 |
 |
make mothering.com your home page |
| shopping guide | ||
editorial columns
family tools
community features
 |
new baby  breastfeeding |
| Related Articles: What Are the Risk Factors for Breast Cancer? Screening Mammogram vs. Diagnostic Mammogram? |
Breast Cancer Screening During Lactation
It happened again last spring. At the edge of a sunny peaceful pond, as my friend and I watched our children splashing in the water and pursuing tadpoles, she quietly shared with me the news that her friend had recently been diagnosed with breast cancer. Another young mother with breast cancer. It's an uncomfortable reminder that I am now undeniably in the age group where breast cancer starts to 'happen'. The news made me a little more nervous than usual, since I was only weeks away from turning the age my mother was when she was diagnosed with terminal breast cancer. Even more distressing, I was well aware that I was already five years 'overdue' for a mammogram.
The National Cancer Institute, the American Cancer Society, and the American College of Radiology all recommend annual screening mammograms for women beginning at age 40. While to date there have been no studies conclusively demonstrating that mammograms given to women before the age of 40 reduce the risk of death from breast cancer, many doctors recommend that women have a 'baseline' mammogram between the ages of 35 and 39 (Medicare and most insurance companies will pay for it).1 Furthermore, if a woman is at high risk for breast cancer (see box), she is encouraged to discuss with her physician the benefits and limitations of even earlier mammogram screening.2,3
I am considered to be at high risk for contracting breast cancer since my mother was diagnosed with premenopausal breast cancer at age 37, my first cousin on my mother's side was diagnosed with breast cancer in his 30's, and my maternal aunt recently had ovarian cancer. Health care professionals have repeatedly told me that because of my high-risk status, I should have a baseline mammogram approximately five years before the age my mother was when she was diagnosed. For me, that would have been in the year 2000, when I was 32.
On the other hand, the same health care professionals also told me that I cannot have a mammogram if I am breastfeeding. It's not that mammography is hazardous to the breastmilk or the nursling; the x-ray radiation used in mammograms does not stay in the tissues so it does not affect the milk or the baby.4 The reason mammograms are contraindicated for a lactating breast, I was told, is for the same reason mammograms are less effective in younger women: Both lactating breasts and young breasts tend to be very dense. This makes the resulting mammogram more difficult to read, and may lead to a higher rate of false negatives (the mammogram appears normal even though breast cancer is actually present). For this reason, at each of my annual clinical breast exams, my certified nurse midwives told me to wait six months after weaning before having a mammogram. One midwife told me she was even sent away from a mammogram clinic when she arrived only five months post-weaning, so I really had to wait the FULL six months.
Well, I have been either pregnant or lactating for the past seven years, with no end in sight. The time when I would have ordinarily been sent in for a mammogram came and went, and since I was apparently 'ineligible' for a mammogram, I did not have one.
Average maternal age is increasing, as more and more women are having babies in their late 30's and early 40's. Furthermore, advancements in the study of breast cancer are making it easier to determine whether an individual is at high risk for developing the disease. At the same time, public health organizations are encouraging mothers to breastfeed for a minimum of one year. Consequently, I suspect I am not the only woman who has encountered an apparent timing conflict between breastfeeding and recommended mammography screening.
Despite never having had a mammogram, I have taken some comfort from the many studies which have demonstrated that breastfeeding itself actually reduces a woman's relative risk for contracting breast cancer,5,6,7 and confers protective benefits on her nursling as well.8 A woman who breastfeeds for 24 months of her life has only half the risk of developing breast cancer as a woman who breastfeeds for between one and six months.7 While added protection from breast cancer is not one of the primary reasons I practice sustained breastfeeding, it is a nice advantage. But the benefit is not something any individual can count on.
When I spoke to a nurse at the breast health center of my local hospital about the possibility of having a mammogram while lactating, she told me that a mammogram of someone in my situation would be 'only about 45% effective' so it wasn't worth having one until after weaning. She delicately suggested that I decide for myself which were more important 'g nursing my child or 'having a mammogram you can trust.'
I have since learned that my decision to delay screening mammography in favor of allowing my child to wean at his own pace was a false choice. Breastfeeding and meaningful mammography are not necessarily mutually exclusive.
Most of the literature concerning mammography in lactating women focuses on what to do when a breastfeeding woman or her healthcare provider find a lump as a result of physical touch. The next step for such a case is often a diagnostic mammogram, possibly followed by ultrasonography, fine needle aspiration, and/or biopsy. Weaning is not necessary for any of these tests.9
But what about the lactating woman who has not discovered a lump, yet who is considered at high risk for breast cancer or is approaching age 40 when screening is recommended? Are screening mammograms appropriate for these lactating women?
