The recognition of breast cancer symptoms and the selection of an appropriate treatment regimen can be a complex and confusing process. We have selected the most frequently asked questions from women regarding breast cancer to aid you in your basic understanding of how to recognize early symptoms, the types of cancer you may face, and what options may be available to you if you are diagnosed with breast cancer.
The answers were formulated by the Robert A. Gardner, MD, PA staff of specialists in association with the Robert A. Gardner MD, Foundation, Inc. It is our hope that these questions and answers will provoke further thought and motivate you to take action if you suspect any abnormalities or sudden changes in your breast health.
This is not intended to provide you with individualized medical advice or in depth solutions to your particular needs. As always, a personal consultation with a medical professional qualified in breast health care is the best answer to any of your specific concerns.
1. WHAT DO I NEED TO KNOW ABOUT EARLY DETECTION?
Early detection simply means detecting breast cancer at its earliest possible stage of development. The earlier a cancer is detected, the less complex and less invasive techniques can be employed to treat it—plus the rate of survival is higher. In the case of breast cancer detection, breast awareness is the key. If you sense, feel or see any changes in your breast follow up with you health care provider. The American Cancer Society recommends women of average risk, without a personal history of breast cancer, family history of breast cancer, genetic mutations or history of chest radiation therapy before the age of 30, to begin screening mammograms at the age of 40. This position is based upon long-standing studies which document that mammography saves lives through early detection.
2. HOW DO I KNOW IF I HAVE A PROBLEM WITH MY BREAST?
The key is with breast awareness, if you see, feel or sense any changes in your breast contact your health care provider.
Do you have a lump or thickening that you can feel?
Is there a change in the skin texture or pores of the breast?
Is there any nipple discharge or change in the nipple?
Is there any change in the size or shape of the breast?
Is there unexplained persistent and worsening breast pain?
These are all changes that need to be followed up by your health care provider.
3. WHAT SHOULD I DO IF MY BREASTS FEEL LIKE THEY HAVE LUMPS ALL OVER AND SOMETIMES HURT?
The most common cause of this condition is fibrocystic disorder. It is present in about 70% of women in developed countries throughout the world. The usual guidelines for breast cancer screening in these cases should be followed. This includes annual mammograms if you are 40 or older but also we strongly advise ultrasound even if you are as young as 25. Ultrasound may reveal cysts, which are collections of fluid in the breast that may need to be aspirated if they present symptoms or are bothersome. The value of ultrasound as an adjunct to mammography in this case cannot be overemphasized. If you are diagnosed with fibrocystic disorder, a change in your lifestyle is recommended. Reducing the amount of caffeine and chocolate in your diet and sometimes even adding 200 units of vitamin E on a daily basis may be helpful in relieving symptoms and may lead to remission of some smaller cysts. You may not be aware that some medications contain caffeine and may exacerbate your condition. We recommend that you request written information on fibrocystic disorder from your breast care provider.
4. IF I DON’T HAVE A LUMP, DISCHARGE, OR PAIN, HOW DO I KNOW THAT I DON’T HAVE BREAST CANCER?
A yearly mammogram, beginning at age 40 (except in unusual circumstances) is your best assurance against advanced stages of breast cancer. The baseline for evaluation should include two views of each breast. In the United States, mammograms should be performed at facilities certified by the American College of Radiology. A mammogram can detect an abnormality in the breast three to four years before physical symptoms are even present. This earlier detection has been proven to reduce the death rate from breast cancer by approximately 30%. Fully 70% of all women diagnosed with breast cancer had no known risk before the time of diagnosis. Mammography is the current “gold standard” for the early detection of breast cancer. Still, newer techniques and emerging technologies are in development and limited use that will produce superior imaging at an even earlier stage than the standard mammogram.
5. IF I HAVE DISCOVERED SOMETHING IN MY BREAST THAT DOESN’T FEEL RIGHT, WHAT SHOULD I DO?
Seek medical advice from a qualified breast clinician. The proper evaluation should always include at a minimum these three diagnostic steps: (1) a thorough physical examination, (2) a mammogram with lead marker placed on the skin above the suspected abnormality, and (3) an ultrasound examination of the breast, especially in the area of concern. If results come back negative for cancer but your instincts tell you that something is wrong, be persistent and request re-testing. It is rare that a serious breast issue would not be revealed through such screening but it can happen.
6. WHAT IS BREAST DENSITY?
Breast tissue is composed of milk glands, mild ducts and supportive and fatty tissue. Radiologists use mammogram images to grade the density of your breast tissue. There are 4 categories of mammographic density. Breasts that are almost entirely fatty are graded a 1 for density and account for 10% of women in the U.S. Extremely dense breast are graded 4 and account for 10% of women in the U.S. 80% of U.S. women are classified into the middle categories.
