BREAST TENDERNESS
Why are my breasts so tender?

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 approaches   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 it 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.

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Will I need a biopsy?

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 and should 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.

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What can I do to decrease my breast tenderness?

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 comes 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 800 U per day. It is available at all drug stores and many supermarkets without a prescription.  Recent studies have warned of possible increased risk of heart disease with vitamin E at the higher doses, over time.  So if you want to try vitamin E for treating your breast tenderness, try the 400 U dose to start with.

Evening primrose oil is carried by many drug stores, though it may be more 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.

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Fibrocystic Disease

Breast Pain. Painful breast tissue is an exceedingly common symptom but is usually of functional origin and very rarely a symptom of breast cancer. Of all women diagnosed with breast cancer, breast pain is only present about 5% of the time. 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 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. 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.

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.

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BREAST LUMPS

I just found a lump in my breast, what should I do?

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.

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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 still need to be biopsied.  An ultrasound may be helpful.

I had a routine mammogram and it showed "calcifications", or a "nodule".  I have been referred to a surgeon.  Does this mean I have cancer?

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 fourth 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 about three fourths of those who have a biopsy will find out that there is no evidence of cancer.

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BREAST CYSTS

My doctor says I just have a cyst in my breast?   What causes cysts?  Should I have it removed?  Should it be drained with a needle?  Will it come back? 

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 breast 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.

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I had a cyst drained, and the fluid looked green.  Should the fluid be tested for cancer?

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.

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My teenage daughter found a lump in her breast.  What should we do?

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.

There is no one in my family who has had breast cancer, so my chances of getting breast cancer are very low aren't they?

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.

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I have some drainage from my nipple.  Is that normal?

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 this type of drainage from your nipples when you squeeze them, it's probably best to just stop squeezing them. 

If the nipple drainage occurs spontaneously, without massaging or squeezing the nipple, it frequently indicates a small growth inside one of the breast ducts just under the nipple.  Most of these tiny growths are benign, and are called "papillomas", but on occasion, the source of the drainage is a small cancer.  This sort of drainage should usually be managed by a type of biopsy, called a "ductal excision", in which the breast tissue just under the nipple is removed.  The cosmetic result is usually very good.  In most cases, this procedure can be done under local anesthesia in the outpatient setting.

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My mother had breast cancer.  Does that mean I will get breast cancer?

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, over the general population of women.  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.  Most women do not need to have this test done.  But it is usually recommended for women who have 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 are 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.

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Is there anything I can do to prevent getting breast cancer?

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.

Another option for women with higher than normal risk for breast cancer have another option.  A large national clinical trial has demonstrated that taking tamoxifen for five years can decrease the relative risk of developing breast cancer by about 50%.  Tamoxifen is a type of hormonal therapy very commonly used in the treatment of breast cancer.  When it is given to women who do not have breast cancer (but have a higher risk of getting it), it's use is called "chemoprevention".

You should understand a bit more about evaluating risk.  For the general population of women, only about 1% are going to develop breast cancer over the next five years and 8-10% over their lifetime.  A woman whose risk is estimated to be high would be in a group whose risk is double, or, about 2% over five years, and over 20% lifetime.  If this group of women all take tamoxifen for five years, only about 1% ( 1/2 of 2%) will develop breast cancer over five years, rather than the 2% that was otherwise predicted.  We don't yet know the long term benefits after completion of five years of tamoxifen, but it is expected that this benefit will continue.  Note that, although the breast cancer incidence is cut in half, there are really only about 1% of the women taking the tamoxifen who actually benefit.

Women who take tamoxifen often experience an increase in hot flashes.  Other potential side effects include an increase in risk of developing phlebitis or blood clots in the leg veins, with its associated complications, as well as an increased risk of developing changes in the cells lining the uterus, sometimes (though rarely) even to the point of cancer.  In view of this, annual Pap smears are particularly important.

If your breast cancer risk is higher than the general population, and you want to consider tamoxifen, discuss these issues in detail with your physician, so you feel comfortable with your decision.  The surgeons at DeKalb Surgical Associates can assist you in this process.

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How can I determine how high my risk of breast cancer is?

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.

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%.

If you would like to determine your risk of developing breast cancer the Gail model is available online at http://bcra.nci.nih.gov/brc/.  We can also do this as part of your evaluation in our office.

If my risk of developing breast cancer is high as calculated by the Gail model, is there anything I can do about it?

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 is the first ever drug study to demonstrate the ability to prevent breast cancer from developing in the first place.  More info can be obtained from the NCI web page at http://www.cancer.gov/newscenter/pressreleases/BCPTfollowup.

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.

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

Raloxifene is a relatively new drug that has been 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.  This incidental finding needs to be confirmed before we are certain of the benefit.  There is currently a study underway to evaluate this.  It is called the STAR trial, which has now been "closed".  Over 13,000 women have been enrolled, to receive either tamoxifen, or raloxifene, for five years, to see if raloxifene provides the same decrease in breast cancer incidence as tamoxifen.  Side effects of both crugs will also be compared.  The results of this important trial should be available in the next year or so.

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BREAST CANCER

I have had a breast biopsy and it showed cancer.  What is the best treatment?

