New Horizons...........Living Well, Feeling Great

Breast Disorders

This page answers the following questions women have regarding breast issues: 

Why do my breasts hurt? (fibrocystic breast changes)
Are breast implants dangerous?
Can anything be done if your breasts are too large?
What is a mammogram?
Are mammograms painful?
Aren't mammograms dangerous?
How reliable are mammograms?
Why do I have to get a breast ultrasound?
I read that breast MRI is more sensitive than mammography. Should I get that instead of a mammogram?
I have a tender area in my breast. Does this mean I have cancer?
Why does the doctor want to aspirate my breast lump?
What does discharge from the nipple indicate?
Is there anything I can do to prevent breast cancer?
Is my risk of breast cancer increased if my mother had breast cancer? When should I get genetic testing?
How can I tell if I have breast cancer?
When is a breast biopsy necessary?
Do I need to have my entire breast removed if there is cancer?
Why do you need radiation after a lumpectomy?
When is chemotherapy necessary?
What is hormonal therapy?
I hear they can reconstruct your breast. Is that true?
I was told that I have CIS. Is that the same as breast cancer?



Why do my breasts hurt?

This may be the most frequently asked question that I hear in my office. Most women will ask this question at one time or another. Besides the discomfort, there is genuine concern that something must be wrong if your breasts hurt. We are conditioned to assume that tenderness and pain reflect an abnormal condition that warrants further investigation. However, pain and tenderness in the breasts (mastalgia) are quite common and only rarely reflect an ominous situation.

 The vast majority of breast tenderness is secondary to fibrocystic breast “disease” (FBD). It seems improper to call this a disease when fibrocystic changes are present in 50-60% of all women. Many people now refer to the condition as "fibrocystic breast changes" (FBC). FBC represents an exaggerated response of breast tissue to your female hormones, estrogen and progesterone. Normal breast tissue is composed of glands, ducts, fat, and fibrous tissue. In FBC, the glands become cystic (enlarged and full of fluid), and nodules of fibrous tissue develop. Doctors recognize many different variations of FBC depending on their microscopic appearance. You will notice FBC as pain and tenderness associated with an increase in lumpiness or nodularity. The condition usually worsens premenstrually which is why you should do self-breast exams (and mammograms) early in your menstrual cycle. The changes may be localized to a specific area within your breast or involve the entire breast. Fibrocystic changes may present in one or both breasts. Fibrocystic breast changes may regress, along with the breast discomfort, after menopause. Hormone replacement therapy will tend to aggravate symptoms related to fibrocystic breasts.

Many approaches have been used to reduce the lumpiness and tenderness associated with FBC. Reducing nicotine (another reason to stop smoking) and caffeine (coffee, tea, cola, and chocolate) is often recommended by physicians. Supplemental vitamin E (400-800 units per day) is also frequently given. Most studies that have looked at caffeine reduction and supplemental vitamin E have concluded that they are of little or no benefit. However, anecdotal reports suggest that some women find these measures useful. Over-the-counter analgesics (Tylenol, Motrin, etc.) may provide some relief. Studies indicate that FBC improves with the use of oral contraceptives. This certainly should be a consideration if you also need contraception. Other hormonal agents used to treat FBC include: • danazol (a hormone sometimes used to treat endometriosis) • bromocryptine (also used to suppress lactation) • tamoxifen (an anti-estrogen used to prevent and treat breast cancer) Each of these has side effects that limit their usefulness, but they should be considered if your discomfort is severe.

Does FBC increase your risk of breast cancer? Most doctors feel that fibrocystic changes in and of themselves do not increase your risk for breast cancer. If the fibrocystic changes are associated with hyperplasia (detected on biopsy), especially atypical hyperplasia, then your risk of breast cancer is increased 2-4 fold. Clearly fibrocystic breasts are more difficult to examine, and are more difficult to interpret with mammography. Self-breast exams are often not performed because, “I feel lumps all the time and I don’t know what I’m feeling.” Detecting lumpiness increases your anxiety, and you stop examining yourself. You should try to examine yourself even if you can’t interpret what you are feeling. Develop a mental image of your breasts. Describe to yourself the position and size of palpable nodules and ridges. Essentially, you create a topographical map of your breasts. After several months, you will have a good feel for the contours and texture of your breasts. If there is a change, you will be as likely to detect it as your doctor.


Are breast implants dangerous?

Breast implants are used in breast augmentation (enlargement) surgery as well as reconstructive surgery following mastectomy (see below). Implants have an outer shell of silicone (similar in texture to a thick plastic freezer bag). It is filled with either silicone gel or saline (salt water). The implant is placed under your breast tissue or chest wall muscles through a small incision.

