Frequently Asked Questions, Breast Health

Q If I don't have a family history of breast cancer, why do I need a mammogram?

A One out of 8 women will be diagnosed with breast cancer resulting in more than 200,000 new cases every year. More than 3/4ths of those women have NO family history with the remainder having either some or a significant family history of breast cancer. Although not perfect, mammogram is the gold standard in screening for early detection of breast cancer.

Q Why should I do self-breast exams?

A Self-breast exams are an important part of breast health awareness for every woman. Becoming “familiar” with how your breast tissue feels can increase detection of early changes during the months between your annual breast exams with your provider. Although these changes may be normal and do not always need additional tests, it is very important to seek care with your provider for further evaluation. A combination of monthly self-breast exams, annual breast exams with your provider, and age-appropriate screening tests result in earlier detection of breast cancer.

Q I have a lump in my breast and the x-rays were negative, now what do I do?

A It is often reassuring when the x-rays are negative, which typically includes a mammogram and ultrasound. However, a small percentage of palpable lumps are not detected on imaging alone. Any new finding in the breast warrants very close follow-up, and depending on your provider’s level of suspicion, may require referral to a surgeon to consider excisional biopsy. Open communication with your provider is critical to ensure appropriate and timely management of any breast concern.

Q Should I worry if my breasts hurt?

A Breast pain is a very common complaint in women of all ages. It can be related to hormonal influence such as menstrual cycles, birth control medications, or hormone replacement therapy. Processes such as infection, beast cysts, and normal breast tissue can cause discomfort. Rarely does cancer cause pain but it may lead to incidental findings of abnormalities. It is very important to see your provider for a complete breast exam and breast imaging if needed. Close follow-up will be necessary to ensure symptoms resolve or improve and referral to specialist if needed.

Q What is the difference between a screening and a diagnostic mammogram?

A A screening mammogram incorporates 2 standard images of the breast commonly referred to as CC and MLO views of the breast which are performed as part of routine surveillance annually. However, should a concern be identified during the screening process, the patient is asked to return for diagnostic views of the affected breast which may include additional images such as spot compression and/or magnification views as well as focused breast ultrasound if necessary. When the patient already has a known breast concern such as short-term follow-up on microcalcifications, densities, or any radiologic abnormality, the clinician will always order the test as diagnostic alerting the radiologist there is a specific reason other than screening that this imaging is being requested. The radiologist will have the expertise to understand what studies will be most helpful in determining if a finding on any breast imaging study should be of concern which could require further views, short-term follow-up imaging, or more aggressive intervention such as biopsy and will provide guidance to your clinician.

Q Should I ask about genetic testing for breast cancer?

A We know that all women have a gradually increasing risk of the development of breast cancer as they grow older, the two biggest risks being (1) a women (2) getting older. Unfortunately, a subset of women have a genetic predisposition to breast malignancy secondary to a known mutation called BRCA 1/BRCA 2 placing these women at several-fold increased risk in the development of invasive breast malignancy in their lifetime. They are also at significantly higher risk for ovarian cancer compared to the average women without the mutation. This is referred to as the Hereditary Breast and Ovarian Syndrome. Several factors can place a women at risk for the mutation, particularly if a first degree relative was diagnosed with breast malignancy prior to age 50. If you think you may be at risk, consider a discussion with your family practitioner, gynecologist, or a medical oncologist. An in depth discussion regarding advantages, disadvantages, and limitations of testing should be reviewed with your clinician since the decision to proceed with genetic testing should not be taken lightly. While a patient can obtain very valuable information to allow earlier screening in addition to risk reduction and prophylactic therapies, these decisions can be very difficult and require a tremendous level of comfort in an individual's ultimate decision making skills.

Q What is a breast biopsy?

A A breast biopsy may be recommended if a radiographic abnormality or palpable breast concern requires pathology to determine if abnormal cells are present, often referred to as tissue diagnosis. Most importantly, these procedures are performed to evaluate for precancerous or cancerous cells of the breast. Breast biopsies can commonly be performed by imaging guidance which includes stereotactic, ultrasound-guided, or MRI-guided biopsies. Obtaining tissue diagnosis through imaging guidance is optimal, since it has the ability to obtain critical information without subjecting a patient to the operating room or complications of open excisional biopsy of the breast. In the event of a cancer diagnosis, minimal disruption of the surrounding breast tissue and lymphatic system has occurred making a surgeons ability to perform the definitive breast cancer operation much easier. When a biopsy cannot be performed through imaging guidance, then it sometimes necessary to perform an open biopsy in the operating room under general anesthesia.

Q Should I be worried about nipple discharge?

A Any new onset nipple discharge, especially unilateral or "one-sided," should be discussed with your clinician immediately. Bloody nipple discharge is always a concern until proven otherwise since it can be an indicator of malignancy. Milky nipple discharge is of less worry but nonetheless requires evaluation with your clinician and likely lab tests done to determine underlying cause such as pregnancy-related galactorrhea, prolactin elevations, or thyroid and pituitary abnormalities. Greenish or yellowish and/or odorous nipple discharge may indicate infection. Clear nipple discharge requires evaluation but most commonly is associated with fibrocystic breast disease. A complete review of your medical history to include most recent pregnancy, breast feeding status, current prescription or herbal medications, breast health including previous biopsies or abnormal breast imaging, and family history would be obtained. A thorough clinical breast exam would be performed. If indicated, appropriate imaging of the breast would be requested. On occasion, more specialized imaging to evaluate the breast ducts is performed to evaluate for filling defects or abnormal lesions within the ducts such as a papilloma. All and any new breast concern not previously evaluated should obtain appropriate workup under care of a clinician. Close clinical followup and management with your clinician is of utmost importance, referral to specialist can be made if warranted.

