QUESTIONS AND ANSWERS ABOUT BREAST LUMPS
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QUESTIONS AND ANSWERS ABOUT BREAST LUMPS (NOTE: This publication was produced by the: U.S. Department of Health and Human Services - Public Health Service - National Institutes of Health - National Cancer Institute - NIH Publication No 92-2401 - For a free copy, send your name and address to: Consumer Information Center - Dept. 553Z - Pueblo, CO 81009) To contribute to the National Cancer Institute, write to: Gift Fund, Box P, 9000 Rockville Pike, Bethesda, Maryland 20892. QUESTIONS & ANSWERS About Breast Lumps It's natural to be concerned if you've found a lump in your breast. But . . . 80 percent of all breast lumps are benign, which means no cancer is present. After reading this booklet, you will know more about the normal changes that can occur in a woman's breasts. And you'll learn what to do if you find a lump or other change in your breasts. Most lumps are found by women themselves, either through regular breast self-exam or just by accident. Others are discovered during routine breast exams by a health professional and through mammograms, special x-rays of the breast. About 20 percent of breast lumps are malignant (cancerous). However, if cancer is found at an early stage and treated promptly, the outlook is good. In fact, 85 to 95 percent of women with early breast cancer will be alive 5 years after diagnosis. Most of them will be free of breast cancer for the rest of their lives. It is normal to be afraid when you find a lump in your breast. But don't let fear stop you from seeing a doctor right away if you think something is wrong. You will feel more confident about finding a breast lump early by: * Having regular mammograms (see the guidelines in this text). * Having a regular breast exam by a health professional. * Doing a monthly breast self-exam (BSE)--as illustrated in this booklet. Q. What is the difference between having a lump in the breast and simply having "lumpy" breasts? A. The breasts are made up of ducts, lobes, and fat. Under the breasts are muscles and ribs. These normal features may make the breasts feel "lumpy" or uneven. In addition, many women have changes in their breasts that are related to their monthly menstrual cycle. Swelling, tenderness, and pain in the breasts may occur before and sometimes during the menstrual period. At the same time, one or more lumps or a feeling of increased "lumpiness" may appear in the breasts. These symptoms are caused by extra fluid collecting in the breast tissue, which is normal. If the "lumpiness" or lumps do not go away after the end of your period, it is important to see a doctor. If you are past menopause and you find any new lump or thickening in your breast, you should see your doctor. Q. What am I looking for when I do BSE? A. You are looking for a lump that stands out as different from the rest of your breast tissue. Many women are confused about BSE because their breasts generally feel "lumpy." Becoming more familiar with your breasts by doing BSE each month will help you tell the difference between your normal "lumpiness" and what may be a change. Ask your doctor or other health professional to do a breast exam with you and to explain what you are feeling in your breasts. They can make sure you are doing BSE correctly and thoroughly, which will make you feel more confident. Q. What should I do if I find a lump in my breast? A. If you notice a lump in one breast, examine the other one. If both breasts feel the same, then what you feel is probably a normal part of your breast. You should, however, mention it to your doctor at your next visit. If a lump of any size appears in either breast and does not go away after your menstrual period, see your doctor. The doctor may refer you to a specialist to discuss the need for further tests. If you do not have a doctor of your own, your local medical society or the Cancer Information Service (CIS) may be able to help you find a doctor or breast clinic in your area. The toll- free telephone number of the CIS is 1-8004-CANCER. Q. How is a breast lump I evaluated? A. Your doctor can evaluate a lump in a number of ways. 1. Palpation is a physical exam of the breast. The doctor examines each breast and underarm by feeling the tissue. Although a doctor can tell a lot by the way the lump feels, no one can be certain what a lump is just by palpation. 2. Aspiration, also called fine needle aspiration can help the doctor discover whether the lump is a cyst (fluid-filled) or a solid mass of tissue. Aspiration is usually done in the doctor's office. First, the doctor uses a local anesthetic to numb the area. Then, the doctor inserts a needle into the lump and tries to withdraw fluid. If it is a cyst, removing the fluid will collapse it. The fluid may be sent to a laboratory for testing to be sure no cancer cells are present. When the lump is solid, the doctor sometimes removes a sample of cells with the needle. These cells are then sent to a laboratory for analysis. 