The last feeling you have when you’re told that you—or someone you love—has breast cancer? Lucky.

And though it feels like it’s so common—one in three of all new cancer cases diagnosed each year in women is a breast cancer—the notion that you’ll have lots of company offers little comfort.

But here’s the reality: if you have been diagnosed with breast cancer, you have every reason to be optimistic. At no point in history has the survival rate from breast cancer been better: overall survival from breast cancer now approaches 90 percent. Which means that if you’re diagnosed with breast cancer, chances are you will survive and thrive. Even more heartening is that over the last decade the death rate from breast cancer has dropped significantly each year, and that trend continues strongly.

Perhaps you’ve heard that, thanks to mammograms and early detection, if you are diagnosed with breast cancer today, it will most likely be early stage, which is extremely treatable and curable. And you may know that even for women diagnosed at more advanced stages, there are a growing number of cutting-edge treatment options available, with more on the way each year. But what you may not have heard is that for everyone, we are using less invasive surgery and treatments while still achieving better outcomes, and offering more options for reconstruction than ever before.

All this is the good news. The bad news is that it can be hard for women to hear this message of optimism against all the background noise.

At forty-eight, Katherine (name and identifying characteristics have been changed for the patient’s privacy) was leading a have-it-all kind of life that, as far as she was concerned, couldn’t get much fuller. She held a demanding job in human relations for a large tech company; her husband worked full-time, and like Katherine’s, his job involved lots of travel. Her two girls, ages thirteen and fifteen, were just hitting all the emotional potholes that come with being teenagers. Her seventy-six-year- old mother, who lived five hundred miles away, had recently had heart valve replacement surgery, and Katherine had spent the last few weeks figuring out how to find her good nursing care.

She was juggling it all at a hundred miles an hour, like so many of us do. Then, in a single moment, the daily rhythm of life faded into the background. After her yearly routine mammogram, she was told there was an “abnormality” and that she had to have a biopsy. When the biopsy results came back, I had to tell Katherine the four words that no woman wants to hear: “You have breast cancer.”

Katherine responded to the news as so many women that I see do, and perhaps as you have as well. After the initial shock, she, her husband, and I huddled together in my office and spent a long time discussing her options and making some important decisions. By the end of it, Katherine was drained, for sure, but relieved to have a clear plan of action. She felt reassured by the process and comfortable in her treatment plan, and she could turn her focus and her energies to her family and the upcoming surgery. She left my office confident that she would be okay and optimistic about her future.

But within a day or two of our visit, something happened that upset Katherine’s clarity and balance. I completely understood what was going on—I see this in my office all the time.

What happened was this: after she left my office, Katherine headed home and started Googling just about everything having to do with her diagnosis, and she began second-guessing everything. Two days after our meeting, she called me apologetically saying she had a long list of questions she hadn’t known to ask during our first meeting, and could she come to see me again? Fortunately, I was able to see her the next day. The Katherine who walked in was a different person. She had a three-inch stack of computer printouts highlighted in three different colors, with Post-it notes flapping off particular pages. Her eyes were bloodshot, and she looked like she hadn’t slept since I saw her last.

She seemed utterly perplexed and defeated.

And then she began. She’d heard there was a new drug that could be given before surgery to reduce the size of the cancer; what did I think of that? (The drug wasn’t right for her kind of cancer.) She had been to a really well-respected website where all the women on it said mastectomy would give her a better survival rate than lumpectomy. (Absolutely not true. In Katherine’s case, the odds were the same.) She had read that it was a good idea to have her other breast removed too so she would have the lowest likelihood of recurrence. (Again, not at all true in her case.)

I wasn’t surprised by Katherine’s questions. Not only have a woman’s odds of surviving and living a full and long life after a breast cancer diagnosis increased, but so have the number of sources for obtaining information. Well-meaning friends send emails linking you to websites with a note in the subject line that says “Must Read.” Family members pass along “required” reading, or insist that they introduce you to their old friend who has a doctor you must see or a survival story you must hear. And while having a disease that is so common—affecting one in eight women—can be an advantage because so much is known about it, it can also be a problem: everyone knows something about breast cancer, knows someone you should call, or knows someone who knows someone.

Thirty years ago, when our mothers and grandmothers were diagnosed, women didn’t even talk about “the big C.” Or if they did, they would literally whisper the word “cancer.” Back then, the word “breast” couldn’t even be used in a magazine advertisement! Twenty years ago, when I first entered the breast cancer field, access to information about breast cancer for the general public was still fairly limited. There was very little information online, only a few books on the market, and significantly fewer options for treatment.