Q I have had a sore on my nipple for several weeks that does not go away. What should I do?

A Paget’s disease of the nipple, a rare form of breast disease which accounts for <3% of breast cancers, has been recognized as a specific clinical entity for more than 100 years. It can be extremely subtle such as a small dry, scaly surface to a grossly abnormal ulcerative lesion making it difficult to diagnose. It may appear initially as a benign-appearing change which may actually improve to some degree. A thorough breast history and clinical breast exam should be performed immediately if you discover any new skin lesion of the breast or nipple, followed by the appropriate diagnostic breast imaging workup often starting with a diagnostic mammogram. Since Paget’s is associated with underlying malignancy in the majority of cases but may not have an associated palpable mass or mammographic abnormality, close observation is crucial to document COMPLETE resolvement. An open biopsy is warranted if a lesion persists.

Q I have been diagnosed with breast cancer. I have seen several specialists over the past few weeks, given a lot of confusing information, and discussed many options for treatment. I feel lost and overwhelmed, what do I do to regain control?

A When a woman is diagnosed with breast malignancy, it is an overwhelming, often emotionally devastating, experience for all those involved. She and those closest to her can feel a sense of helplessness which can quickly lead to a viscous cycle resulting in hopelessness. Most importantly, education and self-knowledge is the key to understanding breast malignancy and the complex, but critical, decision-making necessary to make a well-informed decision for what is best for you. Consider utilizing very reputable resources such as Susan G. Komen for the Cure (www.komen.org), American Cancer Society (www.cancer.org), and the Y-ME National Breast Cancer Organization (www.y-me.org). Remember, your team of specialists is there to help you through a very difficult time in your life, so do not hesitate to ask as many questions as you need and obtain the support you deserve.

Q My best friend was recently diagnosed with breast cancer. I want to help her as much as possible, what should I expect and what can I do?

A As a friend or family member, your ability to provide the much-needed physical and emotional assistance to your loved one or friend is of the utmost importance. A breast cancer patient will typically undergo surgical intervention which requires wound and drain care. For those needing chemotherapy, fatigue and nausea as well as frequent illness or infection can be a big problem resulting in the inability to complete even the most basic daily tasks such as cleaning the house, laundry, or cooking meals. For those with children, it can be overwhelming, and the patient often over extends themselves feeling a sense of responsibility to the family. Frequent transportation and the associated expenses of treatments are daunting and can cause someone to feel helpless with nowhere to turn. Support networks and organizations for both the patient as well as loved ones are available in many communities. Taking the time to address these common issues during treatment can make all the difference in the world, and you are a critical component of the solution.

Q What is the difference between invasive ductal carcinoma and ductal carcinoma in situ (DCIS) of the breast and how are they treated?

A Invasive ductal carcinoma is referred to as cancerous cells having crossed the basement membrane of the ducts lining the breast giving it access to the lymphatics, whereas, in situ disease remains confined within the basement membrane so it does not metastasize. Both of these require surgical excision with “clean” margins; however, invasive disease necessitates biopsy of axillary lymph nodes for staging purposes. Invasive disease often requires chemotherapy. Radiation therapy may be recommended in both, especially in cases of breast conserving therapy. Both invasive and in situ require extremely close follow-up for years to come with possible addition of risk reduction therapies such as Tamoxifen. Genetic testing may also be obtained depending on age and family history.

Q What is breast conserving therapy (BCT) and mastectomy and how does someone choose which is best?

A Breast conserving therapy (BCT) involves removing the portion of the breast with a malignancy and adequate surrounding tissue which is “clean” of disease. If accomplished, a woman could potentially maintain near normal contour of her breast but is variable depending on the size and location of the tumor. However, radiation therapy is necessary in BCT and side effects of the radiation can be problematic on overall appearance of the breast over time. In some cases, a woman may be best suited to see a surgeon specializing in breast oncoplasty, a newer approach to conservation of the breast in individuals with complex disease. Not everyone should have BCT. Some types or extent of cancer clearly benefit from mastectomy. Discussion of the benefits and risks with your “team” of specialists should be accomplished to allow you to make a well-informed decision.

Q What is the difference between a self breast exam (BSE) and a clinical breast exam (CBE) and when should they be done?

A A self breast exam (BSE) is performed by the patient on a monthly basis providing an opportunity to become “familiar” with how your breast tissue feels and identify unusual changes or concerns between visits with your clinician; whereas, a clinical breast exam (CBE) is performed on an annual basis under the care of your clinician, typically during a routine gynecological physical. When a potential breast concern is identified, a diagnostic workup is obtained and more frequent CBEs may be necessary. Breast health is an important part of any woman’s well being, and routine surveillance should incorporate monthly self breast exams, annual clinical breast exams, and age-appropriate screenings such as an annual mammogram.

Q I am 25 years old and recently felt a lump in my breast. I went to my doctor, had some tests done, and was told it was a fibroadenoma. What does this mean and should I be worried?

A A fibroadenoma is a benign fibrocystic lump in the breast often discovered for the first time in young women, typically in teens and 20s. Understandably, when first noticed, an individual is quite alarmed since it can feel hard and irregular much like a breast cancer. A thorough history and clinical breast exam should be performed immediately by your clinician followed by age-appropriate imaging which in younger women will often be only an ultrasound since the density of the breasts makes mammogram not useful in most cases. Depending on the findings, the radiologist may recommend either close observation with serial ultrasounds to document stability or core-needle biopsy. Another option is complete removal if desired, and this is usually performed in the operating room. Newer less-invasive in-office modalities are increasingly available. Complete diagnostic workup, close observation with a clinician or specialist, and thorough discussion of alternatives, benefits, and risks is crucial in determining what is best for the individual.