of ovarian cancer should consider undergoing breast cancer screening at an earlier age than women without a family history.

The American Cancer Society recommends that women with a family history of breast or ovarian cancer consider genetic counseling and testing to determine if they have a higher risk of developing cancer<a href="#accordion">[4]</a>. 
&nbsp;

Women with a BRCA1 or BRCA2 mutation have the following screening options:

<ul>
	<li>Monthly breast self-examinations beginning at 18 years</li>
	<li>Bi-annual clinical breast examinations beginning at 25 years</li>
	<li>Annual MRI scans of both breasts between ages 25 and 29</li>
	<li>Annual breast MRI and mammogram between ages 30 and 75</li>
	<li>Bi-annual pelvic exam, a transvaginal ultrasound, and CA-125 blood test beginning at age 30-35</li>
	<li>Prophylactic salpingo-oophorectomy between ages 35 and 40 and after the woman is done giving birth to children 
	&nbsp;</li>
</ul>

Men with a BRCA1 or BRCA2 mutation have the following screening options:

<ul>
	<li>Monthly breast self-examinations beginning at 35 years</li>
	<li>Annual clinical breast examinations beginning at 35 years</li>
	<li>Baseline mammogram beginning at age 35 (in case of BRCA2 mutation along with gynecomastia)</li>
	<li>Annual prostate cancer screening, PSA blood test, and digital rectal exam beginning at 45 years 
	&nbsp;</li>
</ul>

Note: Talk to your doctor about your screening options as each person is different and also because, with new methods being developed, these options may change over time. 
&nbsp;

The following lifestyle changes can help reduce the risk of breast cancer in women with a family history of ovarian cancer<a href="#accordion">[5]</a>: 
&nbsp;

<h5>Maintaining A Healthy Weight</h5>

Studies have shown that women who are overweight or obese are more likely to develop breast cancer, particularly after menopause. Therefore, women with a family history of ovarian cancer should maintain a healthy weight through a healthy diet and regular exercise. 
&nbsp;

<h5>Sticking With Your Exercise Program</h5>

Regular physical activity can help reduce the risk of breast cancer in women, including those with a family history of ovarian cancer. Studies have shown that women who engage in regular physical activity have a lower risk of developing breast cancer than those who lead a sedentary lifestyle. It is recommended that women engage in at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity exercise per week. 
&nbsp;

<h5>Quitting Alcohol</h5>

Alcohol consumption has been linked to an increased risk of breast cancer. Women with a family history of ovarian cancer should quit alcohol to reduce their risk of breast cancer. 
&nbsp;

<h5>Eating A Healthy Diet</h5>

A healthy diet, which is rich in fruits, vegetables, and whole grains, may help reduce the risk of breast cancer. Additionally, it is recommended that women limit their intake of processed and red meats to further reduce their risk. 
&nbsp;

Note: These lifestyle changes may not eliminate the increased risk associated with a family history of ovarian cancer. However, they can still be beneficial in reducing the risk of breast cancer and improving overall health. 
&nbsp;

A family history of ovarian cancer is a risk factor for breast cancer. Women with a first-degree relative (mother, sister, or daughter) with ovarian cancer have a higher risk of developing breast cancer than women without a family history. Additionally, women with a family history of both breast and ovarian cancer have an even higher risk of developing breast cancer. 
&nbsp;

Women with a family history of ovarian cancer need to undergo breast cancer screening at an earlier age and consider genetic counseling and testing to determine if they have a higher risk of developing cancer.

While lifestyle changes such as maintaining a healthy weight, engaging in regular physical activity, and quitting alcohol can help reduce the risk of breast cancer, they may not eliminate the increased risk associated with a family history of cancer. Therefore, early detection through regular screening and genetic counseling is important to manage the risk of breast cancer in women with a family history of ovarian cancer. 
&nbsp;

<ul>
	<li>Family history of ovarian cancer is a risk factor for breast cancer. Women with a first-degree relative with ovarian cancer have a higher risk of developing breast cancer than women without a family history.</li>
	<li>Women with a family history of both breast and ovarian cancer have a higher risk of developing breast cancer.</li>
	<li>Women with a family history of ovarian cancer should consider undergoing breast cancer screening at an earlier age than women without a family history.</li>
	<li>Early detection through regular breast cancer screening and genetic counseling is important to manage the risk of breast cancer in women with a family history of ovarian cancer. 
	&nbsp;</li>
</ul>

[1] The BRCA1 and BRCA2 genes. Centers for Disease Control and Prevention.

[2] Pruthi S, Gostout BS, Lindor NM. Identification and Management of Women With BRCA Mutations or Hereditary Predisposition for Breast and Ovarian Cancer. Mayo Clin Proc. 2010;85(12):1111-1120. doi:10.4065/mcp.2010.0414

[3] Walker M, Jacobson M, Sobel M. Management of ovarian cancer risk in women with BRCA1/2 pathogenic variants. CMAJ. 2019;191(32):E886-E893. doi:10.1503/cmaj.190281

[4] Hereditary breast and ovarian cancer. Cancer.Net

This article or video has been vetted and verified by Meri Sehat’s specialists. It contains citations and research from validated sources.

Breast Self-Exam: The Hows and Whys

In Pakistan, 1 in every 9 women is at risk of developing <a href="https://www.merisehat.pk/disease/breast-cancer">breast cancer</a><a href="#accordion">[1]</a>.. Moreover, breast cancer is also the most frequent cancer among both men and women in the country, accounting for 14.5% of new cases in 2020<a href="#accordion">[2]</a>. Moreover, the country continues to have a high mortality rate from the disease.&nbsp; 
&nbsp;

Developing countries like Pakistan, despite the lower incidence, have a higher morbidity and mortality rate of breast cancer than developed Western nations. This contrast is due to a myriad of reasons namely: less number of screening and treatment facilities, women are often unaware of <a href="https://www.merisehat.pk/disease/breast-cancer">breast cancer symptoms</a> or treatments and delay seeking help. As a result, many are diagnosed at a later stage and have higher mortality rates. The situation can be reversed with increasing awareness and the widespread availability of&nbsp; breast cancer screening programs.&nbsp; 
&nbsp;

Although mammograms can help detect breast cancers even before one feels a lump, breast self-exams allow you to become more familiar with the anatomy of your breasts and identify any changes.&nbsp;

&nbsp;

Understanding how to perform a self breast exam

Before you begin a breast self-exam, it is always good to discuss the correct technique with a doctor and ask for a demonstration. 
&nbsp;

Since hormonal changes can cause breast changes, a breast self-exam should be conducted a few days after the end of your menstrual cycle. However, post-menopausal women can choose any day of the month. The exam should be done while standing and lying down. It typically begins with a visual inspection.&nbsp; 
&nbsp;

<ul>
	<li>Look In The Mirror: The first step of a breast self-exam is to stand in front of a mirror without your shirt and bra and look for any changes. The arms should be hanging by the sides while you assess the breasts for any swelling, skin changes, nipple changes, dimpling of the skin, redness, or nipple discharge. The same should be repeated with the arms raised overhead. Next, press your hands firmly on your hips to flex the chest muscles as you examine for any breast changes. Remember to visually inspect both the breasts. 
	&nbsp;</li>
	<li>In The Shower: Lathering the fingers with soap and water helps them glide better over the skin. Using the pads of your three middle fingers, press with different levels of pressure on each part of the breast and feel for any lumps or thickening. Next, massage the fingers in a circular motion as you move from one spot to another. The last step is to squeeze the nipples and check for any discharge. The entire breast should be examined from the collarbone to the armpit. You can use the right hand for the left breast and vice versa.&nbsp; 
	&nbsp;</li>
	<li>Lying down: The same steps should be repeated while lying down on the back with one arm under the head. In all positions, it is important to check under the areola and the armpit.&nbsp;</li>
</ul>

