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Breast Health Questions & Answers

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.

Early detection simply means screening for cancer at an early age in order to detect it 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, it is recommended that you perform self-examination beginning at the age of twenty.  The American Society of Breast Disease continues to recommend annual mammography for all women beginning at age 40.  This position is based upon long-standing studies which document that mammography saves lives through early detection.  Generally, most insurance policies provide for a baseline mammogram at age 35 with annual mammograms commencing at 40.  If something is detected, most plans will include mammograms every six months thereafter.  Check with your own health insurance provider and the specific benefits under your plan to determine when and with what frequency mammograms are covered.

 

The answer begins with your history.  Do you have a lump that you can fee, visible discharge or unexplained persistent and worsening breast pain?  These are the three most common symptoms associated with breast cancer.  If these symptoms are not present nor does a physical examination reveal a dominant mass, then we consider the history “negative” and pursue other methods of detection.

In our opinion, the best method for examining your breast is to lie on your back with a pillow beneath one shoulder and a towel under your upper body.  You should lie on a prone surface such as the bed or the floor.  Starting with your right shoulder on the pillow, raise your right arm above your head.  Apply some liquid soap to your left hand for lubrication and begin in the lower inner section of your right breast pressing your three middle fingers held together against the surface of your breast.  Work in a steady stroking manner or circular motion.  Due to the natural consistency of the breast, it may feel lumpy like tapioca or rice pudding or denser in some areas.  An area that feels particularly thick or resembles a frozen pea or lima bean should be noted.  Reverse your position and perform the same procedure on the left breast.  Any unusual thickening in the breasts or a discreet mass that you can move between your fingers, especially if new or persisting for more than one month warrants further investigation by a qualified breast clinician.  You should perform a breast examination every month on or about the fifth day of your menstrual cycle.

 

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.

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.

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 5: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—“Slightly Abnormal with features 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—“Abnormality present with a low probability of malignancy, usually less than 5%”.  A repeat of the mammogram along with a breast ultrasound or other imaging modality in four to six months is typically recommended.In our opinion, if you receive this rating, we advise you not to wait several months for a re-test.  The most common problem associated with this class 3 report is that the six month follow up is not pursued or extended indefinitely due to a breakdown in communication with the healthcare provider.  Some cases have developed into cancer in as early as 6 months to a year from first being classified as BI-RADS 3.  You should immediately consult a qualified breast clinician to review your mammogram and its accompanying report.  We also recommend an ultrasound be performed before or at the time of this consultation.  At this visit, your health professional should explain the mammogram and report in full detail and include you in the discussion of available options.BI-RADS 4—“Prompt further investigation is required”.  Typically, this means additional mammographic views, ultrasound imaging, and a tissue diagnosis through biopsy.

We recommend immediately consulting with a qualified breast clinician before deciding what further imaging and diagnostic procedures are to be undertaken.  An interactive dialog with your breast care specialist will yield a more fruitful approach tailored to your personal pathology.  But there is no need for panic.  Many biopsies in this class are determined to be cancer-free.BI-RADS 5—“An abnormality that is considered highly suspicious for breast cancer”.  In this class a biopsy is necessary.  Immediately consult with a breast care specialist to determine your course of action.

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.

A recently published study 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 experiencing menopause or have very dense breast tissue.  These women comprise less than half the women in the U.S., so a traditional mammogram is still a completely satisfactory and highly effective screening tool.  As of January 2006, only 8% of the mammography units in the U.S. were digital, but the number may increase dramatically in the next several years.  The challenge, though, in bringing this technology forward is the financial investment required per machine.  The initial cost of a digital mammography unit is approximately $500,000 with additional costs for the necessary ancillary equipment in contrast to the current, analog mammography units in use that cost only $120,000 each.  Our best advice to you is to continue with current standard of analog mammograms at an American College of Radiology accredited facility and expect that they may guide you to the more advanced equipment if it is available and if you are a viable candidate.

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.

