Breast Concerns

To read about some common benign breast concerns we treat, click here.

Symptoms

Breast cancer does not always cause symptoms. The appearance of symptoms will depend on factors like the type, size, and location of the cancer. If you experience any symptoms, do not assume it is due to cancer. Many symptoms may be caused by other, less serious health conditions, such as a breast cyst. However, it is still important to discuss them with your doctor. Early detection and treatment improve outcomes for both cancer and other health conditions.

Breast Changes

Early breast cancer usually does not cause physical pain, and symptoms may not initially be noticeable. The most common symptom is a painless lump or thickening in or near the breast, or in the underarm area. In some cases, the lump or thickening may cause pain. If the lump stops growing or shrinks, it does not mean the problem has gone away. Any changes in the breast should be reported to your doctor.

Other changes to be aware of include:

• A change in the shape or size of the breast

• Nipple discharge or tenderness

• Inverted nipple

• Ridges or pitting of the breast (resembling the skin of an orange)

• A change in the way the skin of the breast, nipple, or areola (dark area surrounding the nipple), looks or feels (warm, swollen, red, or scaly)

• A sore or ulcer on the breast that does not heal

Advanced Symptoms

Later stages of cancer may cause:

• Pain or a sensation of a mass

• Decreased appetite and unintended weight loss

• Intense fatigue, abnormally low energy

• Abdominal or back pain caused by pressure on nearby nerves

• Difficulty breathing

• Swelling in the legs, which may be caused by an obstruction in the veins or lymphatic system

• Bone pain

Diagnosis

Your doctor will ask about your medical history, including any family history of breast cancer. Your breasts will be examined for characteristic symptoms, including lumps or thickening, nipple discharge or inversion, redness or changes in the skin or contour of the breast. The underarm area will also be examined. Your doctor may recommend different tests in order to identify tumors and confirm diagnosis.

Assessing Breast Changes

If your doctor finds abnormal results from physical exam the following tests may be done to better identify the changes. Not all breast changes are cancer. Tests to help distinguish noncancerous and potential cancerous changes include:

• Blood Tests

  Blood tests may identify markers or genetic mutations in the blood. For example, tumor markers or specific blood proteins may be elevated in the presence of cancer. Tumor markers are also used to stage the cancer and evaluate if the treatments are working.

• Imaging Tests

  Imaging tests may be used to look for the presence of tumors. They can also help assess their size and location. Some tests use contrast material to highlight structures so images are more clear and detailed. Imaging tests may include:

A mammogram is an x-ray of the breast. It can often find tumors that are too small for you or your doctor to feel. The accuracy of a mammogram to detect cancer will depend on several factors. It may be affected by the size of the tumor, your age, breast density, and the skill of the radiologist. Although mammograms are the most sensitive test currently used to evaluate the breast, they will miss 10%-15% of breast cancers.

During an ultrasound, sound waves are bounced off tissues. The echoes are converted into a picture. Ultrasound is used to evaluate lumps that have been identified through breast self-exam, clinical breast exam, or mammography. They help to see if a mass is solid or liquid-filled. Solid masses are generally more concerning than cystic or liquid-filled masses

Ultrasound may also be used to:

• Determine where the cancer has spread

• Detect any cancer cells that are in the ducts

• Determine if cancer has spread to the lymph nodes in the underarm area

An MRI scan of the breast may have better accuracy in detecting some types of tumors. It may be more accurate in cases where the breast tissue is more dense than usual or when breast cancer of both breasts is suspected. MRI scans can also be used if there are conflicting results from other tests, such as a mammogram and/or ultrasound.

Diagnosis of Breast Cancer

The clinical breast exam and imaging (like a mammogram) can suggest cancer, but a biopsy will confirm the presence of cancer cells. During a biopsy, a sample of suspicious tissue is removed so it can be examined under a microscope.

Biopsy types include:

• Fine needle aspiration —A thin needle is used to remove fluid and/or cells from a breast lump.

