What to expect
A word of caution: If you find a lump or other change in your breast, do not use the following information to try to diagnosed it yourself. There is no substitute for a doctor’s evaluation.
ABOUT BREAST LUMPS AND OTHER CHANGES
Over her lifetime, a woman can encounter a broad variety of breast conditions. These include normal changes that occur during the menstrual cycle as well as several types of benign lumps. What they have in common is that they are not cancers. Even for breast lumps that require a biopsy, some 70% prove to be benign.
Each breast has 15-20 sections called lobes, each with many smaller lobules. The lobules end in dozens of tiny bulbs that can produce milk. Lobes, lobules and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple, which is centered in a dark area of skin called the areola. The spaces between the lobules and ducts are filled with fat. There are no muscles in the breast, but muscles lie under each breast and cover the ribs.
These normal features can sometimes make the breast feel lumpy, especially in women who are thin or who have small breasts.
In addition, from the time a girl begins to menstruate her breasts undergo regular changes each month. Many doctors believe that nearly all breasts develop some lasting changes beginning when the woman is about 30 years old. Eventually, about half of all women will experience symptoms such as lumps, pain, or nipple discharge. Generally these disappear with menopause.
Some studies show that the chances of developing benign breast changes are higher for a woman who has never had children, has irregular cycles, or has a family history of breast cancer. Benign breast conditions are less common among women who take birth control pills and are overweight. Because they generally involve the glandular tissues of the breast, benign breast conditions are more of a problem for women of childbearing age who have more glandular breasts.
TYPES OF BENIGN BREAST CHANGES
Common benign breast changes fall into several broad categories. These include generalized breast changes, solitary lumps, nipple discharge and infection and/or inflammation.
Generalized Breast Changes
Generalized breast lumpiness is known by several names including fibrocystic disease changes and benign breast disease. Such lumpiness, which is sometimes described as “ropy” or “granular”, can often be felt in the area around the nipple and areola and in the upper outer part of the breast. Such lumpiness may become more obvious as a woman approaches middle age and the milk-producing glandular tissue of her breasts increasingly gives way to soft, fatty tissue. Unless she is taking replacement hormones this type of lumpiness generally disappears for good after menopause.
The menstrual cycle also brings cyclic breast changes. Many women experience swelling, tenderness and pain before and sometimes during their periods. At the same time, one or more lumps or a feeling of increased lumpiness may develop because of extra fluid collecting in the breast tissue. These lumps normally go away by the end of the period.
During pregnancy, the milk-producing glands become swollen and the breasts may feel lumpier than usual. Although very uncommon, breast cancer has been diagnosed during pregnancy. If you have any questions about how you breasts feel or look talk to your doctor.
Benign breast conditions also include several types of distinct, solitary lumps. Such lumps, which can appear at any time, may be large or small, soft or rubbery, fluid-filled or solid.
Cysts are fluid-filled sacs. They occur most often in women ages 35-50 and they often enlarge and become tender and painful just before the menstrual period. They are usually found in both breasts. Some cysts are so small they cannot be felt; rarely cysts may be several inches across. Cysts are usually followed by observation or treated with fine needle aspiration. They show up clearly on ultrasound.
Fibroadenomas are solid and round benign tumors that are made up of both structural (fibro) and glandular (adenoma) tissues. Usually, these lumps are painless and found by the woman herself. They feel rubbery and can easily be moved around. Fibroadenomas are the most common type of tumors in women in their late teens and early twenties and occur twice as often in African-American women as in other American women.
Fibroadenomas have a typically benign appearance on mammography (smooth, round masses with a clearly defined edge) and they can sometimes be diagnosed with fine needle aspiration. Although fibroadenomas do not become malignant they can enlarge with pregnancy and breast-feeding. Most surgeons believe that it is a good idea to remove fibroadenomas to make sure they are benign.
Fat necrosis is the name given to painless, round and firm lumps formed by damaged and disintegrating fatty tissues. This condition typically occurs in obese women with very large breasts. It often develops in response to a bruise or blow to the breast even though the woman may not remember the specific injury. Sometimes the skin around the lumps looks red or bruised. Fat necrosis can easily be mistaken for cancer so such lumps are removed in a surgical biopsy.
