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 atypical hyperplasia.
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 normal shape.
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 discharge:
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 screening include:
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.
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.