Breast Disorders

Breast tenderness is a very common symptom. It is rarely associated with breast cancer, but a thorough exam by an experienced physician is important to be sure.

Most women experience at least some increase in sensitivity or tenderness in their breasts as their menstrual cycle In some women this can become quite severe. The tenderness may be diffuse, involving all of the breast tissue, or it may be localized to one breast, or one area of one breast. Though it usually lessens after the menstrual period it may be constant. It is clear that changing hormone levels in the blood stream are the primary explanation, but there may be other contributing factors. Certain medications may increase tenderness, including birth control pills, estrogen or progesterone (Premarin, Provera, Ogen, Climara, Estratest, and others), and medications which contain xanthines (Theodur, caffeine containing stimulants). Caffeine seems to cause increased breast tenderness for many women, though it seems to have no effect in others. Marked breast tenderness frequently occurs in the very early stage of pregnancy also. Sometimes a cyst can develop and enlarge rapidly, causing localized tenderness. Less commonly, an area of infection may occur which can be extremely tender.

If you have recently noticed that your breasts are more tender, you should be sure to do a good self-exam of your breasts. See if can identify a specific area that hurts, and feel for any lumps. Look for any visible changes such as a visible lump, or a dimpling of the skin, or redness. Schedule an appointment with your physician, and take a list of your current medications. Be aware of how much caffeine you are using, including coffee, tea, sodas, chocolate, and any caffeine-containing medications, such as diet pills or stimulants. Be able to pinpoint when your last menstrual period was, and whether is was normal or not. Ask your physician's office if you should have a mammogram or other studies before your appointment, and if you should bring your mammograms with you.

For most women with breast tenderness, the physician's exam will not identify any problem which needs a biopsy. However, occasionally there is an associated lump, which could be a fluid-filled cyst, an abscess, or a solid growth of tissue. Such findings will likely require a procedure, such as use of a needle, or other sort of biopsy or removal. This may frequently be done at the time of the initial visit. (Please note that some insurance companies do not cover procedures to be done on the same day as your exam. If not, you will be scheduled to return for the procedure after your insurance company has given authorization .)

Cysts can be treated simply with drainage of the fluid through a needle. The pain from the fluid drainage is similar to what you would feel if you have a blood test done. The cyst fluid usually has a greenish, yellowish, or brownish tint. There is usually no need to "test" the fluid if it has this typical appearance.

Abscesses usually require a small incision to drain the infection. For small abscesses, treatment can be done immediately. The infection causes more surrounding tenderness than a cyst, so the drainage procedure is likely to be more painful, but brief. The advantage of immediate treatment may outweigh the extra tenderness. Larger abscesses may require drainage in a hospital setting in order to provide adequate sedation and /or anesthesia.

Solid growths of tissue may be biopsied with a needle at the initial visit. Some anesthetic is injected around the area to be biopsied. The needle is then inserted into the lump to obtain a sample of tissue for analysis. An ultrasound machine is frequently used to place the needle precisely. Most women experience little or no discomfort with the procedure.

Once your physician has examined for any possible problems such as a cyst, abscess or possible cancer, there are several things you can do. If you are taking in any caffeine on a daily basis, try cutting out all caffeine products for a period of six weeks. This simple step may be all that is necessary. If your tenderness goes away, you may want to experiment by starting back on caffeine to see if your tenderness cames back. You may find that there is a certain amount of caffeine which you can tolerate without the symptoms.

Both vitamin E and evening primrose oil have been found to be helpful for many women. Though the exact mechanism of action is not known, both supplements have been found to be beneficial in decreasing tenderness. Recommended dosages for vitamin E range from 400 U to 1000 U per day. It is available at all drug stores and many supermarkets without a prescription. As an added benefit, there appears to be a decrease in riak of heart disease in patients taking vitamin E on a regular basis.

Evening primrose oil is carried by many drug stores, though it may be difficult to find than vitamin E. It is more commonly recommended in England than here in the United States . Recommended dosage is up to four tablets per day. It can cause some gastrointestinal side effects, such as bloating or gas, and changes in your bowel movements. These side effects are less likely at lower dosages.

There are many simple measures to try that may help. If your tenderness is predictable with each menstrual cycle, you may want to begin taking on over-the-counter pain medicine, such as Tylenol, Advil, Alleve, or other, for the week before your period. A good hot bath once or twice a day can help. Changing to a different bra is also occasionally beneficial.

