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Detecting and Treating Breast Problems
By: Warren Volker, M.D., Ph.d.

Your breasts are always changing. They change during the menstrual cycle, pregnancy, breastfeeding and menopause (when menstrual periods end). Along with these normal changes, problems can arise. Most of the problems are minor, but a few can be severe. One major problem, breast cancer, remains one of the leading causes of death in women.

Screening for Breast Problems

Screening tests are used to find a health problem early. If they are done on a routine basis, they may detect a problem even before symptoms appear. There are three screening exams for breast problems that can be done by you or your doctor:

• Mammography
  
• Breast self-exam
  
• Doctor's exam of the breasts

• Increase Risk
  
  • Breast cancer in the family, especially mother, daughter or sister
    
  • Older age
    
  • No pregnancies or pregnancy later in life (after age 30)
    
  • Early menarche - the time in a young woman's life when menstrual periods begin
    
  • Late menopause
    
  • Obesity, especially in older women
  
  
  
  • Decrease Risk
    
    • Pregnancy early in life (before age 20)
      
    • Ovaries removed before age 40
      
    • Early menopause (before age 50)
      
    • Risk factors are not found in all women who have breast cancer. Many women have none of them.
    
    
  
  Some women worry about a link between breast cancer and the hormones that are used in oral contraceptives (birth control pills) and hormone replacement therapy. It does not appear that oral contraceptives increase the risk of breast cancer in most women. It appears that the benefits of hormone replacement therapy, when taken in moderate doses to replace hormones no longer produced after menopause, greatly outweigh the risks.
  
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  The Breast Self-Exam
  
  Most breast lumps (about 90 percent) are found through breast self-exams. That is why it is key to examine your breasts every month. Self-exams help you learn the normal feel and shape of your breasts and make it easier to notice any changes (see box). It is best done a few days after your menstrual period starts, when your breasts are not tender or swollen. It may help to do the exam at the same time each month.
  
  The breast self-exam is one of the best things you can do for your health. Keep doing the self-exam even after you've reached menopause. Routine exams become even more important after menopause because the risk of breast cancer increases with age. About 85 percent of women with breast cancer are over age 40.
  
  If you have breast implants of any type, you still need to do a breast exam, especially around the chest wall. Ask your doctor how to examine your breasts.
  
  How To Do a Breast Self-Exam
  
  1. The self-exam should always be done in good light. Stand or sit in front of a mirror. Place arms at your sides. Look for dimpling, puckering, or redness of the breast skin, discharge from the nipples, or changes in breast size or shape.
     
     
  2. Look for the same signs with your hands pressed tightly on your hips and then with your arms raised high.
     Lie flat on your back. Place a folded towel or a pillow under your left shoulder and place your left hand under or over your head.
     
     
  3. With your right hand, keeping the fingers flat and together, gently feel your left breast without pressing too hard. Use small, circular motions.
     
     
  4. Picture your breast as the face of a clock. Begin your small circles at 12:00 - at the very top of your breast. Repeat the circular motion at 1:00, 2:00, and so on. Do this in smaller and smaller circles until you have examined all the breast tissue.
     
     
  5. Lower your right arm and do the exam on your other breast. Place the folded towel or pillow under your right shoulder, put your right hand under or over your head, and use your left hand to feel your right breast.
  
  
  Steps 4 to 6 also can be done when you are taking a shower or bath. It is easier to examine your breasts when they are smooth and wet with soap and water.
  
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  The Doctor's Exam of the Breasts
  
  Your doctor will examine your breasts during your routine checkups. Most women should be examined at least once a year. A breast exam by a doctor takes only a short time. The breasts are first checked for any changes in size or shape. The doctor also looks for puckering, dimpling or redness of the skin. You should tell your doctor if you have noted any discharge from your nipples. He or she then will check each breast for signs of a problem.
  
  If you have noticed a change in your breasts at any time, you should have your doctor examine them. He or she will review when you started having symptoms and how long they have lasted. Then your doctor will look at your medical past to check for other factors that could point to an increased risk of breast cancer.
  
  Breast Problems in Women
  
  Benign Breast Problems
  Most breast problems, especially in younger women, are benign growths (not cancer). This includes lumps (which may be felt in one exact place or throughout the breast), discharge from the nipple, and tender places.
  