The physical exam, mammography and ultrasonography are intended to detect any abnormalities in the breast.  If an abnormality is present and is either bothersome or suspected of malignancy, the preferred next step—as recommended by an international panel of experts—is image-guided aspiration or biopsy.  If the abnormality is detectible by mammogram or ultrasound, either of these imaging modalities may be used by your breast clinician to guide the placement of a tiny needle into the area using local anesthesia.  Your breast clinician will either draw out fluid (aspiration), sample it for cells (fine needle aspiration), or most reliably, perform a needle biopsy (core needle biopsy) in which four or five tiny slivers of tissue are removed from the area.  This procedure has experienced a very low incidence of complications.  Following this, a tiny titanium clip is installed to serve as a permanent marker for the area biopsied.  The results of the sampling are then compiled in a pathology report.  If, for some reason, an outpatient biopsy can not be performed, then plan to have the procedure performed at the hospital.  Whatever you do, do not ignore the results of an abnormal mammogram.

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.  This visit is crucial as there is a 4 to 5 percent miss rate with image-guided biopsy and the medical team must be certain that all are in agreement.  If concordance is not achieved, you will most likely be scheduled for a second procedure at the hospital.

All breast cancer is genetic in the sense that it is a developed or acquired abnormality in the DNA of cells causing them to divide uncontrollably over and over leading to large growths within the breast that may spread elsewhere in the body.  This is referred to as metastasis and invariably leads to death.  This progression is what we wish to avoid at all costs.  Hence, early detection and diagnosis are key to the survival from breast cancer.  With respect to the specific issue of genetic breast cancer, at present about 15% of breast cancers in North America are related to a mutation in the tumor suppressor gene family of the two genes identified as BRCA1 and BRCA2.  These genes normally function to repair damage in the DNA of healthy cells but if they are abnormal, they will trigger the out-of-control growth associated with cancer cells.  50% of women with a BCRA mutation will develop breast cancer before age 50 and roughly 70% by age 80.  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.  If you suspect a genetic disposition runs in your family, a blood test, referred to as the BCRA test, and a thorough review of your family history will identify whether you are at risk genetically.  Before you take this blood test, you should discuss with your breast clinician, or otherwise qualified health professional, what courses of action may be taken if the test reveals that you have a BCRA gene mutation.

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.

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.

You should visit a qualified breast clinician who will perform an ultrasound of the condition.  In most cases, a well defined, small mass is usually benign but should be investigated to be on the safe side.  The most common cause of a benign lump in the breast is due to fibroadenoma.  Typically when such a lump is present, it is completely removed through a tiny incision or removed by needle biopsy to establish a diagnosis.  Either approach will diminish your ability to feel the lump.  In summary, while most lumps in the breast are not associated with cancer, all lumps in women of any age should be investigated by a qualified breast clinician.

The two most common risk factors are simply female gender and aging.  The incidence of breast cancer increases with each decade and peaks at age 86.  If you have no history of breast cancer, which may require a more intensive program, continual diligence commencing with self examination at age 20 and a baseline mammogram obtained at age 35 are advisable.  Once you reach age 40, you should obtain annual mammograms through your 80’s.

The detection of breast cancer is still best achieved through annual mammograms commencing at age 40.  The historical data demonstrates that this technique reduces the number of breast cancer deaths.  Two other tools that are consistently effective are ultrasound and a form of magnetic resonance imaging, the bilateral gadolinium-enhanced simultaneous breast MRI.  Ultrasound utilizes the interpretation of rebounding sound waves while MRI combines a powerful magnet with radio waves to create an image.  The state-of-the-art MRI approach is painless with the woman lying on her stomach so that the breasts are suspended beneath the table without compression.  The gadolinium is an injected dye that provides greater contrast in the images.  MRI’s can detect almost 95% of all abnormalities present in the breast with such specificity that a radiologist can identify the underlying disorder with an accuracy of around 65% without biopsy—and the accuracy rate is getting better each year.  Breast MRI’s are invaluable for women with a BRCA1 gene mutation or extremely dense breast tissue and a documented high risk for breast cancer.  The high risk factor is defined as a likelihood greater than 1.7% to develop breast cancer in five years or a lifetime risk in excess of 10 to 25 percent.  These percentages can be easily calculated by your breast clinician or through various websites.  MRI’s are also useful as a “second opinion” when a mammogram or ultrasound cannot be interpreted clearly or remains “indeterminate”.  Through our own extensive experiences, our practice can attest that the breast MRI is an invaluable tool for detecting abnormalities.  In some cases, it is the only way we can visualize a breast cancer as it is developing in its earliest stages.  MRI is also indicated for women with a proven diagnosis of breast cancer from biopsy to determine whether cancer is present in other areas of the breast or in the other breast also—which can occur in 2 to 5 percent of cases.  It is also very useful in the years following cancer treatment to determine whether there may be a recurrence of the cancer or if it has developed in the other breast.