3. A mammogram is a type of x-ray that creates an image of the breast on film or paper. It can help determine whether a lump is benign or cancerous. In fact, it often can detect cancer in the breast before a lump can be felt. The National Cancer Institute (NCI) suggests that beginning at age 40, all women should have a mammogram every 1 to 2 years. When a woman reaches 50, she should have a mammogram each year. A doctor may also recommend a mammogram if any sign or symptom of breast cancer is found, regardless of age. Several other methods also are being studied. None is now reliable enough to be used alone, but they may be helpful when combined with other methods. * Ultrasound uses high-frequency sound waves to get an image of the breast and can help determine if a lump is a cyst or a solid mass. It is usually used along with palpation and mammography. * Diaphanography, or transillumination, shines a light through the breast to show its inner features. * Thermography measures the heat patterns in the breast to produce an image. 4. A biopsy is the only certain way to learn whether a breast lump or suspicious area seen on a mammogram is cancer. In a biopsy, the doctor surgically removes all or part of the lump and sends it to the laboratory for analysis. There are several biopsy methods that a doctor may use: needle biopsy, incisional biopsy, excisional biopsy, and mammographic localization with biopsy. Occasionally the doctor will do a needle biopsy to remove a small amount of tissue from the lump. A needle biopsy can be performed in the doctor's office. This is most often done when cancer is suspected and the doctor hopes to confirm the diagnosis immediately. If cancer is not found, a more thorough biopsy will follow. Once, it was thought that inserting a needle or cutting into a breast lump might cause cancer to spread. This is not true. An incisional biopsy is the surgical removal of a portion of a lump. This procedure is often used when the growth is very large. Again, if no cancer is found, a more thorough biopsy may follow to make sure the entire lump is free of cancer. In an excisional biopsy the doctor removes the entire lump. This is currently the "standard" biopsy procedure and the most thorough method of diagnosis. Incisional and excisional biopsies are usually done in the outpatient department of a hospital. Either a local or general anesthetic may be used. Mammographic localization with biopsy (also known as needle localization) is used for suspicious areas such as microcalcifications (tiny specks of calcium) that cannot be felt but can be seen on a mammogram. During this procedure the breast is x-rayed and small needles are placed to outline the suspicious area for the surgeon who then removes the tissue for biopsy. This can be done using a local anesthetic in the outpatient department of a hospital. Your doctor may suggest one or more of these procedures to evaluate a lump or other change in your breast. The doctor may also suggest watching the suspicious area for a month or two. Because many lumps are caused by normal hormonal changes, this waiting period may provide additional information. However, if you feel uncomfortable about waiting, speak with your doctor about your concerns. You also may want to get a second opinion, perhaps from a breast specialist or surgeon. Many cities have breast clinics where you can get a second opinion. The Cancer Information Service also may be able to help you locate doctors to consult. Q. What will the doctor be able to learn from a biopsy? A. The biopsy can tell the doctor whether your lump is benign or malignant. If it is cancer, your doctor will talk with you about choices of treatments, and you may be advised to get a second opinion. (You can call the Cancer Information Service for other NCI publications that deal with breast cancer treatment.) If no cancer is found, you may be told that the lump or suspicious area is the result of a fibrocystic condition, fibrocystic disease, benign breast disease, or one of many other conditions. Remember, 80 percent of all breast lumps are not cancer. Q. What is a fibrocystic condition, fibrocystic disease, or benign breast disease? A. Unfortunately, doctors do not agree on standard terms for benign breast changes. We prefer to use the term benign breast condition for those changes in a woman's breasts that are not cancerous. These include normal changes that occur during the menstrual cycle as well as benign lumps that can appear in the breast. If your doctor uses a different term, or one you do not understand, ask for an explanation. Q. How many women have a benign breast condition? A. It is estimated that at least 50 percent of all women have irregular or "lumpy" breasts. In addition, many doctors believe that nearly all women have some benign breast changes beginning at age 30. A woman is more likely to have these breast changes if she has never had children, has had irregular menstrual cycles, has a family history of breast cancer, or is thin. Women who have had more than one child and women who are taking birth control pills have a reduced risk. Q. What are the symptoms of a benign breast condition? A. Women may have increased "lumpiness" with tenderness, pain, and swelling just before their period begins. These symptoms lessen after the menstrual period, only to reappear the next month. Many