&nbsp;

The following signs and symptoms are often associated with breast cancer: 
&nbsp;

<ul>
	<li>painless lump near the breast or underarm</li>
	<li>the skin over the breast thickens or becomes red</li>
	<li>breast swells, becomes painful, or develops a pitted appearance like an orange peel</li>
	<li>a recent change in nipples (become inverted)</li>
	<li>nipples or areola become scaly, sore, or develop a rash</li>
	<li>bloody or clear nipple discharge 
	&nbsp;</li>
</ul>

Don&#39;t panic if you feel a lump or find any other abnormality. Several conditions can also cause breast lumps such as fibroadenoma, and fibrocystic breast disease, both of which are benign. However, do not ignore the lump and instead make an appointment with an expert to gain a professional diagnosis. 
&nbsp;

<h4>"An early diagnosis is vital to improving one’s quality of life. Head on over to our <a href="https://www.merisehat.pk/page/sehat-scan/" target="_blank">sehat scan</a> and check your stress level today!" </h4>

In Pakistan, 1 in 4 cases of hereditary breast cancer and 1 in 5 cases of male breast cancer is a result of the BRCA1/2 gene mutation<a href="#accordion">[3]</a>,&nbsp;Moreover, women with a BRCA gene mutation also have a higher risk of ovarian and other cancers. On the other hand, men with genetic changes are at a higher risk of prostate and other cancers. Therefore, if a family member has a gene mutation or a history of breast cancer, it is best to consult a genetic counsellor. They might suggest genetic testing to look for various gene mutations associated with breast cancer.&nbsp;

According to the American Cancer Society, the 5-year survival rate for all women diagnosed with breast cancer is almost 91%<a href="#accordion">[4]</a>. However, the survival rates are highly dependent on the stage one is diagnosed at, the type of cancer, the person&#39;s age, and several other factors. Early-stage diagnosis can help increase the five-year survival among these patients. Although the ACS does not recommend breast self-exams for cancer detection, researchers predict that a simple breast exam can detect around 60% of cases<a href="#accordion">[5]</a>. Hence, women are often advised to conduct regular breast self-exams to reduce their risk of delayed diagnosis. 
&nbsp;

In Pakistan, most women are unaware of breast self-exams. A study done in Islamabad, among newly diagnosed breast cancer patients, found that none of the patients with stage III and IV cancer had any concept of self-exams<a href="#accordion">[6]</a>. A lack of knowledge among women is one of the major reasons behind these statistics. Therefore, there is a need for widespread breast cancer awareness programs for women to reduce the disease burden among the population. 
 
&nbsp;

<ul>
	<li>In Pakistan, breast cancer is the most frequent cancer among both men and women and accounted for 14.5% of all new cancer cases in 2020.</li>
	<li>Breast self-exams can help women understand their breasts better and timely identify any pre-cancerous changes. The examination should be done monthly while standing and lying down.</li>
	<li>While conducting a breast self-exam, one should look out for signs such as a painless lump near the breast or armpit, skin changes, breast swelling or redness, nipple changes, and any bloody nipple discharge.&nbsp;</li>
	<li>The majority of women in Pakistan are unaware of breast self-exams or breast cancer symptoms; therefore, there is a need for effective screening and health awareness programs for the population.&nbsp;</li>
</ul>

&nbsp;

[1].Sohail, S. & Alam, S. N., 2007. Breast cancer in pakistan - awareness and early detection. Journal of the College of Physicians and Surgeons Pakistan, 17(12), pp. 711-2.

[2].International Agency for Research on Cancer, 2021. Pakistan Globocan 2020.

[3].Rashid, M. U. et al., 2019. Spectrum and prevalence of BRCA1/2 germline mutations in Pakistani breast cancer patients: results from a large comprehensive study. Hereditary Cancer in Clinical Practice, 17(27).

[4].American Cancer Society, n.d. Breast Cancer Facts & Figures 2019-2020. , Atlanta: American Cancer Society.

[5].Weiss, N. S., 2003. Breast cancer mortality in relation to clinical breast examination and breast self-examination. The Breast Journal, Volume 9, pp. 86-9.

[6].Manzoor, A., Waqar, S. H., Janjua, A. & Shah, S. A., 2017. Breast Self-Examination Knowledge and Practice Among Newly Diagnosed Patients of Carcinoma Breast. J. Soc. Obstet. Gynaecol. Pak., 7(3).

Breast Cancer Prognosis (By Stage)

Understanding the prognosis of <a href="https://merisehat.pk/disease/breast-cancer">breast cancer</a> is crucial for patients and their healthcare providers, as it helps guide treatment decisions. The prognosis varies greatly based on the stage at which the cancer is diagnosed, considering factors like tumor size, lymph node involvement, and molecular characteristics. 
&nbsp;

Understanding Breast Cancer Prognosis by Stage

Breast cancer staging is a critical process that helps categorize the extent of the disease. The stages range from 0 to IV, each indicating the size of the tumor and its potential spread to nearby lymph nodes or distant organs.<a href="#accordion">[1]</a> 
&nbsp;

<ul>
	<li>Stage 0: Ductal Carcinoma In Situ (DCIS)</li>
</ul>

Cancer cells are confined to the milk ducts and have not invaded surrounding tissues at this stage. The prognosis for DCIS is usually excellent, with a very low risk of recurrence after appropriate treatment.

<ul>
	<li>Stage I: Early-Stage Invasive Breast Cancer</li>
</ul>

The tumor is small and has not spread beyond the breast. The prognosis is often favorable, with a high chance of successful treatment and long-term survival.

<ul>
	<li>Stage II: Locally Advanced Invasive Breast Cancer</li>
</ul>

Stage II is divided into IIA and IIB, with varying tumor sizes and lymph node involvement. Prognosis can vary, but timely and comprehensive treatment can significantly improve outcomes.

<ul>
	<li>Stage III: Advanced Invasive Breast Cancer</li>
</ul>

Stage III breast cancer is locally advanced and may involve multiple lymph nodes. It&rsquo;s relatively more challenging to treat. However, advancements in therapies have improved survival rates for patients with Stage III disease.

<ul>
	<li>Stage IV: Metastatic Breast Cancer</li>
</ul>

At Stage IV, cancer has spread to distant organs. While metastatic breast cancer is not curable, ongoing treatments and personalized approaches can extend survival and maintain quality of life. 
&nbsp;

Several factors impact breast cancer prognosis, including:

<ul>
	<li>Tumor Size</li>
</ul>

Larger tumors often indicate a more advanced stage and a potentially worse prognosis. Early detection and treatment play a crucial role in improving outcomes.

<ul>
	<li>Lymph Node Involvement</li>
</ul>

Cancer that has spread to nearby lymph nodes suggests a higher risk of metastasis, influencing prognosis and treatment decisions.

<ul>
	<li>Hormone Receptor Status</li>
</ul>

Hormone receptor-positive tumors respond well to hormone therapy, which can positively affect prognosis.<a href="#accordion">[2]</a>

<ul>
	<li>HER2 Status</li>
</ul>

In the case of HER2-positive or HER-2 tumors, targeted therapies can help improve outcomes.