Depending on the severity of your tenderness, you may want to use some or all of these measures. Most women will obtain sufficient relief with the steps described above. For the small group of women with persistent disabling tenderness despite all these measures, there is a hormonal treatment which is very effective, but which has a high likelihood of side effects. It involves use of Danazol, a hormone used in treatment of endometriosis. Side effects include changes in menstrual cycle, voice changes, and body hair growth.

Breast Pain. Painful breast tissue is an exceedingly common symptom but is usually of functional origin and very rarely a symptom of breast cancer. Haagensen 24 carefully recorded the symptoms of women presenting with breast carcinoma and found pain as an unprompted symptom in only 5.4% of patients. Although not a symptom of cancer, breast pain is a common reason for patients to seek medical attention. Breast pain appears to be aggravated by abnormal menstrual cycles and may be seen in young women with menstrual irregularity, as a premenstrual symptom, or when exogenous ovarian hormones are administered during and after the menopause. In addition, fibrocystic change, in its severest forms, may cause disabling breast pain. Although many observers find painful cystic mastopathy is aggravated by excessive intake of caffeine, nicotine, or commonly used antihistamines, other investigators disagree.

Fibrocystic Change (Cystic Mastopathy, Cystic Mastitis). Fibrocystic change, popularly referred to as fibrocystic disease, represents a spectrum of clinical and histologic findings and describes a loose association of cyst formation, breast nodularity, stromal proliferation, and epithelial hyperplasia. 34 Fibrocystic change appears to represent an exaggerated response of breast stroma and epithelium to a variety of circulating and locally produced hormones and growth factors. Clinically, patients with fibrocystic change have dense, firm breast tissue with palpable lumps and frequently gross cysts. This condition is commonly painful and tender to touch. Histologically, the lesion recognized as fibrocystic complex contains macrocysts, microcysts, stromal fibrosis, adenosis, and a variable amount of epithelial metaplasia and hyperplasia. All these changes can occur alone or in combination and to a variable degree in the normal female breast. Autopsy studies have questioned whether any of these changes, except perhaps macrocysts, are abnormal. In fact, all of these lesions occur commonly in the breasts of elderly patients and appear to have no particular pathologic potential. It appears preferable to describe each of the lesions separately and comment about the extent and severity of the process. The term fibrocystic disease should be abandoned in the absence of any well-defined clinical and pathologic syndrome.

As discussed later, there is no consistent association between fibrocystic complex and breast cancer. It is well established that women who have undergone breast biopsy for any reason, regardless of the underlying pathology, have a slightly higher risk of developing subsequent breast cancer. Moreover, the incidence of finding fibrocystic disease in autopsied breasts from women dying of causes other than breast cancer exceeds the incidence of these same changes in cancer-containing breasts. For those patients with fibrocystic changes, higher risk appears to concentrate in those whose biopsy specimens show abnormal ductal and lobular hyperplasia and, to a lesser extent, cyst formation. Therefore, the fibrocystic complex appears to be an exaggerated or abnormal response to otherwise physiologic stimuli in most patients and represents a health risk only in certain subsets.

Any lump in your breast should be checked by a qualified physician to determine what it is. If you are not sure whether it's really a "lump", or not, you may wish to wait through a menstrual period to see if the new finding is still present. But if it is a definite lump, you should not delay.

A new lump may simply be a benign cyst, or it may be the first sign of a breast cancer. In most cases, additional studies will be done, such as a mammogram, or ultrasound, and frequently some sort of biopsy is also necessary. In some cases, where the new finding is not a distinct lump, you may be asked to return for a re-exam in a few weeks or months.

I have a lump, but my mammogram is normal, so it's not cancer, right?

You must understand that not all cancer shows up on mammography. Any lump needs to be examined by a qualified physician, whether it shows up on mammography or not. If the lump is not seen on mammography, it may be still need to be biopsied. An ultrasound may be helpful.

Screening mammograms have become an important method to screen for breast cancer. We have learned that mammograms can often detect the earliest signs of breast cancer, at a point in time when it can not yet be felt. Early breast cancer often shows up as a small cluster of calcifications, which look like a small grouping of tiny white flecks on the mammogram, or as a small nodular area which is more white than the surrounding breast tissue. But, these same abnormalities can be caused by breast changes that are not breast cancer as well. Only about one in six of these abnormalities end up being cancer when they are biopsied. But the only way to be sure is to sample the tissue with some sort of biopsy. This means that most of those who have a biopsy will find out that there is no evidence of cancer.