 
Breast implants containing silicone gel have been placed in women for more than 20 years. It has become evident that the silicone from these implants “bleeds," or “sweats” through the outer shell. This may cause local tissue reaction around the implant. There is also concern that the silicone may travel to other areas in the body and cause problems. It was reported that silicone breast implants could induce the development of autoimmune diseases such as Systemic Lupus and Rheumatoid Arthritis. Because of these concerns, the FDA in 1992 placed limitations on the use of silicone gel implants. Since 1992, studies have compared women with and without silicone gel implants. The results do not indicate a greater incidence of connective tissue or autoimmune disease in women with silicone gel implants. These diseases are more frequent in women than men. They are often diagnosed in the third or fourth decade of life, when insertion of implants is common. In 2006 the FDA re-approved the use of silicone gel implants for all women. Many women prefer this type of implant because it has a softer, more natural feel.

Saline implants (filled with salt water) are also used for augmentation and breast reconstruction in place of silicone gel implants. Although they have a firm external shell of silicone, this does not seem to be a problem. Saline is totally nontoxic to your body so there is no concern if the saline implant leaks or ruptures. It is unlikely that saline implants pose a substantial health risk.

The most common complication of breast augmentation is capsular contracture. In this condition, your body forms a hard fibrous capsule around the implant. This produces a firm breast that has lost its soft, natural texture. The breast may also be painful. Fortunately, improved implants and surgical techniques have decreased the frequency of this complication. When the contracture is severe, a second operation may be required for correction of the problem, or the implant may have to be removed. Occasionally, decreased nipple sensitivity will occur after breast augmentation. A breast implant may also rupture, or deflate. When this happens, it must be replaced to maintain breast symmetry. It may be more difficult to visualize breast abnormalities with mammography after you have implants.

 Can anything be done if your breasts are too large?

Exceptionally large breasts create numerous problems. They often produce a sense of heaviness and pain, particularly before a menstrual period. Large breasts cause shoulder, neck and upper back strain with pain in those regions. Chronic skin irritation may develop in the folds under the breasts.

 
Reduction mammoplasty is surgical procedure that reduces the volume of breast tissue. It can significantly improve the comfort and quality of life in women with abnormally large breasts. However, there are drawbacks (Why does there always have to be a catch?). Breast reduction involves rather extensive incisions (in contrast to breast augmentation). Scar formation along these incision lines can be unsightly. Lactation and breastfeeding may not be possible following breast reduction surgery. There may also be decreased sensitivity of the nipples. Nevertheless, the vast majority of women who undergo breast reduction surgery are pleased. The relief obtained appears to outweigh the shortcomings of this procedure.


What is a mammogram?

A mammogram is an x-ray of the breasts. A technician places each breast between two plates and the x-ray machine produces an image. In the past these images were printed onto film. Most facilities today use digital mammography which transfers the images into a computer. The radiologist interprets the images looking for densities within the breast tissue that could represent cancer. Nodules are evaluated as to their size and shape in order to determine the likelihood of cancer. Other factors taken into consideration include the sharpness of the margins and any associated microcalcifications (small calcium deposits). A small nodule with a regular shape, smooth margins, and no microcalcifications is suggestive of a benign (noncancerous) process. Scattered, large calcifications are fairly common and usually benign. An enlarging nodule that is irregular, with indistinct margins, is suggestive of cancer. Clustered microcalcifications are also suspicious. In these situations, the radiologist recommends a breast biopsy.

Are mammograms painful?

This definitely depends on whom you ask. Most women find mammography somewhat uncomfortable but tolerable. A small number of women find mammography painful. Usually these are women with fibrocystic breast disease. However, mammograms are particularly important in women with fibrocystic breasts because they are more difficult to examine. Fibrocystic breasts are “lumpier” on examination, making the detection of cancer more difficult.

Mammograms will be more uncomfortable when performed in the premenstrual part of your cycle. Cystic areas in the breast are also more prominent premenstrually, which makes the interpretation of the mammogram more difficult. Schedule your mammogram early in your cycle (right after your period) and both you and your radiologist will be happier.

If you are menopausal, mammograms will be more uncomfortable if you are treated with hormone replacement therapy. Don’t misinterpret the discomfort as a sign of a problem. If the pain is intolerable, discuss the situation with your gynecologist. He may be able to make an adjustment in your hormone regimen to remedy the problem.

The amount of discomfort associated with mammography sometimes varies from one technician to another. This was more typical in the past, when the technician was responsible for deciding on the amount of pressure applied. These days, the applied pressure is usually determined by the machine in order to produce consistent, high quality images.

Aren’t mammograms dangerous?

Although there is a small exposure to radiation, it is a low dose. You are actually exposed to a similar dose of radiation from the environment each year. Studies do not demonstrate an adverse effect from this low dose of radiation. If there is any risk, it certainly is small. With the high incidence of breast cancer, there is no doubt that the risk to benefit ratio favors obtaining mammograms according to established guidelines.

How reliable are mammograms?

The media has thoroughly confused the public concerning this issue. There is variation in the quality of radiologic equipment used for mammograms. Studies have also demonstrated a large degree of inter-observer variance (radiologists giving different interpretations of the same films). Therefore, it is important to utilize a facility with “state of the art”equipment that employs radiologists with a long track record of reliably interpreting mammograms. Your gynecologist can recommend a facility that has provided him or her with reliable results. Make sure the facility is accredited by the American College of Radiology.

