Evaluation of a suspicious breast should proceed until both the doctor and the patient are convinced there is a reasonable chance no cancer exists.

Early detection of breast cancer involves a progression of steps.  A combination of breast self-exam, clinical breast exams and mammography is the first line of defense.

Mammography, which shows the internal structure of the breast, can screen for signs of a problem well before anything can be felt or symptoms expressed.  By definition, breast cancers found before they are symptomatic are more likely to be smaller and, in the case of the less aggressive forms, still confined to the breast.

Unfortunately, no technology is perfect and mammograms miss up to 20% of the breast cancers that are present at the time of screening. These false-negatives occur more often in younger women than in older women because the breast tissue of younger women is denser .  Other causes for false-negative results include:

• A tumor's location (it may be in an area that is not easily imaged);
• The presence of shadows that can obscure a mass; 
• The size of the tumor;
• The tumor's rate of growth;
• The level of hormones, such as estrogen and progesterone, in a woman's body;
• The experience and skill of the radiologist.  

On the opposite end of the spectrum is the false positive.  If a woman gets 10 or more mammograms, there's about a 50/50 chance that one of them will result in a false positive.

Bottom line - mammography is not perfect.  But, most doctors feel (and our panel of experts agree) that it is improving, and it does make a difference.  Many mammography providers have started to provide double reads - meaning mammograms are read by two radiologists.  When they do, false negative and false positive rates drop considerably. Finally, while there has been controversy about mammography in the medical community and in the press over the years, the American Cancer Society continues to recommend that women get routine mammograms starting at age 40.

What if you get a clean mammogram but develop a suspicious symptom like a breast lump, skin change or unusual nipple discharge?  In short, don't delay.  Talk to your doctor about further evaluation.  There are a number of other diagnostic procedures that can be done to put your mind at rest or to confirm that you need to begin treatment.  They include:

• Diagnostic mammography
• Ultrasonography
• Breast Magnetic Resonance Imaging (MRI)
• Ductography
• Ductal lavage
• Biopsy

How far do you go?  Our panelist, Gretchen Ahrendt, M.D., puts it this way.  "You should advocate for yourself."  She adds, "Doctors go by the rule of threes.  The physical exam, breast imaging and pathology all have to agree."       

The ultimate answer is a triad:  

• Try not to be more apprehensive than you need to be.  After all, statistics are on your side, and not all lumps or changes in breast tissue mean you have breast cancer.  
• Recognize the inherent shortcomings of today's breast cancer detection procedures, and do not be complacent if your mammogram fails to find a problem.  In other words, keep doing your breast self-exams and going to your doctor for a regular clinical breast exam.  If you do find a problem, pursue it until you get a definitive answer, even if it means a biopsy.
• Support research efforts to develop better tests to detect breast cancer at its earliest stages.