BREAST EXAM

Breast self-exam

Monthly breast self-exams should always include: visual inspection (with and without a mirror) to note any changes in contour or texture; and manual inspection in standing and reclining positions to note any unusual lumps or thicknesses

Lump in the breast

Definition

A localized swelling, protuberance, or lump in the breast.

Considerations

Normal breast tissue, including glands and connective tissue, is present in both males and females of all ages. This tissue is responsive to hormonal changes. For this reason, a breast lump has different significance in different situations. Since some lumps and some changes are considered normal, understanding the structure of the breast and how it functions may help eliminate some concerns.

The first lump that concerns parents is often the lump found beneath the nipple of the newborn infant. This is true breast tissue that is enlarged in response to estrogens that the baby receives from the mother during pregnancy. It resolves on its own as the estrogen effects wear off. The breast enlargement may be found in both male and female infants and is not only normal but also expected. The amount of breast tissue is used in evaluating how close to term the newborn infant is.
The next most worrisome lump is that found in girls, often as young as 6 years old. A "breast bud" generally heralds the onset of puberty. They most often are discovered around 9 years of age. Often only one breast is involved or if both are involved, one side is larger than the other. The breast may be somewhat tender. This is normal development and should not be cause for worry.
Sometimes tender breast enlargement or a lump beneath the nipple is found in teenage boys. The enlargement may be small or fairly noticeable. This is called gynecomastia and is common in boys during mid-puberty. It is a response to changing hormones and resolves over a period of months. Significant enlargement may be psychologically stressful but treatment consists of reassurance and time. Only rarely is surgery necessary.
Of greatest concern is a lump in the mature female breast. A medical professional should check out every lump in a mature woman’s breast. Lumps found in the upper outer quadrant (the area closest to the shoulder and armpit) are of most concern. This is an area where most breast cancers occur because this is where most of the breast tissue is found relative to the other quadrants of the breast. Although most lumps are not dangerous (less than one-fourth of all breast lumps are found to be cancerous), early diagnosis and treatment of breast cancer greatly improves the chance of a good outcome. Fortunately, more women are learning how to perform a breast self-exam and lumps are being found and diagnosed earlier.

Breast Cancer Detection

Breast cancer is the second most common cancer among women and 1 in 8 women will be diagnosed with breast cancer during their lives. The disease can occur in men as well. It is by far the most feared of possibilities when a breast lump is found. Only a small portion of breast lumps are malignant. Because the clinical signs of breast cancer are not easily distinguished from those of benign breast disease, a medical professional should always evaluate persistent breast lumps in both men and women.

Since breast cancer prevention is still theoretical, efforts have focused on early detection. Breast cancer is more easily treated and often curable if it is found early. Self breast-examination, clinical breast examination, and screening mammography are the three tools in doing this. Of these three, screening mammography combined with clinical breast examination is the most effective detection method.

Every woman over the age of 20 should practice a self-breast exam monthly. The American Cancer Society distributes booklets demonstrating the proper technique (see cancer - support group). While self-breast examination is important, a woman will not usually find lumps as small as what a health care provider can find.
Clinical breast exams are performed by a trained medical professional, usually as part of a physical exam. At these times, instruction and encouragement of self-breast examination are typically offered. A lump is usually the size of a pea before a skilled examiner can detect it. Any abnormal findings should be investigated further. If it is suspected that a breast lump is related to hormonal changes, for example, the exam can be repeated at a different time in the menstrual cycle. It is recommended that women over 40 years old have an annual clinical breast exam and women 20-39 years old have one at least every three years.
Mammograms may be performed at any age to evaluate a breast lump or other problem. But a routine screening mammogram is recommended for the first time in a woman without any symptoms at about age 40. Additional mammograms should be obtained every 1 or 2 years. Women in their forties and older should be aware that a monthly breast self-exam is not a substitute for regularly scheduled screening mammograms and clinical breast exams by a health professional. Current mammography represents very little x-ray exposure and is safe. Additional x-ray or ultrasound studies of the breast are often used to look more closely at a certain area of the breast or to determine if a lump is solid or fluid-filled (cystic).

When breast cancer is diagnosed, the type of cell involved and the degree of spread are important to establish. These factors determine what treatment choices are best and give clues about what to expect in the future. The clinical stage of breast cancer is the best indication of the likely outcome. Ten-year survival rates (the proportion of people who are still living 10 years after diagnosis) in appropriately treated breast cancer are approximately:

88-95% for disease confined to the breast with the skin intact (stage 0 and 1)
66% when the axillary ("armpit") lymph nodes are involved (stage 2)
36% when the cancer has broken through the skin or attached to the muscle (stage 3)
7% for breast cancer invading the chest wall or spreading beyond the breast and axilla (stage 4)

Common causes

Some of the causes of lumps in a mature woman’s breast are discussed below.