Sclerosing adenosis is a benign condition involving the excessive growth of tissue in the breast’s lobules. It frequently causes breast pain. Usually the changes are microscopic but adenosis can produce lumps and it can show up on a mammogram often as calcifications. Short of a biopsy, adenosis can be difficult to distinguish from cancer. The usual approach is surgical biopsy, which furnishes both diagnosis and treatment.
Nipple discharge accompanies some benign breast conditions. Since the breast is a gland, secretions from the nipple of a mature woman are not unusual or necessarily a sign of disease. For example, small amounts of discharge commonly occur in women taking birth control pills or certain other medications including sedatives and tranquilizers. If the discharge is being caused by a disease, the disease is more likely to be benign than cancerous.
Nipple discharges come in a variety of colors and textures. A milky discharge can be traced to many causes including pregnancy, thyroid malfunction and oral contraceptives or other drugs. Women with generalized breast lumpiness may have a sticky discharge that is brown or green.
The doctor may take a sample of the discharge and send it to a laboratory to be analyzed. Benign sticky discharges are treated chiefly by keeping the nipple clean. A discharge caused by infection may require antibiotics.
One of the most common sources of a bloody and sticky discharge is an intraductal papilloma, a small fern-like growth that projects into the breast ducts near the nipple. Any slight bump or bruise in the area of the nipple can cause the papilloma to bleed. Single (solitary) intraductal papillomas usually affect women nearing menopause. If the discharge becomes bothersome, the diseased duct can be removed surgically without damaging the appearance of the breast. Multiple intraductal papillomas, in contrast, are more common in younger women. They often occur in both breasts and are more likely to be associated with a lump than with nipple discharge. Multiple intraductal papillomas or any papillomas associated with a lump need to be removed.
Infection and/or Inflammation
Infection and/or inflammation including mastitis and mammary duct ectasia are characteristic of some benign breast conditions.
Mastitis (sometimes called “postpartum mastitis”) is an infection most often seen in women who are breast-feeding. A duct may become blocked allowing milk to pool causing inflammation and setting the stage for infection by bacteria. The breast appears red and feels warm, tender and lumpy.
In its earlier stages mastitis can be cured by antibiotics. If an abscess forms, it will need to be drained or surgically removed.
Mammary duct ectasia is a disease of women nearing menopause. Ducts beneath the nipple become inflamed and can become clogged. Mammary duct ectasia can become painful and it can produce a thick and sticky discharge that is gray in color. Treatment consists of warm compresses, antibiotics, and if necessary, surgery to remove the duct.
IF YOU FIND A LUMP
If you discover a lump and the lump is something new or unusual and does not go away after your next menstrual period, it is time to call your doctor. The same is true if you discover a bloody discharge from the nipple or skin changes such as dimpling or puckering. If you do not have a doctor, your local Medical Society may be able to help you find one in your area.
You should not let fear delay you. It is natural to be concerned if you find a lump in your breast, but remember that
Four-fifths of all breast lumps are not cancerous. The sooner any problem is diagnosed, the sooner you can have it treated.
The only certain way to learn whether a breast lump or mammographic abnormality is cancerous is by having a biopsy. This is a procedure in which tissue is removed by a surgeon or other specialist and examined under a microscope by a pathologist. A pathologist is a doctor who specializes in identifying tissue changes that are characteristics of disease including cancer.
Tissue samples for biopsy can be obtained by either surgery or needle. The doctor’s choice of biopsy technique depends on such things as the nature and location of the lump as well as the woman’s general health.
WHAT HAPPENS DURING A BIOPSY?
Most women have biopsies in the hospital’s “outpatient” or “same day surgery” department. They usually do not need to stay overnight. Your doctor or nurse will tell you if you may eat or drink before surgery. At the hospital, you may have some routine tests such as blood and urine tests, a chest x-ray and an EKG (electrocardiogram), which records the activity of your heart. These tests tell your doctor about your general health. Sometimes these tests are done a few days before the biopsy.