It’s good that you are having annual mammograms done. Of course, every woman hopes that nothing abnormal will be seen, and in fact about 90% of women do indeed have a “normal” mammogram. And of the other 10%, even though the mammogram may show something abnormal, most of these women don’t have cancer.

Abnormalities seen on mammograms fall for the most part into 2 categories; suspicious calcifications, or densities. Not all calcifications are suspicious, and it would be too complicated to go into all the subtle distinctions that are considered in evaluating any calcifications. Generally speaking, the calcifications which are small, clustered (and multiple), and variable in shape and size (this is called pleomorphic), are the ones that should be biopsied. Now if the radiologist sees just one or two calcifications, or if they are not that variable in size, or if for some other reason, they aren’t that suspicious, he may recommend a “short term followup”, which usually means, a repeat mammogram of just the involved breast in 6 months. It doesn’t really make sense to recommend a biopsy when the findings are not that suspicious, since it would require doing biopsies in 50 women to find the 1 of 50 who actually has a cancer. As it stands, only about 15% of the abnormal calcifications which are biopsied (BIRAD 4 cases) are cancer; the other 85% of suspicious calcifications are due to benign changes in the breast tissue.

It is important that the radiologist reviewing your films has lots of experience reading mammograms. At our institution, all the radiologists who read mammograms are reading thousands of studies every year. Our facility is accredited by the American College of Radiology. We use the most up to date technology for digital mammography, which provides high resolution images, and with much less inconvenience for the patient (rarely do the pictures need to be “done over”).

Those women who are requested to return for followup films in 6 months in most cases will be given further reassurance with the 6 month film and then return to an annual schedule. A few women may be advised to have a biopsy based on the followup. If you feel anxious about being told to come back in 6 months, you should ask your primary care physician for a referral to DeKalb Surgical Associates for a breast consultation. We are experienced in evaluating breast abnormalities and will carefully review your specific case, including the findings on physical exam, and on mammography. If appropriate, ultrasound can be performed at the time of your visit for additional information (though for calcifications, ultrasound rarely is utilized).

When your mammogram is read by the radiologist, he will categorize the findings according to whether anything looks suspicious or not. The American College of Radiologists set up standards for rating mammograms, which is called BIRADS (Breast Imaging Reporting and Data System). Here is a table of the possible designations.

Category	Diagnosis	Number of Criteria
0	Incomplete	Your mammogram or ultrasound didn't give the radiologist enough information to make a clear diagnosis; follow-up imaging is necessary
1	Negative	There is nothing to comment on; routine screening recommended
2	Benign	A definite benign finding; routine screening recommended
3	Probably Benign	Findings that have a high probability of being benign (>98%); six-month short interval follow-up
4	Suspicious Abnormality	Not characteristic of breast cancer, but reasonable probability of being malignant (3 to 94%); biopsy should be considered
5	Highly Suspicious of Malignancy	Lesion that has a high probability of being malignant (>= 95%); take appropriate action
6	Known Biopsy Proven Malignancy	Lesions known to be malignant that are being imaged prior to definitive treatment; assure that treatment is completed

You can see that the BIRAD 4 classification refers to findings for which the radiologist feels biopsy should be considered, even though it might not be cancer. This designation covers a wide range of suspicious findings, and for this reason, some radiologists will further categorize the findings as 4a, 4b, or 4c, indicating progressively higher suspicion. For example, if he sees a group of three tiny calcifications, not very tightly clustered, and all rounded, he may feel biopsy is appropriate, even though these are most likely benign, and so may designate this as a BIRAD 4a. If he sees a “tight” cluster of numerous tiny calcifications that are variable in shape and size, and perhaps showing branching, he would predict that these are much more likely to indicate cancer, and may designate these as BIRAD 4c. In most cases, both of these situations are going to require a biopsy, even though the level of suspicion is quite different.

It is important that in addition to annual screening mammograms after age 40, you should have an annual breast exam by a physician who does a thorough physical exam of your breasts. This is especially important if your mammogram is abnormal. If you are referred for a biopsy, and no breast exam is done beforehand, you might not have the proper biopsy method, or there may be findings missed that would alter the recommendations for biopsy. The surgeons at DeKalb Surgical Associates are highly trained and skilled in the assessment of breast problems, particularly mammogram abnormalities. In most cases of BIRAD 4 abnormalities, you would be scheduled for a stereotactic biopsy. But if the abnormality corresponds to something the surgeon can feel, or can see on ultrasound, a core needle biopsy with ultrasound guidance is usually a better option, and this can usually be done on the same day as your first visit.