Mammography in women over 50 is not controversial. Approximately 90% of cancers are detected in this age group. With earlier detection, there is a thirty percent decrease in mortality (deaths from the cancer). Women over fifty should undergo mammograms annually.

There is greater controversy as to the benefits of mammography in women under fifty. Because breast tissue in younger women is denser, it is more difficult to spot a cancer on the images. More cancers are missed. Another concern is that breast cancer in young women often behaves aggressively. Therefore, detecting it at an earlier stage may not improve survival rates as much. Recent studies suggest that regular screening does reduce the number of deaths due to breast cancer. Currently, the most common recommendation for this age group proposes a baseline mammogram at age 40, and then every one to two years (with most organizations recommending annual exams). If there is a close relative, who developed her cancer premenopausally, then annual mammograms are definitely recommended.

Interpretation of mammographic abnormalities is not an exact science. The radiologist cannot always be certain whether a finding is benign or cancerous. 3D mammography (also known as tomosynthesis) is often covered and increases the detection rate of breast cancer in women who have dense breasts. Automated breast ultrasound is another option for women with dense breasts. Diagnostic breast ultrasound, MRI (magnetic resonance imaging), thermography (detecting temperature differences between normal and abnormal tissue), and scintimammography (using a radioactive tracer to provide tumor specific imaging) are additional imaging methods used to supplement (not take the place of) mammography in women who have particularly difficult breasts to image, such as women with dense breasts, fibrocystic breasts, and breast implants. (see below) may help the radiologist determine the nature of an abnormality. High cost (your insurance company won't necessarily pay for it) and limited accessibility can limit the use of these adjuvant screening tools. 

 Why do I have to get a breast ultrasound?

Although mammography is good at detecting a breast nodule or mass, it cannot determine if it is solid or cystic. Breast ultrasound provides this information. A fluid filled structure is considered cystic and is not suspicious. The risk of cancer is greater with a solid mass. It is usually biopsied. The breast ultrasound does not replace the mammogram, but rather gives additional information to supplement the mammogram. If your mammogram is normal, a breast ultrasound is usually not necessary. In certain high risk situations, or if your doctor feels an abnormality in your breast, ultrasound may be added to mammography for diagnosis.

I read that breast MRI is more sensitive than mammography. Should I get that instead of a mammogram?

Mammography is still the standard of care for screening for breast cancer. Breast MRI can be more sensitive at detecting breast problems but it is extremely expensive (which means your insurance won't pay for it), prone to a higher incidence of false positives (saying there is a problem when there really isn't), and requires more sophistication in its interpretation. Because of its high sensitivity, it should be considered in the following circumstances:

 • High risk patients who are determined to have a greater than 20% lifetime risk of breast cancer using one of the accepted breast calculators.

 • Patients with a history of atypical hyperplasia on biopsy.

 • Patients with a personal history of breast cancer or DCIS or LCIS (see below).

 • Patients with a breast implant where there is a suspicion of rupture.

 • Patients with a known BRCA1 or BRCA2 mutation (see below) Most insurance companies will cover breast MRI under these circumstances. Also patients who have a first degree relative with a BRCA mutation and have not had testing themselves and patients with other genetic syndromes associated with an excess risk for brest cancer.

Patients with a history of radiation thearapy to the chest between the ages of 10 years and 30 years are also reccomended for MRI screening.

 I have a tender area in my breast. Does this mean I have cancer?


A tender area within the breast is usually a focal area of fibrocystic change. If a lump is palpated in the area, it is probably a cyst. This can be confirmed by ultrasound or aspiration in the office. Breast cancer is not typically associated with focal tenderness. It is more apt to present as a painless, hard lump. Other causes of tenderness include trauma, infectious mastitis, superficial phlebitis, and inflammatory breast cancers. Fibrocystic breasts do not appear inflamed (redness, heat, swelling) and are not associated with fever. If you develop localized tenderness associated with either fever or inflammation, contact your doctor.

Why does the doctor want to aspirate my breast lump?

Most breast lumps are benign cysts. Your doctor may attempt to aspirate the lump to confirm that it is cystic. Once the fluid is aspirated, the lump should disappear. Sometimes the fluid is sent to a laboratory for analysis. Cells in the fluid are evaluated microscopically for atypical features. Inability to aspirate fluid from the lump suggests that it is solid. Most solid lumps should be biopsied (see below). However, don’t assume that the lump is cancerous if your doctor cannot aspirate fluid from it. The lump may represent a conglomeration of fibrocystic tissue, as opposed to an isolated cyst. It may also be a fibroadenoma, which is a benign, solid tumor of the breast. If a lump is confirmed to be a simple cyst on ultrasound, there is no specific need to aspirate it. However, if the lump is bothersome, aspiration is certainly an easy fix of the problem. "Complicated" cysts (cysts that have junk in them on ultrasound) are generally aspirated to confirm their benign nature.

What does discharge from the nipple indicate?