Why is breast density important?
Having dense breast tissue may increase your risk for getting breast cancer. Dense breast tissue can obscure abnormal findings on the mammographic images. It is still important to have mammograms since they are the only medical imaging screening test proven to reduce breast cancer deaths. Many cancers are seen on mammograms even if you have dense breast tissue.
Are any tests better than a mammogram for dense breasts?
Additional tests can be ordered to help detect abnormalities in women with dense breast tissue. Studies have shown that ultrasounds and MRIs (magnetic resonance imaging) can help detect cancers that can’t be seen on mammogram.
What should I do if I have dense breasts or what if don’t?
If you have dense breasts, talk to your doctor about options for additional screening exams that may be right for you.
If you do not have dense breasts, other factors may place you at an increase risk for breast cancer these include family history of breast or ovarian cancer, previous chest radiation treatment for cancer and previous biopsies that show you are at high risk.
Even if you are low risk and have fatty breast tissue the recommendation is still to have annual mammograms starting at age 40.
7. WHAT DO I NEED TO KNOW ABOUT MAMMOGRAPHY?
Mammography is a safe and non-invasive test. It is 80 to 90 percent accurate in detecting an abnormality in your breast. When reviewed by the radiologist, it is reported as one of six classes known as BI-RADS which are rated from 0 to 6:
BI-RADS 0—“Incomplete study, more new images or old images required”. An additional mammogram and comparison to the first mammogram will need to be performed before a conclusion and number assignment can be made.
BI-RADS 1—Normal. Annual mammogram is typically advised.
BI-RADS 2—This is also a negative mammogram result, but there may be findings known to be benign, such as benign calcifications, lymph nodes, cysts or calcified fibroadenoma. These are areas of little concern, previously present, or if biopsied, would lead to a benign diagnosis and; therefore, can be safely left alone and not commented on further. Annual mammogram is typically advised to be continued.
BI-RADS 3—An abnormality is present with a high probability of being benign (greater than 98%) A repeat of the mammogram along with a breast ultrasound or other imaging modality in four to six months is typically recommended.
BI-RADS 4—Prompt further investigation is required. Typically, this means additional mammographic views, ultrasound imaging, and a tissue diagnosis through biopsy.
BI-RADS 5—An abnormality that is considered highly suspicious for breast cancer. In this class a biopsy is necessary.
BI-RADS 6—Mammogram with biopsy proven cancer.
8. WHAT IS THE DIFFERENCE BETWEEN MAMMOGRAPHY AND TOMOSYNTHSIS?
A mammogram is an X-ray of the breast. It is usually 2 views that are taken of each breast from different angles. Mammography is obtained by a special machine that uses a lower dose of radiation than the usual x-ray.
Mammograms are very good, but do have some limitations:
The compression of the breast that is required for good imaging can be uncomfortable.
The compression also causes overlapping of the breast tissue. A breast cancer can be hidden in the overlapping tissue and not show up on mammogram.
Mammograms only take one picture across the entire breast in 2 directions.
Digital tomosynthesis is a special kind of mammogram that produces a 3-dimensional image of the breast. It takes multiple X-ray pictures of each breast from many angles. The breast is positioned in the same way as conventional mammogram, but only gentle pressure is applied. The X-ray tube moves in an arc around the breast will 11 images are taken during the 7 second exam.
9. WHAT IS ULTRASOUND AND WHAT IS ITS ROLE IN THE DETECTION AND DIAGNOSIS OF BREAST CANCER?
An ultrasound of the breast is a noninvasive and painless technique that creates two dimensional images used for the examination of the internal structures of the breast and the detection of abnormalities. With this, we can literally see the anatomy of the breast. Ultrasound utilizes a surface probe called a transducer that is held by the technician and requires no compression of the breast tissues as with mammography. The transducer emits sound wave energy into the breast which is then reflected back to the transducer creating a picture of the type and density of the tissues present. Ultrasound is used as an additional diagnostic tool when abnormalities are detected in the mammogram or physical examination. It is not intended as a replacement for mammography nor is it as cost effective as mammography as the initial screening tool due to the labor intensive nature of the imaging techniques. In the hands of a skilled sonographer with superior interpretive skills, the ultrasound can produce a highly reliable study. Since ultrasound does not utilize x-ray energy, it can be repeated more frequently and is completely safe for the patient.
10. WHAT DO I DO IF I HAVE AN ABNORMAL MAMMOGRAM?
Do not panic if you are told your imaging is abnormal. The majority of abnormal mammograms are caused by benign processes. It may be overlapping tissue, or an area of thicker more dense tissue, possibly a cyst or benign lump.