You will be asked to sign a paper called an informed consent form. It explains what the doctor is going to do and gives your permission for the procedure. If you do not understand this form be sure to ask the doctor or nurse to explain it to you.
After the biopsy, you will be taken to your room or the outpatient care area. Most women have very little discomfort after a biopsy. If you have general anesthesia or IV sedation, you will probably be sleepy and want to rest. Depending on how you feel, you will be ready to go home one to two hours after the biopsy. It is best for a family member or friend to take you home. Before leaving the hospital, you will get instructions on how to take care of the incision. If you have any questions, ask your doctor or nurse.
You should be able to return to your normal routine within a day or two. However, for the next week or so your breast may be sore and slightly bruised. Also, the incision may feel firm for 3-4 months.
TYPES OF BIOPSIES
Surgical biopsies can be either excisional or incisional. An excisional biopsy removes the entire lump or suspicious area. Excisional biopsy is currently the standard procedure for lumps that are smaller than an inch or so in diameter.
An excisional biopsy is typically performed in the outpatient department of a hospital. A local anesthetic is injected into the woman’s breast. She is given IV sedation before the procedure. The surgeon makes an incision along the contour of the breast and removes the lump along with a small margin of normal tissue. Because no skin is removed, the biopsy scar is usually small. The procedure typically takes less than an hour. After spending an hour or two in the recovery room, the woman goes home the same day.
An incisional biopsy removes only a portion of the tumor (by slicing into it) for the pathologist to examine. Incisional biopsies are generally reserved for tumors that are larger. They are usually performed under local anesthesia with the woman going home the same day.
Whether or not a surgical biopsy will change the shape of your breast depends partly on the size of the lump and where it is located in the breast as well as how much margin of healthy tissue the surgeon decides to remove. You should talk with your doctor beforehand so you understand just how extensive the surgery will be and what the cosmetic result will be.
Localization biopsy (also known as needle-localization) is a procedure that uses mammography to locate and place a needle to biopsy breast abnormalities that can be seen on a mammogram but cannot be felt (nonpalpable abnormalities). Localization can be used with surgical biopsy or a core needle biopsy.
For a surgical biopsy, the radiologist locates the abnormality on a mammogram (or a sonogram) just prior to surgery. Using the mammogram as a guide, the radiologist inserts a fine needle or wire so the tip rests in the suspicious area-typically an area of microcalcifications. The needle is anchored with a gauze bandage and a second mammogram is taken to confirm that the needle is on target.
The woman along with her mammograms goes to the operating room where the surgeon locates and cuts out the
needle-targeted area. The more precisely the needle is placed, the less tissue needs to be removed.
Sometimes the surgeon will be able to feel the lump during surgery. In other cases especially where the mammogram showed only microcalcifications, the abnormality can be neither seen nor felt. To make sure the surgical specimen in fact contains the abnormality, it is x-rayed on the spot. If this specimen x-ray fails to show the mass of the calcifications, the surgeon is able to remove additional tissue.
Stereotactic localization biopsy is another approach that relies on a three-dimensional x-ray to guide the needle mammatome biopsy of a nonpalpable mass. With one type of equipment, the patient lies face down on the examining table with a hole in it that allows the breast to hang through; the x-ray machine and the maneuverable needle probe are set up underneath. Alternatively, specialized stereotactic equipment can be attached to a standard mammography machine.
The breast is x-rayed from two different angles and a computer plots the exact position of the suspicious area. (Because only a small area of the breast is exposed to the radiation, the doses are similar to those from standard mammography). Once the target is clearly identified, the physician positions the probe and advances the biopsy needle into the lesion.
AWAITING THE DIAGNOSIS
Many women who have had a breast biopsy say that bringing their suspicions of breast cancer to the doctor was one of the most difficult experiences of their lives. When you find a lump or breast change, you may find it very hard to go to your doctor. You may be afraid just waiting for your appointment. Once you go to your doctor, you will probably have to wait for test results. You also may have to wait for an appointment with another doctor for a second opinion or referral. The waiting may be hard because you do not know what you may have to cope with or how to plan for the future. These feelings are common for women facing the possibility of breast cancer. You may not have all of these problems and you may have your own way of coping with them. Throughout this stressful time, seek support from your friends and loved ones who can help you.