  The most common breast problem is a benign condition called fibrocystic changes. These changes include lumpy breasts and thickened (fibrous) and tender areas. They may include cysts. A cyst is a small sac filled with fluid. It can be almost any size, from a fraction of an inch to about the size of a golf ball. Cysts occur most often in women between the ages of 25 and 50.
  
  Often cysts will vary in size, changing with the menstrual cycle. In many cases, they decrease in size after a menstrual period or at the time of menopause. Most women who have fibrocystic changes do not have a greater chance of getting breast cancer.
  
  Symptoms of fibrocystic change include pain and tenderness, often in both breasts. It occurs most often in the upper, outer part of the breast and is most severe 7 to 14 days before a menstrual period. You should inform your doctor of any symptom of breast problems right away.
  
  Some women are bothered by caffeine. Some find that cutting out or cutting down on drinks that contain caffeine (for instance, coffee, tea and colas) may help.
  
  Fibroadenomas are another common type of breast lump. They are solid, benign lumps that occur most often in young women.
  
  Breast Cancer
  Breast cancer is the leading cause of death from cancer in women aged 34 to 50. If breast cancer is found and treated early, most women can be cured. This is why routine breast self-exams, mammography, and checkups by your doctor are vital.
  
  Tests
  
  If you have found a lump in your breast or the results of your mammography are not normal, other tests may be used to help diagnose breast problems. Sometimes, these tests are done by your doctor. Other times, you will be referred elsewhere.
  
  Ultrasound
  In ultrasound, sound waves are used to create pictures of the inside of some body organs or tissues, like the breast. This painless method can tell your doctor about certain types of breast lumps. These pictures can show whether the lumps are solid or filled with fluid, such as with a cyst.
  
  Aspiration
  Sometimes, when the doctor suspects you have a cyst, fluid or tissue is withdrawn through a needle to be examined. This is called needle aspiration. If the fluid is clear and the cyst goes away, it is likely that no more tests will be needed. Aspiration also can be used to drain a cyst. Ultrasound may be used to help guide the needle. The sample may be sent to a lab to be checked.
  
  Biopsy
  The only way your doctor can find out the exact nature of a lump is to study cells from it or take a sample of it. To check a solid mass or a suspicious area, your doctor may advise a biopsy. A biopsy may be done if a lump feels abnormal, even if a mammogram is normal. In a fine-needle biopsy (aspiration biopsy), a small sample of cells from the mass is withdrawn through a needle.
  
  Two other types of biopsy involve a surgical incision (cut). With a portion biopsy, part of the mass is removed. In an excisional biopsy, all of it is removed.
  
  When a fine-needle biopsy is needed, it often can be done in a doctor's office. A surgical incision biopsy most often is done in a surgical clinic or a hospital. After the breast lump is removed, cells taken from it are looked at under a microscope. Results will be negative (no cancer) or positive (cancer). Your doctor will discuss the results with you and determine what type of treatment is best.
  
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  Treatment
  
  Benign breast disease often goes away on its own over time. If not, it often can be treated with medication or minor surgery.
  
  The treatment of breast cancer depends a great deal on:
  
  
  • The type of cells
    
  • The size and location of the tumor
    
  • How much the cancer may have spread
  
  Most first treatments include either removal of the lump (lumpectomy) plus radiation treatment (with X-rays) or complete removal of the breast and the lymph nodes in the armpit (modified radical mastectomy). Treatment with either lumpectomy and radiation or modified radical mastectomy is now standard for breast cancer in early stages. Radical mastectomy, in which the chest muscles are also removed, is rarely done.
  
  In some cases, cancer also may be treated with medication (chemotherapy) once the lump has been removed. For instance, some patients may receive chemotherapy after surgery and radiation are complete. This is especially true in younger women whose cancer has spread to the lymph nodes in the armpits.
  
  More than one treatment may be needed. Chemotherapy may help prevent the cancer from coming back. Sometimes, hormones, such as tamoxifen, may be used.
  
  A woman who has all or part of a breast removed will begin a program of exercise to help her return to daily tasks. Some women consider having plastic surgery.
  
  Finally...
  
  Most breast problems are benign. Still, you should be aware that breast cancer can occur. Examine your breasts every month. Visit your doctor promptly at the first sign of any problem. Follow your doctor's advice about having routine mammograms. Breast problems can be treated with success if they are found early.

  Warren Volker, M.D., Ph.d.