- Do you have a Breast Change?
- Submitted by Dr. Andreas Lambrianides
- General Surgeon - Brisbane, Australia
- Women commonly experience a breast change, however the majority of these are not breast
cancer. Change in the breast may be caused by:
- Cysts: Cysts are fluid filled sacs found more commonly in women between the 30 and 50
years of age or women who are on hormone replacement therapy. They are sometimes single
but often multiple. They can be bilateral and recurrent. The fluid within a cyst varies in
color from gray to green to brown. They are rarely malignant. If the cyst is painful or is
a lump that can be felt, it can be drained using a fine needle so that the lump
disappears. Aspiration is virtually painless and usually easily performed, although a
degree of expertise in necessary. Cytology is not necessary unless there is cause for
suspicion, such as blood stained fluid or failure of the mass to disappear after
aspiration. Cysts do not predispose to the development of cancer and should only be
approached if they are symptomatic or upon the patients request.
- Fibroadenomas: These are benign tumors of the breast, and arise from epithelial and
stromal tissue. They occur in about 10% of women commonly between 15 and 35 years of age.
They are smooth, lobular and mobile, usually presenting when they reach the size of about
10mm. They can double in size about every 12 months, usually growing to a maximum of about
30mm. Diagnosis should be made by fine needle aspiration biopsy, and therefore allowing
the patient flexibility either to proceed with excision or to be reviewed. Occult
malignant change within these benign tumors is rare. In patients with complex
fibroadenomas (those showing proliferative change in their cells on histopathology) there
is a two to threefold increase in the relative risk of invasive breast carcinoma and this
persists for decades after diagnosis. When there is a positive family history of carcinoma
the risk increases to 20% at two years.
- Hormonal change may cause swollen, tender or lumpy breasts during times of the menstrual
cycle, or when taking hormone replacement therapy. Changes may be unilateral and segmental
or bilateral and mostly symmetrical. It can also be diffuse in both breasts. Women with
proliferative disease without hyperplasia have 1.3 times the relative risk and those with
non-proliferative changes have no increased risk of breast cancer. A positive family
history increases the risk to 2.4 - fold and has a synergistic effect when associated with
- Nipple change: If there is a change in the shape or look of the nipple you should visit
your doctor. A cancer may be present if:
- There is nipple inversion - the nipples are pulled in and cannot be pulled out to the
- Scaling or crusting of the nipple
- Ulceration of the nipple
- Unusual redness of the nipple
- Lump is felt behind the nipple
- Nipple discharge - Many women have a minor degree of discharge caused by hormone
fluctuations, medications or local skin problems. A cancer may be present if the nipple
- Comes from a single duct in one nipple
- Blood stained or tests positive for blood
- Comes out without the nipple or breast being squeezed
- Is new and in a woman who is 60 years or older.
- The appearance of the discharge may be green, brown, milky, bloody, serous or clear.
- Investigations of patients who presented with nipple discharge showed 8% to have
carcinoma and this proportion increases to one- third in those over 60 years. Among the
patients with carcinoma, 6% had a serous discharge, 12% had a serosanguineous discharge,
24% had a sanguineous and 45% had a watery discharge.
- Breast Cancer: This occurs when normal cells in the breast grow out of control. It
occurs more often in older females with more than 70% occurring in women 50 years or
older. It is important that early diagnosis is achieved and treatment instituted before
the cancer spreads to other parts of the body.
- Tests to investigate the breast change: If you or your doctor has identified a breast
change there are a number of steps that can be followed to establish the cause. The triple
test approach is often used. This includes:
- 1. Examination of the breasts
- 2. Imaging test: such as mammography and or ultrasound
- 3. Fine needle aspiration biopsy or core biopsy to obtain a sample of cells or tissue
- from the area of change for examination under
the microscope by a pathologist.
- The Tests -
- History and clinical examination. The first step is to visit your doctor, who will
examine your breasts and ask some questions about the breast change and about any family
history and medical history.
- Imaging with mamography and/or ultrasound.
- Ultrasound uses high frequency sound waves to find changes within the breast. When you
have an ultrasound a gel is smeared onto the breast to make it slippery and a small
transducer will be moved over the skin. Ultrasound is more accurate than mammography in
young women whose breasts are very dense. It is therefore recommended as the first imaging
test in women under 35 years of age and for women who are pregnant or lactating as their
breasts are dense on mamography.
- Mammograms use low dose X-rays of the breast, which can pick up very small cancers
sometimes the size of a grain of rice. When a mammogram is taken the breast will be
flattened between the two plates of the X-ray machine for a few seconds, which some women
may find uncomfortable or painful. Mammograms are usually the first imaging test
recommended for women who are aged 35 or older who have a breast change.
- Mammography will only detect 95% of all breast cancers. It is however, the best
screening tool available for detecting breast cancer, and is the only screening method for
any malignancy, which has been shown to be of value in randomized trials. Randomized
control trials have shown screening by mamography can significantly reduce mortality from
breast cancer. Mortality can be reduced up to 40% in women who attend for screening and
the benefit is greatest in women over 50. Swedish trials showed an overall reduction in
breast cancer mortality of 29% during twelve years of follow up in women over 50 who were
invited to attend screening and 13% reduction in younger women. Outcomes of mammographic
- True positive 0.60 %
- False positive 5.40%
- True Negatives 94%
- False Negatives 0.06%
- Disadvantages of mammographic screening include.
- Over diagnosis and over treatment
- Radiation exposure
- False reassurance
- Possible delay in clinical breast cancer diagnosis
- Financial Costs
- Advantages Include:
- Early diagnosis
- Mortality reduction
- It has been calculated that for every two million women aged 50 who have been screened
by means of a single mammogram one extra cancer a year after ten years may be caused by
the radiation delivered to the breast, so the risk is very small.
- Taking a sample:
- This can be either a fine needle aspiration biopsy or a core biopsy. The fine needle
involves a small sample of cells being drained by a thin needle from the lump or area of
breast change while the core biopsy is similar to the fine needle except a larger needle
is used under local anesthetic. In case of nipple discharge, a smear can be taken of the
discharge for exfoliative cytology, which unfortunately has a high false negative rate.
- Mammography with cone magnification compression views and ultrasound localization of the
suspected segment is the best investigation. Excision biopsy of the duct and surrounding
tissue is done by a procedure called Microdochectomy after localization with a lacrimal
probe (a day only procedure under general anesthetic). The 8% of discharges associated
with malignancy usually represent in situ ductal or papillary carcinoma. Hormonal changes
causing discharge from the nipple may be associated with neoplasia of the pituitary gland,
and investigation of this should be by CT scan of the brain.
- If you or your doctor has identified a change in your breast it should be investigated
by means of clinical examination, imaging, aspiration biopsy, and referral to a surgeon if
any signs of cancer are identified. Early diagnosis is wildly accepted as the most
effective means currently available to reduce breast cancer mortality.
- ASK YOUR SURGEON
- This article is intended to provide you with information. It is not a substitute for
advice from your surgeon and does not contain all known facts about this subject. If your
not sure about benefits and risks of treatment ask your surgeon. Your surgeon will answer
your questions about diagnosis and treatment. This article should be used only in
consultation with your surgeon.