<ul>
	<li>Treatment Options</li>
</ul>

The prognosis for breast cancer is also closely tied to the treatment approach. Common modalities include surgery, chemotherapy, radiation therapy, hormone therapy, and targeted therapy. 
&nbsp;

Survivorship is an essential aspect of breast cancer prognosis. Advances in treatments and supportive care have led to increased survival rates and improved quality of life for patients post-treatment. 
&nbsp;

The term &ldquo;prognosis&rdquo; refers to the expected outcome of a disease. In the case of cancer, most doctors discuss 5-year survival rates with their patients to discuss their prognosis. This does not mean the person will survive only for 5 years. It implies that certain research studies have followed people for 5 years.

While breast cancer is challenging to live with, the good news is that the condition has one of the highest 5-year survival rates compared to other cancers, given that it&rsquo;s diagnosed early. However, these numbers don&rsquo;t predict what will happen to you. The outlook is different for everyone and depends on a lot of other factors.

Don&rsquo;t be afraid to have an open conversation with your doctor. The survival rates have improved so much over the past few years. More people now have a better understanding of the disease and, from screening to treatment options, are adopting a positive approach to it regardless of the stage of cancer. 
&nbsp;

<ul>
	<li>Breast cancer prognosis varies significantly by stage and individual characteristics.</li>
	<li>Early detection, personalized treatment plans, and ongoing research play pivotal roles in improving outcomes.</li>
</ul>

[1] Breast Cancer Stages. (2021). American Cancer Society.

[2] Breast Cancer Treatment (PDQ) - Health Professional Version. (2021). National Cancer Institute.

Staff Writer

Nipple Discharge

While it sounds strange, nipple discharge is actually an occurrence that affects both males and females. However, it affects women more than men, with 50-80% of women experiencing it during their reproductive years<a href="#accordion">[1]</a>.

It is the third most frequent breast complaint, after breast pain and breast mass. 97% of cases have a benign origin and nearly 6.8% of cases in women are referred to a breast surgeon<a href="#accordion">[1]</a>. 
&nbsp;

Understanding the causes of nipple discharge

The most common types of nipple discharge are: 
&nbsp;

<ul>
	<li>Milky Discharge - The most prevalent kind of nipple discharge. This occurs in women for various reasons. For instance, if you&rsquo;re a premenopausal woman experiencing hormonal changes or if you&rsquo;ve recently stopped breastfeeding, you&rsquo;ll most likely get a milky discharge.</li>
	<li>Bloody Discharge - Blood discharge can be induced by a papilloma, a noncancerous tumor that can agitate the tissue on the inside of a breast duct. However, this occurs only in rare circumstances.</li>
	<li>Clear Discharge - Bloody or clear nipple discharge can be an indication of breast cancer, particularly if it originates from a single breast. Individuals experiencing nipple discharge related to cancer often detect a lump on the affected breast as well. Clear discharges can happen in papilloma too.</li>
	<li>Green-Tinged Discharge - This mostly indicates that there&rsquo;s a cyst beneath the areola or nipple which is draining.</li>
	<li>Brown Or Cheese-Like Discharge - This is a sign of mammary duct ectasia, which is a blocked milk duct. 
	&nbsp;</li>
</ul>

Please Note: Seeking medical consultation is essential for any nipple discharge. At the very least, it can aid in the early detection of underlying conditions or help exclude potential diseases<a href="#accordion">[2]</a>. 
&nbsp;

Common causes of normal nipple discharge are: 
&nbsp;

<ul>
	<li>Pregnancy - During the early stages of pregnancy, women often have clear discharge coming from their nipples. In later stages, the discharge becomes watery or milky.</li>
	<li>Ending Breastfeeding - A milk-like fluid continues to be discharged from the breasts for a while after discontinuing breastfeeding. This can go on till 2-3 years after breastfeeding is stopped.</li>
	<li>Stimulation - Nipple discharge due to arousal is common. Natural nipple discharge can also happen when the bra rubs against the nipples frequently or when the individual engages in strenuous exercise like jogging.</li>
	<li>Hormones - Nipple discharge occurs due to fluctuation of hormones during menstruation<a href="#accordion">[1]</a>. 
	&nbsp;</li>
</ul>

Please Note: Seeking medical consultation is essential for any nipple discharge. At the very least, it can aid in the early detection of underlying conditions or help exclude potential diseases. 
&nbsp;

Common causes of abnormal nipple discharge are: 
&nbsp;

<ul>
	<li>Fibrocystic Breast Changes - The term &quot;fibrocystic&quot; describes the growth or presence of fibrous tissue and cysts. In this case, your breast tissue will develop lumps or thicken as a result of fibrocystic alterations and these alterations will occasionally result in the emission of clear,&nbsp;yellow, white,&nbsp;or green nipple discharge in addition to pain and itching. However, they do not suggest malignancy.</li>
	<li>Galactorrhea - You might have galactorrhea if you have a milky nipple discharge even though you are not pregnant or breastfeeding. Relax, this is not a disease. There can be multiple reasons for this condition, including:</li>
</ul>

<ol>
	<li>Tumors of the pituitary gland</li>
	<li>Medications, like psychotropic drugs or certain hormones</li>
	<li>Herbs, such as fennel or anise</li>
	<li>Hypothyroidism</li>
	<li>Illegal drugs, like marijuana</li>
</ol>

<ul>
	<li>Infection - Pus-filled nipple discharge is a sign that your breast is infected. You will also notice that your breast is tender, red, or heated to the touch if you have an infection or abscess there. This inflammation of breast tissue that occasionally involves infection is known as mastitis. Even though the condition is typically diagnosed in nursing mothers, it can also occur if you are not nursing.</li>
	<li>Mammary Duct Ectasia - It is the second most common reason for abnormal nipple discharge. It typically happens to women who are near menopause. The condition will cause inflammation and blockage of the ducts below your nipple. When these ducts are blocked, it can cause an infection, which will present as a thick, green nipple discharge.</li>
	<li>Intraductal Papilloma - These are benign or noncancerous tumors in the breast&#39;s ducts. They are the most frequent cause of abnormal nipple discharge in women. When inflamed, intraductal papilloma will cause a bloody or sticky kind of nipple discharge<a href="#accordion">[3]</a>. 
	&nbsp;</li>
</ul>

Nipple discharge is also possible in men. Some of the most common causes are:

<ul>
	<li>Deficiency of testosterone</li>
	<li>Gynecomastia, i.e., breast enlargement or tenderness</li>
	<li>Pituitary tumor</li>
	<li>Breast cancer</li>
</ul>

Nipple discharge is less common in men. Hence, they should see a doctor when and if they experience it. 
&nbsp;

Yes, you read it right &ndash; nipple discharge can also occur in babies! But don&rsquo;t be alarmed; the condition is usually NOT a cause for concern.

Nipple discharge in newborns is often related to the mother&#39;s hormones that they are exposed to during pregnancy and childbirth. Irrespective of gender, the baby will most likely have swollen breast tissue and will experience discharge from their nipples due to the presence of hormones in the mother&#39;s body, particularly estrogen. These hormones tend to stimulate the baby&#39;s breast tissue, causing it to become enlarged and sometimes produce milk.

An older name for this condition is &ldquo;witch&rsquo;s milk&rdquo; because people of the 17th century believed that witches would come and steal this milk from the baby to use in black magic! So, elders would squeeze the fluid out themselves to prevent that from happening. The practice continued until the 19th century when doctors began to discourage it as it would often result in abscesses and inflammation. Thank God for science, right?