• Core needle—A larger, hollow needle is used to remove a wider area of tissue.

• Vacuum-assisted—A small incision is made in the skin before a hollow device is placed into the breast tissue. The suspicious tissue is pulled into the device. A small knife inside the device can also cut the biopsy sample from the remaining breast tissue.

• Surgical —During a surgical biopsy, all or part of a breast lump is removed for microscopic examination. An incisional biopsy removes a small portion of a large lump, while an excisional biopsy removes the entire lump (usually a small one).

Biopsies needles may be guided by imaging, such as an MRI scan or ultrasound, to improve accuracy.

Staging of Breast Cancer

If breast cancer is confirmed, results from completed tests and new tests will help determine the stage of cancer. Staging is used to identify characteristics of the tumor that will help determine the prognosis and treatment plan. Factors that play a role in staging include how far the original tumor has spread, whether lymph nodes are involved, if cancer has spread to other tissue, and microscopic cellular details.

Staging Tests may help determine breast cancer stage:

Imaging tests—To help determine how deep the tumor has moved into the layers of the breast or nearby structures. They may also help to determine if there are any metastatic growths in other areas of the body. Imaging tests may include:

• CT scan

• MRI scan

• Bone scan

• PET scan with or without CT scan

Lymph node biopsy—Cancer cells can drain from the tumor site into nearby lymph nodes. From here, cancer cells can travel through the lymph fluid to the bloodstream and other areas of the body. Lymph nodes under the arm are normally checked if suspicious tissue is removed, or if they are swollen or felt during the physical exam. Lymph biopsies can be done with a fine needle aspiration during the breast biopsy. Specific types of lymph node biopsies include:

Sentinel lymph node biopsy—Sentinel lymph nodes are the first nodes that a tumor will drain into. These nodes are located by injecting a traceable material near the tumor and watching which nodes take up the material first. If these nodes are free of cancer cells, it is unlikely that the cancer has spread. If cancer cells are present, then more lymph nodes may need to be removed to determine how far the cancer has spread.

Axillary node dissection—Removal of a lymph node from the underarm. Will be done if the sentinel lymph nodes have cancer cells. This is also done as part of a modified radical mastectomy for breast cancer treatment.

Tissue evaluation—Cancer tissue from the biopsy will be closely examined to look for characteristics that can help with prognosis and treatment selection.

Important characteristics include presence of :

• Estrogen and progesterone receptors

• HER2/neu and Oncotype DX

Stages of Breast Cancer, Breast cancer is staged from 0-IV:

• Stage 0- Carcinoma in situ—A very localized group of abnormal cells are still contained in the primary site. The cancer remains in the breast and has not spread.

• Stage IA- The tumor is no larger than 2 centimeters (cm) in size and has not spread beyond the primary tumor site in the breast.

• Stage IB- The tumor is not present OR up to 2 cm in size WITH small clusters of cancer cells in the lymph nodes.

• Stage IIA- The tumor is not present OR is up to 2 cm in size WITH cancer found in 1-3 lymph nodes in the underarm or in the lymph nodes near the breastbone (in the center of the chest) OR The tumor is 2-5 cm in size, but has NOT spread to any lymph nodes

• Stage IIB- The tumor is 2-5 cm in size WITH small clusters of cancer cells found in the lymph nodes OR The tumor is 2-5 cm in size WITH cancer found in 1-3 lymph nodes in the underarm or in lymph nodes near the breastbone OR The tumor is more than 5 cm in size, but has NOT spread to any lymph nodes

• Stage IIIA- The tumor is not present OR is any size WITH cancer in 4-9 lymph nodes in the underarm or in lymph nodes near the breastbone OR The tumor is more than 5 cm in size WITH small clusters of cancer cells found in the lymph nodes OR The tumor is more than 5 cm in size WITH cancer found in 1-3 lymph nodes in the underarm or in lymph nodes near the breastbone

• Stage IIIB- The tumor is any size and WITH cancer in the the chest wall WITH/WITHOUT swollen or ulcerated skin on the breast AND Up to 9 lymph nodes in the underarm OR in lymph nodes near the breastbone Note: If cancer has spread to the skin causing swelling or ulcers, it may be inflammatory breast cancer. This type of cancer can be stage IIIB or higher.