Not knowing what the future holds can cause a great deal of emotional stress. This is especially true for a woman about to have a breast biopsy. You may feel better if you:
Talk about your fears and concerns. It is very important for you to be open about your feelings with those people who are close to you. Openness can set the tone for continued sharing. This is a good time to talk frankly with family and friends. Do not hide your hurt or pain-share it. Do not hesitate to seek out professionals such as psychologists, social workers, or members of the clergy to help you deal with your anxiety or anger.
Think through how you might deal with a diagnosis of cancer and what plans you would make. Learn about your treatment options. Think about your needs-for example, who will care for your children or who can fill in for you at work. Find the best medical facility and kind of care that are available to you. Talk to others who have gone through similar things and learn from their experiences.
Fear of Cancer
Cancer is frightening, but it can often be treated successfully. More than five million Americans who have been treated for cancer are considered cured. If you need to have treatment, you may have to change your daily activities temporarily, but most cancer patients return to their usual lifestyle. Many women who have been treated for breast cancer say that they found new sources of strength within themselves to cope with the emotional demands they faced.
Fear of Loss
If you think you may have breast cancer, of course, you are concerned about the possibility of losing a breast. You may be worried about sex and how your partner may react. If you have a mastectomy, you (and your partner) may be depressed or have other feelings similar to those associated with other losses. Coping with loss is difficult for each woman. However, recognizing and talking about your feelings-such as anger, frustration, sadness and fear can help. These feeling lessen with time. You may even find that your relationship with loved ones is stronger than before.
Abscess: A pocket of pus that forms as the body’s defenses attempt to wall off infection-causing germs.
Areola: The colored tissue that encircles the nipple.
Aspiration: Removal of fluid from a cyst or cells from a lump using a needle and syringe.
Atypical Hyperplasia: Cells are both abnormal (atypical) and increased in number. Benign microscopic breast changes
known as atypical hyperplasia moderately increase a woman’s risk of developing breast cancer.
Benign: Not cancerous. Cannot invade neighboring tissues or spread to other parts of the body.
Benign Non-cancerous changes in the breast. Benign breast conditions can cause pain, lumpiness, nipple
Breast Changes: discharge and other problems.
Benign Tumor: A growth that is not cancer; it will not spread to other parts of the body.
Biopsy: The removal of a sample of tissue or cells for examination under a microscope for purpose of diagnosis.
Breast Density: Glandular tissue in the breast common in younger women making it difficult for mammography to detect breast cancer.
Calcifications: Small deposits of calcium in tissue, which can be seen on mammograms.
Cancer: A general name for more than 100 diseases in which abnormal cells grow out of control. Cancer cells can invade and destroy healthy tissues, and they can spread through the bloodstream and the lymphatic system to other parts of the body.
Clinical Breast Exam: A physical examination by a doctor or nurse of the breast, underarm and collarbone area, first on one side then on the other.
Core Needle Biopsy: The use of a small cutting needle to remove a core of tissue for microscopic examination.
Cyclic Breast Changes: Normal tissue changes that occur in response to the changing levels of female hormones during the menstrual cycle. Cyclic breast changes can produce swelling, tenderness and pain.
Cyst: Fluid-filled sac. Breast cysts are benign.
Diagnostic The use of a breast x-ray to evaluate the breasts of a woman who has symptoms of disease
Mammogram: such as a lump or whose screening mammogram shows an abnormality.
Ducts: Channels that carry body fluids. Breast ducts transport milk from the breast lobules out to the
Excisional Biopsy: The surgical removal (excision) of an abnormal area of tissue usually along with a margin of
healthy tissue for microscopic examination. Excisional biopsies remove the entire lump from the breast.
Fat Necrosis: Lumps of fatty material that form in response to a bruise or blow to the breast.