A more medical name for the condition is neonatal galactorrhea, and it is usually harmless and goes away on its own within a few weeks to months after birth. However, parents should consult a healthcare provider if they notice any unusual or persistent symptoms, such as redness, warmth, or tenderness in the breast area, or if the discharge is accompanied by a fever<a href="#accordion">[4]</a>. 
&nbsp;

According to the International Journal of Preventive Medicine, nipple discharge can be a symptom of breast cancer. According to the same study, 7-15% of women who report nipple leakage with an unclear origin tend to develop breast cancer.

The most frequently identified diseases in women with malignant nipple&nbsp;discharge are ductal carcinoma in situ or papillary carcinoma.

Another rare kind of cancer that could result in nipple discharge is Paget&rsquo;s disease of the breast, a condition that develops in the ducts of the breasts and later moves to the nipple. 
&nbsp;

Note:&nbsp;If your doctor is unable to identify a clear benign underlying cause for nipple discharge, they&nbsp;will usually propose an imaging scan to confirm the absence of a possibly malignant lesion<a href="#accordion">[2]</a>. 
&nbsp;

Doctors use the patient&rsquo;s medical history and physical exam to diagnose nipple discharge. Some tests that are useful in diagnosing the cause of nipple discharge are:

<ul>
	<li>Imaging - mammography (X-ray of the breast), ultrasound, and MRI are recommended.</li>
	<li>Biopsy - if there is any abnormality in the previous tests, a sample of the breast tissue is taken.</li>
	<li>Blood Tests - hormone levels are measured by taking a sample of blood. 
	&nbsp;</li>
</ul>

Treatment involves eliminating the causative factor:

<ul>
	<li>Stopping or changing a medication that may be causing the discharge</li>
	<li>Removal of a cyst or lump</li>
	<li>The surgical removal of a milk duct that contains any abnormality or pathology.</li>
	<li>Treating any underlying disorders 
	&nbsp;</li>
</ul>

If you experience any of the following symptoms, visit your doctor immediately:

<ul>
	<li>A palpable lump in the breast</li>
	<li>A change in the shape or size of the breast</li>
	<li>Discharge from only one nipple</li>
	<li>Blood-colored discharge</li>
	<li>Discharge that goes on for days</li>
	<li>Swelling around the collarbone or under the armpit</li>
	<li>Nipple discharge in males</li>
	<li>Nipple discharge in females over the age of 40</li>
	<li>Smelly discharge</li>
	<li>Changes in the nipple shape, color, or texture (crusting) 
	&nbsp;</li>
</ul>

In conclusion, nipple discharge is a common condition that affects both men and women. While it can be a symptom of breast cancer, the vast majority of cases are not cancerous and can be treated easily.

It is important to seek medical attention, though, if you notice any changes in your nipple discharge, such as a change in color or consistency, or if it is accompanied by other symptoms like a lump in the breast, pain, or swelling.

Your healthcare provider will be able to diagnose the cause of your nipple discharge and recommend the appropriate treatment. Remember, early detection is key to the successful treatment of breast cancer, so it is important to stay vigilant and monitor any changes in your breast health. 
&nbsp;

<ul>
	<li>While it sounds strange, nipple discharge is actually an occurrence that may affect both males and females. </li>
	<li>The most prevalent kind of nipple discharge is white or milky. This can happen to women for a variety of reasons, including hormonal changes in premenopausal women or recently stopping breastfeeding.</li>
	<li>During the early stages of pregnancy, women often have clear discharge coming from their nipples. In later stages, the discharge becomes watery or milky. </li>
	<li>Nipple discharge in babies can also occur and is usually not a cause for concern. It is often related to the mother&#39;s hormones that the baby is exposed to during pregnancy and childbirth.</li>
	<li>According to the International Journal of Preventive Medicine, nipple discharge can be a symptom of breast cancer. According to the same study, 7-15% of women who report nipple leakage with an unclear origin tend to develop breast cancer</li>
	<li>Early detection is key to the successful treatment of breast cancer, so it is important to stay vigilant and monitor any changes in your breast health. 
	&nbsp;</li>
</ul>

[1] Sajadi-Ernazarova KR, Sugumar K, Adigun R. Breast Nipple Discharge. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls

[2] Nipple discharge: Causes and treatments. Medical News Today.

[3] Breast and nipple discharge: What it could mean. WebMD

[4] Crider C. Witch's Milk: Treatment and causes of neonatal galactorrhea. Healthline.

[5] Watson S. Nipple discharge. Healthline

Mariam Chughtai

Unknown Facts About Breast Cancer

While most of us have an elementary understanding of breast cancer, there are many lesser-known facts that are worth exploring. Whether you&#39;re a medical professional, someone who has been personally affected by breast cancer, or just a curious learner, read on to know more about the condition. 
&nbsp;

<a href="https://merisehat.pk/article/is-surgery-the-only-treatment-for-breast-cancer">Breast cancer</a> is one of the most common types of cancer worldwide, affecting both men and women. The World Health Organization (WHO) reported that 685,000 individuals died in 2020 due to breast cancer, and 2,300,000 people were diagnosed with the disease<a href="#accordion">[1]</a>.

Among Asian countries, Pakistan has the highest occurrence of breast cancer, with 1 out of 9 women being diagnosed with breast cancer at some point in their lives. As per the 2018 report by the International Agency for Research on Cancer, there were 34,066 new instances of breast cancer reported among women in Pakistan<a href="#accordion">[2]</a>. 
&nbsp;

Despite the extensive research done in the field of breast cancer, there are still unknown facts about the disease.

<ol>
	<li>Breast Injury And Cancer</li>
</ol>

Injury to the breast cannot cause breast cancer, but it can cause changes like a bruised lump or scar tissue. This is called &#39;fat necrosis.&#39; And it&rsquo;s often confused with breast cancer on imaging. A mammogram, for instance, displays it as an irregular mass with jagged edges. So, the best way to distinguish between the two is to go for a needle biopsy<a href="#accordion">[1]</a>. End of the day, these lumps do not increase the risk of cancer, but treatment is necessary if they persist<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<ol start="2">
	<li>Underwire Bras And Breast Health</li>
</ol>

Wearing an underwire bra can sometimes cause discomfort and irritation to the skin under the breast, which may lead to infection or an abscess. Some claim that underwire bras can cause breast cancer by blocking the flow of lymph fluid, but this theory is not supported by scientific research<a href="#accordion">[1[4]</a>. 
&nbsp;

<ol start="3">
	<li>In-Vitro Fertilization And Breast Cancer</li>
</ol>

Drugs prescribed during the IVF process stimulate the ovaries to produce eggs. Since these drugs imitate the effects of estrogen, a concern is that they may also encourage the growth of breast cancer cells with estrogen receptors. This has not been proven yet. However, other factors, such as family history and inherited genes, may be at play, too<a href="#accordion">[1</a>]<a href="#accordion">[5]</a>.

Heads up, if you&rsquo;re considering IVF, talk to your doctor about all the possible implications of the treatment. 
&nbsp;

<ol start="4">
	<li>Genetic Mutations And The Risk Of Breast Cancer</li>
</ol>

Many people with breast cancer are surprised when they learn about their condition because they have no family history or other risk factors.

Being a woman is the major risk factor for breast cancer. 1 in 8 women in the US develops breast cancer in their lifetime<a href="#accordion">[1]</a>.

That said, 5-10% of breast cancer cases are caused by genetics, where specific genes are inherited from family members. The most prevalent genetic cause of hereditary breast cancer is a mutation in either the BRCA1 or BRCA2 gene<a href="#accordion">[6]</a>.