• Stage IIIC- The tumor is not present OR is any size WITH/WITHOUT cancer in the chest wall AND/OR swollen or ulcerated skin on the breast WITH spreading to 10 or more lymph nodes in the underarm OR To lymph nodes above and below the collarbone OR To the lymph nodes in the underarm and lymph nodes in the breastbone

• Stage IV- Cancer has spread beyond the breast and lymph nodes to other parts of the body. The most common sites for metastatic breast cancer are in the bones, lungs, brain, and liver.

Treatment

Treatment and outcomes depend on several factors, such as location, tumor size, stage, overall health, and age. In a large study, for example, younger women (less than age 40 years), who were initially diagnosed with Stage I or II breast cancer, had lower survival rates compared to older women. Researchers are investigating what may account for this unexpected result. Treatment and outcomes depend on several factors, such as location, tumor size, stage, overall health, and age. In a large study, for example, younger women (less than age 40 years), who were initially diagnosed with Stage I or II breast cancer, had lower survival rates compared to older women. Researchers are investigating what may account for this unexpected result.

The goal of treatment is to remove as much of the cancer as possible, while preserving the as much of the breast and its function. Additional treatment may help to prevent the spread or recurrence of cancer. The treatment plan will often involve a combination of approaches based on the characteristics of the cancer, woman's age, general health, and prognosis. Treatment for advanced stages may include management of symptoms for comfort measures. The healthcare team will be made up of a variety of health professionals including doctors, surgeons, nurses, and pharmacists. It is important to maintain contact with your medical team, adhere to recommended treatment, and go to any recommended appointments for best outcomes possible.

Screening

The purpose of screening is early diagnosis and treatment. Screening tests are administered to people without current symptoms, but who may be at average or high risk for certain diseases or conditions. Several professional organizations have published sometimes differing guidelines for breast cancer screening. Though this may seem confusing, the ultimate goal is to encourage individuals to discuss the risks, harms, and benefits of different breast cancer screening tests with their doctor.

The most current guidelines below are from the United States Preventive Services Task Force, the American Cancer Society, and the American Congress of Obstetricians and Gynecologists.

Screening Guidelines for Average Risk

Mammogram Clinical Breast Exam Breast Self-exam

• US Preventive Services Task Force Age 40-49: Shared decision with doctor to have a mammogram every 2 years until age 50.

• Age 50 and older: Every 2 years until age 74.

• Age 75 and older: No recommendation given.

American Cancer Society Age

• 40-44: Women can start screening if that is their choice. Start talking about screening tests with your doctor.

• Age 45-54: Every year.

• Age 55 and older: Start transitioning to every 2 years, and continue as long as overall health is good and life expectancy is 10 years or more. A mammogram every year can be done for women who choose to do so.

American Congress of Obstetricians and Gynecologists (ACOG)

• Age 40-49: Shared decision with doctor to have a mammogram every 1-2 years.

• Age 50-75 years: Every 1-2 years.Age older than 75 years: Shared decision with doctor to continue with mammograms.

• Age 25-39: Every 1-3 years.Age 40 and older: Every year. Encourage breast self-awareness. Information given on self-exam for women who choose to do so.

Breast self-awareness is very important at any stage of life. Be aware of any changes, such as new or disappearing lumps, clear or bloody nipple discharge, dimpling or thickening of the skin, pain, or a feeling of fullness in the underarm area. Not all breast cancers cause symptoms and not all breast changes are caused by cancer, but it is important to discuss these with your doctor so they can determine if further testing is needed.

Screening Guidelines for High Risk

If you are in a high-risk group for developing breast cancer, you and your doctor will schedule more frequent screening tests, which will start at an earlier age.