Fast-forward to today. There is no shortage of information out there if you are newly diagnosed with breast cancer, including books like this one. But the omnipresent Internet is definitely the game changer, and not always in a good way. When you type the words “breast cancer” into your browser, you’re faced with literally millions of pages. And a breast cancer diagnosis is no longer spoken of in hushed tones; it is often blogged and tweeted about by women chronicling their journey through treatment, sending selfies from the chemo chair for all to see. I applaud those women for finding high-tech ways to cope, and for their sincere efforts to help others get through it as well. But as you may already have seen, the problem isn’t access to information anymore; instead, it’s too much information, with no filter. Some of what you can find online is credible; some isn’t. Some information will be relevant; most won’t be. Most important, the critical information that you need to make decisions  for yourself and your particular case is actually quite limited relative to the huge amount of information that’s out there. Getting information should be empowering, but too much information without the correct guidance to figure out its relevance can have the opposite effect.

Katherine and I spent as much time as she needed addressing all of the issues she’d raised, and a significant amount of time revisiting her options. I commended her on her diligence—but then refocused her on what was important: her particular case. At the end of our discussion, what Katherine understood was that while doing her research was an important part of the process, all of the information she had gathered came with a catch: without the right guidance, it was a challenge to assess its relevance to her particular case. We had to make those determinations together. Our discussions continued until Katherine regained her comfort and expressed genuine confidence in the plan we had initially established just for her. I confirmed for her that the treatment options we had were very likely to give her an excellent outcome, and Katherine left my office that day knowing that the odds of cure in her case—and for most women diagnosed with breast cancer today—were overwhelmingly in her favor, and that she was on the right path toward wellness.

It’s stories like Katherine’s—and literally thousands of others from the patients I’ve had the privilege to treat over the years—that have led me to write this book. The mental high-wire act women face—empowered to seek out  information 24/7,  but also overwhelmed by the TMI factor—can be exhausting. There’s no question that a woman diagnosed with breast cancer today faces a very different world than a woman diagnosed in decades past, and most women, I think, could use some guidance on how to navigate this world. Furthermore, many will not be able to get in to see a doctor as quickly as Katherine was able to with me. For many women newly diagnosed with breast cancer, it can be days, if not weeks, before a visit to a doctor who can provide any meaningful information to you and your family about your particular case. What I have been told by so many patients is that the time between diagnosis and actually meeting with the doctor and developing a plan of attack is the toughest. It is during this period when you (and often your spouse or family) feel so vulnerable, with no one to answer your questions. This is the time when, desperate for information, you can end up burning the midnight oil (who can sleep after receiving a diagnosis of breast cancer?) trolling the Internet for any meaningful information you might find.

And that’s where this book comes in. Whether you are concerned about a lump, are worried about a friend, or have already been diagnosed with breast cancer, there is a way to travel this road knowing that you have every reason to be optimistic. My goal with my patients—and now with my readers—is to provide guidance from an insider on all aspects of breast cancer treatment and care. This is where you can go to check in and make sure you’re on the right path at every step of your journey, so that you can come out on the other side with your health and positive outlook intact, leaving the background noise behind. I will help you set your priorities and pare down your list of concerns to the ones that are relevant to you and your particular situation. I hope to also arm you with a honed sense of what questions you need to ask and keep asking throughout your treatment and experience with breast cancer.

 

For many women, the diagnosis of breast cancer starts with a mammogram. These women in particular usually do not need much convincing of the value of mammograms in the early detection of breast cancer. Over the past few years, however, there has been a huge amount of conflicting information out there regarding mammograms, leaving many other women feeling uncertain and confused. As a breast cancer surgeon and specialist, I’m often asked to speak to the general public about issues surrounding breast cancer screening, treatment, and care. Some of the most common questions I get during the Q&A portion go something like this:

“My sister was diagnosed with breast cancer when she felt a lump one month after a normal mammogram. Why should I get one if it didn’t work for her?”

“I have a friend who was diagnosed with breast cancer at age thirty-eight, before she had even started mammograms. Shouldn’t we all be starting earlier?”

“I heard that sonograms and MRIs are better than mammograms at picking up cancers in women with dense breasts. Why aren’t they recommended for all women?”

It doesn’t surprise me that so many women have so many questions about mammograms and screening: they are looking for answers on some very controversial issues.

Mammograms aren’t flawless—no test is. Mammograms have been associated with both underdiagnosis (missing cancer) and overdiagnosis (when we find things on a mammogram that, if left alone, would not have caused a problem). Hence the frequent controversy about when and whether to use them. But even when all these variables are taken into account, mammograms are still the best tool currently available for identifying breast cancer in the vast majority of women.