A stereotactic biopsy is a clever method designed to obtain a small but sufficient amount of tissue from the breast for biopsy when the area of suspicion cannot be felt, but is seen on the mammogram. It requires some sophisticated equipment, and a skilled physician, but usually is relatively easy for the patient. You will lie on your stomach on a special flat table that can be raised up; your breast drops through an opening in the table. A mammogram plate holds your breast stationary while digital images are taken at two slightly different angles. This allows the physician to precisely localize the abnormality in your breast, using a computer that is hooked up to the table. After injecting some local anesthesia in the skin of your breast, a core needle is advanced through the skin to the target, and several cores of tissue are removed. An x-ray of the removed tissue will immediately confirm that the suspicious area has been removed. The procedure usually only takes about 20 minutes, and is usually painless after the local anesthetic injection.

In most cases, the physician will place a small metal marking clip in the area where the biopsy was taken. This clip is about the size of a tooth filling, and will not be felt, will not move around, and will not set off any metal detectors. This marker is important whether you have cancer or not. If the biopsy shows cancer (results will usually be available in 2-3 days), your surgeon will need to remove more tissue from around the biopsy area. Since the original suspicious abnormality may have been completely removed with the biopsy, the marker will be a certain way of knowing precisely where the biopsy was done. If you don’t have cancer, the marker will remain permanently in your breast, documenting that the suspicious area has been adequately biopsied.

In most cases, the initial biopsy can be done without placing a wire, and without having to go to the operating room. Since most such abnormalities on mammogram are benign, it’s usually better to do a less invasive biopsy initially, rather than going to the operating room for a surgical biopsy. There are exceptions to this, but the surgeon should have given a logical explanation for why a less invasive procedure was not chosen. If you don’t feel comfortable with the recommendation for an open surgical (excisional) biopsy, you could always request a second opinion.

It is almost always best to know there is cancer present BEFORE going to the operating room. If it is not yet determined whether there is cancer, a less invasive core needle biopsy (either a stereotactic biopsy or ultrasound guided biopsy) is almost always preferred.

The term “pre-cancerous cells” might be used for different situations. There are some benign cells that are more heaped up and irregular than normal breast cells, which are considered to be an indication that a woman is at higher risk for developing a cancer. There are 2 such categories, atypical ductal hyperplasia (ADH), and atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS). Although these findings are not cancerous, the possibility of finding a tiny cancer nearby is high enough to consider a larger surgical excision of surrounding breast tissue, if these cell types are seen on a core needle biopsy. Though estimates vary, the possibility of finding a nearby hidden cancer in this case is probably about 10%.

Although no one ever wants to be told that they have cancer, the finding of ductal carcinoma in situ (DCIS) is one of those situations where we truly have found a cancer at a stage where it can be nipped in the bud. The “in situ” phrase means that we can tell for sure that these cells have the POTENTIAL to do their cancer thing (which means, to invade into surrounding tissue and eventually spread elsewhere), but that they have not yet invaded even the tissue right around the DCIS cells.

When DCIS is seen on a biopsy, you will need to have more tissue removed from your breast (usually the additional tissue removed is about the size of an ice cream scoop). This is almost always done as on open surgical excision in the operating room, either with sedation or general anesthesia, though sometimes under local anesthesia. This surgical excision is the most important treatment, and it is necessary to remove enough tissue so that none of the DCIS is seen along any of the margins of the removed tissue.

This is not always as simple as it might seem, because the DCIS can only be seen under the microscope, and the tissue is not usually examined under the microscope until after preserving the removed tissue in formalin overnight. This method gives more reliable information than trying to examine the tissue immediately (called a frozen section). This means that there are some women in whom the margins will show some more DCIS, and this will require another trip to the operating room to remove more tissue. This return to the operating room is necessary more often than you might think, as often as 50% of the time at some centers. At DeKalb Surgical, this is only necessary about 12% of the time. I wish it would never happen, but sometimes even the non-invasive cancer cells can extend along the breast ducts in various directions. Obtaining clear margins is a matter of experience, compulsion with orientation of the tissue for the pathologist, and to some extent, how much additional breast tissue is removed. Our technique involves the use of a customized surgical device that is not yet available for general use, which helps to minimize the likelihood that you would need a second procedure.