The American Cancer Society recommends a yearly mammogram with an MRI scan starting at age 30 years for women with:

• A high risk assessment score

• One of the BRCA genes—if tested

• First-degree relative with one of the BRCA genes—if not tested

• A history of high-dose radiation to the chest from ages 10-30 years

• A personal history or first-degree relative with certain syndromes that increase risk of breast cancer, such as Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba

The United States Preventive Services Task Force recommends:

• Monthly breast self-exams for women aged 18-21 years

• For women aged 25-35 years:

• Clinical breast exam every 6-12 months

• Yearly mammogram

The American Congress of Obstetricians and Gynecologists recommends that high-risk women consider doing regular breast self-exams.

Screening Tests

There are 3 main tests to screen women for breast cancer. Not all organizations recommend these methods, but you may choose to do them after you discuss the risks, harms, and benefits with your doctor. These include:

• Breast self-exam —Overall, there is a a lack of evidence that breast self-exams are effective in reducing the risk of death from cancer. A self-exam can cause unnecessary anxiety. Before you do breast self-exams, talk to your doctor about proper technique.

• Clinical breast exam—The doctor will carefully feel your breasts and under your arms to check for lumps or other unusual changes.

• Mammogram —An imaging test that takes an x-ray of the breast, which may detect tumors that are too small to be felt. The accuracy of a mammogram to detect cancer depends on several factors including the density of breast tissue. Although a mammogram is the most sensitive test currently used to evaluate the breast, it will miss 10%-15% of breast cancers. Mammograms can also indicate a tumors when there is no tumor almost 1/3 of the time. The possibility for this false-positive is one of the reasons some organizations changed screening guidelines.

Other Imaging Tests

MRI scans may be used to screen high-risk women.

General Guidelines for All Women

Quit Smoking

Smoking introduces a variety of harmful chemicals into your body. Every cell is affected by smoking. The risk of many cancers, including breast cancer, is much higher in women who smoke. The risk increases with the number of cigarettes smoked and the number of years as a smoker. Quitting smoking is an important step in preventing breast and other cancers. The sooner smoking is stopped, the sooner the body can start to heal. Talk to your doctor about the options available to help you successfully quit.

If You Drink Alcohol, Drink in Moderation

Alcohol may cause estrogen levels to rise, which increases the risk of certain breast cancers. You can reduce your risk by avoiding alcohol or drinking in moderation, which is no more than one drink per day (for women).

Eat a Healthful Diet

Eating a diet with plenty of fruits, vegetables, and whole grains will maintain your overall health and strengthen your immune system. A strong immune system is one of the best tools against breast cancer. On the other hand, a diet high in processed and red meat is associated with an increased risk of breast cancer. Look for healthy alternatives like lean meat (like chicken) and/or fish or vegetarian options. Good nutrition can also help to maintain a healthy weight. Excess body weight, especially after menopause, which increases breast cancer risk. Fat cells secrete the hormone estrogen. The more fat on the body, the higher the estrogen level. Estrogen is associated with breast cancer development.

Exercise

Regular exercise is good for overall health, wellness and maintaining a healthy weight. Moderate physical activity has been shown to decrease breast cancer risk of both pre- and postmenopausal women. Aim for 30 minutes of moderate exercise (including brisk walking) on most days of the week. If you currently do not exercise, talk to your doctor about how to get started on a program safely.

Limit Exposure to Estrogen When Possible

High levels of estrogen have been linked to the development of breast cancer. For older women, the greatest exposure to estrogen is through postmenopausal hormone replacement therapy. Talk your doctor as to the risks and benefits of estrogen replacement before using them.

General Guidelines for Women at High Risk

Certain factors increase the risk for breast cancer. The following groups have a higher risk:

• Age over 60 years

• Age over 35 years and history of lobular carcinoma in situ (LCIS)

• Genetic mutations like BRCA1 or BRCA2, or strong family history

• History of irregular breast biopsies

• History of previous breast cancer

If you are in a high risk group, in addition to guidelines above, your doctor may recommend:

• Genetic Testing- If you have a strong family history of breast cancer, talk to your doctor about whether you should be tested for gene mutations associated with breast cancer. Women who carry these particular genes are at very high risk for breast and ovarian cancers.