As a thumb rule, every woman over the age of 40 should get a mammogram annually, even if they have no family history of breast cancer. In case of a family history of breast or ovarian cancer, they should discuss screening options with a genetics counselor by the time they turn 30<a href="#accordion">[1]</a>. 
&nbsp;

<ol start="5">
	<li>Stress May Cause Breast Cancer</li>
</ol>

No evidence suggests that stress directly increases the risk of breast cancer. However, stress negatively affects the overall health, both physically and mentally. While dealing with stress is important, it will not reduce the risk of breast cancer<a href="#accordion">[1</a>]<a href="#accordion">[7]</a>. 
&nbsp;

<ol start="6">
	<li>Breast Lumps And Breast Cancer</li>
</ol>

Not all breast lumps are cancerous. In fact, the majority of them are benign. They can be caused by certain medical conditions like fibrocystic breast disease and cysts. The fibrocystic breast change makes breasts lumpy, tender, and sore, but it is not cancerous. Cysts are small sacs filled with fluid that can develop in the breast<a href="#accordion">[8]</a>.

Also, if you recently had a mammogram and it came back normal, your chances of a new lump being benign are even higher. Make sure to have any new lumps examined by a healthcare professional<a href="#accordion">[1]</a>. 
&nbsp;

<ol start="7">
	<li>Abortion And Breast Cancer</li>
</ol>

Abortion is a controversial issue that stirs up strong emotions in people due to personal, religious, and political beliefs. At the same time, breast cancer is a common and serious disease for many women. However, there is no scientific evidence to support the idea that there is a direct link between the two<a href="#accordion">[9]</a>. 
&nbsp;

<ol start="8">
	<li>Nipple Piercing And Breast Cancer</li>
</ol>

There is a false belief that nipple piercing increases the risk of getting breast cancer. A nipple piercing can cause problems, such as infection, blocked milk ducts, nerve damage, and some serious illnesses like HIV and hepatitis B and C due to lack of proper sterilization during the piercing process. However, it does not cause cancer<a href="#accordion">[1]</a>. 
&nbsp;

<ol start="9">
	<li>Men Can Get Breast Cancer, Too</li>
</ol>

While breast cancer is more common in women, men can also develop the disease. Therefore, men should be aware of any lumps or changes in their breasts and seek medical attention if they notice anything unusual. According to the Centers for Disease Control and Prevention, it&rsquo;s estimated that almost 1% of all breast cancer cases in the United States occur in men<a href="#accordion">[10]</a>. 
&nbsp;

<ol start="10">
	<li>&nbsp;No Lump, No Cancer</li>
</ol>

It&#39;s a common misconception that if a person does not feel a lump in their breast, they don&#39;t have breast cancer. However, this is not entirely true. Breast cancer can develop without causing any symptoms, and in its early stages, it may not be visible on a mammogram. Thus, regular breast cancer screening is recommended even for women who do not feel any lumps or changes in their breasts.

Other symptoms of breast cancer can include changes in breast size or shape, nipple discharge, or skin changes on the breast, such as dimpling or redness. It&#39;s important to be aware of these signs and to seek medical attention if any changes are noticed. 
&nbsp;

Understanding Lesser-Known Aspects of Breast Cancer

Adopting a healthy lifestyle can reduce the risk of the disease. This includes:

<ol>
	<li>Exercise And Physical Activity</li>
</ol>

Exercise helps to maintain a healthy weight, which lowers the risk of breast cancer. At least 150 minutes of moderate-intensity exercise per week is recommended. 
&nbsp;

<ol start="2">
	<li>Healthy Diet</li>
</ol>

A healthy diet rich in fruits, vegetables, whole grains, and lean proteins can help reduce the risk of breast cancer. Limit saturated and trans fats, processed foods, and added sugar because they increase the risk of breast cancer. 
&nbsp;

<ol start="3">
	<li>Quit Alcohol Consumption</li>
</ol>

Alcohol consumption increases the risk of breast cancer. It is recommended to quit drinking alcohol and there are several avenues that can be explored by people who need help quitting. 
&nbsp;

<ol start="4">
	<li>No Smoking</li>
</ol>

Smoking is linked to several types of cancer, including breast cancer. Quitting smoking can reduce the risk of developing breast cancer. 
&nbsp;

<ol start="5">
	<li>Avoiding Environmental Toxins</li>
</ol>

Exposure to environmental toxins, such as pesticides and chemicals, can increase the risk of breast cancer. Avoiding or limiting exposure to these toxins can help reduce the risk of breast cancer. 
&nbsp;

<ol start="6">
	<li>Early Detection</li>
</ol>

Regular breast cancer screenings, such as mammograms, can help detect breast cancer early when it is most treatable. It is recommended that women begin regular mammograms at age 40, or earlier if there is a family history of breast cancer. 
&nbsp;

Breast cancer is a complex disease with many unknown factors. However, being aware of the risk factors and maintaining a healthy lifestyle can help reduce the risk of developing breast cancer. Men and women of all ages should perform regular self-examinations and seek medical attention if they notice any changes in their breasts. 
&nbsp;

<ul>
	<li>It is important for both men and women to be aware of the signs and symptoms of breast cancer, including changes in the breast tissue, nipple discharge, and lumps in the breast area.</li>
	<li>Breast cancer can occur at any age, although it is more common in women aged 50 and above. All women should perform regular self-examinations and schedule regular mammograms as recommended by their healthcare provider.</li>
	<li>Breast cancer is not always detectable through a mammogram. In some cases, breast cancer may not show up on a mammogram due to the type or location of the tumor. Other imaging techniques, such as ultrasounds or MRIs, may be necessary to detect breast cancer.</li>
	<li>Breast cancer is not always caused by genetics. While having a family history of breast cancer can increase the risk, some women who develop breast cancer do not have a family history of the disease.</li>
	<li>Certain lifestyle factors can increase the risk of developing breast cancer, such as smoking, drinking alcohol, and being overweight or obese. Maintain a healthy lifestyle and discuss any concerns with a doctor to reduce this risk.</li>
	<li>Breast cancer treatment has come a long way in recent years. Many treatments are now available, including surgery, radiation therapy, chemotherapy, and targeted therapy. An effective treatment plan depends on the type and stage of breast cancer, besides the individual patient&#39;s needs and preferences.</li>
</ul>

[1] 15 breast cancer myths busted. Medical News Today.

[2] Khan NH, Duan S-F, Wu D-D, Ji X-Y. Better Reporting and awareness campaigns needed for breast cancer in Pakistani women. Cancer Management and Research. 2021;Volume 13:2125-2129. doi:10.2147/cmar.s270671 .

[3] Can an injury or blow to the breast cause cancer? Cancer Research UK.

[4] Can wearing a bra to bed increase your risk of breast cancer? Cancer Council.

[5] Farhud DD;Zokaei S;Keykhaei M;Hedayati M;Zarif Yeganeh M; In-vitro fertilization impact on the risk of breast cancer: A review article. Iranian journal of public health.

[6] Myths and facts about breast cancer - healthcentral.com.

[7] Can stress cause cancer? Cancer Research UK.

[8] What are the symptoms of breast cancer? Centers for Disease Control and Prevention.

[9] Abortion and cancer risk. Abortion and Cancer Risk.

[10] Breast cancer in men. Centers for Disease Control and Prevention.