Fibroadenoma: Benign breast tumor made up of both structural (fibro) and glandular (adenoma) tissues.
Fibrocystic Disease: See generalized breast lumpiness.
Fine Needle Aspiration: The use of a slender needle to remove fluid from a cyst or cluster of cells from a solid lump.
Frozen Section: A sliver of frozen biopsy tissue. A frozen section provides a quick preliminary diagnosis but is
not 100% reliable.
Hormones: Chemical produced by various glands in the body, which produce specific effects on specific
target organs and tissues.
Hyperplasia: Excessive growth of cells. Several types of benign breast conditions involve hyperplasia.
Incisional Biopsy: The surgical removal of a portion of an abnormal area of tissue by cutting into (incising) it for
Infection: Invasion of body tissues by microorganisms such as bacteria and viruses.
Inflammation: The body’s protective response to injury (including infection). Inflammation is marked by
heat, redness, swelling, pain and loss of function.
Intraductal Papilloma: A small wart-like growth that projects into a breast duct.
Lobes, Lobules, Bulbs: Milk-producing tissues of the breast. Each of the breast’s 15-20 lobes branches into smaller
lobules and each lobule ends in scores of tiny bulbs. Milk originates in the bulbs and is
carried by ducts to the nipple.
Localization Biopsy: The use of mammography to locate tissue containing an abnormality that can be detected only on
mammograms so it can be removed for microscopic examinations.
Lymphatic System: The tissues and organs that produce, store and transport cells that fight infection and disease.
Mammary Duct Ectasia: A benign breast condition in which ducts beneath the nipple become dilated and sometimes
inflame, and which can cause pain and nipple discharge.
Mammogram: A x-ray of the breast.
Mammography: The examination of breast tissue using x-rays.
Mastectomy: Surgery to remove the breast (or as much of the breast as possible).
Mastitis: Infection of the breast. Mastitis is most often seen in nursing mothers.
Menopause: The time when a woman’s monthly menstrual periods cease. Menopause is sometimes called
the “change of life”.
Menstrual Cycle: The monthly cycle of discharge during a woman’s reproductive years of blood and tissues from
Microcalcifications: Tiny deposits of calcium in the breast, which can show up on a mammogram. Certain patterns of
microcalcifications are sometimes a sign of breast cancer.
Needle Biopsy: The use of a needle to extract cells or bits of tissue for microscopic examination.
Nipple Discharge: Fluid coming from the nipple.
Palpation: Use of the fingers to press body surfaces so as to feel tissues and organs underneath. Palpating
the breast's for lumps is a crucial part of a physical breast examination.
Pathologist: A doctor who diagnoses disease by studying cells and tissues under a microscope.
Permanent Section: Biopsy tissue especially prepared and mounted on slides so that it can be examined under a
microscope by a pathologist.
Prophylactic Surgery to remove a breast that is not known to contain breast cancer for the purpose of reducing
Mastectomy: an individual’s cancer risk.
Radiologist: A doctor with special training in the use of x-rays (and related technologies such as ultrasound)
to image body tissues and to treat disease.
Sclerosing Adenosis: A benign breast disease that involves the excessive growth of tissues in the breast’s lobules.
Screening Breast x-ray used to look for signs of disease such as cancer in people who are symptom-free.
Sonogram: The image produced by ultrasound.
Specimen x-ray: A x-ray of tissue that has been surgically removed (surgical specimen).
Localization Biopsy: A technique that employs three-dimensional x-ray to pinpoint a specific target area. It is used in
conjunction with needle biopsy of nonpalpable breast abnormalities.
Surgical Biopsy: The surgical removal of tissue for microscopic examination and diagnosis. Surgical biopsies can
be either excisional or incisional. (See excisional biopsy or incisional biopsy).
Tumor: An abnormal growth of tissue. Tumors may be either benign or cancerous.
Ultrasound: The use of sound waves to produce images of body tissues.
X-ray: A high-energy form of radiation. X-rays form an image of body structures by traveling through
The body and striking a sheet of film. Breast x-rays are called mammograms.