Nipple discharge is fairly common and usually not indicative of a severe problem. Almost half of women in their reproductive years can express a few drops of liquid from their breasts. In fact, squeezing the nipple during self-breast exams is no longer encouraged by the American Cancer Society (although you should still look for spontaneous discharge and report it to your physician). Let’s examine the significance of various types of nipple discharge.

A milky discharge from the nipple is normal during pregnancy. It is also seen for up to one year following the cessation of nursing. It is not commonly seen at other times. Milky discharge from the nipples (may be one or both) is referred to as galactorrhea. Usually, it is from inappropriate secretion of prolactin, the hormone responsible for breast milk production. Most of the time it is white or clear, although it may also appear yellow or green. When the color is yellow or green, consideration must be given to other breast diseases (see below).

 Elevated prolactin in association with galactorrhea may be seen in the following situations:

 • Birth control pills

 • Certain medications -- ask your doctor. If he is not sure, ask him to check in the PDR (Physician’s Drug Reference) to see if it is listed as a side effect.

 • Prolonged and intense suckling (Whoa! Back off tiger!)

 • Conditions that stimulate the nerves in the chest wall (thereby simulating suckling) such as shingles, chest surgery, and upper spinal cord lesions.

 • Hypothyroidism -- a decrease in circulating levels of thyroid hormone indirectly stimulates the secretion of prolactin.

• Central nervous system injuries or tumors that effect the pituitary gland -- the pituitary gland is located at the base of the brain and is responsible for the secretion of many important hormones including prolactin.

 • Pituitary tumors -- a prolactin secreting tumor can grow in the pituitary gland itself. Although it is a benign tumor, it can have disabling neurologic (affecting the brain), endocrinologic (hormonal), and opthalmologic (affecting the eyes) consequences.

 Your doctor will order a prolactin level if you have galactorrhea. Your doctor may also check your thyroid status. If the prolactin is elevated without explanation, he or she may order a scan to rule out a pituitary tumor. When a pituitary tumor is discovered, it can usually be treated with a medication that inhibits prolactin secretion and shrinks the tumor. Bromocryptine (Parlodel) and cabergoline (Dostinex) are two medications used for this purpose. Occasionally, surgery will be recommended for removal of the tumor.

 Nipple discharge may also be purulent (pus), watery (clear), yellow, multicolored, or bloody (pink, red). Purulent discharge is usually caused by a bacterial infection and is accompanied by pain, tenderness, redness, and swelling. Breast infection (mastitis) is most common after pregnancy (especially with nursing). Bloody discharge is of greater concern since it may be a sign of cancer. The rare occurrence of a profuse, crystal-clear discharge may also be associated with cancer. Not all bloody discharges are secondary us to cancer. In fact, the most likely culprit for a bloody discharge is an intraductal papilloma. An intraductal papilloma is a benign growth located within one of the breast ducts, usually near the nipple. It may produce a discharge that is yellow or bloody. Ductal ectasia is an uncommon disease of the breast causing nipple discharge. The discharge is usually nonbloody and may be multicolored (green, brown, grey, reddish-brown, yellow, or white). Ductal ectasia may present as thickening and inflammation around the nipple and areola (the darker skin surrounding the nipple), a breast mass, and/or an abscess. Fibrocystic breast changes may also produce nipple discharge (discussed above).

 Further evaluation is necessary if you have a nipple discharge, particularly if it is bloody. Your doctor will examine your breasts for lumps and obtain a mammogram. Microscopic analysis of the fluid (cytology) will usually be performed. Some doctors use galactography, which demonstrates ducts by instilling contrast. An intraductal papilloma may be detected by exerting pressure circumferentially around the margin of the areola. When pressure is applied to the affected duct, discharge is expressed. There may be tenderness overlying the involved duct. A papilloma may be palpable, although this is less common.


The treatment of nipple discharge varies with the cause. Mastitis is treated with antibiotics. Ductal ectasia is treated by bedrest, ice packs, and anti-inflammatory drugs. Surgical excision may be required if the condition persists or a mass develops. Papillomas are excised through minor, outpatient surgery. Findings suspicious for cancer are biopsied (discussed below).


Is there anything I can do to prevent breast cancer?

There are many risk factors for breast cancer. Most of these are beyond your control. There is an increased risk in women with a strong family history of breast cancer, but we don’t get to choose our genes. The risk is also greater in women with an early menarche (onset of menses) or late menopause (cessation of menses). This is also beyond your control. There is an increased risk in women who delay childbearing. The earlier you have your first child, the lower your risk will be for breast cancer.

Nutritional risk factors are within your control. Your risk of breast cancer increases as the amount of total fat in your diet increases. It also increases with alcohol consumption (greater than 3 drinks per week). There is a relationship between weight and breast cancer, especially in postmenopausal women. Maintaining a healthy diet that is low in fat and alcohol may reduce your risk of breast cancer. Regular exercise may also reduce your risk.

