With the symbolic pink ribbon gracing everything from yogurt lids to celebrity lapels, there’s no shortage of publicity about breast cancer. Nonetheless, it’s difficult for many women to stay focused on what they should do to make sure the disease is detected as early as possible and, if it is, to get the right treatment.

For example: Only 1 out of 20 American women consistently followed the recommendations on mammographic screening over a 10-year period, according to a recent study of 72,000 women by researchers at Harvard and the Massachusetts General Hospital. And many women, especially older ones, with early-stage breast cancer don’t know that they could reasonably choose to forgo radiation following surgery.

The problem isn’t a lack of information—it’s that the message has become increasingly complex. Technological advances have shifted detection and treatment strategies from a one-size-fits-all approach to one that’s tailored to individual histories, profiles, and risks. We’ll look at how the latest advances apply to you, and we’ll provide you with the information you’ll need to make the most of your choices.

Ultrasound. MRI. Digital mammography. You may have heard or read about the newer imaging techniques now available to detect breast cancer. Despite all the new players, however, traditional film mammography is still the cornerstone of early detection for most women.

“For the immediate future, broader and better use of [existing] mammography holds the greatest potential to save lives,” concluded a June 2004 report of a panel of experts, convened by the National Academy of Sciences’ Institute of Medicine (IOM) and National Research Council (NRC), who reviewed strategies to improve breast-cancer detection and diagnosis. The committee pointed to substantiating evidence that, in many communities, screening mammography reduces breast-cancer mortality by 20 to 30 percent. In populations where most of the women get mammograms, however, screening helps reduce mortality by 50 percent.

In addition, women who have their cancers detected by mammographic screening have a much lower risk of metastases, or recurrence in other parts of the body, than those whose cancer is detected in other ways, such as by clinical exam, according to a September 2004 study in the Journal of the American Medical Association. In that study, Finnish researchers followed nearly 3,000 women with breast cancer for an average of 10 years. They found that those whose tumors were detected outside of screening had nearly twice the risk of distant tumor recurrence than women whose tumors were found on a mammogram.

And while mammograms do lead to a fairly high number of false alarms, very few of them result in unnecessary invasive procedures, according to an October 2004 analysis in Cancer, a journal of the American Cancer Society. Using data collected by Norway’s national screening program from more than 83,000 women in their 50s and 60s, researchers concluded that a 50-year-old woman who had regular mammographic screening for 20 years would have a one in five chance of getting a false-positive result.

However, most of the follow-up procedures would entail additional mammograms or ultrasounds. The risk of undergoing an invasive procedure for an area that proved noncancerous was only 6 percent. Most of those would be fine-needle aspirations, in which the physician uses a thin, hollow needle to draw a sample of tissue or fluid. The risk of undergoing an open, surgical biopsy that turned out to be benign was less than 1 percent.

The IOM panel envisioned new technologies as a complement to, rather than a replacement for, conventional mammography. For example, in the U.S., where a shortage of mammographers often makes the recommended double readings of films a practical impossibility, computer-aided detection (CAD) can serve as a second set of eyes. While CAD systems can’t substitute for a human radiologist, they occasionally pick up a missed cancer because the computer often flags areas that the trained eye recognizes as normal.

Aggressive marketers have touted magnetic resonance imaging (MRI), which creates an image with magnetic fields rather than radiation, as a more sensitive alternative to mammography. Unfortunately, while MRI can potentially detect more cancers than mammography, it also leads to more false alarms. In addition, MRI is expensive and time-consuming, and it’s often not available outside major cities. For those reasons, physicians have typically reserved MRI for confirming a diagnosis.

Recent studies have suggested that MRI is also useful for screening women at very high risk for cancer. The best evidence to date comes from a three-year study of nearly 2,000 women in the Netherlands who had a strong family history of breast cancer or who carried a genetic mutation for the disease. Researchers screened the women using clinical breast exams every six months and yearly mammograms and MRIs. Overall, MRIs were much more sensitive—80 percent of invasive growths were detected by MRI compared with only 33 percent by mammogram and 18 percent by clinical exam.

However, MRI was also the least specific, leading to twice as many unneeded additional examinations as mammograms (420 for MRI compared with 207 for mammography) and three times as many needless biopsies (24 for MRI compared with 7 for mammography).

Our experts say the benefit of MRI screening is greatest in women who carry the BRCA1 or BRCA2 gene, which places their lifetime risk of breast cancer at 50 to 85 percent. Any edge in detection is critical in that group because the women tend to develop cancers at a younger age than usual and the tumors are often more aggressive and less responsive to treatment. The case is not clear-cut for women with a moderately high risk—those whose mother or sister developed the disease before age 40, for example—and women in that group should discuss the risks and benefits of MRI with a breast specialist. Our experts caution that all women considering MRI screening should make sure the imaging facility offers MRI-guided biopsy, in case follow-up is necessary.

Ultrasound, which creates an image using high-frequency sound waves, is most useful as an adjunct to mammography, especially in women with cystic breasts. It’s particularly good for screening pregnant women, to avoid exposing the fetus to X-rays, and for young women, who typically have denser breasts that can obscure hidden cancers on mammograms.

However, ultrasound is time-consuming, tends to be more difficult in women with larger, fattier breasts, and often misses the tiny flecks of calcium (microcalcifications) that can indicate a very early cancer. The American College of Radiology is currently conducting a large, multicenter trial to help find out if ultrasound and mammography combined can detect more cancers than either test alone.