women find that these symptoms disappear after menopause. Benign breast lumps may appear at any time. Some cause pain, others don't. They may be large or small, soft or rubbery, fluid- filled or solid, and movable. In addition, some benign breast conditions may produce a discharge from the nipple. Q. What kinds of benign breast conditions are there? A. 1. Normal hormonal changes may A cause a feeling of fullness in the breast, which goes away after the menstrual period. This condition is most common in women 35 to 50 years of age. 2. Cysts are fluid-filled sacs that often enlarge and become tender and painful just before the menstrual period. Cysts are found most often in women 35 to 50 years of age. They usually are found in both breasts. There may be many cysts of different sizes. Some cysts are so small that they can't be felt: others may be several inches across. 3. Fibroadenomas are solid, round, rubbery, and freely movable breast lumps. Usually they are painless. They appear most often in young women between 15 and 30 years of age. Fibroadenomas occur twice as often in black women as in others. They are benign but should be removed to be certain of the diagnosis. Fibroadenomas do not go away by themselves and may enlarge during pregnancy and breast-feeding. 4. Lipomas are single, painless lumps that are sometimes found in older women. They are made up of fatty tissue and are slow- growing, soft, and movable. They can vary in size from a dime to a quarter. Lipomas should be removed or biopsied to make sure that they are not cancerous. 5. Intraductal papillomas are small wartlike growths in the lining of a duct near the nipple. They usually affect women between 45 and 50 years old and can produce bleeding from the nipple. 6. Mammary duct ectasia is an inflammation of the ducts that causes a thick, sticky, gray-to green discharge from the nipple. Without treatment, the condition can become painful. 7. Mastitis (sometimes called "postpartum mastitis") is most often seen in women who are breast-feeding. It is an inflammatory condition in which the breast appears red and feels warm, tender, and lumpy. 8. Traumatic fat necrosis occasionally appears in older women and in women with very large breasts. The condition can result from a bruise or blow to the breast, although the woman might not remember the specific injury. The trauma causes the fat in the breast to form lumps that are painless, round, and firm. Sometimes the skin around them looks red or bruised. Again, a doctor should examine the area. A word of caution: If you find a change in your breast, do not use these descriptions to try to diagnose it yourself. There is no substitute for a doctor's evaluation. Q. What is the treatment for a benign breast condition? A. Treatment varies, depending on the type of condition a woman has. If you have a single lump, it is usually removed in the biopsy. Most cysts are aspirated, and if they don't disappear, they are removed by surgery. Although there is no treatment for normal monthly breast changes, some studies have looked at various ways of treating the uncomfortable symptoms. The results of those studies do not all agree. You may wish to discuss the treatments described below with your doctor. For a long time doctors thought that eliminating beverages and foods that contain caffeine such as coffee, tea, cola, and chocolate (all of which also contain a substance called methylxanthine) would reduce monthly breast pain and tenderness. Recent studies have been unable to prove that such a change in diet affects symptoms. However, women continue to report to doctors that when they stop drinking coffee or eating chocolate, the pain and swelling in their breasts is less. Vitamin E is another treatment that has been suggested. It is generally accepted that taking this vitamin may help reduce the symptoms of breast pain and tenderness. You should speak with your doctor before taking vitamin E. Occasionally doctors will suggest an antihormone treatment (Danazol) when a woman has severe symptoms. Danazol may relieve pain and tenderness and decrease "lumpiness"; however, serious side effects are possible, and you should discuss all aspects of this treatment with your doctor if it is recommended. Q. Do doctors ever suggest more extensive surgery for benign breast disease? A. In cases where a woman's breasts are extremely difficult to examine, when there have been many biopsies or there are biopsy- proven tissue changes that place that woman in a high-risk category and there is a family history of breast cancer, a doctor may suggest a prophylactic mastectomy. In this surgery, both breasts are removed. Some women then choose to have breast reconstruction. If your doctor suggests this treatment, you should consider getting a second opinion, preferably from a breast specialist. Remember that there is no reason to hurry into this decision. You should be comfortable with your choice and learn everything about the procedure, its possible side effects, and your risks of future problems. Prophylactic mastectomy is a controversial treatment, and many doctors prefer instead to schedule frequent exams to check for any breast changes. Q. Will insurance pay