There is always controversy as to the role of estrogen and progesterone in the development of breast cancer. There may be a small increase in the detection of localized breast cancer (those confined to the breast) in current users of the birth control pill. However, this may be primarily explained by the fact that women using birth control pills are examined annually. If there is an increase, it disappears within ten years after stopping the pills. On the other hand, birth control pills clearly, and substantially, reduce your risk for both endometrial cancer and ovarian cancer. The role of hormone replacement therapy in the etiology of breast cancer remains more controversial. Most people feel that there is a small excess risk with hormone replacement therapy, especially if a synthetic progesterone is included in the regimen.

Women who are at high risk for breast cancer can use hormonal, chemoprevention to reduce their risk of breast cancer by approximately 50%. Tamoxifen and raloxifene are both used for this purpose. A gynecologist, breast surgeon, medical oncologist, or genetic counselor can calculate your lifetime risk for breast cancer. If your lifetime risk for breast cancer is greater than 20%, chemoprevention should at least be considered. Your doctor can review the side effects for each of these medications.


Is my risk of breast cancer increased if my mother had breast cancer? When should I get genetic testing?

Family history is definitely important in assessing your risk of breast cancer. If you have a first degree relative (mother or sister) who develops breast cancer, your risk is doubled. This is particularly true if the cancer presented before menopause. Inherited breast cancer generally presents at a younger age than non-familial cancer. If there are multiple female members of your family with either breast or ovarian cancer, your risk may be 50% or higher. The inherited tendency can be transmitted through the maternal or paternal side of your family, through various gene mutations, referred to as BRCA1 and BRCA2 mutations. Genetic testing is available to screen men and women for these abnormalities. Genetic testing is generally recommended in each of the following situations:

a woman who develops breast cancer under the age of 40, or under the age of 50 if there are other family members who have had breast or ovarian cancer.

 • a personal history of ovarian cancer (especially if presenting at a young age) or family history of ovarian cancer in multiple relatives.

 • a family history that includes two first degree relatives with breast cancer or three or more first and second degree relatives.

 • a family history of male breast cancer.

 • a personal history of bilateral breast cancer.

 • a person of Ashkenazi Jewish background (Eastern European) with a family history of anyone developing breast or ovarian cancer.

 • a person who has a relative test positive for a BRCA1 or BRCA2 mutation.

 What can you do if it is determined that you have a BRCA1 or BRCA2 mutation? Self-breast exams should be done monthly and breast exams by a physician should be performed every 6 months. Annual mammography and/or breast MRI should begin at an early age (determined by the age at which breast cancer developed in your relatives but no later than age 25-30). Prophylactic mastectomy (removal of both breasts) should be considered, especially in women with a BRCA1 mutation which conveys a 70 to 80% lifetime risk for breast cancer. This reduces the risk of breast cancer but does not eliminate it because surgery may leave behind breast tissue along the chest wall. Studies indicate that prophylactic mastectomy does decrease your risk by more than 90%. Breast reconstruction techniques and implants have improved dramatically over the last decade making this a more acceptable option. Prophylactic (preventative) use of tamoxifen or raloxifene, can also be considered. Prophylactic removal of your ovaries should be undertaken after childbearing is complete, usually between 35-40 because BRCA1 and BRCA2 mutations dramatically increase your risk for ovarian cancer. Your hormones can be temporarily replaced until you are closer to the natural age of menopause. Birth control pills are also used in premenopausal patients to reduce their risk of ovarian cancer.

 How can I tell if I have breast cancer?

There are no symptoms associated with early breast cancer. Early detection is only possible with self-breast exams, physician exams, and screening mammograms (with or without other imaging techniques). The most common physical finding is a painless, hard lump. If you or your physician detects a lump, it must be investigated (see below), even if your mammogram is normal. Other signs include the following:

Discharge from your nipple, particularly if it is bloody: However, remember that most bloody discharges are from intraductal papillomas, which are not cancerous. Don’t panic!

 • Nipple inversion: If your nipples normally point outward, nipple inversion (nipples pulled inward) is considered ominous. This does not apply to women with chronically inverted nipples.

 • Particular skin changes: Sometimes the skin overlying a breast cancer develops the texture of an orange peel (called peau d’orange). Dimpling of the skin may be caused by an underlying cancer. Finally, inflammatory cancers may cause the breast to appear red and swollen although there are noncancerous conditions that also present with inflammation.

 • A lump in your axilla (armpit): This may reflect an enlarged lymph node from breast cancer.

 You should perform self-breast examinations monthly. Premenopausal women should do the exam early in their cycle to avoid the increased lumpiness and tenderness experienced premenstrually. Lie on your back and place one arm over your head. With your other arm, reach over and examine your breast. You should use a pattern (such as concentric circles) to ensure that no area of the breast is missed. Include the armpits in your examination. Keep your fingers flat and the pressure light to maximize your ability to sense changes in the breast tissue. Perform the same procedure on the opposite breast. Some women find the examination easier in the shower (or bath) when your skin is wet and slippery. Ideally, you should perform the exam in upright and recumbent positions.