Although surgical excision for clear margins is the most important treatment, radiation therapy AND 5 years of hormonal therapy (with tamoxifen) is fairly standard additional treatment, with the intention of minimizing the possibility that you might ever develop another cancer in your breast. Your surgeon should discuss these issues with you in more detail. Probably the most important thing to remember if you have DCIS is that almost all women are cured of their cancer when it is found at this stage.

You will need to be evaluated to decide on an individualized treatment plan, based on the specific details of your case. Several factors must be considered, including the type of breast cancer (ductal is the most common subtype, and lobular is the other, but there are even subtypes of the subtypes), your age and menopausal status, the apparent size of the tumor, your medical history, and any pertinent abnormalities noted on a thorough physical exam, findings on mammogram and possibly additional imaging studies, and some molecular characteristics of the cancer (you might think of these as the “fingerprint” of the cancer), primarily the estrogen receptor (ER) and HER2 status. For some women, an additional assay called the OncotypeDX Recurrence Score may be ordered as well.

All these elements should be considered by your surgeon. At DeKalb Surgical, many patients are offered a Roundtable Consultation as soon as the diagnosis of cancer is made. At this unique meeting, a multidisciplinary team of doctors and our nurse navigator will all meet together with you simultaneously, in order to come to a unified treatment plan, customized to your specific situation, to offer you the greatest likelihood of a cure. Since we have developed a variety of effective weapons for breast cancer, including surgery, radiation therapy, hormonal treatments, and chemotherapy, we want the doctors who specialize in each of the treatment modalities to meet and work together to recommend the best sequence of treatments. We don’t have to use all of these modalities in every case, but it is best to decide up front, what the best plan would be, with input from the entire team, including you, the patient.

In some cases, it may be best to undergo chemotherapy first, to shrink down the tumor, and then follow with the surgery to remove any remaining cancer cells. An advantage of this sequence is that we can see that in your specific case, the selected chemotherapy is effective, since we will be able to see that the cancer, if it’s palpable, actually shrinks during treatment. In some cases, we even may see that the chemotherapy is so effective, that when the surgery is done, ALL the remaining cancer has disappeared. These patients have a particularly good prognosis.

At DeKalb Surgical, we have available many clinical trials for patients with breast cancer. Clinical trials allow us to offer tomorrow’s breast cancer treatments today. These trials often include newly approved drugs, which have shown benefit in more advanced breast cancers, and now are being tested in women with breast cancers that are more contained (ie, a lower stage). Or they may be testing a less radical method of giving the usual radiation therapy to the breast after surgery. Other trials are proving that hormonal treatment (which is much easier to tolerate compared to chemotherapy) is effective in shrinking tumors before surgery. Not all women are candidates for clinical trials, but studies have shown that women who participate in clinical trials tend to have better outcomes than those who don’t go on a trial.

This is one of those questions that has a very complex answer, and the answer may change over the next few years. MRI stands for “Magnetic Resonance Imaging”, and is a very sophisticated method of viewing anatomy in the body. It probably first found a valuable niche in medicine for evaluating the back part of the brain, where CAT scans sometimes were lacking in the desired detail. As time has passed, MRI has been applied to virtually all body parts, and now has many daily uses, particularly in evaluating joints and other musculoskeletal abnormalities, particularly the spine, and the pelvis and back part of the abdomen. The breast has been evaluated with MRI as well, and no doubt will continue to have important applications. But doctors are not yet agreed as to how best to utilize MRI for breast problems.

The benefit of MRI in breast problems is its extremely high sensitivity, which means that it can show a very high level of detail, and some hidden cancers (a very small percentage) will not be seen with any other imaging study. The down side of MRI has to do with its relatively low specificity, meaning that not everything it “sees” is bad.

With screening mammograms, less than 10% of women will have abnormalities that require more evaluation, and of all the women who have a cancer hiding somewhere in their breast, about 95% of them will be in that small 10% group. So mammography does a very good job of sorting out which women have silent cancers, but it does not find 100% of the cancers. With mammography, we find 1 cancer out of about every 5-6 women for whom we recommend a biopsy.

With MRI, about 25% of women will have abnormalities that require more evaluation, and in many cases, there will be two, three, or even more abnormalities that might require a biopsy. Of all women with a cancer hiding in their breast, about 98% will be in that group of 25%. But you can easily see that the number of women undergoing biopsies is 2½ times that required based on the mammograms. There are a few more cancers found, but it is hard to decide whether it’s worth the cost, inconvenience, and anxiety for all the women who don’t have cancer, who now are undergoing biopsies.

