Questions

Answers

1. How do I know if I have a problem with my breast?

The answer begins with the history.  Do you have a lump that you can feel, discharge you can see, or unexplained persistent and worsening breast pain?  These are the three most common signs or symptoms elicited in taking a history from each woman or man who presents regarding the issue of breast health.  If there is no lump, dominant mass, spontaneous nipple discharge, or persistent and/or progressive pain, then we consider the history negative and go on to other methods of detection.

2. How do I know if I have a breast lump?

In our opinion, the best way to examine your breast is to do it on your back with a pillow beneath your shoulder.  The instructions are as follows:  Put a towel on the mattress or floor and a pillow down.  Take some liquid soap in your hand, get down on the mattress or floor, and put your right shoulder on the pillow and your right arm above your head.  With a little liquid soap on your left hand, begin in the lower inner section of your breast and feel the breast, working with a smooth steady stroking manner or a circular manner with your three middle fingers put together to serve as an exam platform.  Be aware that because of the anatomy of the breast, all breasts are lumpy as in tapioca pudding-lumpy or rice pudding lumpy that is irregular and dense in some areas.  An area that feels particular thick or in which your fingers can palpate or feel something that resembles a frozen pea or lima bean are the areas that require further investigation because what your finger is feeling may be an unusual thickening in the breast or, in fact, a discreet mass that you can move between your fingers or feels stuck in the breast.  Those types of areas, especially if they are new or persistent for more than one month, definitely require investigation.

3. If I don’t have a lump or discharge or unusual persistent and progressive pain, how do I know that I don’t have breast cancer?

Through mammography.  The use of x-ray of the breast taken once a year beginning at age 40, except in unusual circumstances, are your best assurance that there is not a problem beginning in your breast which requires further evaluation.  In the United States, the mammogram should be done in facilities which are American College of Radiology certified and you should expect a report back from the facility within a few weeks which tells you basically that everything is okay, or that you need to go further.  The purpose of mammography is to detect an abnormality in the breast at a time earlier than it would otherwise be felt by about three to four years.  The proven effectiveness of mammography in selected areas in western Europe and replicated here in the United States has been to demonstrate that the death rate from breast cancer is reduced by approximately 30% when a breast cancer is detected through mammography rather than waiting another three years until it can be recognized by what you feel or see by looking at the breast.  Mammography is the gold standard for the early detection of breast cancer.  There are multiple other techniques in development and in testing, some of which will be mentioned below.  The baseline for evaluation is a mammogram and it should be done ideally with two views of each breast and be done once a year, except in special circumstances. 

4. If I feel something that doesn’t feel right in my breast, what should I do?

Obtain an opinion from a qualified breast clinician, obtain a mammogram and obtain ultrasound.  Notice that the answer here is three parts.  If you go to a physician or nurse practitioner and they tell you that everything is okay, if you know in your heart that it is not okay, you must go further.  Do not accept that advice.  Going further and, in our opinion, the proper evaluation when you suspect that you have an abnormality that you can feel in your breast should at least and always include 1) repeat examination by the same or different healthcare practitioner, 2) a mammogram with lead marker placed on the skin over the spot where you believe there is an abnormality, and 3) a modern ultrasound examination of your breast, especially in the area of concern.  It would be rare that there would be a serious breast issue that does not show up repeatedly on physical examination and/or is not seen on mammography or ultrasonography but it can happen so be persistent.

5. What do I need to know about mammography?

Mammography is safe and effective at an 80 to 90% level in detecting an abnormality in your breast.  When the mammograms are reviewed by the radiologist, they are put in one of six classes.  They are called BI-RADS classes and each mammogram report should have a number from 0 to 5 on it as follows: 

6. What is ultrasound and what is its role in breast detection and diagnosis of breast cancer?

An ultrasound of the breast is a virtually painless examination requiring no compression with the application of a little jelly and a box-like device, known as a transducer, held by a sonographer.  The transducer emits sound wave energy into the breast and all structures—solid, cystic, benign, or malignant—reflect the sound back to the transducer result in a picture on a screen.  The picture can be interpreted by your healthcare provider as meaning a cyst or solid tissue tumor or normal area or thickened area, etc.  We can literally see the anatomy with the use of ultrasound.  It not only complements our breast examination, it is a mandatory part of our breast examination when there are any abnormalities seen on mammography or felt on physical examination.  It is not designed to be a screening tool of the breast like mammography because it is very labor intensive and user dependant.  Therefore, the greater the skill of the ultrasonographer with a modern linear array high frequency ultrasound machine, and the greater the interpretive skills of the person looking at the image obtained, the greater the reliability of the study.  It is an invaluable study of the breast, but it is not a replacement for mammography but rather an adjunct to mammography in almost all cases where there is any breast abnormality including nipple discharge from the breast.  Since the ultrasound does not use x-ray, it can be repeated more frequently in a manner completely safe for the patient with an abnormality palpated on breast examination.