 
The next part of the exam is visual inspection. Stand in front of a mirror with your arms behind your head. Look for any changes in the size, or shape of your breasts. Identify any change in the skin texture, or color, as well as any dimpling of the skin. Make sure there is no inversion of the nipples. If there is any discharge, note its color.

 Remember that the primary responsibility for your health rests with you. Any abnormalities should be brought to the doctor’s attention. The survival rate with early breast cancer is excellent. Self-breast exams, coupled with physician exams and mammography, provide you with an excellent chance for early detection.

When is a breast biopsy necessary?

Most solid lumps should be biopsied or removed. If it has a noncancerous appearance on mammography, your physician may choose to follow it with frequent examinations and mammography. However, most doctors would recommend biopsy. Scattered calcifications (calcium deposits) in breast tissue are common and usually do not warrant biopsy. However, suspicious clusters of calcifications are biopsied. If a lump is cystic (see above), biopsy is not necessary. Biopsies can be performed in several different ways.

Fine needle aspiration is a procedure done in the office with a syringe and needle. It is only done if the doctor can feel a discrete lump. The doctor passes a needle through the lump several times while aspirating. This collects cells that are then analyzed for cancer. The reliability of this varies tremendously, depending on the doctor’s level of experience. Fine needle aspiration collects cells, but not an actual piece of tissue (in distinction to those techniques described below).

Core needle biopsy is a procedure that collects breast tissue in the core of a large needle. If the mass is not palpable (cannot be felt on exam), stereotactic core biopsy can be performed under radiologic guidance. You lie prone on a table with the breast extended through an opening in the table (Gee, could this possibly get more embarrassing). The suspicious area is identified through imaging. A radiologist or breast specialist advances the biopsy needle to the abnormal spot and the needle collects tissue for analysis. Core needle biopsy may also be performed under ultrasound (using sound waves to image your breast) or MRI guidance. Open biopsy is performed in the operating room as an outpatient. If a lump is palpable (able to be felt), an incision is made and the lump removed entirely (excisional biopsy) or partially (incisional biopsy). If the lump is not palpable, a needle is first placed into the mass under radiologic guidance. The surgeon can then follow the needle down to the mass (or other suspicious areas seen on mammography).

 Your doctor may choose any of the above methods to evaluate a breast abnormality. Excisional biopsy is sometimes chosen for a solid palpable lump. Stereotactic biopsy or core needle biopsy under ultrasound guidance are popular for nonpalpable abnormalities discovered through mammography.

Do I need to have my entire breast removed if there is cancer?

Surgery has undergone quite an evolution over the past century. Dr. William S. Halsted devised the radical mastectomy and reported his success with this procedure in 1894. A radical mastectomy removes all the breast tissue, along with the overlying skin and underlying muscles. The axillary lymph nodes are also removed. Radical mastectomy remained the treatment of choice until the 1970’s. Earlier diagnosis of breast cancer emerged with the use of self-breast exams, physician exams, and mammography. It became evident that less radical surgery could be successful. This led to a shift towards the modified radical mastectomy that preserves the pectoralis muscle (the large muscle in the front of the chest, under the breast). More recently, studies have indicated that often the breast can be conserved. If the breast cancer is early and does not appear to be muticentric (arising from multiple areas within the breast), it can be removed while preserving the rest of the breast. This is referred to as a lumpectomy. A lumpectomy is usually followed by radiation (see below) of the remaining breast tissue. Breast-conserving surgery is not indicted in all cases. You must discuss this with your doctor to see if it is a reasonable choice.

In the past, dissection (removal) of the lymph nodes under your axilla (armpit) accompanied either a mastectomy or lumpectomy. This axillary dissection of lymph nodes was crucial in determining the risk of metastasis (spread of the cancer). The status of the lymph nodes is also important when choosing additional therapy after the surgery. Sentinel node biopsy is a newer approach used for assessing lymph nodes. A radioisotope or dye is injected into the affected area of the breast. It is followed to the first lymph node(s), referred to as the sentinel node(s). A small incision is made to excise this node, or grouping of nodes, and if there is no cancer, further lymph node dissection is avoided. This has proven to be reliable and is a great asset since lymph node dissection can create axillary scarring, pain, and swelling in the arm.

Why do you need radiation after a lumpectomy?

Cancer cells will migrate from the main cancerous lump. The spread of these cells can cause local recurrence of the tumor. The cells can also enter your lymphatic system or blood stream and create recurrence of the cancer elsewhere in the body. Radiation is given to eradicate cancer cells remaining in the breast after lumpectomy. The radiation is given over 5-7 weeks. It is usually tolerated well. You may experience some degree of fatigue over the course of treatment. Local effects include skin changes (dryness, redness, or tanning), swelling, and muscle stiffness. Most effects from the radiation resolve within a few weeks after the completion of treatment, although swelling may persist longer. Severe complications from radiation can occur but are rare. Recently, new techniques for delivering fast, powerful, and precise radiation to lumpectomy sites has shown promise in replacing traditional whole breast radiation, with fewer side effects. However, these techniques are newer and long-term studies will be needed to see if they achieve the same results as the more traditional approach.