At DeKalb Surgical, MRI is used in selected cases, primarily in women who are already diagnosed with breast cancer. In addition, women who have a distinctly higher breast cancer risk, due to strong family history (eg, either a documented carrier of one of the BRCA genes, or two immediate family members with breast cancer, etc.), may be screened with MRI. In cases where the likelihood of developing a cancer is extremely high, the use of MRI, even with its low specificity, makes more sense. (If you are interested in more information, here is a table put out by the American Cancer Society in 2007 that lists their indications for using breast MRI, and a link to the full article from which it came.)

As I said above, the role of MRI is evolving, so our use of MRI may also change as time goes on, and as more data is published about the specific situations which may benefit from its use.

Breast cysts are very common. They are frequently quite large, and often a bit tender. They may seem to have popped up overnight, as a very large lump, the size of a grape or larger. Although we don't know why they occur specifically, it seems they develop as a response to the normal hormone variations that occur through the monthly menstrual cycle. Sometimes they will go away on their own as quickly as they come, but often they remain for some time.

Cysts can be classified as "simple" or "complex". An ultrasound is especially helpful in evaluating cysts; in fact, if a lump has all the characteristics of a simple cyst on ultrasound, it can be safely "left alone". But when it can be clearly felt, and doesn't go away, it may be best to drain it with a needle. This is simple to do, and it can relieve any tenderness. What's more, there is nothing more reassuring about a new lump in your breast than to make it disappear!

Cysts can come back, but most do not. Some women tend to develop new cysts over and over, and some women develop so many cysts that it seems impossible to try to drain all of them. This situation is challenging, because it makes it hard to decide if there may be a "new" lump hiding in the background of all the cysts. In such cases, it may be best to plan to have your breasts checked by a physician more frequently, perhaps every 3-6 months. Though this is no guarantee of finding any beast cancer early, it should help. Having lots of cysts does not appear to increase your chances of having breast cancer; it just makes it harder to check.

In years past, doctors routinely sent cyst fluid to be analyzed for cancer. But it turns out that the information obtained is not really helpful in deciding what to do, so most doctors have stopped doing this routinely. There may still be situations in which cyst fluid analysis is helpful. This may include cases in which the fluid is crystal clear, bloody, in cases where the cyst looks unusual on ultrasound, or in a patient who has an especially high risk of cancer.

It is very rare for lumps in teenagers to be cancer, but it should still be checked out by a physician. In most cases, it is a benign growth called a fibroadenoma, which is not cancer, and except for rare cases, will not turn into cancer. If left alone, they usually will eventually go away (regress), but this process may take years.

Fibroadenomas usually have very typical features on ultrasound, and they have a very typical rubbery feel, and can be "pushed around" in the breast tissue very easily, so your physician may be quite certain that your lump is a fibroadenoma even without a biopsy. But, a biopsy is very simple to do, using a "fine needle" or a "core biopsy", so if you or your doctor have any anxiety about it, a biopsy or excision should definitely be done.

Sometimes it may make more sense to just remove the lump rather than do a biopsy. A lump brings with it a certain amount of anxiety even if a biopsy is "benign". If you feel that leaving the lump in would cause you too much anxiety, even if benign, then you and your doctor may want to skip the biopsy and just remove it.

Don't assume that you won't get breast cancer just because it doesn't run in your family! Most breast cancers are not inherited, meaning that any female is at risk. If you have a lump in your breast, or if you have a suspicious finding on your mammogram, it must be evaluated carefully, regardless of whether cancer runs in your family.

There are different types of nipple discharge, some of which are of little concern, and others which are suspicious. Many women may see a little milky, or slightly greenish discharge from the nipples at times. It might be seen when the breast is massaged or the nipple is squeezed or stimulated, and may be seen from more than one of the ducts on the nipple. This type of discharge is considered normal. If you notice tis type of drainage from your nipples when you squeeze them, it's probably best to just stop squeezing them.

If someone in your immediate family has been diagnosed with breast cancer, then your risk of developing breast cancer is increased by about a factor of 2. If there are more than one with breast cancer in your family, your risk goes up further, especially if the cancers occurred at a young age (younger than 40).

