Breast cancer

Finding a breast lump or some other change in your breast may stir fears of breast cancer — and understandably so.

Try not to worry. The odds are in your favor. Most breast lumps — as many as four out of five that are biopsied — are noncancerous (benign). But it’s still important to have the breast lump evaluated by a doctor to be certain you don’t have cancer.

If evaluation of the breast lump reveals breast cancer, you’ve taken a vital step toward dealing with the disease. Early detection gives you the best chance for successful treatment.

During a breast self-exam, you’ll feel tissues of varying consistency. Glandular tissue usually feels firm and slightly rope-like, bumpy or lumpy (nodular); it’s primarily felt in the upper, outer region of your breast. Surrounding fat tissue is soft; it’s often felt in the inner and lower portions of your breast. The contrast between these two types of tissue is often more pronounced just before your period due to hormonal influences on the breast.

Besides changes related to your menstrual cycle, breast tissue also changes as you age. In the majority of women, breast tissue becomes more fatty and less dense over time. You may find that your breast-related symptoms, such as tenderness or lumpiness, also differ over the course of your menstrual cycle and as you get older.

If you’ve found a breast lump or detected a change in one of your breasts, check your other breast. Some lumpiness may be normal — especially if your other breast feels the same to you.

But make an appointment with your doctor if:

  • The breast lump is new or unusual and feels different from breast tissue in that breast or your other breast.
  • The breast lump doesn’t go away after your next menstrual period.
  • You notice the breast lump has changed, for instance it gets bigger or becomes firmer.
  • You have bloody, possibly spontaneous, discharge from your nipple.
  • You notice skin changes on your breast, such as redness, crusting, dimpling or puckering.
  • Your nipple is turned inward (inverted), although it isn’t normally positioned that way.

Evaluation of a breast lump begins with a breast examination performed by your doctor or nurse practitioner (clinical breast examination).

During this exam, your doctor or nurse practitioner:

  • Questions you about your symptoms
  • Looks at your breasts, noting their shape and size
  • Observes the condition of the overlying skin on your breasts
  • Checks for nipple problems, such as inversion or discharge
  • Feels (palpates) deeper tissue in your breasts and armpits for lumps, prominent nodular areas or areas of thickening

If your doctor confirms that you have a breast lump or other area of concern, the next step is to determine whether it’s caused by a noncancerous condition or whether it’s a cancer. However, the cause of a breast lump or other change can’t be determined based on a clinical breast exam alone — more testing will be needed.

To further evaluate a breast lump — including determining whether it’s fluid-filled or solid — your doctor may recommend one or a few of these tests or procedures.

Fine-needle aspiration
Your doctor performs fine-needle aspiration (FNA) during an office visit or refers you to a surgeon or radiologist for this procedure.

In FNA, the doctor inserts a thin, hollow needle into the lump and removes (aspirates) any fluid. If the results of FNA show:

  • Straw-colored, nonbloody fluid, the breast lump is most likely a benign cyst and will probably disappear with aspiration.
  • Bloody fluid, the fluid is sent to a laboratory for further analysis.
  • No fluid, the breast lump is likely solid and requires further testing to determine whether it’s cancer.

Your doctor may perform FNA with or without ultrasound guidance. Ultrasound — a noninvasive procedure that uses sound waves to create images of organs and tissues — can ensure the accuracy of FNA. If your doctor performs the FNA without ultrasound guidance, he or she will probably ask you to come back for a follow-up exam in four to six weeks. If the breast lump has returned during that time, you’ll need to undergo more testing.

Ultrasound
Your doctor might not perform FNA right away, opting instead for a breast ultrasound to examine the area of concern. If you don’t feel any pain associated with the lump, and the ultrasound confirms that it’s a cyst, you may not need aspiration. If you do have pain, the doctor can use ultrasound to guide FNA. Removing the fluid from the cyst helps relieve the pain. If ultrasound reveals that the lump is solid, the doctor can collect a small amount of breast tissue with a needle (biopsy). Samples collected go to a laboratory for analysis.

Mammography
Mammography uses X-rays to reveal early evidence of breast cancer. It can detect calcium deposits (microcalcifications) that mark benign or cancerous (malignant) conditions. Diagnostic mammography helps your doctor investigate lumps and other signs and symptoms such as pain, nipple discharge, areas of thickening, or change in breast size, shape or overlying skin. It differs from screening mammography — a test done when there are no particular breast concerns — which usually requires only two standard views of your breasts.

A diagnostic mammogram requires views at higher magnification from more angles, and it focuses on the area where the lump is. It can help the radiologist and surgeon precisely locate and determine the size of the lump or other abnormality. Findings may indicate whether the area of concern is benign or cancerous. If the radiologist suspects cancer, you’ll need a needle biopsy and possibly surgery.

Depending on your age, your doctor might rely on ultrasound to make a diagnosis — either alone or in conjunction with mammography. Because a younger woman’s breasts are denser than are an older woman’s breasts, a mammogram on a younger woman can be more difficult to interpret. In general, if you’re younger than 30, ultrasound may be the only imaging test ordered. If you’re 30 or older, your doctor might order a diagnostic mammogram of both breasts and an ultrasound of the breast lump.

Magnetic resonance imaging
In conjunction with mammography, magnetic resonance imaging (MRI) can be of help in distinguishing between benign and cancerous lumps — and it’s becoming more and more widely used. Cancerous tissue requires a greater blood supply than does normal tissue to support the growth of a malignant tumor. Because MRI shows greater contrast in areas of increased blood supply, your doctor can tell which areas might be cancerous and which aren’t, based on the images. Your doctor may recommend an MRI if he or she still has concerns about a breast lump despite normal mammography and ultrasound test results.

Breast biopsy
If the breast lump is solid, your doctor obtains a tissue sample to send for laboratory analysis. This may be done through one of several procedures:

  • Fine-needle aspiration biopsy. During FNA, your doctor uses a special needle to collect a sampling of cells and not just fluid.
  • Core needle biopsy. Core needle biopsy uses a larger needle than used with FNA biopsy to obtain a small, solid core of tissue.
  • Stereotactic biopsy. This type of needle biopsy uses mammography to pinpoint an abnormal area that shows up on a breast-imaging test but isn’t felt during a clinical examination. The technique uses stereo images — images of the same area obtained from different angles — to locate the area of concern, and a radiologist or surgeon removes a sample of breast tissue through a hollow needle.
  • Excisional biopsy. This type of biopsy — also called surgical biopsy or lumpectomy — removes the entire breast lump as well as some surrounding breast tissue for analysis.

If you have a biopsy performed, you should have your test results in about a week.

After you’ve undergone a clinical breast exam, imaging tests and a needle biopsy, your doctor checks to see that all findings are in agreement. Your doctor may suspect that a breast lump is cancerous after the clinical breast exam and the mammography results may show areas of suspicion, but the pathology results from the needle biopsy reveal benign tissue. In this case, despite benign biopsy results, your doctor can’t tell you for certain that you don’t have breast cancer. You may be referred to a surgeon for a consultation.

If, after the clinical breast exam, your doctor thinks your breast lump likely isn’t cancerous, the mammography results are normal, and the needle biopsy is benign, you and your doctor can keep a close watch on the area for a few months. If your breast lump changes at all, your doctor will probably send you for a surgical consultation for further evaluation and, possibly, an excisional biopsy.

Remember that a normal mammogram, ultrasound or breast MRI doesn’t mean the breast lump you feel isn’t cancer. See your doctor right away for re-evaluation of the breast lump if you notice any changes or if you develop any new areas of concern.