The Fear Of Recurrent Cancer – How To Support Breast Cancer Survivors

Despite treatment. It&rsquo;s not just the physical trauma; a patient&rsquo;s survival also depends on their<a href="https://merisehat.pk/wellness/mental-health-sleep"> mental health</a> and how well their mind copes with it, something most people overlook or do not pay much attention to. 
&nbsp;

Understanding the Recurring Breast Cancer

Recurrent cancer is one that comes back. Breast cancer, in particular, can recur in the same or the opposite breast. It can also spread to other parts of the body. Moreover, it can recur months or even years after the initial treatment has ended. 
&nbsp;

It&rsquo;s pertinent to mention here that even though breast cancer may be more common in women, men can have it, too. As per the CDC, 1 out of every 100 cases diagnosed in the US occurs in a man<a href="#accordion">[1]</a>. Also, the most common types of breast cancer in men are the same as those in women, including invasive lobular carcinoma, invasive ductal carcinoma, and ductal carcinoma in situ. 
&nbsp;

A loved one can develop breast cancer again depending on multiple factors, like the type of tumor, the stage of the original breast cancer, and the type of treatment they received. 
&nbsp;

<ul>
	<li>Generally, anyone who has had breast cancer is at risk of recurrence.</li>
	<li>Women who develop breast cancer before the age of 35 are at a higher risk of getting it again compared to those who develop it later in life.</li>
	<li>Aggressive cancers, such as triple-negative breast cancer and inflammatory breast cancer, are hard to treat and more likely to return.</li>
	<li>If the cancer did not spread to the surrounding lymph nodes, the individual has a 6% risk of recurrence in the same breast within five years<a href="#accordion">[2]</a>.</li>
	<li>If the cancer spreads to the surrounding lymph nodes, the chance of recurrence is 1 in 4<a href="#accordion">[3]</a>. This risk increases to 23% if they had a mastectomy without radiation therapy<a href="#accordion">[2]</a>.</li>
	<li>In the case of estrogen-receptor-positive breast cancer, there is a constant risk of recurrence &ndash; 20 years at least &ndash; after the original cancer diagnosis.</li>
	<li>A study involving women aged 35 and younger noted that the risk of recurring regional breast cancer was smaller compared to that of recurring local breast cancer<a href="#accordion">[2]</a>. 
	&nbsp;</li>
</ul>

While one study in 2014 stated that a local recurrence of breast cancer increases the risk of dying, a recent study established that survival rates have improved to a great extent over nearly four decades<a href="#accordion">[2]</a>. 
&nbsp;

Factors that influence a patient&rsquo;s survival include:

<ul>
	<li>Being younger than 45 when it recurs</li>
	<li>How early the recurrence is diagnosed</li>
	<li>How long after initial cancer the recurrence occurs</li>
	<li>The treatments used</li>
	<li>The type of breast cancer 
	&nbsp;</li>
</ul>

Study shows alarming distant breast cancer recurrence survival rates<a href="#accordion">[3]</a>:

<ul>
	<li>Metastatic breast cancer: 27% survival after five years</li>
	<li>Regional breast cancer: 86% survival after five years</li>
	<li>Localized breast cancer: 99% survival after five years 
	&nbsp;</li>
</ul>

&ldquo;Why me?&rdquo;

&ldquo;What&rsquo;s next? Is it ever going to go away?&rdquo;

&ldquo;Who&rsquo;s going to pay for the treatment? How will my child(ren) cope with my illness?&rdquo;

&ldquo;How do I move on from cancer, be cancer-free, and have my life back?&rdquo; 
&nbsp;

Ideally, beating cancer once should be reason enough for you to celebrate. At the same time, it&rsquo;s natural to feel angry, afraid, stressed, and depressed after diagnosis and subsequent treatments for recurring cancer.

According to a recent study, the fear of cancer recurrence (FCR) is a common psychological phenomenon among cancer patients. Family history of cancer, depression, anxiety, stress, and pessimism are responsible for high FCR levels<a href="#accordion">[4]</a>. 
&nbsp;

Also, younger age and physical comorbidities influence FCR levels. For instance, younger breast cancer survivors display an increased FCR during the first 18 months post-surgery compared to older survivors with stable levels during the first six months that later decline. According to studies, difficulties in coping and childhood severe illness experiences (past trauma) may contribute to higher FCR<a href="#accordion">[4]</a>. 
&nbsp;

Most patients spend their entire life living by &lsquo;certain&rsquo; rules to avoid another breast cancer diagnosis even though they do not experience a recurrence.

This fear can stem from: 
&nbsp;

<ul>
	<li>
	<h5>Potential Surgeries</h5>
	</li>
</ul>

Usually, the same therapy is not effective in treating recurrent breast cancer. Some tumors tend to develop a tolerance to treatments like chemotherapy. 
&nbsp;

If the original tumor is treated with radiation and lumpectomy, local recurrence may require a bigger surgery like mastectomy to be controlled. On the other hand, if the original tumor is treated with mastectomy, then a local resection, usually followed by radiation therapy, is considered.

Note: Breast cancer that spreads to other body parts is still treated like breast cancer. E.g., breast cancer cells that move to the lungs will not be lung cancer; it&rsquo;s simply breast cancer in the lungs. 
&nbsp;

<ul>
	<li>
	<h5>Medical Treatments</h5>
	</li>
</ul>

Chemotherapy has numerous short- and long-term side effects. These include hair loss, skin and nail changes, chemo brain, and infertility. Moreover, hormonal therapy (e.g., tamoxifen) can affect mood and cause early menopause. Consequently, the individual starts to feel sad and isolated. 
&nbsp;

<ul>
	<li>
	<h5>Radiation</h5>
	</li>
</ul>

Some types of radiation therapy in the chest or neck area impact the thyroid&rsquo;s ability to work effectively, causing hypothyroidism. 
&nbsp;

While the prevalence of psychological and emotional issues varies among breast cancer patients, a study shows that cancer diagnosis leads to<a href="#accordion">[4]</a>:

<ul>
	<li>41.9% experiencing anxiety</li>
	<li>32.2% experiencing depression 
	&nbsp;</li>
</ul>

People diagnosed with breast cancer may also experience at least one of the following:

<ul>
	<li>Fatigue</li>
	<li>Addiction</li>
	<li>Insomnia</li>
	<li>Mood swings</li>
	<li>Memory loss</li>
	<li>Post-traumatic stress disorder 
	&nbsp;</li>
</ul>

FCR can be overwhelming and affects the patient&rsquo;s quality of life, presenting as persistent dysfunctional behaviors like over-vigilance for symptoms of recurrence or avoidance. Even physical symptoms like difficulty swallowing, chronic chest pain, and numbness in the arm/shoulder can definitely reduce the quality of life. 
&nbsp;

<ol>
	<li>
	<h5>Know The Symptoms</h5>
	</li>
</ol>

It&rsquo;s best to consult a mental health professional if the individual seems to be struggling with:

<ul>
	<li>A lack of interest or joy in activities they normally enjoy</li>
	<li>Sleep disturbances, such as difficulty staying asleep or falling asleep</li>
	<li>Difficulty focusing or concentrating</li>
	<li>Changes in appetite resulting in weight gain or weight loss</li>
	<li>Mood changes, such as constantly stressed or anxious</li>
	<li>Difficulty getting out of bed due to lack of energy</li>
	<li>Increase in body aches</li>
	<li>Using drugs or alcohol to reduce stress 
	&nbsp;</li>
</ul>

Often, these symptoms are intensified if the patient:

<ul>
	<li>Belongs to a low socio-economic class</li>
	<li>Lacks access to higher education</li>
	<li>Has a history of mental illness</li>
	<li>Is diagnosed with breast cancer at a young age</li>
	<li>Has a previous history of trauma</li>
	<li>Lacks social support from family and friends 
	&nbsp;</li>
</ul>

<ol start="2">
	<li>
	<h5>Get Help</h5>
	</li>
</ol>

The first step was to help them accept their emotions. The second is to take control of their health.