for the diagnosis and treatment of a benign breast condition? A. Talk with your doctor about your diagnosis and call your insurance company to ask about their coverage for benign breast conditions. Only a very small percentage of women with a benign breast condition are at greater risk of developing cancer. Despite this fact, some insurance companies have canceled policies or raised premiums for women who have been diagnosed with "fibrocystic disease." Q. Can benign lumps turn into cancerous ones? A. Benign lumps do not turn into cancer. However, cancerous lumps can develop near benign lumps and can be hidden on a mammogram. This is another reason why removal of a benign lump is usually recommended. Q. What are microcalcifications? A. They are tiny specks of calcium in L the breast tissue that are sometimes detected by a mammogram. They can be related to a benign breast condition or breast cancer. In some cases, microcalcifications are seen when there is no lump present. The pattern and location of microcalcifications help the doctor determine if additional tests are needed. Q. What causes a discharge from the nipple and should I be concerned? A. You should see your doctor A whenever you notice a spontaneous discharge from the nipple (when something comes out without the breast being squeezed). The fluid may be clear, milky, bloody, or even green. If you have a discharge when you do BSE, you should also check with your doctor. Many conditions can cause a discharge. The doctor will take a sample of the discharge and send it to a laboratory to be analyzed. Occasionally, the doctor may order special tests to help in diagnosing the cause of the discharge. Your doctor can then recommend treatment. If you are pregnant, breast-feeding, or have recently had a baby, a milky fluid that comes out of both breasts is most likely related to your pregnancy. If you have questions or if the fluid is bloody, talk to your doctor. Q. What if I notice a lump in my breast during pregnancy? A. During pregnancy, the milk-producing glands become swollen and the breasts might feel lumpier than usual. It can be difficult to examine your breasts when you are pregnant, but you should continue to do so. Although not common, breast cancer has been diagnosed during pregnancy. So, if you have a question about the way your breasts feel, talk to your doctor. Q. Does every new lump need to be biopsied? A. Not necessarily. If a new lump appears, you cannot be sure that it is benign, even if you have had a benign lump removed in the past. Your doctor should evaluate it and decide whether a biopsy is needed. Q. Is a biopsy going to change the shape of my breast? A. Generally, a breast biopsy leaves only a minor scar, but this depends on the location and size of the lump and how deep it is in the breast. You should discuss the procedure with your doctor so you understand just what is going to be done and what the result is going to look like. Q. Does having a benign breast change mean I am at greater risk of developing breast cancer? A. Generally, no. Most benign breast changes do not increase a woman's risk of getting breast cancer. Recent studies show that only certain, very specific breast changes, which are detected by biopsy, put a woman at higher risk of developing breast cancer. Most important, 70 percent of the women who have a breast biopsy for a benign condition are not at any increased risk of cancer. About 26 percent of breast biopsies show changes that slightly increase the risk of developing breast cancer, and only 4 percent show breast changes that moderately increase the woman's risk. If your biopsy shows benign changes, discuss with your doctor what kind of changes were found and whether those changes increase your risk of developing breast cancer. Q. What other factors cause a woman to be at increased risk of getting breast cancer? A. Age is a factor. The older you are, the greater your chance of getting breast cancer. About one in five women diagnosed with breast cancer has a family history of the disease. Other risk factors include having your first child after age 30, never being pregnant, getting your first period at an early age, or having a late menopause. Do not place too much faith in being safe" if you have none of these risk factors--what puts you at risk for getting breast cancer is that you are a woman. The majority of women who are diagnosed with breast cancer do not fall into any special high-risk" category. QUESTIONS TO ASK YOUR DOCTOR We hope that this booklet has answered many of your questions about noncancerous breast lumps. However, no booklet can take the place of talking with your doctor. Feel free to ask the doctor any questions you have. If you do not understand the answer, ask your doctor to explain. It is helpful to write down questions as you think of them. The questions below are some of the most common that women have; you may have others. Jot your questions down and take this list with you when you see your doctor. 1. Do I need to have a mammogram? If yes, how often? 2. How often should I make an appointment to see you? 3. Will you teach me how to do breast self-examination (BSE) and check to see that I'm doing it properly? 