When is chemotherapy necessary?

Some women with very early breast cancer can be treated with surgery alone or lumpectomy with radiation (see above). However, many women will receive chemotherapy after their surgery for breast cancer. Microscopic cancer cells travel to other areas of the body even when it appears that the cancer is confined to the breast. These cells cause recurrence of the cancer if they are not treated. Breast cancer in premenopausal women can spread quickly if not treated aggressively. Most premenopausal women will receive chemotherapy as part of their treatment regimen. Postmenopausal women who have estrogen receptor negative tumors (ER-, see below) may also receive chemotherapy. Even estrogen positive (ER+) cancers may be treated with chemotherapy if they are advanced at the time of diagnosis. Your surgeon will consult a medical oncologist to help him decide whether chemotherapy or hormonal therapy is necessary. A new test, Oncotype DX, can help your oncologist decide whether an early stage ER+ cancer warrants consideration for additional treatment with chemotherapy.

Occasionally, chemotherapy is started before surgery. This is usually done when the cancerous lump is large and it is suspected that cancer cells have already spread beyond the breast. The preoperative chemotherapy may shrink the size of the lump thereby allowing more conservative surgery.

Chemotherapy is usually given for no longer than 6 to 9 months. Side effects from chemotherapy vary, depending on what agent is used. Probably the most common side effects are nausea, vomiting, and hair loss. Medications are given to control the nausea. Most chemotherapeutic agents suppress bone marrow, which makes your blood cells, and thus can lead to anemia and poor blood clotting and can make you more susceptible to infections. During chemotherapy, your blood counts are monitored closely, and sometimes special drugs are administered to boost the bone marrow.

Targeted therapy, using a drug called Herceptin (trastuzumab),may also be a part of your treatment regimen. HER2 receptors tells cells to grow and divide.in some breast cancers, HER2is overexpressed(The cancer cells have many more HER2receptors than usual). Herceptin is then given to selectively bind to these receptors, thereby stopping cell growth.


What is hormonal therapy?

 “So what’s this estrogen receptor stuff all about?” Your cancer will be tested to see if there are estrogen and progesterone receptors on the surface of the cancer cells. If your cancer is ER+, an anti-estrogen called tamoxifen (brand name Nolvadex) will be given to decrease your risk of recurrence. Tamoxifen is usually given for five years. Side effects are usually mild and do not require discontinuation of therapy. The most common adverse reactions include hot flashes, nausea and vomiting, menstrual irregularities (in premenopausal women), vaginal discharge, and skin rash.


Tamoxifen does have risks associated with its use. There is a small increased risk of thrombophlebitis (blood clots in your veins). You are also more likely to develop endometrial polyps and endometrial cancer when treated with tamoxifen. Tamoxifen acts as an anti-estrogen with breast tissue, but similar to estrogen with endometrial tissue. This may seem quite disturbing. “What are they trying to do, trade one cancer for another?” Fortunately, most endometrial cancers bleed while the cancer is still early and are curable with a hysterectomy. If you are on tamoxifen and experience abnormal bleeding (or any bleeding after menopause) tell your gynecologist who will then investigate in order to rule out an endometrial polyp or cancer. The small possibility of endometrial cancer should not deter you from using tamoxifen. The benefit in reducing your risk of breast cancer recurrence clearly outweighs the small risk for endometrial cancer. Since tamoxifen binds to estrogen receptors elsewhere, investigators have also looked at its potential impact on the heart and bones. It appears to protect against osteoporosis and have no adverse cardiovascular impact.

More recently, oncologists have used a newer class of medications called "aromatase inhibitors"(ex. Femara, Arimidex, Aromasin) in the treatment of ER+ breast cancer in postmenopausal women. In pre-menopausal women, estrogen is made in the ovaries. In post-menopausal women, estrogen is made in the fatty tissues elsewhere in the body. Aromatase inhibitors block this peripheral estrogen production effectively. There is some evidence that aromatase inhibitors may even be more successful than tamoxifen. Sometimes they are given in place of tamoxifen in the postmenopausal patient while other oncologists will give tamoxifen for five years and then add an aromatase inhibitor for another five years. Because aromatase inhibitors do not inhibit estrogen production from the ovaries, they are not typically used in premenopausal women unless their ovaries are removed or chemically suppressed. Adverse effects of aromatase inhibitors include joint pain or inflammation, osteoporosis (bone loss), hypercholesterolemia (high blood cholesterol), and vaginal atrophy (thinning and dryness of the walls of the vagina). Cholesterol and bone density levels can be monitored during therapy and abnormal findings treated if necessary.

 I hear they can reconstruct your breast. Is that true?

Breast reconstruction is a major advance in the rehabilitation of patients undergoing mastectomy. Breast conservation surgery is not always possible. Loss of your breast can be psychologically devastating. A woman may feel deformed, resulting in low self-esteem. Thirty to forty percent of women report a loss of sexual desire or reduction in arousal following mastectomy. This is not because of marital estrangement. Most relationships remain intact and, on occasion, even strengthen. The disruption in sexual functioning is more a product of your body image and the perception of disfigurement that accompanies mastectomy. Breast reconstruction restores a woman’s sense of femininity and sexuality.