When people are less stressed or upset, they are more likely to stick to their treatment plans and show up to appointments. Yes, the earlier the diagnosis and intervention, the better. However, that doesn&rsquo;t mean they cannot talk to a counselor or join a support group any time later after their diagnosis. 
&nbsp;

Talking to a professional or even other people who share a similar recovery trajectory can be beneficial in:

<ul>
	<li>Alleviating feelings of depression, anxiety, and chronic stress</li>
	<li>Improving sleep patterns</li>
	<li>Promoting feelings of happiness, optimism, and contentment</li>
	<li>Strengthening relationships with family and friends</li>
	<li>Learning coping skills 
	&nbsp;</li>
</ul>

Encourage them for individual counseling, group counseling, family counseling, grief counseling, and support groups &ndash; in person or online &ndash; whichever option works. 
&nbsp;

<ol start="3">
	<li>
	<h5>Complementary Therapy</h5>
	</li>
</ol>

Also known as alternative therapies, they have proved to be effective in managing stress and anxiety after a breast cancer diagnosis. These include:

<ul>
	<li>Art therapy</li>
	<li>Journaling</li>
	<li>Acupuncture</li>
	<li>Biofeedback</li>
	<li>Meditation</li>
	<li>Yoga 
	&nbsp;</li>
</ul>

<ol start="4">
	<li>
	<h5>Lifestyle Changes</h5>
	</li>
</ol>

Small changes, like proper hydration, getting at least seven hours of sleep each night, and quitting smoking and alcohol, can actually help reduce the symptoms of anxiety and depression. Moreover, being active also lowers the risk<a href="#accordion">[1]</a>. 
&nbsp;

<ol start="5">
	<li>
	<h5>Plan Ahead</h5>
	</li>
</ol>

If you&rsquo;re familiar with the side effects of cancer treatments, you can help them prepare accordingly. For instance, you can get a head covering or a wig to help them cope with hair loss. Similarly, it&rsquo;s possible to store eggs, sperm, and embryos for the future.

You can also make arrangements at home and work on their behalf before they begin treatment again. 
&nbsp;

Talk to a doctor to get a fair idea of the timing and frequency of their visits. For instance, depending on their health, chemotherapy can go from once a week to once every three weeks. Moreover, each session is followed by a recovery period.

Note: Remind them as often as possible that recurring cancer IS NOT their fault! There is no evidence exactly why it recurs. But a recurrence is not because a patient fails to do something or does something wrong. 
&nbsp;

In conclusion, the emotional well-being of breast cancer survivors is crucial for their recovery. Understanding the impact of late recurrence and providing holistic support can lead to improved health outcomes. Encouraging strong relationships, mental health services, and group therapy can enhance their quality of life. Adhering to treatments and maintaining a healthy lifestyle lowers the risk of recurrence. By addressing survivors&#39; psychological needs, we can offer empathetic and comprehensive support during this challenging journey. 
&nbsp;

<ul>
	<li>According to the American Cancer Society, 1 in 4 people diagnosed with breast cancer experiences depression<a href="#accordion">[5]</a>.</li>
	<li>10-30% of breast cancer patients experience anxiety due to uncertainty about the future, anticipation of negative outcomes, worry about the side effects of treatment, and concern over recurrence<a href="#accordion">[6]</a>.</li>
	<li>Elderly women may be less inclined to seek medical help for any breast symptom, including psychological help.</li>
	<li>Older survivors diagnosed with recurrent breast cancer may not be affected as much as younger survivors because they are usually retired from work and are not responsible as primary caregivers to their parents, partners, or children. </li>
	<li>Older people also cope better with medical crises.</li>
	<li>A recent review described &ldquo;scanxiety&rdquo; as anxiety that patients feel when undergoing imaging scans following treatment for their cancer<a href="#accordion">[7]</a>. For instance, flashbacks of a particular treatment at a particular place can lead to a kind of Pavlovian response. </li>
	<li>According to a study, breast cancer survivors are more prone to psychological issues, like depression and anxiety, compared to those who have not been diagnosed with cancer<a href="#accordion">[7]</a>.</li>
	<li>According to a study, women who overestimated their risk of recurrence had higher distress scores and lower mental health<a href="#accordion">[8]</a>. This is important because it influences informed decision-making and management of the disease.</li>
	<li>The risk of recurrence is highest during the first two years following the initial diagnosis of breast cancer. Over time, this risk gradually decreases. </li>
	<li>The majority of survivors who do not have a recurrence during the first five years after diagnosis have a relatively low risk of recurrence. </li>
	<li>Some may present with a late recurrence of breast cancer, i.e., cancer that recurs after five years.</li>
	<li>The risk of late recurrence increases if survivors have progesterone receptor-positive tumors, estrogen receptor-positive tumors, or HER2-negative tumors. </li>
	<li>Premenopausal survivors who had a high number of involved lymph nodes or a tumor bigger than 2 cm are also at greater risk of late recurrence. The same goes for postmenopausal survivors younger than 60. </li>
	<li>Postmenopausal survivors older than 60, however, with a high number of involved lymph nodes, low levels of estrogen expression from the tumor, and who received adjuvant hormone therapy (e.g., aromatase inhibitors) for a short time can also have late recurrent breast cancer. </li>
	<li>Treatment should not be just about surviving. It&rsquo;s also about improving the patient&rsquo;s overall health. Develop strong personal relationships and seek mental health services to manage stressors.</li>
	<li>Good nutrition, moderate physical activities, taking hormone therapies as prescribed, and sticking with follow-up care and other screenings are also important steps to lower the risk of recurrence. </li>
	<li>Group therapy for patients with breast cancer reduces tension, depression, mood disorders, and confusion, improving their overall quality of life. 
	&nbsp;</li>
</ul>

[1] Breast cancer in men. Centers for Disease Control and Prevention.

[2] Breast cancer recurrence: Statistics, symptoms, and more. Medical News Today.

[3] Breast cancer recurrence: Symptoms &amp; treatment. Cleveland Clinic.

[4] Yuan Yang a 1, a, 1, et al. Predictors and trajectories of fear of cancer recurrence in chinese breast cancer patients. Journal of Psychosomatic Research.

[5] How breast cancer can affect mental health

[6] Dinapoli L, Colloca G, Capua BD, Valentini V. Psychological aspects to consider in breast cancer diagnosis and treatment - current oncology reports. SpringerLink

[7] Vaughn L, Gore RJ, Hochwald L, et al. Breast cancer survivorship and mental health. EverydayHealth.com.

[8] For breast cancer, when does worry outweigh risk? [Home].

Shermeen Zuberi

<a href="https://merisehat.pk/disease/genetic-testing-for-breast-cancer">Breast cancer </a>has been a serious public health concern for generations, with cases dating back to ancient Egypt. Significant medical advances over the past 100 years have made breast cancer a highly treatable condition. Moreover, early detection programs have considerably improved survival rates globally.

