will prove to be cost-effective, considering the rapid increase in the expense of chemotherapy drugs.
I do agree with critics that women should be given an informed choice. The reality is that most primary care physicians, who are likeliest to order screening studies, do not have time to provide the information necessary for fully informed consent.
Although our primary goal in detecting cancers in women forty and over is to diagnose them before symptoms occur, it is not always possible. This is especially true in the underserved population, not because mammograms don’t work in this population, but because this population is less likely to participate in screening.
Knowing what to do about breast problems as they arise often means the difference between a potentially curable cancer and one in which the prognosis is poor. The answer to this problem is quite simple: Educate yourself. Just reading this book will provide you with more information than you will ever get from the vast majority of physicians.
WHAT I’D TELL MY DAUGHTER
• Start yearly mammograms at age forty (or earlier if high risk; see Appendix I).
• Start monthly self-exams at age twenty-one, and see your physician if you detect a new lump or other changes.
• Report spontaneous nipple discharge to your physician, but do not squeeze your breast looking for discharge.
• Breast pain is common so don’t worry unless it is in one spot and increasing in intensity.
For Women of Childbearing Age: Birth Control, Pregnancy, and Lactation
FINDING SMALL BREAST CANCERS during pregnancy and lactation is a huge challenge, mainly because significant changes take place in the size, shape, and texture of the breasts while women are pregnant or nursing. As a result, the diagnosis of breast cancer is often delayed, and delays can be associated with adverse consequences.
Since the problems of early detection during pregnancy are different from those of lactation, it is best to consider the two issues separately. However, this section covers a number of issues besides cancer. Amid lingering but mostly unfounded concern about birth control pills and breast cancer, we also discuss the surprising number of options for birth control that women now have available to them.
BIRTH CONTROL
The “pill” first became available to the public in 1960 and proved to be an immediate success. Despite ongoing controversies, its popularity has only increased with time. Millions of young American women are now on this medication and with good reason. Not only is the pill effective in protecting against an unwanted pregnancy, it also has other desirable benefits, including the reduction of mood swings, the limiting of heavy menstrual flow, the improvement of acne, and a lowering of the risk of developing ovarian cancer.
Although this form of birth control has proven to be safe and effective for the majority of women, it does have some limitations, and it is important that young women be aware of them. One significant concern is that the pill is not 100-percent effective. It is estimated that one in 100 women who take it will nevertheless become pregnant. The primary explanation for failure in some women is simple: Usually it’s because they forget to take it on a daily basis.
Another worry is that the pill may influence a woman’s risk of developing breast cancer. The standard combination tablet contains two hormones: estrogen and progesterone. Both are synthetic, or manmade, hormones, designed to match the two naturally occurring hormones in a woman’s body. The first BCPs (birth control pills), which were introduced in the 1960s, contained high levels of estrogen. It was subsequently shown that high-estrogen medications were associated with an increased risk of breast cancers. Today’s BCPs contain a much lower dose of estrogen—but even with these diminished doses, concerns linger about the pill’s safety.
Recent studies have clearly demonstrated that, for the vast majority of healthy young women, these fears are unfounded. The modern combination pill has become the first choice in birth control for most young women up to the age of thirty-five.
However, some users should strongly consider other options. Certainly, if you have either a personal history or a strong family history of breast cancer, an estrogen-containing BCP should be avoided. For example, if your grandmother was diagnosed with breast cancer in her eighties, the risk is inconsequential. But if your mother or sister was diagnosed before the age of fifty, alternative methods of birth control need to be considered.
Women who are concerned about their personal risk should discuss other types of birth control with a doctor, or go to a family planning clinic to get additional, specific information. It is also worth noting that women sometimes overestimate their personal risk, so expert advice on this subject is valuable in making an informed choice.
Women with strong family histories of breast cancer should be evaluated in a high-risk clinic . . . and should also be counseled on the many options of non-hormonal approaches to birth control (such as IUDs, diaphragms, and spermicidal gels).
Other health care issues should be taken into account when deciding on the best form of birth control for a specific woman. Those with clotting problems, such as a history of blood clots in the veins of the leg, should avoid the combination pill. The same is true of women with a history of heart disease, such as high blood pressure or a stroke.
Age is another important consideration. Since the possibility of a malignancy increases with age, I generally recommend that women over thirty-five consider alternatives to the standard pill. In addition, health risks for taking the combination pill are further increased in females who smoke or are overweight.
Fortunately, there are safe alternatives to the standard combination pill. The “mini-pill” is the method of choice for most high-risk women. Besides containing no estrogen, it offers only a synthetic form of progesterone. The mini-pill is extremely effective when taken daily and avoids many of the potential side effects of the combination. This medication has become the preferred birth control choice for women over thirty-five.
The mini-pill is also ideal for women who are at risk of breast cancer because of a strong family history, or who previously had a high-risk biopsy. The same can be said for women with a history of clotting or heart issues. Finally, the mini-pill is the right choice for breast-feeding mothers, since it does not reduce the flow of breast milk as does the combination pill.
Of course, there are other practical reasons for not taking either. For the medication to work, it must be taken on a daily basis—ideally, at the same time each day. If you are concerned about your potential for missing a dose, other alternatives, such as intrauterine devices (IUDs) and contraceptive implants may be the practical answer.
A second limitation is that none of these pills protect against sexually transmitted diseases (STDs). Women who want protection from that possibility should insist their partner wear a condom.
At present, there is incredible competition for creating the ideal pill. As a result, a bewildering list of choices from different manufacturers are available for both the combination and the mini-pill. Although this multitude of possibilities may seem confusing at first, there are
