Symptoms

Breast Mass

• One of the most common presentations of breast cancer is the mass.

Example of why following up on your body with a BSE is important:

Linda, of age 62, who after years of follow up, got into the habit of doing a monthly BSE; despite a negative exam and mammogram in November, Linda felt a lump in March which turned out to be a cancer.

• A lump can be a distinct nodule (small mass of tissue, lump) but it can be a vague nodularity or asymmetry that is especially worrisome if it is new.
• Some changes occur in the premenstrual period and that is why we advise women against self-breast exams at that time of their cycle.
• Masses that are cancerous are often, but not always, hard, irregular or non tender .
• A patient with a new mass or lump should seek immediate consultation with her primary care physician or preferably breast care specialist if she already has one.
• A noticeable mass can be easily evaluated with an ultrasound and a needle biopsy (removal and examination of a sample of tissue) which are done in our office.

Pain:

Although breast pain is not typically a sign of breast cancer, some breast pain is. Localized pain sometimes associated with a mass or dimpling of the skin is suspicious. The cyclical diffuse pain associated with the premenstrual period is almost always benign.

To help reduce pain, diet should consist of:

• Low caffeine
• Low fat
• Vitamin E up to 200 I.U./day
• Primrose oil

Nipple Discharge:

Nipple discharges are relatively common, frequently unpleasant and often alarming. The vast majority of nipple discharges are not cancerous but are related to fibrocystic disease (presence of one or more benign/non-fatal breast cysts), duct ectasia (dilatation), inflammation or caused by medications. A rare form of nipple discharge is caused by a pituitary tumor and may cause headaches and visual changes.

Suspicious nipple discharges are

• Single duct opening
• Spontaneous
• Bloody
• Associated with a mass
• Radiological abnormality
• Skin Changes
• Redness or puckering of the breast skin are highly concerning and should be promptly checked by a breast surgeon.

Symptom Detection Tools

Mammographic Abnormality:

Mammograms can detect cancers that are less than a fifth of an inch in size; these cannot be felt. Mammograms are either screening or diagnostic.

Screening

• The patient will get two standard views of each breast.
• The radiologist will review these films and report them in a standardized fashion.
• Done annually for women over 40.

Diagnostic Mammogram

• For patients who have symptoms or had recent cancer or surgery.
• More time consuming.
• Requires more views.
• Higher cost.
• Requires a prescription/referral.

To report the mammogram the radiologist will classify it according to the BIRADS (Breast Imaging Reporting and Data System):

• '0' - Needs further evauation. (Abnormal needs additional testing)
• 'I' - Completely negative.
• 'II' - Has a clearly non-cancerous abnormality.
• 'III' - Has an abnormality that is highly likely to be benign. (Less than 2% chance of cancer on biopsy.) A six month follow up is often recommended although some patients choose a biopsy.
• 'IV' - Suspicious abnormality with over 20% chance of cancer. Needs immediate biopsy.
• 'V' - Highly suspicious with over 50% chance of cancer. Needs immediate biopsy.

Since mammographic lesions (infected patch of skin/tissue) are often not palpable they require mammographic guidance for any biopsy. (See stereotactic biopsy or open biopsy with needle localization)

The most common findings on mammography are microcalcifications and mammographic shadows.

• Microcalcifications are calcium deposits that are often the size of grains of salt. In themselves they are not a problem but they may point us to cancers since calcium in the breast deposits in areas of inflammation, fibrocystic change, benign tumors and sometimes in cancers.
• Mammographic shadows are often benign. The typical irregular, speculated lesions are often cancerous but the majority of shadows are benign.

Digital mammography

• Allows better visualization of the breast.
• More expensive.
• Less radiation exposure.
• Not widely available yet.
• Indicated for pre and peri-menopausal women and for women with dense breasts.

Ultrasound

• Widely used in the breast surgeon's office.
• Inexpensive
• No exposure to radiation
• Helps characterize many lumps and abnormalities
• Helps with biopsy.
• Many masses, lumps and mammographic shadows are further evaluated using an ultrasound.