When a mammogram shows an abnormal area the patient may be asked to return for additional imaging. The radiologist may also recommend an ultrasound or MRI of the breast. If the abnormality persists you may be asked to see a breast specialist or have a biopsy done of the area.
A breast biopsy is the removal of a piece of tissue done under ultrasound (core needle biopsy) or mammographic imaging (stereotactic biopsy). The biopsy is done with local anesthetic to the area of the needle puncture and generally painless with a low incidence of complications. The results of the sampling are then compiled in a pathology report.
Most breast biopsies give a benign result.
Whatever you do, do not ignore the results of an abnormal mammogram.
11. IF I HAVE A BIOPSY, WHAT SHOULD I EXPECT AFTERWARDS?
The area may be somewhat sore for a few days and there may be some swelling. The incidence of infection or internal bleeding is under 1% and frequently even these issues will resolve themselves. You should expect a return visit to your breast clinician to verify complete agreement between the imaging and the sampling as interpreted by the clinician, the radiologist, and the pathologist. This is known medically as a concordance visit where further imaging may be performed to compare to the pre-biopsy images and, as well, conduct a physical re-examination.
12. WHAT DOES THE PATHOLOGY REPORT TELL ME?
The pathology may take several days to obtain. After your breast procedure, the breast tissue is sent to the lab, where the pathologist will exam the tissue under the microscope and run special test on the tissue.
The pathology report will be sent to the doctor who will review the report with you.
Many conditions such as adenosis, cysts, fat necrosis and fibroadenomas are benign findings and do not increase your risk of breast cancer.
Breast changes that are not cancerous but increase your risk of breast cancer include atypical lobular hyperplasia (ADH), atypical ductal hyperplasia (ADH) and lobular carcinoma in situ (LCIS).
Lobular carcinoma in situ (LCIS) is a disease of the breast that is not considered to be cancer in the strictest sense but serves as an important indicator for the future development of invasive breast cancers. The likelihood of cancer stemming from LCIS is 15 to 25 percent over a period of 20 to 25 years. This is double the U.S. national average of 11% for overall cancer risk so it is significant. Treatments options include surgery, increased surveillance, MRI’s, hormonal therapy with include Tamoxifen or Raloxifene (medications shown to lower some women’s risk of breast cancer or clinical trials).
Intraductal carcinoma of the breast or ductal carcinoma in situ (DCIS) is considered the earliest from of breast cancer—often referred to as pre-cancer or pre-invasive cancer. In DCIS, abnormal cells multiply and form a growth within a milk duct of your breast. DCIS is noninvasive, meaning it hasn’t spread out of the milk duct to invade other parts of the breast. Treatment is needed and based on how much of the breast is affected and the grade of the DCIS. Treatment options may include surgery, radiation, hormonal therapy and clinical trials.
If the cancer has grown into the normal tissues, it is called invasive. After breast cancer is diagnosed tests are done to tell the type of cancer the extent and the stage of the cancer. Treatment will depend on these factors. Your doctor will review all this information and options that are available.
13. HOW DO I KNOW IF I HAVE GENETIC BREAST CANCER?
Most people who develop breast cancer have no family history of the disease. When a strong family history of breast and/or ovarian cancer is present, there may be reason to believe that a person has inherited an abnormal gene. The most common genes associated with a high risk of breast or ovarian cancers are the BRCA1 and BRCA2 genes.
BRCA 1 and BRCA 2 are tumor suppressor proteins. These proteins help repair damaged DNA and insuring stability of the cell’s genetic makeup. When there is a mutation in these genes the person has an increased risk of developing breast cancer or ovarian cancer.
Only 5-10 percent of breast cancers in the U.S. are linked to a genetic mutation. The presence of the mutated gene is higher in women with one or more immediate relatives such as parents or siblings who have experienced breast cancer or in a family with multiple cancers especially under age 50. Particularly, families of Ashkenazi Jewish decent are found to have a higher incidence of the mutated gene.
How much of a risk does a woman have with a BRCA1 or BRCA2 mutation?
Breast cancer: A woman in the general population has a 12% risk of developing breast cancer. If you have a BRCA1 mutation your risk is 55 to 65 %, and 45% for a BRCA2 mutation of developing breast cancer by the age of 70.
Ovarian cancer: A woman’s risk for ovarian cancer is about 1.3%. Woman with a positive BRCA1 mutation have a 39% risk and BRCA2 positive have an 11-17% risk.
Who should consider testing?
BRCA testing is only recommended for people who have a high risk of having a BRCA1/2 mutation, these include those individuals with:
- Family member with a BRCA1/2 mutation
- Personal history of breast cancer before the age of 45
- Personal history of ovarian cancer
- First degree family members diagnosed before age 50 years
- Cancer in both breasts in the same woman
- Ovarian cancers in a first degree family member
- Male relative with breast cancer
- Ashkenazi Jewish ethnicity
How is the test done?