Digital mammography, in which an electronic image taken of the breast is stored directly in a computer where it can be enhanced for further evaluation, is now available at some mammography centers. In September 2005, the National Cancer Institute released preliminary results from a study of almost 43,000 women who were given both film and digital mammograms. Digital was no better than film mammography in detecting breast cancer for the general population of women in the trial. However, researchers concluded that women with dense breasts and those who are younger than age 50 or are pre- or permimenopausal (had their last menstrual period within 12 months of their mammography) may benefit from having a digital rather than a film mammography.

However, researchers concluded that digital mammography was better than conventional film mammography at detecting cancer in women with dense breasts and those who are younger than age 50 or are pre- or permimenopausal (had their last menstrual period within 12 months of their mammography).

Another reason for catching cancers early: Recent research has yielded more options for the treatment of women with smaller tumors whose cancer has not spread beyond the breast. “Many women with breast cancer have been overtreated because we don’t know who’s going to benefit,” says Debbie Saslow, Ph.D., director of breast and gynecological cancers for the American Cancer Society. “As we learn to identify those with the highest risk, we’re moving in the direction of being less aggressive.”

For example, the standard of care for women with early-stage breast cancer who undergo breast-conserving surgery (lumpectomy) instead of mastectomy has been to follow up with several weeks of radiation treatment to prevent recurrence in the same breast. But researchers are re-evaluating this practice in light of recent advances, including more accurate tools to pinpoint tumors, improved surgical techniques, and medications that reduce the risk of recurrence. Two studies published in the Sept. 2, 2004, issue of The New England Journal of Medicine help shed light on the issue.

Canadian researchers compared the combined use of radiation therapy with tamoxifen (generic, Nolvadex), an estrogen-blocking drug that helps prevent cancer recurrence, and therapy with tamoxifen alone in more than 700 women age 50 and older who had undergone lumpectomy for early breast cancer. After about five years of follow-up, there was no difference in overall survival between the groups, but the tamoxifen-only patients experienced an 8 percent risk of recurrence in the same breast compared with a less-than-1 percent risk in those on combined therapy.

The rate of recurrence in lymph nodes was 2.5 percent in the tamoxifen-only patients compared with 0.5 percent in the combined-therapy group. In women age 60 and older, whose tumors are typically slower-growing, results showed no difference in the rate of recurrence between the two groups, but the sample size was too small to be conclusive.

A similar multicenter American trial looked specifically at women age 70 and older. That study found a significant, but much smaller, risk of recurrence in older women who skipped radiation—4 percent compared with a 1 percent risk in those on combined therapy. There was no difference between the two groups in overall survival or the number of women who subsequently had to undergo mastectomies or developed metastases. However, radiation did cause a number of (mostly short-term) side effects, including stiffness in the shoulder and arm, breast pain, swelling, skin-color changes, and scar-tissue formation. The authors concluded that older women and their physicians can reasonably weigh the slight increased risk of local recurrence against the cost, inconvenience, and possible adverse effects of radiation.

Most women stop taking tamoxifen after about five years because side effects—including an increased risk of blood clots, uterine cancer, or stroke—increase at that point, while the protective effect appears to extend for several years after the medicine is discontinued.

New evidence suggests that another drug that affects estrogen can further reduce the risk of recurrence. The Canadian-led international trial published in the Nov. 6, 2003, issue of The New England Journal of Medicine compared the aromatase inhibitor letrozole (Femara) with a placebo in more than 5,000 postmenopausal women who had undergone treatment for early-stage breast cancer followed by five years of tamoxifen. Letrozole reduced the risk of a cancer recurrence by 43 percent, so researchers halted the five-year trial at its midpoint to give all participants an option to take the drug.

Unfortunately, stopping the study early left several questions unanswered. It’s not clear how long women should take the drug, for example, or if it carries long-term risks. Unlike tamoxifen, which only blocks the binding of estrogen to tumor receptors, aromatase inhibitors limit the body’s ability to make estrogen. Most postmenopausal women continue to produce small amounts of estrogen; limiting that could raise cholesterol levels and thin the bones.

On the other hand, unlike tamoxifen, letrozole and other aromatase inhibitors including anastrozole (Arimidex) and exemestane (Aromasin) do not appear to increase the risk of uterine cancer, blood clots, and stroke.

The letrozole trial confirms similar positive results from a large international trial published in the March 11, 2004, issue of The New England Journal of Medicine, which suggested that women switched to exemestane after two to three years of tamoxifen cut their risk of recurrence compared with those who completed a five-year course of tamoxifen.

Trials currently under way will address long-term side effects and compare tamoxifen head-to-head with aromatase inhibitors. Until those results are in, our experts say that women should consider an aromatase inhibitor only after completing tamoxifen and only if their personal or family history puts them at high risk for recurrence. Because of the increased risk of osteoporosis, post-menopausal women who take aromatase inhibitors should be especially careful to follow standard recommendations to get 1,500 milligrams of calcium and 600 to 1,000 IU (international units) of vitamin D daily and should be sure to have their bone density monitored.

If you suspect you have or are at risk for breast cancer, make an appointment with your doctor soon. Prompt, proper treatment can help limit the spread of breast cancer and restore your quality of life. With many surgical and therapeutic options available, having up-to-date, unbiased information is crucial.