At present, we really do not know what causes breast cancer but it is clearly linked to lifestyle.  The developed countries of the world have the highest incidence of breast cancer while the underdeveloped regions have the lowest incidence.  The incidence of breast cancer in China, where rapid changes in lifestyle are occurring, is increasing at one of the highest rates worldwide at 3 to 5 percent annually.  A practical aspect of what we know is that diet plays a significant role in its association with lifestyle.  A healthy diet rich in protein, fresh vegetables and fiber while low in fat, sodium and processed foods is less likely to contribute to cancer. 

Women with a high risk of breast cancer, that have certain conditions such as lobular carcinoma in situ (LCIS), or have a family history of breast cancer combined with a biopsy confirmed atypical hyperplasia—abnormal cells that are not yet cancerous—may choose removal of the breast combined with reconstruction as a preventive measure against future cancer.  This is referred to as a prophylactic mastectomy as the word literally means “tends to prevent disease”.  According to the National Cancer Institute, prophylactic mastectomy in high-risk women may be able to reduce the risk of developing breast cancer by 90%.  The decision to proceed with this approach should be considered carefully by the patient with input from a breast care specialist weighing all the benefits and risks.  In the proper circumstances, it is the medically appropriate decision but you must understand that it is permanent and irreversible.

The most common answer is that everything is okay but that is not the final answer.  If you have had either of these procedures or an aspiration where fluid has been extracted, the physical sampling is sent to a laboratory for analysis by a pathologist.  In the case of cell examination, it is technically a cytology report and in the case of tissue examination, it is a pathology report but these are both referred to as the pathology report.  In about two weeks or less, the pathologist will issue his report that will include his interpretation of the results.  The laymen explanation of this report falls to your breast clinician who performed the procedure.  Your breast clinician will explain the report as falling into one of three categories:Category 1—“benign benign”
This means that the cells or tissues that were examined are associated with completely non-cancerous conditions of the breast at this time and also for the future with respect to the specific location in the breast.  This report indicates the lowest level of concern for future malignancy.Category 2—“benign but”
This means that either an abnormal amount of cells are present or some unusual features within the abnormal amount of cells are present.  Florid hyperplasia means that the cell production is overactive but not necessarily cancerous.  The hyperactive growth could lead to abnormal growth with a greater possibility for cancer.  Hyperplasia with atypia means that the cell production is also too high but some of the cells appear abnormal or unusual and may be borderline malignant.Category 3—“malignant”
These reports always require further investigation by the breast clinician.  Most likely, surgery to remove the malignancy will be recommended.

The traditional way would be to seek a consultation with a breast health specialist, usually a breast surgeon, a general surgeon with considerable expertise in breast, or occasionally, a breast medical oncologist.  You can find these professionals through referrals from your OB/GYN, family practitioner, or satisfied patients that you know.  It is advisable to verify their credentials, if possible, prior to establishing the consultation. 