Although most breast cancers are not primarily due to genetic factors (related to family history), there is a group of women who carry a gene that carries with it an extremely high risk for developing both breast and ovarian cancer. These genes are called the BRCA1 and BRCA2 genes. These gene mutations can be identified by a blood test, but the cost is over $2000 currently. Most women do not need to have this test done. But it is usually recommended for women who have two or more young family members with breast cancer, or if there is also a family history of ovarian cancer. Each patient considered for the test must be counseled about what the test involves, and what ae the implications of the test results. If you want more information, please contact our office. The genetic testing and counseling is available through the Kann Cancer Center at DeKalb Medical Center.

We do know something about risk factors for breast cancer. Breast cancer incidence is higher in patients who are overweight, those who drink moderate to high amounts of alcohol daily, and those who consume a diet high in saturated fats. There is also a higher incidence in those who have early onset of menstruation, those who have no full-term pregnancies until late in life, or those who never have any pregnancies. Also, for those with children, breast feeding appears to decrease the incidence of breast cancer.

Most women will not want to base their family planning on decreasing their cancer risk, but it's at least helpful to understand these potential implications. But some basic preventive life styles make sense for most everyone, namely, avoiding saturated fats as much as possible, abstaining from alcohol, and maintaining an ideal body weight. Other good life style measures in general include complete abstinence form tobacco products, a diet high in fiber, and a regular exercise program.

We can give an estimate of a woman's risk of developing breast cancer based on several factors such as family history, prior breast biopsy results, age at onset of menstrual periods, etc. One popular "model" for quantifying this risk is called the Gail model. By "plugging in" all the pertinent information, a calculation of the 5-year and lifetime risk can be made. For the "no risk" women, her 5 year risk would be about 1%, meaning that if there were 1000 women with no risk factors, in five years, approximately 10 of them would have developed breast cancer. A woman who has one or more risk factors, such as family history, no pregnancies, etc, her 5 year risk may be 1.5%, or 2.5% or higher. This would mean that in a group of 1000 women with all those same risk factors, 15 or 20 would develop cancer over the next five years.

You may want to look at a similar risk calculation tool at the National Cancer Institute website, where you can do your own calculation.

Lifetime risk for a woman with no risk factors would be in the range of 10%, meaning that 100 of 1000 similar women would develop breast cancer sometime during their lifetime. For women with one or more risk factors, their lifetime risk may be 15% or perhaps as high as 50%.

In 1998, a landmark study was published regarding the use of tamoxifen in the prevention of breast cancer. About 13,000 women were enrolled in this five year trial, comparing tamoxifen to a placebo (sugar pill). The incidence of breast cancer development over about five years was decreased by about 50%. In the placebo group, about 20 out of 1000 women developed cancer, whereas only about 10 out of 1000 women developed cancer in the tamoxifen group. These results are dramatic, in that this the first ever drug study to demonstrate the ability to prevent breast cancer from developing in the first place.

If a women chooses to take tamoxifen for prevention, it must be taken for a total of five years. One must be aware that there are some potential undesirable side effects. There were a few more cases of endometrial cancer when taking tamoxifen, and there were more women with blood clot problems. And there may be side effects of hot flashes, vaginal discharge, cataract formation, and depression. But for some women the benefits may clearly outweigh the risks.

I have heard that Evista (raloxifene) can also decrease my risk of getting breast cancer. Is this true?

Raloxifene is a drug that was initially approved for the prevention of osteoporosis. In the study which was conducted to look at its effect in osteoporosis, it was noted incidentally that there were fewer women diagnosed with breast cancer when taking raloxifene.

On the basis of these findings, a large trial was conducted a few years ago, including almost 20,000 women, which compared the use of Evista (raloxifene) to tamoxifen for the prevention of breast cancer in women who were at higher than average risk for developing breast cancer. This was called the STAR trial (Study of Tamoxifen and Raloxifene). The results were published in 2006, and showed that Evista also decreased the incidence of breast cancer over a 5 year period. It is important to understand the size of the benefit. These women had an average estimated risk of about 4% for developing breast cancer over the next 5 years. This means that out of 100 women in the trial, only 4 would be expected to be diagnosed with cancer in 5 years. But in the general population only 1 or 2 out of 100 will develop cancer in 5 years, so the risk is double or more. Now in the study, with 5 years of either tamoxifen or Evista (raloxifene), only about 2 out of 100 women were diagnosed with breast cancer over 5 years, so the drugs both decreased the incidence of cancer by half. While this is really good, the benefit is limited to only 1 or 2 women out of 100 who take it, at least over the first 5 years. It seems that the higher one’s risk is, the more attractive these drugs become as preventive treatment. You can find more information at the National Cancer Institute website about this trial. Another informative NCI site can be viewed here.