            Once a breast cancer is diagnosed, there are a number of steps taken to determine the treatment options.  In most cases, a mastectomy is not necessary.  Your physician will review your medical history, and do a physical exam, in order to predict whether the cancer is localized in the breast.  The size and nature of the tumor in the breast will be assessed after its removal, and when appropriate, removal of one or more lymph nodes under the arm will be done to look for evidence of cancer spread.  This information will be used to customize your treatment plan.

            Treatment options for breast cancer include a variety of modalities, including surgery, radiation therapy, chemotherapy and hormonal therapy.  The extent of your cancer will determine whether just some, or all, of these modalities will be recommended.  In general, the smaller and more localized cancers can be treated with fewer of the modalities. 

            Women sometimes think that doing more is better, for example, that doing a complete mastectomy is better than just a lumpectomy.  However there is very clear proof that women do not need to lose their breast in order to be free of cancer.

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What is DCIS (ductal carcinoma in situ), or non-invasive cancer?  What is the treatment for it?

            DCIS is the earliest form of breast cancer that can be identified. The term is used to describe cells that have characteristics of cancer that have not yet grown beyond the borders of the breast duct where they started.  Since the cancer cells have not yet “invaded” the surrounding tissue, the risk that there are cancer cells elsewhere in the body is almost zero.

DCIS is the most commonly identified type of cancer if a biopsy is done for calcifications seen on a mammogram.  In most cases, it can be successfully treated with a simple surgical removal of a portion of breast tissue, followed by radiation therapy to that breast.  Lymph node removal is rarely necessary.  Chemotherapy is not necessary.  Recent studies have shown that your risk for any new breast cancer can be reduced further if the DCIS in your breast has receptors for hormones.  In such cases, your physician may recommend taking tamoxifen for five years.   There is also a clinical trial that is available, which compares taking tamoxifen to anastrozole for five years.  This new drug has already shown efficacy for invasive breast cancer, and is now being tested for similar efficacy in DCIS.  Your physician may discuss this trial further with you.

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Isn’t it better to just have a mastectomy to be sure all the cancer is removed?

            In most cases, mastectomy is not a better treatment for breast cancer, compared with breast-conserving methods.  Over 100 years ago, there was no known effective treatment for breast cancer.  A famous surgeon, William Halsted, tried doing a very extensive procedure, known as a radical mastectomy, for women presenting with advanced breast cancer.  He showed that these women did better than those with lesser treatment.  Over the next 50 years, radical mastectomy became the standard treatment for all women with breast cancer.

            Since these early days, breast cancer is usually being diagnosed at a much earlier stage.  For Dr. Halsted, the typical woman with breast cancer had a large cancer, with many involved (cancerous) lymph nodes already present in the armpit.  These days, most breast cancers are less than an inch in diameter, and have not yet spread to the lymph nodes.  Numerous publications have proven that breast-conserving surgery combined with radiation therapy, gives the same long-term results as mastectomy.

            There are a few exceptions where mastectomy may still be recommended.  Some women with breast cancer actually have multiple cancers in the breast at one time.  Others may have a large cancer relative to the size of their breast, such that breast-conserving surgery would not provide a cosmetically acceptable result.  Women who have a very high breast cancer risk may wish to decrease their risk by having bilateral mastectomy.  Your physician can discuss these options further with you.

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What does “sentinel lymph node biopsy” mean?

            Sentinel lymph node biopsy is a new way of evaluating the lymph nodes under the arm for evidence of breast cancer spread.  Ever since Dr. Halsted began doing radical mastectomy for breast cancer, surgical treatment for breast cancer has included removal of the lymph nodes under the arm.  This is usually the first place a breast cancer might spread, so it is considered an important part of the therapy, to at least see if there is any cancer there.  In Dr. Halsted’s day, virtually all women diagnosed with breast cancer had cancer already in the lymph nodes.  For this reason, it was only logical that the lymph nodes under the arm should be removed.  But currently, only about 20-30% of women have any cancer found in the lymph nodes, and it is usually limited to just one or two.

            If there is no cancer in the lymph nodes, there clearly is no therapeutic benefit to removing them, and in fact, there can be some harm.  After lymph node removal, some women develop arm swelling, called lymphedema, which can be either mild, and self-limited, or may at times become almost disabling.  And so, if we can determine that the lymph nodes are free of cancer without removing a lot of them, we can avoid possible problems with lymphedema.  This is what sentinel lymph node biopsy allows us to do.

            Recent research has shown that essentially all the lymphatic flow from the breast filters first through just one or two lymph nodes under the arm, and from there, onward to all the others.  By isolating these first nodes, or “sentinel nodes”, and removing only those nodes, we can find out if there is any cancer spread to the nodes without removing all the others.  Dye is injected into the breast, and the (blue) dye is carried into these sentinel nodes.  Then through a small incision under the arm, the sentinel nodes can be easily spotted and removed.

            The surgeons at DeKalb Surgical Associates participated in the national multicenter clinical trials that demonstrated the reliability of sentinel node biopsy.  Currently, sentinel node biopsy is the preferred method for evaluating the lymph nodes, unless the lymph nodes are palpable. 

            If the removal of the sentinel node shows cancer, it is usually recommended that a more complete removal of the lymph nodes be done.  In cases where the cancer in the lymph node is very small, or seen only with special stains (called immunohistochemistry), there is probably no advantage to remove any other nodes.

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What is chemotherapy?