7. What should I know about digital image mammography?

A recent study completed and published has demonstrated that digital mammograms are slightly more effective at detecting shadows that may lead to a diagnosis of breast cancer in women who are perimenopausal or who have heterogeneously dense or extremely dense breasts.  These groups of women constitute less than half the women in the country, so a traditional analog or regular mammogram is a completely satisfactory and highly effective examination at this time.  At this time, only about 8% of the mammography units in the United States are digital and over the next several years, that number will increase dramatically.  The challenge in digital mammography is the financial investment necessary to bring that technology to our women.  These mammography machines cost about $500,000 with additional costs on top of that for imaging workstations, etc., for a procedure which is a financial breakeven now with the old machines, which cost about $120,000 (analog mammography) procedure for the facilities doing these studies.  As of January 2006, our best estimate is that only 8% of the mammography units in the United States are digital in type.  Therefore, the best advice we can give you is, if you are in the United States, have your mammogram in an ACR-accredited facility and expect that that facility will guide you to a more sophisticated examination if you are a candidate for them. 

8. If my breasts feel like they have lumps all over and sometimes hurt, what should I do?

The most common cause of this condition is fibrocystic disorder.  It is present in about 70% of women in developed countries.  The usual guidelines are indicated in terms of investigation.  Mammography if you are 40 or over and ultrasound is typically always advised in these settings, even if you are 25.  Ultrasound may show cysts, which are collections of fluid in the breast, some of which, because they are symptomatic or bothersome to the women, should be aspirated as described below.  Again, the value of the ultrasound as an adjunct to mammography where that is indicated cannot be overestimated.  Please seek out breast ultrasound by a qualified examiner.  If you are detected and diagnosed as having fibrocystic breast disorder, a change in lifestyle may be indicated.  Reducing the amount of caffeine and chocolate in your diet, and sometimes adding even 200 units of vitamin E to your diet on a daily basis may be helpful in relieving symptoms and may result in the spontaneous remission of some of the smaller cysts.  Medications that contain caffeine may exaggerate this condition.  We advise you to ask for the written information on fibrocystic disorder from your breast healthcare facility.

9. If I have an abnormal mammogram and biopsy is recommended by my breast healthcare practitioner, how should I proceed?

The purpose of mammography and ultrasonography and physical examination is to detect an abnormality in the breast, i.e., just to know that there is something abnormal there.  If there is an abnormality in the breast which might be a malignancy or which is bothering the person, the preferred next measure is image-guided aspiration or biopsy.  This means that the abnormality must be able to be seen with mammography or ultrasound.  If so, either of these imaging modalities can be used to allow your breast specialist to place a tiny needle under local anesthesia into this area and either draw fluid off (known as aspiration), sample it for cells (known as fine needle aspiration), or most reliably, perform needle biopsy (known as core needle biopsy) in which four to five tiny slivers of tissue are removed from that area with direct visualization utilizing either the ultrasound or mammogram.  At the same time that the removal of tissues is complete, a tiny titanium clip is placed, which is to serve as a permanent marker for the area biopsied.  The results of this sampling technique, i.e., fine needle aspiration, in most cases, aspiration, or core needle biopsy will result in a pathology report which defines what the abnormalities are in the breast.  These procedures are done in your breast healthcare facility under local anesthesia with an extremely low incidence of problems and complications and, as recommended by a recent panel of experts internationally-oriented, is the preferred method of diagnosis of abnormalities in the breast.  If, for some reason, this cannot be done, then a trip to the operating room may be required.  Please ask lots of questions and talk about this issue before moving further, but do not ignore the issue of an abnormal mammogram or abnormal ultrasound.