Genetic tests are performed on a sample of blood or saliva. The sample is sent to a laboratory where technicians look for specific changes in the genes. The laboratory reports the test results in writing to your health care provider who will go over the results and review the options depending on the results.
14. WHAT SHOULD I DO IF I HAVE SPONTANEOUS NIPPLE DISCHARGE?
The breast is obviously designed for breastfeeding. It is normal to experience non-bloody discharge from the nipple in the latter phases of pregnancy and immediately thereafter. When breastfeeding ceases, it is not unusual to see some continued leakage from both nipples for up to six months. But if the discharge is bloody at any time, it requires investigation. The most common symptom for a non-lactating woman is a single nipple discharge that is more watery than thick, typically greenish in nature but may be clear or bloody. The presence of either clear or bloody fluid from the nipple can often indicate a small tumor developing in the ducts behind the nipple. An investigation that includes a comprehensive history of the patient, a physical examination, ultrasound and, if over the age of 30, a mammogram, should be conducted by a qualified breast clinician. Many cases of nipple discharge require that the duct that is the source of the discharge be removed to eliminate the problem and to also verify whether cancer is present in the duct.
15. WHAT SHOULD I KNOW ABOUT NIPPLE DISCHARGE OR CHANGE IN THE APPEARANCE OF THE NIPPLE?
A persistent irritation or sore of the nipple may be a benign skin condition that will clear up with typical dermatological treatment. The most common mistake is to ignore a sore on the nipple that is accompanied by a bloody or non-bloody discharge for several months. If the sore has not healed in three to four weeks after commencing the use of topical wound care including antibiotics, then you should consult with a qualified breast clinician to rule out the beginnings of Paget’s disease. Paget’s disease is a particular nipple disorder associated with cancer in the breast tissue immediately underneath the nipple. The breast clinician will require a biopsy to determine whether the condition is cancerous.
16. HOW DO I DETERMINE THE MAJOR RISK FACTORS FOR DEVELOPING BREAST CANCER AND HOW DO I AVOID THIS DISEASE?
There are two groups of risk factors for developing breast cancer. The first group is genetic factors or factors we cannot control these include:
Gender: Breast cancer occurs nearly 100 times more often in women than in men.
Age: Two out of three women with invasive cancer are diagnosed after age 55.
Race: Breast cancer is diagnosed more often in Caucasian women than women of other races.
Family History: If your mother, sister, father or child has been diagnosed with breast or ovarian cancer, you have a higher risk of being diagnosed with breast cancer in the future. Your risk increases if your relative was diagnosed before the age of 50.
Personal History: If you have been diagnosed with breast abnormalities including atypical hyperplasia, lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS) your risk for developing breast cancer increases.
Menstrual and Reproductive History: Early menstruation (before age 12), late menopause (after 55), having your first child at an older age, or never having given birth can also increase your risk for breast cancer.
Certain Gene Changes: Mutations in certain genes, such as BRCA1 and BRCA2, can increase your risk for breast cancer.
Dense Breast Tissue: Having dense breast tissue can increase your risk for breast cancer and make lumps harder to detect.
The second group is environmental or lifestyle risk factors, these are factors we can control, these include:
Physical Activity: A sedentary lifestyle with little physical activity can increase your risk for breast cancer.
Diet: A diet high in saturated fat and lacking fruits and vegetables can increase your risk for breast cancer.
Being Overweight or Obese: Being overweight or obese can increase your risk for breast cancer. Your risk is increased if you have already gone through menopause.
Drinking Alcohol: Frequent consumption of alcohol can increase your risk for breast cancer. The more alcohol you consume, the greater the risk.
Radiation to the Chest: Having radiation therapy to the chest before the age of 30 can increase your risk for breast cancer.
Hormone Replacement Therapy (HRT): Taking combined hormone replacement therapy, as prescribed for menopause, can increase your risk for breast cancer and increases the risk that the cancer will be detected at a more advanced stage
17. WHAT IF THE CONDITION I AM INTERESTED IN IS NOT LISTED HERE OR THE ANSWER IS NOT SPECIFIC ENOUGH FOR ME?
There are numerous other websites containing a wealth of information as well as magazine articles, journals and books on the subject. There are links throughout this website. A consultation with a provider in your area is highly recommended if you perceive any abnormalities in your breasts or wish to explore preventive solutions if you are classified as high risk. A frank, open discussion will lead to a better understanding of your condition and available options.
Remember, early detection can set off a positive chain reaction of early diagnosis, a kinder & gentler treatment, less chance of recurrence, and a higher probability of survival.