Traditionally, breast reconstruction was delayed until it was determined that there was little risk of recurrence. There was also concern that reconstruction would interfere with the detection of local recurrences. This has not been found to be true. Breast reconstruction can often be performed immediately following the mastectomy, thereby limiting you to one hospitalization. Reconstruction may involve the placement of an implant, or reconstruction of a breast from muscles and skin rotated onto the chest from your back or abdomen (Now try to picture that!). Not all physicians agree that immediate reconstruction is best. They feel your risk of surgical infection is increased and your recuperation delayed. They also think that delayed reconstruction results in a cosmetically superior breast. Not every woman is a candidate for immediate reconstruction, but you should certainly discuss it with your physician before your mastectomy.

Not all women perceive mastectomy as disfiguring. You may feel comfortable wearing an external prosthesis. This is certainly reasonable and has the advantage of decreasing the amount of surgery. You can always change your mind and undergo breast reconstruction later.

 I was told that I have CIS is that the same as breast cancer? 

There are two types of CIS. Lobular Carcinoma in Situ (LCIS) means that abnormal cells are starting to grow in the lobules, or milk producing glands, at the end of breast ducts. “In situ” means that the abnormal growth remains inside the lobule and does not spread to surrounding tissues. Despite the fact that its name includes the word "carcinoma" LCIS is not a breast cancer, or breast cancer precursor. However, it is an indicator that a person is at a higher than average risk for developing invasive breast cancer in the future. Patients with this condition should be followed more closely and breast MRI should be included in their surveillance. Ductal Carcinoma in Situ (DCIS) is a noninvasive ductal breast cancer, meaning breast cancer that remains in the duct and hasn't spread to surrounding tissues. However, unlike LCIS, DCIS is a precursor to invasive breast cancer and therefore requires treatment. The most common treatment for DCIS is lumpectomy and radiation. If the tissue tests positive for estrogen receptors, then hormonal therapy may also be given (see above). In certain circumstances, mastectomy may be recommended. Chemotherapy is not given with DCIS because it has not invaded other tissues. 

How do you treat breast cancer that has spread to other parts of the body?

Perhaps the worst fear that women harbor is the fear that their cancer has spread beyond the breast to other places in the body. In the not-too-distant past, only 10% of women were still alive five years after the progression of metastatic cancer into places like the bones, lungs, or liver. However, with the development of new, targeted drugs, as many as 40% of women with recurrent or metastatic breast cancer survive at least five years.

The approach to metastatic breast cancer will vary depending on one's receptor status. If the metastatic cancer is ER+, then hormonal treatment like tamoxifen, or one of the aromatase inhibitors (see above), will be given. Herceptin will be used to specifically target cells that overexpress the HER2 protein, something that happens in about one of every four breast cancers. Chemotherapy will be used for the ER–, HER– cancers.

 Chemotherapy for metastatic disease is different from the aggressive regimens used for early-stage breast cancer. Early stage breast cancer is often treated with relatively high doses of multiple chemotherapeutic drugs. For metastatic cancer, oncologists usually prefer to use sequential single-agent chemotherapy. Their goal is obtaining enough of a response rate to control the tumor, while having minimal impact on the quality of a woman's life. Newer treatment approaches have reduced the often painful symptoms of the disease. Supportive care has gotten a lot better so that the symptoms that people have from treatments and progression of the disease are much more controlled. In addition to chemotherapy, adjunctive drugs may be given. The most common examples of this are bisphosphonates (Aredia, Zometa, Reclast). These drugs are normally used to prevent and treat osteoporosis. In metastatic cancer patients they slow down damaging metastatic bone disease that leads to fractures. Occasionally, radiation or surgery may be used to treat metastatic disease located in a specific localized area.

Coping with the uncertainty of life with metastatic breast cancer affects different women in different ways. Some women want to continue working full-time for as long as possible, which often helps keep their focus away from the illness. Other women say, "OK, since I may have a limited amount of time, I don't want to spend it in my office. I'd rather travel, enjoy my hobbies, and spend time with my family." Everyone has different priorities and there is no one right answer for coping with metastatic breast cancer. Many women will obtain support from counselors, therapists, or group therapy sessions, which can usually be found through cancer centers. Women can also find support online at web-based support groups such as BCmets (www.bcmets.org), one of the oldest and largest. One of the most important things for women with metastatic breast cancer to remember is that there is always exciting progress being made through research in this field. Approaches being worked on now may be something available to you in the near future. While there are no guarantees, this is certainly possible.



Additional Information

If you have breast cancer and would like additional information or support, contact the following resources:

Reach to Recovery, American Cancer Society http://www.cancer.org/Treatment/SupportProgramsServices/reach-to-recovery

 Y-Me National Organization for Breast Cancer Information and Support www.Y-me.org

National Cancer Institute  http://www.cancer.gov/cancertopics/types/breast