10. If I have a biopsy done, what should I expect afterwards?

First, the area may be a little sore for a few days.  Occasionally, it is a bit swollen.  The incidence of any major problem such as collection of blood or hematoma or infection is under 1% and frequently, even these issues will resolve by themselves.  You should expect to have a visit back with your healthcare professional known as a concordance visit.  This is a visit where further imaging may be done, as well as additional examination and your healthcare practitioner will look at you, look at the old image, look at the new image, look at your pathology report, explain it to you and make sure that in his or her mind, there is concordance or complete agreement between what is seen on the imaging and what is sampled in the report as reflected by the words of interpretation from the tissue given to the pathologist.  This visit is extremely crucial, as there is a 4 or 5% miss rate with image-guided biopsy and we must be certain when we see a person back in the clinical setting or a concordance visit that what we, meaning the breast healthcare practitioner and/or radiologist, thinks the image shows and what the pathologist tells us it shows are one in the same.  If there is no concordance, then a trip to the operating room should be planned. 

11. How do I know if I have genetic breast cancer?

All breast cancer is genetic in the sense that it is a developed or acquired abnormality in the nucleus, or brain, of the cell causing the cell to divide over and over again in an uncontrolled manner, which can lead to a large, abnormal, uncontrolled growth within the breast that can spread elsewhere in the body, known as a metastasis, and result in the death of a woman.  This is what is to be avoided at all costs.  Hence, early detection and early diagnosis are crucial.  With respect to the specific issue of genetic breast cancer, what we know at the present time is that about 15% of the breast cancers in western Europe and north America are related to an abnormality in the genetic makeup of the individual known as BRCA1 or BRCA2.  This is an abnormality in the brain of the cell, which can result in high frequency of breast cancer.  50% of the women who have the BRCA gene will develop breast cancer by the time they are 50, and about 70% by the time they are 80.  Also, 35% or more of the women will develop ovarian cancer.  Hence, this is known as the breast cancer and ovarian cancer gene.  The presence of this gene is higher in women who have one or more first degree relatives, i.e., sister, mother, daughter, brother, or father who have had breast cancer, in whose families there have been multiple cancers present in the breast, ovary, and other organs, especially at ages under 50, or whose families are of Ashkenazi Jewish background.  There are certain specific indications to have the counseling and blood tests done to determine the presence or absence of the BRCA gene.  This information can be provided for you by your breast healthcare practitioner and a visit specifically on that issue in the instances outlined above is indicated to ask the question, “should I have a BRCA test done?”  The answers are readily available, but it requires a visit and detailed history and some serious conversation about where do we go from here if the test is positive in advance of even doing the test.

12. What do I do if I have spontaneous nipple discharge?

The breast is designed for breastfeeding.  It is normal to have non-bloody discharge from the nipple in the latter phases of pregnancy and immediately afterwards.  If breastfeeding is chosen by the woman and is carried out, it is not unusual to have some continued leakage from both nipples up to six months after cessation of breastfeeding.  If there is bloody nipple discharge at any time, that requires investigation.  The most common presenting issue with breast discharge is from a woman who is coming in with one-sided 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 and requires investigation.  That investigation should be a competent history, physical examination, ultrasound, and always should include mammogram as well in women over the age of 30.  Many cases of nipple discharge require that the duct from which the discharge is coming be removed in order to 1) rid the person of this problem and 2) define that there is no cancer present or developing in that duct. 

13. What should I know about nipple discharge or change in appearance of the nipple?

A persistent irritation of the nipple commonly known as a sore of the nipple may be a benign dermatologic condition which clears with typical dermatologic measures.  The most common error is to ignore a sore or ulcer on the nipple accompanied by non-bloody or bloody discharge for more than a few months.  If it has not cleared up with local wound care including the use of topical antibiotics in a three to four week period, the person who has such a nipple abnormality is advised to see his/her breast healthcare practitioner because this may be the beginning of Paget's disease of the nipple.  This is a particular type of nipple disorder, which has cancer associated with it an important percentage of the time in the breast tissue right underneath the nipple.  Investigation and biopsy are always required.

14. If I am a young woman age 12 to 30 and I feel a clear lump in my breast like a jellybean that moves around easily, what should I do?

Two things would be needed in this scenario.  A) Breast ultrasound to take a look at this lump and B) a visit to the healthcare practitioner.  As a general rule, lumps in the breast—a discreet three-dimensional mass—most of these in women of all ages are benign, but all must be investigated.  The most common cause of a lump in the breast as described above is a fibroadenoma, a benign tumor of the breast.  Typically, when present, these are either completely removed through a tiny incision that ultimately is barely visible, or they are biopsied away with a tiny needle to establish tissue diagnosis and/or to diminish the ability to feel the abnormality in the breast.  In short, while most lumps in the breast are not associated with cancer, some are and all lumps in all women of all ages require investigation with that minimum investigation being a visit to your breast healthcare practitioner, knowledge of a current mammogram, i.e., within a few months and a current ultrasound. 

