In summary, African American women tend to get breast cancer at younger ages and diagnosis is at a later stage than White women of comparable ages.

Recommendation: annual mammograms in African American women starting at age 40. Special efforts should be made to encourage regular screening. There is not enough evidence to support starting screening before age 40 (Jones, 2003).

There is controversy in the literature regarding whether or not lesbians are at higher risk for developing breast cancer than their heterosexual peers.

To unravel this, we need to acknowledge:

• There is nothing about being a lesbian per se that would put women at increased bio-physiologic risk.
• However, many lesbians avoid seeking health care because of:
• unwelcoming and hurtful interactions with health care workers
• lack of need for gyn exams for contraception
• lack of health insurance because of lack of spousal coverage and/or lower salaries or benefits.
• Just as all heterosexual women are not similar, all lesbians are not similar.

Rather, it is the health-related behaviors that put all women at risk that also would put lesbians at risk. In one recent study, researchers used the Gail Breast Cancer Risk Model to calculate 5-year and lifetime risks of breast cancer among lesbians and their birth sisters. (This model includes many, but not all possible, risk factors for breast cancer.)

These researchers (Dibble, Roberts, & Nussey, 2004) found that the Gail Model scores were higher for lesbians than for their heterosexual sisters. More specifically, the risk factors of particular importance to lesbians that could put them at higher risk for breast cancer are pregnancy-related factors. These include:

• Less use of oral contraceptives
• Fewer pregnancies
• Fewer full term births
• Less breast feeding
• Delaying childbearing until after 30

Other changeable risk factors that could increase lesbians' breast cancer risk are (Dibble, et al., 2004; Fletcher, 2004):

• Being overweight post-menopausally (e.g., Body Mass Index > 30.7)
• Having a higher waist to hip ratio
• Having a history of drinking more than 9 alcoholic drinks per week
• Having a higher rate of prior breast biopsies

However, lesbians may be more likely to engage in weekly recreational exercise, putting themselves at lower risk.

To the extent that lesbians engage in behaviors that increase their risk for breast cancer, they would be more likely to develop breast cancer.

To the extent that lesbians' health behaviors are changing with society (e.g., drinking less, exercising more, experiencing less obstacles to childbearing), then their risks of breast cancer may be similar to that of other women.

The Mautner Project is a rich web site that describes special programs and information for lesbians about cancer in general, and breast cancer in particular. This site also has facts in Spanish about general risk factors for cancer. This organization also provides strong programs promoting inclusiveness in clinicians' knowledge, beliefs, and practices--watch for any in your area.

Almost two million women in the United States have had augmentation mammoplasty. Eighty percent of these operations are performed for cosmetic purposes and the other twenty percent are performed for reconstructive purposes, mostly after breast cancer surgery. All implants have two components: an external shell and a filler material. All external shells contain silicone and may be textured or smooth. Filler material can be silicone gel, saline, or oil. Since 1992, when the FDA placed a moratorium on silicone gel filler, the majority of breast implants are now filled with saline.

Presence of breast implants can make both clinical breast exams and screening mammography more difficult. Many clinical findings, that in most women would signal possible tumor, are complications of breast implants. For instance, capsular rupture or contracture of the implant can cause breast asymmetry, breast lumps, or wrinkling of the skin. Leakage of silicone can cause an axillary mass that can be mistaken for lymphadenopathy.

Presence of breast implants also makes screening mammograms more difficult to evaluate. Implants can be opaque and block views of breast tissue depending on placement. In addition, compression of the breast does risk rupture of the implant if done rigorously. Implant displaced views have been developed to screen women with implants and special compression techniques can minimize the risk of rupture. Overall, however, women with implants who get mammograms need more views, are exposed to more radiation, and have a risk of rupture.

The top picture shows a mammogram where the implant was not moved out of the way. The implant shows up as a solid white area; only a rim of breast tissue can be seen around the implant itself. By pushing the implant out of the way, a much better breast image is obtained (lower picture).

Recommendation: Breast implants do not increase the risk of breast cancer, but make mammograms harder to read. Mammograms with implant displaced views are used for screening women with implants. Mammogram frequency should be based on their ages and other risk factors.