The diagnosis of breast cancer is a very frightening event for any woman. It is accompanied by many fears and anxieties, especially anxieties about the need for chemotherapy, and the fear that the cancer will come back. These concerns arise for many women despite that fact that cancer is most often diagnosed in its early stages, when the risk for recurrent disease is fairly low. A new test is available that will help women and their doctors in predicting their risk for recurrence, and to determine if their cancer would respond to chemotherapy.

The new test, called the OncotypeDX test, is performed on tissue from the initial biopsy or lumpectomy specimen. It uses the unique genetic profile of each woman’s breast cancer to make an accurate prediction about whether the cancer will recur. It measures an array of genes that are known to be associated with more aggressive tumors. The test has been shown to be much more powerful than current predictive methods, which are based on “clinical staging”, which is based on the size of the tumor and the status of the lymph nodes.

This OncotypeDX test has been studied in a large group of women who had participated in two large national breast cancer clinical trials through the National Surgical Adjuvant Breast and Bowel Project (NSABP) several years ago. All of these women had early stage breast cancer at diagnosis, and all were treated in a similar fashion, with tamoxifen. The OncotypeDX test was performed on the initial tissue specimens for all these women. The women were then grouped according to the OncotypeDX test results. All women had been followed for at least 10 years, so it was known who had recurrent cancer.

For the group as a whole, there were 15% who had recurrence within the first ten years after diagnosis. Using the OncotypeDX test, this group could be split into 3 sub-groups, one whose recurrence risk was extremely low, at 7%, a second group with an intermediate risk, and a third group whose recurrence risk was quite high, at 31%, despite being classified as “early stage” by our current criteria. About half of the women were in the low recurrence risk group. The researchers concluded that the test is highly prognostic for this group of breast cancer patients, independent of treatment.

The test was also studied to see if it could predict who would benefit from receiving chemotherapy. Currently, many women with early stage breast cancer are advised to receive chemotherapy, in a “one size fits all” fashion, even though only a very small number are actually going to benefit. Based on current clinical staging, there is no simple way to decide which women would not benefit from chemotherapy. In other words, we overtreat many women with chemotherapy, for lack of being able to distinguish which women will actually benefit.

Using the OncotypeDX test, 50% of the women, all with a low Recurrence Score, had no benefit from receiving chemotherapy. Stated another way, if the Recurrence Score is low, the risk of recurrence is extremely low, and receiving chemotherapy makes no difference in the outcome. On the other hand, in the remaining 50% of women with an intermediate or high recurrence score, there a much more dramatic benefit from receiving chemotherapy, especially with a high Recurrence Score. Incorporation of this test into the decision process allows the doctor to individualize treatment based on the “fingerprint” of the patient’s cancer. Approximately 50% of women with early breast cancer can thus avoid the toxicity that comes with receiving chemotherapy.

This exciting new study was reported at the annual San Antonio Breast Cancer Symposium held in December 2004 and subsequently published in the New England Journal of Medicine. The test currently is only indicated for patients with breast cancer that has not spread to the lymph nodes, and also is “positive” for estrogen receptors. The test is available for women at DeKalb Medical Center. Most insurance companies cover the cost of the test. It is expected that in the near future the test will be validated in women with more advanced breast cancer, potentially sparing additional women the toxicity of chemotherapy. There is already data showing that OncotypeDX is predictive of the benefit of chemotherapy even in women with positive lymph nodes, but its use in this setting is not yet considered appropriate outside of research settings. Use of the test may also eventually accelerate our ability to identify unique molecular targets in breast cancer, allowing for even greater precision and individualization in treatment planning.

As the use of this test has expanded, there has been a need to decide how best to treat those women who fall into the “Intermediate” Recurrence Score group. Currently, most oncologists would recommend chemotherapy for many of these patients, though the data so far appears to show no real difference in outcomes for women whether they have chemotherapy or not. There is a large national clinical trial underway to study this further. It is called the TAILORx trial (Trial Assigning IndividuaLized Options for Treatment (Rx)). In this trial, women with a low Recurrence Score are treated with hormonal therapy only, and women with a high Recurrence Score are treated with chemotherapy followed by hormonal therapy. Patients with an Intermediate Recurrence Score are randomized either to receive hormonal therapy alone, or combined with chemotherapy. You can get more information about this trial from the surgeons at DeKalb Surgical, or you may visit this NCI website for more details.