15. I would like to know what are the major risk factors for developing breast cancer and how do I avoid it?

The two most common risk factors for the development of breast cancer are being female and growing older.  Neither of these conditions can be changed.  The incidence of breast cancer goes up in each decade of life and peaks in the 86^th year of a woman’s life.  Therefore, continued surveillance of the breast beginning at age 35 for baseline mammography in the absence of any family history or personal history of breast disease is what is recommended.  Once a woman reaches age 40, at this time, it is advised that she have annual mammography right straight through into her 80’s.

16. What do I need to know about other ways of detecting breast cancer?

17. What in general can I do to protect myself from breast cancer and what is prophylactic mastectomy?

At the present time, we really do not know what causes breast cancer.  It is clearly associated with lifestyle and has a high incidence in north America, selected areas of south America including Argentina and Uruguay, and throughout western Europe and Australia.  All of the developed countries have a high incidence of breast cancer except, for reasons unknown, Japan.  In the Asian and sub-Saharan African nations, the incidence is lowest, but in all countries which are typically called “emerging”—Korea, China and some of the eastern European nations, the incidence is intermediate, i.e., not high and not low but rising.  For example, the incidence of breast cancer in China is increasing 3 to 5% per year.  That is about the highest incidence of increase in the world and we believe is related to rapid changes in lifestyle in China.  The practical aspects of what are known is that diet may play a role and that the healthiest diet could be one which has increase in proteins and decrease in fat.  We believe estrogen is associated as a promoter of breast cancer if not a causal agent.  Therefore, eating animal products such as chicken, while encouraged in general, it may be safer to eat chicken or turkey which is a free range type rather than a type which is artificially fed including, in many cases, with hormones to stimulate the growth.  The same may be applicable to other products in the diet.

Women who have a high risk for breast cancer or who have certain pathological conditions such as lobular carcinoma in situ (LCIS) or who have a strong family history of breast cancer and who have biopsy-proven atypical hyperplasia of the breast, a pathologic diagnosis is that of abnormal cells but not yet cancer cells of the breast may choose to have the breast removed, usually with reconstruction assuming no co-morbid operative conditions that would increase the risk.  A prophylactic mastectomy carried out under these conditions reduces the risk of breast cancer from as high as 25 to 50% in some women down to a number at about the level of 2 or 3% below which risk it is not possible at the present time to go.  Discussion of prophylactic mastectomy is performed increasingly in the United States as a consequence of increased knowledge among our women about the risks of breast cancer and choices which women choose to make regarding their own bodies.  Where the woman has been carefully evaluated ahead of time and appropriate information given and discussion held, a decision to proceed with prophylactic mastectomy is a medically appropriate decision and can be carried out in most cases very safely and, as always, the choice to do prophylactic mastectomy must take into account the benefits to be achieved versus the risk to be undertaken.  This requires extensive discussion between the woman and one or more healthcare practitioners.

18. If I have had fine needle aspiration or core needle biopsy done, how do I know what my pathology report means?

19. How do I get more information about breast abnormalities which may be pertinent to me?

20. What is intraductal carcinoma of the breast?

The most common type of breast cancer is invasive breast cancer where cancer cells have escaped from the milk ducts of the breast into the surrounding breast tissue.  Left unchecked, this cancer can spread to the lymph glands, bones, lungs, brain and other areas resulting in an untimely and often painful death on the part of the patient.  There is a condition of the breast known as ductal carcinoma in situ in which cancer cells develop within the ducts but have not yet developed the capacity to travel outside the ducts and therefore spread.  This condition, which we have recognized in medicine for about 100 years and seen clearly for the last 30 with mammography, has been traditionally treated with removal of the breast known as mastectomy and a cure rate of 97% or more.  In the last two decades, scientific knowledge has allowed us to investigate the area of the breast which has ductal carcinoma in situ within it typically discovered through mammography or sometimes through nipple discharge and less commonly through the presence of a lump, but where the abnormal area is confined to one relatively small segment of the breast, that segment of the breast can be removed and typically the breast treated with radiation therapy and therefore not have to remove the whole breast.  A huge majority of the time, there is a great cosmetic result and the woman is very happy with the result and then she just needs to have surveillance over time to ensure that it does not come back on that side or on the other side.  In simplest terms, ductal carcinoma in situ may be thought of as a pre-cancer or pre-invasive cancer of the breast.  This disease, when detected and diagnosed early, is curable nearly 100% of the time with either partial mastectomy or mastectomy but requires extensive discussion between you and your healthcare practitioner.