Since the creation of the first mammogram machine in the late 1960s, mammography has become a key component of breast cancer screening and prevention. However, it wasn&rsquo;t until the 20th century that mammograms became widely used for breast cancer screening.&nbsp;&nbsp;&nbsp;

Mammograms are currently advised for women starting at age 40 or earlier if risk factors are present. Despite some controversy and disagreement, mammograms continue to be a crucial tool in the fight against breast cancer since they can help discover tumors early and potentially save lives. 
&nbsp;

Understanding The Importance of Mammograms

Breast cancer affects approximately 30% of all cancers in women worldwide, making it the most common disease among women and the most common occurring cancer overall. Among Asian countries, Pakistan has the highest rate of breast cancer, with 1 in 9 women having a lifetime risk of being diagnosed with breast cancer1. In 2018, more than 34,000 new breast cancer cases were reported in the country1. A lack of awareness, delayed referrals to appropriate facilities, and late diagnosis has led to a high mortality rate among breast cancer patients. Early detection plays a key role in increasing the chances of survival. Therefore, mammograms are a crucial tool in winning the war against breast cancer in the country. 
&nbsp;

Mammograms involve using low-dose X-rays to produce images of breast tissue. Even before a lump can be felt, these scans can assist in detecting any changes in the breast tissue that may suggest the presence of breast cancer.

The procedure of mammogram is typically carried out as follows:

<ol>
	<li>The patient will undress from the waist up and put on a hospital gown.</li>
	<li>The technologist will position the patient&#39;s breast on the mammogram machine&#39;s platform and adjust the height of the platform to the patient&#39;s height.</li>
	<li>The technologist will compress the breast between two plates on the machine. The compression is necessary to spread the breast tissue and allow for a clearer image.</li>
	<li>The technologist will take two images of each breast, one from the top and one from the side. The patient will need to hold their breath for a few seconds during each image to minimize any movement.</li>
	<li>The technologist will then repeat the process on the other breast.</li>
	<li>After the images are taken, the technologist will review them to ensure they are clear and accurate. If necessary, additional images may be taken.</li>
	<li>The entire procedure typically takes about 20-30 minutes. 
	&nbsp;</li>
</ol>

It&#39;s significant to remember that when the breast tissue is compressed during mammography, some women may experience some discomfort. The compression, which is required to deliver precise and clear results, lasts for a short while during each image. If you feel any severe discomfort during the procedure, let the technician know immediately. 
&nbsp;

While mammograms are mostly known for their role in breast cancer screening in women, they are also crucial in identifying the disease in males. However, due to the limited data on breast cancer screening in men and the low prevalence of male breast cancer, there are currently no recommendations for screening in asymptomatic men.

The American Cancer Society recommends that men who have a family history of breast cancer or other risk factors should consider screening mammography. Men with a high risk of breast cancer may also benefit from genetic counseling and testing<a href="#accordion">[2]</a>.

In men aged 25 years or older with a palpable breast lump, diagnostic mammography is typically recommended. The test is 92-100% sensitive and 90-96% specific for male breast cancer<a href="#accordion">[3]</a>. 
&nbsp;

The primary benefit of mammograms is their ability to detect breast cancer early. According to the American Cancer Society, mammograms have been shown to reduce breast cancer deaths in women aged 50 and older. This is because mammograms can detect breast cancer in its early stages which is easier to treat and more likely to be curable.

Mammograms can also help detect other breast abnormalities such as cysts, calcifications, and other non-cancerous conditions. In addition to helping detect breast cancer early, mammograms can also help monitor any changes in the breast tissue over time, which can help detect breast cancer at an even earlier stage. 
&nbsp;

Mammograms have potential hazards, just like any medical treatment. The little radiation exposure that takes place during a mammogram is the main danger linked with the operation. Nevertheless, mammography uses a very small quantity of radiation, and the advantages far exceed any possible dangers. Moreover, modern digital mammography methods employ radiation doses significantly lower than those of conventional mammography.

Mammograms also have a minor risk of producing false positive or false negative findings. In contrast, a false negative result indicates that mammography looks to be normal while cancer is present. A false positive result is when a mammogram appears to show an abnormality when there is no cancer present. False positives can lead to additional testing, which can cause anxiety and may be unnecessary. False negatives can delay diagnosis and treatment, potentially allowing cancer to progress. 
&nbsp;

If mammography reveals an anomaly, more testing may be required to identify whether cancer is present. A woman does not always have breast cancer if her mammography is abnormal. In actuality, the majority of abnormal mammography findings are benign (non-cancerous) alterations in the breast tissue. Further imaging tests, such as ultrasound or MRI, may be advised if an abnormality is discovered. To determine whether cancer is present, a biopsy may be required in some circumstances. 
&nbsp;

It is recommended that women undergo mammogram screening regularly, beginning at age 40 or earlier if they have a family history of breast cancer or other risk factors. The frequency of mammogram screening may vary depending on a woman&#39;s age and medical history. Women should discuss the recommended frequency of mammogram screening with their healthcare provider.

The American Cancer Society recommends the following mammogram guidelines for women<a href="#accordion">[4]</a>: 
&nbsp;

<ul>
	<li>Women with an average risk of breast cancer should undergo mammograms annually starting at age 45, and then every two years starting at age 55.</li>
	<li>Women with a higher risk of breast cancer (such as those with a family history of breast cancer) may need to start screening earlier and/or have more frequent screenings. 
	&nbsp;</li>
</ul>

In addition to mammogram screening, women should also perform regular breast self-exams and have clinical breast exams performed by a healthcare provider. Women should be aware of any changes in their breasts, including lumps, skin changes, nipple discharge, or pain, and report these changes to their healthcare provider immediately. 
&nbsp;

In conclusion, mammograms have come a long way since their development in the 1960s, and have revolutionized the early detection and treatment of breast cancer. While mammograms are not perfect and can result in false positives or false negatives, they remain a critical tool in the fight against breast cancer. The benefits of mammograms, including their ability to detect cancer in its earliest stages and improve survival rates, far outweigh any potential risks. Women should work with their healthcare provider to determine the appropriate frequency of mammogram screening based on their risk factors. With continued research and improvements in technology, mammograms will undoubtedly continue to play an important role in modern medicine and the fight against breast cancer. 
&nbsp;

<ul>
	<li>Mammograms are recommended for women beginning at age 40 or earlier if there are risk factors present.</li>
	<li>Among Asian countries, Pakistan has the highest rate of breast cancer, with 1 in 9 women having a lifetime risk of being diagnosed with breast cancer.</li>
	<li>Mammography is an effective screening method for finding breast cancer in males and females.</li>
	<li>The American Cancer Society recommends that men who have a family history of breast cancer or other risk factors should consider screening mammography.</li>
	<li>Mammograms can also help detect other breast abnormalities such as cysts, calcifications, and other non-cancerous conditions.</li>
	<li>Mammograms also have a minor risk of producing false positive or false negative findings.</li>
	<li>Women with an average risk of breast cancer should undergo mammograms annually starting at age 45, and then every two years starting at age 55.</li>
	<li>Women with a higher risk of breast cancer (such as those with a family history of breast cancer) may need to start screening earlier and/or have more frequent screenings.</li>
</ul>

[1] Khan NH, Duan SF, Wu DD, Ji XY. Better Reporting and Awareness Campaigns Needed for Breast Cancer in Pakistani Women. Cancer Manag Res. 2021;13:2125-2129. Published 2021 Mar 2. doi:10.2147/CMAR.S270671

[2] American Cancer Society. (2021). Breast cancer in men.

[3] Woods RW, Salkowski LR, Elezaby M, Burnside ES, Strigel RM, Fowler AM. Image-based screening for men at high risk for breast cancer: Benefits and drawbacks. Clin Imaging. 2020;60(1):84-89. doi:10.1016/j.clinimag.2019.11.005

[4] American Cancer Society. (2021). American Cancer Society Recommendations for Early Breast Cancer Detection in Women Without Breast SymptomsAmerican Cancer Society. (2021). American Cancer Society Recommendations for Early Breast Cancer Detection in Women Without Breast Symptoms