• Estrogen-Blocking Drugs- There are 2 FDA-approved medications to prevent breast cancer in high-risk, postmenopausal women. Tamoxifen and raloxifene work by blocking estrogen from binding to estrogen-sensitive cells, which prevents the cells from growing and dividing. However, these medications also increase your chances of having blood clots, which can lead to a heart attack or stroke.

• Prophylactic Surgery- Surgery to remove both breasts (prophylactic mastectomy) may be an option for women who are at very high risk for breast cancer. If you have many risk factors for breast cancer, talk to your doctor to see if this is an option for you.

Some women can also lower their risk by having their uterus and/or ovaries removed.

Talking to Your Doctor

You have a unique medical history. Therefore, it is essential to talk with your doctor about your personal risk factors and/or experience with breast cancer. By talking openly and regularly with your doctor, you can take an active role in your care.

Here are some tips that will make it easier for you to talk to your doctor:

• Bring someone else with you. It helps to have another person hear what is said and think of questions to ask.

• Write out your questions ahead of time, so you don't forget them.

• Write down the answers you get, and make sure you understand what you are hearing. Ask for clarification, if necessary.

• Don't be afraid to ask your questions or ask where you can find more information about what you are discussing. You have a right to know.

• Ask your doctor if it is acceptable to audio tape the interview session so that you can listen again to the interview and discussion when you are at home. Most qualified doctors will welcome the opportunity to have the session taped.

• What kind of breast cancer do I have?

• How will you determine whether the disease has spread?

• What lab tests were done on the tumor tissue, and what did they show?

• How will these results affect my treatment decision?

• Based on my medical and family history, and symptoms, am I at an increased risk for developing breast cancer? Though family history and genetics play a role, breast cancer very often occurs in those with no distinct risk factors.

• Are other members in my family at an increased risk for developing breast cancer?

• What can I do to manage that risk? Is prophylactic mastectomy appropriate considering my risk profile?

If you have been diagnosed with breast cancer, you should first try to get at least one other opinion from another doctor. If both you and your doctor agree with the diagnosis, you may want to get specific information about the surgery, chemotherapy, hormonal therapy, and the radiation therapy. No one doctor will likely answer all of your questions about all of these therapies, but they should be able to give you some general pointers. Additionally, you should get very specific information from the individual specialist.

• What kinds of surgery should I consider? Is breast-sparing surgery an option for me?

• What are the risks of surgery?

• Do I need to have my lymph nodes removed? If so, how many?

• Where will the scars be? What will they look like?

• If I decide to have breast reconstruction, how and when can that be done? Can you suggest a plastic surgeon?

• Will I need chemotherapy?

• What drugs will I be taking?

• What side effects should I expect?

• What are the risks?

• When will my treatments begin and end?

• Are there certain foods to avoid (such as fresh fruits and vegetables)?

• Do I need to avoid my grandchildren if they get sick?

• Will I need radiation therapy? If so, will it be external or internal?

• How long will the radiation treatments last?

• How often will I have them?

• What side effects should I expect?

• What are the risks of radiation therapy?

• Are there certain activities (such as, smoking) or certain herbs and supplements that I should avoid during my radiation? If so, why?

• How will I feel after the operation? How will my daily activity be affected?

• Will I have to do special exercises?

• How long will it take for me to resume my normal activities?

• Will I need a special diet?

• Are there any alternative or complementary therapies I should consider?

• What are the chances that the breast tumor will recur?

• Can you recommend a support group or a counselor for me and my family?

• What is my prognosis?

• How will I feel during therapy?

• What physiological changes should I expect? How will they affect my fertility and my sexual life?

• Are there any clinical trials that are being conducted that may be of interest to me?