The American Cancer Society's website reads 'Women who are breast-feeding can still get mammograms, although these are probably not quite as accurate. They can express their breast milk before the mammogram.'2 Similarly, at the La Leche League International website, I found an abstract entitled 'Breast Health in Lactating Women' by Anne Montgomery, MD, IBCLC. The author notes the potential limitations of mammography in lactating women because breast density may obscure some problems, but ultimately she concludes: 'Mammography, combined with self-exam and periodic clinical breast exam, should continue during pregnancy and lactation as per published guidelines.'10
I also found evidence that not all mammograms of young or lactating breasts are confounded by problems with density. One study found that 'a^?|lactating women do not always have dense breasts, and mammography can be performed without substantial concern for the limitations of breast density'.11
Whether pursuing a diagnostic or a screening mammogram, experts agree the best way to get a useful result from mammography during lactation is to have the mammogram read by a radiologist who is experienced in reading mammograms of lactating breasts.10 A friend who had had a diagnostic mammography after finding a lump while she was nursing ten years ago recommended that I check out the Faulkner-Sagoff Breast Imaging and Diagnostic Center. When I scheduled my mammogram there, I informed the staff I was still lactating in my right breast (my son inexplicably stopped nursing from the left side about 20 months ago). Without missing a beat, they told me to bring my son with me to the appointment so that he could nurse directly before the mammogram, thereby draining as much as the milk as possible and maximizing the clarity of the picture. My lactation status presented no complications to the way the test was performed, and, interestingly, the radiologist found no difference in density between my lactating right breast and my non-lactating left breast.
The doctor who read my mammogram found no abnormalities in my mammogram, but that does not mean I can be sure that I don't have breast cancer. Mammography results are not 100% guaranteed no matter on whom they are performed. Nevertheless, I appreciate having whatever information my mammogram offers. For my particular case, the radiologist recommended that in addition to breast self-exams, clinical breast exams, and annual mammography, I ought to have a breast MRI in about six months. Preliminary studies indicate MRI and other imaging techniques for breast cancer screening may be especially helpful for dense and/or lactating breasts, when used in conjunction with traditional mammography.
As a health care consumer I appreciate having a broader understanding of the medical options available to me. My discovery that many experts believe mammography during lactation can still be a useful screening tool appears to be somewhat controversial in some medical circles. While it still may make sense for some women to postpone mammograms until after weaning, this approach may not be appropriate for those of us who are at high-risk for breast cancer, are older, who breastfeed our children for years rather than months, and/or who become pregnant before weaning. At this time there are no guidelines for what health care professionals should tell breastfeeding women who reach the age where mammogram screening is recommended. I encourage any nursing mother to discuss with her physician how to manage breast cancer screening during lactation.
ENDNOTES
1. American Cancer Society, "Medicare Coverage for Cancer Prevention and Early Detection" (2004): http://www.cancer.org/docroot/PED/content/...
2. American Cancer Society, "Can Breast Cancer Be Found Early?" (2005): http://www.cancer.org/docroot/CRI/content/...
3. National Cancer Institute, "What You Need to Know About Breast Cancer, " http://www.nci.nih.gov/cancertopics/wyntk/breast
4. La Leche League International, "Frequently Asked Questions: Can breastfeeding mothers get mammograms?" http://www.lalecheleague.org/FAQ/mammogram.html
5. Collaborative Group on Hormonal Factors in Breast Cancer, "Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease," The Lancet 360, no. 9328 (2002): 187-195.
6. P. A. Newcomb, B. E. Storer, M. P. Longnecker, et al., "Lactation and a Reduced Risk of Premenopausal Breast Cancer," New England Journal of Medicine 330 (1994): 81-87.
7. Zheng et al., "Lactation Reduces Breast Cancer Risk in Shandong Province, China." American Journal of Epidemiology 152, no. 12 (2000): 1129.
8. J. Freudenheim et al., "Exposure to Breast Milk in Infancy and the Risk of Breast Cancer." Epidemiologyno. 5 (1994): 324-331.
9. Kathy Koch MEd, IBCLC, "Breast Health and Breastfeeding," Leaven 39 no. 5 (2003): 136-137. http://www.lalecheleague.org/llleaderweb/LV/LVDecJan03p136.html
10. Anne M. Montgomery MD, IBCLC, "Breast Health in Lactating Women," Breastfeeding Abstracts 20 no. 4 (2001): 27-28. http://www.lalecheleague.org/ba/May01.html
11. A. E. Swinford, D. D. Adler, and K. A. Garver. "Mammography appearance the breasts during pregnancy and lactation: False assumptions." Academic Radiology 5, no. 7(1998): 467-72.
Cait Goodwin is a naturalist, educator and LLL Leader who lives with her husband and two children in Newport, Oregon.
Featured Product
Advertisement