Fibrocystic changes can occur in either or both breasts and is most common in the upper outer quadrants. These changes are common (especially during the reproductive years), benign, and do not increase the risk of breast cancer. Fibrocystic change is basically an exaggeration of normal breast architecture. There is variable enlargement of some of the milk glands and a thickening of the fibrous tissue that supports the glands and gives the breast its shape.
Fibroadenomas are the most common tumors found in women’s breasts. They occur most often during the reproductive years. They usually have a rubbery feel, are fairly movable within the breast tissue, and may feel more prominent over a rib. They are not tender and usually do not become malignant. Most often, there is fibrocystic change as well. A physician can usually diagnose a fibroadenoma by palpating (feeling) the breast, but the only way to be sure that such lumps are not cancerous is to remove them or biopsy them. In some cases fibroadenomas can show changes that are suggestive of increased risk of breast cancer in the future.
Cysts are the other extreme of fibrocystic changes. These are fluid-filled lumps that often feel like soft grapes. These can sometimes be tender, especially just before the menstrual period begins. Cysts can often be drained in the doctor’s office under local anesthesia with a needle. The fluid removed is sent for laboratory studies. If the lab reports that the sample is benign or not cancerous then it is likely the cyst will disappear completely after it is drained and no further treatment will be needed.
In some women, fibrocystic changes along with many cysts and fibroadenomas can cause serious problems of swelling, pain, and tenderness. In these cases the term "fibrocystic breast disease" is used.
Milk cysts and infections, including abscesses, can occur in the breast but this is almost always among women who are breastfeeding or who have recently given birth.
An "intraductal papilloma" is a small growth inside a duct of the breast near the areola, the colored part of the breast surrounding the nipple. It is harmless and frequently cannot be felt. In some cases the only symptom is a watery, pink discharge from the nipple. Since a watery or bloody discharge can be seen in cases of breast cancer, your physician must evaluate this.
Cancer can cause a lump. A microscopic examination of the fluid, as well as a mammogram, is recommended to check this possibility. Surgical removal is in most cases recommended.
Sometimes an injury to the breast will cause a bruise large enough to appear as a lump. The lump is actually a collection of blood in the traumatized area. There may be significant swelling and tenderness, but this should slowly return to normal over a few days or weeks. When necessary, it can be drained surgically but there is some risk of infection in doing so.
Hormones (such as birth control pills) and certain medications can cause the breasts to become swollen, tender, and sometimes to develop lumps.
Other benign causes of breast lumps include skin growths, fatty tumors (lipoma), duct ectasia, and other conditions.

Home care

Treatment of benign breast lumps varies with the situation. As outlined above, solid breast lumps are often best removed. Cysts can be drained. And for women in their reproductive years who do not wish to become pregnant, birth control pills are often helpful in managing fibrocystic changes. The role of methylxanthines in the diet, such as caffeine in coffee, theophyllines in tea, and theobromine in chocolate are somewhat controversial, but some women report improvement when they discontinue their use.

There is some evidence that daily vitamin E can reduce fibrocystic changes as well, but higher doses of this substance (more than 600 mg) should be avoided. In cases of severe fibrocystic disease, prescription medications may be used. Hormones or other medications that seem to be related to breast pain, tenderness, or lumps should never be discontinued without consulting a medical professional.

Since breast lumps and other symptoms are common, often benign, and frequently get better without treatment, it is tempting for some to make unsubstantiated claims about various vitamins, herbs, or other "nutritional supplements." In some cases these claims are irresponsible and dangerous, particularly if they cause delay in seeking proper evaluation and treatment. Products that supposedly increase breast size are frauds.

When a lump in the breast is diagnosed as cancer, treatment must be thoroughly discussed with a physician. The available options are usually based on the circumstances, including the type of cancer, how much it appears to have spread, and the age, hormonal status, physical condition, and family history of the patient. A great deal of information is now available that can help guide treatment decisions. Among the options:

Surgery may involve as little as removing the lump (lumpectomy), or partial, total, or radical mastectomy, usually with the removal of one or more lymph nodes from the axilla ("armpit"). Special procedures to find the most likely lymph nodes to which cancer may have spread ("sentinel nodes") are often used.
Radiation therapy can be directed at the tumor, the breast, the chest wall, or other tissues known or suspected to have remaining cancer cells.
Chemotherapy is used to help eliminate cancer cells that may still remain in the breast or that may have spread to other parts of the body.
Hormonal therapy has also been shown to improve survival. It works by blocking the hormones that can otherwise help breast cancer cells to survive and grow.

Most women receive a combination of these treatments.

Call your health care provider if

There is any unexplained breast lump! A health care provider should check EVERY breast lump. This is because ANY breast lump could be cancer unless proved otherwise.
You are a woman, 20 years or older, and do not know how -- or need help to learn how -- to perform a self-breast examination.
You are a woman, 40 years or older, who has not had a mammogram in the past year.

What to expect

Your doctor will obtain a complete history from you, with special attention to factors that may increase your risk of breast cancer. A thorough breast examination will be performed. If you don’t know how to perform breast self-examination, ask your health care provider to teach you the proper method.

Medical history questions documenting breast lumps include: when and how you first noticed the lump; its location; recent changes; whether your breast was injured in any way; whether you are taking hormones, medications, or supplements of any kind; and whether you have other symptoms such as pain, nipple discharge, or fever.

Tests that may be performed, besides a clinical breast exam, include: microscopic study of any nipple discharge; needle aspiration of any cysts; biopsies by various means; use of a light or ultrasound to try to distinguish between solid and cystic lumps; mammography; and, in some cases, rinsing out the milk ducts of the breast with a very fine needle to obtain cells for study. If you have a family history of breast cancer, your doctor may also suggest checking to see if you have any variant genes known to predispose to this disease such as p53, BRCA1 and BRCA2, and BARD1.