It’s important to get the facts straight, beginning with this one: the mammogram is the only test that has been shown to decrease the actual risk of dying from breast cancer by detecting cancer earlier— effectively reducing mortality by 15 percent or more in women from ages forty to seventy.

And here’s a lesser-known fact: 80 to 90 percent of women diagnosed with breast cancer have no preexisting risk factors—no family history, no genetic issue, nothing. So we are all at risk, and that’s why appropriate screening is relevant to all women.

When we look at the breast cancer cure rate, the good news is that it has increased substantially in the past few decades. To a large degree, this is because of early detection—a direct result of better screening, primarily with mammograms. Currently over 60 percent of newly diagnosed breast cancers are early stage. These cancers are localized, and are usually detected by mammography before a woman or her doctor could feel anything on examination. So with all the conflicting information out there, it can be easy to lose sight of the bottom line here: mammograms help to detect breast cancer earlier and save lives.

Mammograms: what to expect

A mammogram is an X-ray of the breasts. Most often—including during a routine, annual mammogram—both breasts are X-rayed. This is called a bilateral mammogram, and two pictures are taken of each breast, resulting in a total of four pictures. A unilateral mammogram ( just one side, right or left) consists of two pictures. There are a variety of different reasons why a woman may need a mammogram on only one side: occasionally a follow-up at a shorter interval, usually six months, for one side only will be needed to make sure something we saw previously is indeed normal or has not changed. In addition, for women who have had a prior breast cancer and had one breast removed, we only perform mammograms on the one remaining breast. Finally, if a recent bilateral mammogram was normal but a few months later a woman feels a lump on self-examination, repeating the mammogram just on that one side might be needed. In any case, when a mammogram is done, the breast is pressed between two paddles to flatten out the breast tissue, and the entire process of positioning and shooting the picture takes about a minute for each picture, or a couple of minutes for each side. I don’t think anyone would argue that having your breast pressed between two paddles is exactly pleasant. Women do sometimes complain that mammograms are painful or at least uncomfortable, and there are many jokes circulating about how men could never tolerate the same procedure on certain parts of their anatomy. But the discomfort should be short and tolerable, especially at a mammography facility with experienced, well-trained technicians. If you are someone with especially sensitive breasts, discomfort may be minimized by making sure your mammogram is not scheduled right before or during your menstrual period, when breasts are usually most sensitive.

On a mammogram, cancers typically show up as white, irregular spots against the darker background of regular, mostly fatty breast tissue. Denser normal breast tissue also shows up as whiter, so in dense breasts it can be harder to see the white cancer against a white background (imagine trying to spot a polar bear in a snowstorm). If you do have dense breasts (very common in younger women), you may get a recommendation for additional tests, such as a sonogram, and you also may want to make sure that you are getting a digital mammogram. Digital mammograms have been shown to be better at picking up can- cers in younger women with denser breast tissue. Other findings that we look for on a mammogram that could indicate cancer are areas of calcifications, which are tiny clusters of white spots, almost like grains of salt grouped together. And lastly, an area of asymmetry, where the tissue looks distorted or pulled, especially if different from what is seen in the other breast, could raise suspicion for a cancer as well.

One of the most exciting new developments currently available is 3-D mammography. Although it is associated with a slightly higher dose of radiation exposure with each mammogram, the 3-D images that we capture extend through the breast, section by section, in great detail. Looking at the results is a little like looking through the pages of a book, and we can pick up more cancers that are hidden among overlapping dense breast tissue as a result. In addition, 3-D mammograms have been shown to significantly reduce callbacks for additional tests, which means fewer scary phone calls and less nail-biting time for you. This new mammography technique has been widely integrated into many practices, but not everywhere.

NEED TO KNOW

What  is the most appropriate screening regimen for  the average woman?

My recommendation, the recommendation of countless breast cancer physicians across the country, and the recommendation of the American Cancer Society, the American College of Radiology, and the National Comprehensive Cancer Network (NCCN) is that your first mammogram should be at age forty, with yearly mammograms after that. The average woman’s risk of getting breast cancer over her lifetime is approximately 10–12 percent if she lives to be about eighty years old. For the average woman there is less risk toward the earlier part of her life and more risk toward the later part of her life—the average age of women who get breast cancer is approximately sixty years old.

MYTH: “If you don’t have a family history of breast cancer, then you are not really at risk and there’s no reason to start mammograms at forty.”

The normal screening guidelines are for women at average risk for breast cancer. The reality is that 80 to 90 percent of women diagnosed with breast cancer have no special risk factors. So we are all at risk, and that’s why appropriate screening is relevant to all women.