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.  This condition, which we have recognized in medicine for about 100 years, has been seen clearly with mammography for the past 30 years.  This was traditionally treated with complete removal of the breast through mastectomy.  The cure rate was 97%.  Due to the fact that DCIS is noninvasive and confined to one relatively small segment of the breast, a less radical and aggressive approach to surgical removal has evolved in the past two decades.  The current standard of care which achieves the same cure rate as the full mastectomy is surgical removal of only the involved segment (commonly referred to as a lumpectomy) followed by post-operative radiation therapy.  In a majority of cases, the cosmetic results are highly superior and pleasing to the patient.  The only follow up after the completed treatment regimen is periodic monitoring to ensure the cancer does not recur. Unfortunately, due to a lack of early detection and diagnosis that still exists in too many cases, invasive cancer is still the most common type of breast cancer.  Invasive cancer, when left unchecked can spread to the lymph nodes, bones, lungs and brain resulting in an untimely and often painful death.

The prevention of breast cancer has been studied extensively here in the U.S. and in Europe.  What we know presently is that for women with a high risk of breast cancer based on family history or prior biopsy results, breast cancer may be effectively treated by either surgical intervention or chemopreventive means.  A prophylactic mastectomy is performed as a preventive measure by removing one or both breasts reducing the risk of future cancer from 50% down to about 2%.  Chemoprevention utilizes medications to reduce the risk of cancer.  One medication that has proven to be the most effective as reported in a five-year study involving 13,000 women is Tamoxifen, an estrogen blocker.  It has reduced the incidence of cancer in women diagnosed with hyperplasia with atypia or lobular carcinoma in situ and women with a family history of cancer.  Tamoxifen, taken at a dosage of 20 mg per day over a five year period can reduce the risk from 49 to 85 percent depending upon the patient’s particular pathology.  Complications and side effects are associated with the use of this drug so an in depth discussion with your breast health professional is necessary to determine whether it is the right choice for your individual case.

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.  Also considering that your lifespan could exceed 90 years, the time period is also highly relevant.  Therefore, appropriate detection and treatment are very important due to the future consequences if not addressed early.  A diagnosis of LCIS can only be confirmed through the examination of a tissue sample and is usually found incidental to the original reason for a biopsy such as the removal of a fibroadenoma (a benign tumor) or to verify a suspected abnormality seen on a mammogram.  Treatment options include chemopreventive medications such as Tamoxifen or the preventive surgery, bilateral prophylactic mastectomy, where a “pre-emptive” double mastectomy is performed.  Because LCIS is not an invasive cancer it still should be taken seriously since there is a high degree of risk that it could evolve into a life-threatening cancer.

Breast removal, or mastectomy, includes removal of the nipple/areolar complex and all breast tissue.  Although tried and true, it is a radical procedure and only necessary in more aggressive or invasive later stage cancers.  The full mastectomy is not the appropriate methodology for non-invasive and early stage cancers.  Many years ago, a U.S. consensus panel recommended that breast conservation management (BCM) is the preferred treatment for early breast cancer.  BCM means removal of the minimum amount of breast tissue necessary to achieve the maximum effectiveness.  With BCM, only that portion of the breast containing the cancer and a small rim of surrounding normal tissue, called the margin, is removed.  This is referred to as a lumpectomy or partial mastectomy.   During this same surgery, the breast is reconstructed with its own tissues to provide a highly aesthetic outcome.  This is followed by a series of radiation treatments post-operatively.It is important to emphasize that the widespread adoption of mammography has led to an ever increasing detection of breast cancer in its early stages when it is small and localized.  It is now possible to treat up to 70 percent of cases in the U.S. with BCM where lumpectomy is combined with radiation therapy to achieve the same effectiveness as a full mastectomy.

There are numerous other websites containing a wealth of information as well as magazine articles, journals and books on the subject.  As much as this knowledge is widespread, proper healthcare is individualized.  There is no substitute for personal consultation with a qualified breast care provider.  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. 

 

PALM BEACH BREAST INSTITUTE Breast Care by Design

ROBERT A. GARDNER, M.D., FOUNDER
2151 45th Street, Suite 208
West Palm Beach, FL 33407
(561) 881-9100