4. What should I look for when I do BSE? 5. How can I distinguish lumps from the other normal parts of my breast? 6. What kind of lumps do I have? 7. Do you think I need to have a biopsy? If no, why not? FOR ADDITIONAL INFORMATION For answers to questions you may have about breast lumps or breast cancer, call the following toll-free telephone number and you will be automatically connected to the Cancer Information Service office serving your area: 1-800-4-CANCER+ +Spanish speaking CIS staff members are available. GLOSSARY Anesthetics: Drugs or gases that cause complete or partial loss of feeling or sensation. When local anesthetics are used, the patient is usually awake. General anesthetics put the patient to sleep. Aspiration: Withdrawal of fluid from a cyst with a hypodermic needle. Benign: Not cancerous. Benign breast condition: Noncancerous changes in the breast that can cause pain, lumpiness, or other problems. Also called fibrocystic condition. Biopsy: The removal and microscopic examination of cells or tissues for diagnosis. Breast self-exam (BSE): A method for women to check their own breasts for changes in appearance or feel. Cancer: A general name for over 100 diseases in which abnormal cells grow out of control. Cyst: A fluid-filled sac or cavity. Discharge: Any fluid coming from the nipple. It may be clear, milky, bloody, gray, or green. Duct: A pathway in the breast through which milk passes from lobes to the nipple. Fibrocystic condition: Breast irregularities or lumpiness that are not cancerous; sometimes referred to as "fibrocystic disease" or "benign breast disease." Lobes: Group of glands in the breast that produce milk. Malignant: Cancerous. Mammogram: An x-ray of the breast. Mastitis: Inflammation of the breast causing pain and tenderness. Menopause: The time of a woman's life when her monthly menstrual periods stop, sometimes called "change of life." Microcalcification: A small deposit of calcium in the breast that can appear on a mammogram and may sometimes indicate breast cancer. Normal hormonal changes: Tissue changes that occur in response to the changing levels of female hormones during the menstrual cycle. Palpation: Feeling the breast for any abnormalities. Pathologist: A doctor with special training in diagnosing disease from samples of tissue. Prophylactic mastectomy: Removal of the breast when no disease is present in order to prevent breast cancer from developing. BREAST SELF-EXAMINATION (BSE) INSTRUCTIONS Please open and tear out the BSE chart. For easy reference, tape it on your medicine cabinet or any convenient location to remind yourself to do BSE. Women taking charge of their own health are doing BSE regularly; they are also eating healthy foods, exercising, and not smoking. REMEMBER, BSE IS NOT A SUBSTITUTE FOR ROUTINE MAMMOGRAMS OR REGULAR BREAST EXAMS BY A DOCTOR. BREAST SELF EXAMINATION Breast self-examination should be done once a month so you become familiar with the usual appearance and feel of your breasts. Familiarity makes it easier to notice any changes in the breast from one month to another. Early discovery of a change from what is "normal" is the main idea behind BSE. The outlook is much better if you detect cancer in an early stage. If you menstruate, the best time to do BSE is 2 or 3 days after your period ends, when your breasts are least likely to be tender or swollen. If you no longer menstruate, pick a day such as the first day of the month, to remind yourself it is time to do BSE. Here is one way to do BSE: 1. Stand before a mirror. Inspect both breasts for anything unusual such as any discharge from the nipples or puckering, dimpling, or scaling of the skin. The next two steps are designed to emphasize any change in the shape or contour of your breasts. As you do them, you should be able to feel your chest muscles tighten. 2. Watching closely in the mirror, clasp your hands behind your head and press your hands forward. 3. Next, press your hands firmly on your hips and bow slightly toward your mirror as you pull your shoulders and elbows forward. Some women do the next part of the exam in the shower because fingers glide over soapy skin, making it easy to concentrate on the texture underneath. 4. Raise your left arm. Use three or four fingers of your right hand to explore your left breast firmly, carefully, and thoroughly. Beginning at the outer edge, press the flat part of your fingers in small circles, moving the circles slowly around the breast. Gradually work toward the nipple. Be sure to cover the entire breast. Pay special attention to the area between the breast and the underarm, including the underarm itself. Feel for any unusual lump or mass under the skin. 5. Gently squeeze the nipple and look for a discharge. (If you have any discharge during the month-- whether or not it is during BSE--see your doctor.) Repeat steps 4 and 5 on your right breast. 6. Steps 4 and 5 should be repeated lying down. Lie flat on your back with your left arm over your head and a pillow or folded towel under your left shoulder. This position flattens the breast and makes it easier to examine. use me same circular motion described earlier. Repeat the exam on your right breast.