21. How do I prevent breast cancer?

The prevention of breast cancer has been studied extensively in this country and in multiple European countries.  What we know at the present time is that for women who have high risk of breast cancer based on their family history or prior biopsy information, breast cancer risk may be reduced by either surgery or chemopreventive measures.  Surgery involves a prophylactic mastectomy of one or both breasts and reduces the risk from high risk, meaning 20 to 50% or higher down to about 2% risk, but not completely to zero.  Separate discussion for that is held.  Chemoprevention of breast cancer involves the use of medications which reduce the risk of breast cancer.  The one medication that has been most extensively studied and validated in this regard, at least in a national study published here in the United States involving over 13,000 women, involves the use of the medication tamoxifen, which is an estrogen blocker.  At least during the timeframe that it has been studied, i.e., a five year timeframe, it reduces the risk of breast cancer from women who have hyperplasia with atypia and other high risk groups such as lobular carcinoma in situ or strong family history of breast cancer reduces that by about 50%.  Thus, the use of tamoxifen, taken at a dosage range of 20 mg per day over a five year period is associated with risk reduction between 49 and 85%, depending on the category of risk a woman has before she enters the trial.  There are complications and side effects associated with the use of tamoxifen and a detailed discussion with your healthcare provider and a decision unique to you needs to be made. 

22. What do I do if I have a pathology report that shows lobular carcinoma in situ?

Lobular carcinoma in situ (LCIS) is a disease of the breast which is considered as, in strictest terms, not breast cancer at the present time, but rather a marker for the development of breast cancer.  The average woman in the United States has an 11% risk of developing breast cancer.  Lobular carcinoma in situ is detected at the present time only through obtaining tissue sampling and is typically found incidental to the biopsy for some other reason, i.e., the removal of a fibroadenoma and some surrounding breast tissue or the biopsy for microcalcifications in the breast based on the abnormal mammogram leading to a detection of lobular carcinoma in situ.  Lobular carcinoma in situ means that a woman has an increased risk of breast cancer from 15 to 25% absolute risk over a 20 or 25 year period.  While that seems like a long period and not too much of an increased risk over 11%, it basically can be thought of as a doubling of the risk of breast cancer from her native American born risk of about 11% up to about 22%.  With women living into their 80’s and 90’s, a 20 or 30 year period in which these risk factors apply is a relevant period of risk to consider for her.  Therefore, appropriate measures such as increase in surveillance, frequency, use of MRI, tamoxifen, or other chemopreventive medication risk-reducing strategies or bilateral prophylactic mastectomy are choices open to the woman.  LCIS is a marker for the development of breast cancer in either breast and it is for the development of not just cancer known as lobular carcinoma but invasive ductal carcinoma or ductal carcinoma in situ, i.e., all kinds of breast cancer.  It is a diagnosis that should be taken seriously and the issues associated with same very carefully considered by the woman involved.

23. If I have cancer of the breast, either invasive cancer type or intraductal cancer, do I necessarily require a breast removal?

Several years ago, an American consensus panel recommended that for early breast cancer, breast conservation management is the preferred treatment.

24. What do I do if the condition which I am interested in is not one of the most common questions listed here?  How should I proceed?

There are numerous other websites which have a host of information on them.  There are magazine articles and journals.  There are books in the library and book stores.  In the end, however, as much as the knowledge is global, healthcare is local in the sense that it involves you and a competent person to share with you his or her knowledge about any disease of the breast in particular, but your disease in your person.  Therefore, there is no substitute for talking about this with your breast healthcare provider.  A consultation with your breast healthcare provider in your area or region is strongly recommended for any perceived or real abnormalities of the breast, as earlier detection leads to earlier diagnosis leads to higher cure rate and can leave you with a life unimpeded by fears and concerns of breast cancer, recurrence of same, or untimely death from same.  These are crucial issues in the life of every woman in the world.  The knowledge is empowering and the way to get that is through talking about the particular condition or concern or diagnosis or mammogram that you have with a competent breast health practitioner.  Breast-related talk is a new subject introduced into America and if you have need of or desire to proceed further in this regard, you can consult Breast Talk as part of this website and we will guide you to a novel valid new approach to gaining knowledge and insight regarding your breast condition.