Breasts have variable consistency, which varies with the menstrual cycle. And with advancing age, breasts become less dense and fattier. Women are encouraged to get used to how their breasts look and feel. This makes it easy to notice any change which appears unusual. You will easily differentiate tenderness and lumpiness that varies with the menstrual cycle from other changes that may be abnormal.
You need to consult a doctor when you notice new or unusual lumpiness that does not change with the menstrual cycle. Skin changes on the breast that warrant consultation include redness, itchiness, and dimpling. And if the nipple has an unusual discharge, turns inwards or becomes flatter, a consultation is also indicated.
Your doctor will ask several questions that may give clues to guide further evaluation. In particular, your risk of breast cancer will be quantified based on family history and other factors. A clinical breast examination is then carried out, aimed at confirming the presence of the lump, its size, location, and tenderness. Deeper breast tissues are also examined, including checking your armpits for swollen nodes or areas of thickening. The examination of the other breast is also done at the same time.
If a lump is confirmed, further testing becomes necessary in order to make a definite diagnosis and decide if any treatment is required. You may be asked to have a diagnostic mammogram or a breast ultrasound scan. This may be all that is necessary for the majority of women. However, more precise imaging with MRI may be required, especially if initial imaging with other modalities is inconclusive. Even though breast cancer has specific features on imaging, a biopsy is often required to make a diagnosis. This can often be done in the clinic using imaging guidance and is known as fine-needle aspiration biopsy (FNA). A Pathologist usually analyses the biopsy and gives a final report confirming or refuting the presence of cancer cells.
Following the medical evaluation, the majority of women will not have breast cancer. All they need is reassurance, and further review should any symptoms recur. Should cancer be diagnosed, referral to a specialist center must be done immediately. Breast cancer treatment centers have teams of specialists and the resources required to provide optimal treatment, ensuring the highest chances of cure. After completing treatment, ongoing follow-up is required to detect any recurrence. And in rare cases, early screening of family members may be advised.
Answers to frequently asked questions.
Q. Is a lump always cancer?
A. No, a lump is not always a cancer. Benign conditions (i.e. non-cancerous conditions) such as cysts, fibroadenomas, and infections such as an abscess can also present as lumps. Sometimes, prominent normal breast tissue can also feel a bit ‘lumpy’.
Q. When I do a self-exam on my breasts I feel lumps everywhere - what’s normal?
A. It is very important for women to regularly examine their breasts, as nobody else knows their breasts better than themselves. The more you examine your breasts, the more you will get to know them. The advice however remains that if you are at all worried about your breasts, then you should see a doctor who can examine you and give advice.
Q. I get breast pain on and off. Should I be worried?
A. Breast pain is a very common condition and most women will experience this at some point in their lives. The pain can either be a burning sensation, stabbing, prickly, or sometimes a dull ache and can affect both or just one breast.
The cause of breast pain can be multifactorial. It could be hormonally related, but other contributing factors include chest wall muscle sprains, heavy breasts, and previous breast surgery. The majority of the time, breast pain does not mean that there is an underlying worrying condition. This is especially true in the absence of any lumps. However, if pain persists, then you should see your GP.
Q. I’m pregnant and have found a breast lump. Should I get it checked?
A. Yes you should. When you are pregnant, the breast undergoes changes in preparation for the birth and baby. They may be tender and bigger. A doctor however should check any lumps you notice.
Q. I’m a man and have found a lump in my breast - what should I do?
A. A benign condition called gynecomastia where the breast tissues enlarges can affect men. However, even though breast cancer in men is rare, any breast lump must be examined by a doctor. Other symptoms to look out for in men include withdrawing of the nipple, any skin changes/ulcerations, and nipple discharge.
Q. What changes should I look for when I examine my breasts?
A. Your examination should including looking as well as feeling your breasts. Things to look out for include:
- lumps or thickening that feels different from the rest of the breast
- any change in the shape of the breast
- skin changes such as redness or rash around the breast or nipple
- skin dimpling/puckering
- nipple pulling inwards (inversion)
- liquid or bloody nipple discharge that occurs without squeezing. You may notice this on your undergarments
- swelling in the armpit or around your collarbone
- constant pain in the breast or armpit.
If you notice any of these, then you should see your GP who will then refer you to a breast clinic.
Q. What will happen during the consultation in a breast clinic?
A. In a breast clinic, the breast surgeon will ask about the condition you present with, whatever that may be (e.g. breast lump, breast pain, nipple discharge). They will also ask you about your general health, your past medical history, and any family history of breast cancer you may have. A full breast examination will then be performed, whilst sitting up and lying down. Your armpits will also be examined.
After this, if indicated, you will be referred to the radiology department for further diagnostic tests. If the clinic is a one-stop clinic, this will be done on the same day.
The scan recommended may either be an ultrasound scan, a mammogram, or both. This depends on your age and the condition you present with. If we find anything that we would like to investigate further, then a biopsy/needle test will be performed.
In a rapid access clinic, you will go back and see the surgeon straight after you have had the scans and have a discussion about the results. If all is well, then that is the end of the consultation. If you had a biopsy, then a follow-up appointment will be made to give you the results.
Q. What happens if the lump is not cancer?
A. Benign (non-cancerous) breast lumps are treated depending on their nature. Areas of fibrocystic change that can present as ‘lumpiness’ can be left alone. If we find cysts, again we can either leave it alone or if they are large we can aspirate the fluid it normally contains under ultrasound guidance. Benign lumps such as fibroadenomas are usually surgically excised if they are large. You will have a discussion with the breast surgeon as to how best to treat benign lumps.
Q. What happens if the lump is cancer?
A. Breast cancer treatment involves several modalities, which include surgery, as well as chemotherapy, radiotherapy, and endocrine therapy (i.e tablets). The treatment recommended to you will be tailored according to the cancer you have. Some people may need all the treatment above; others may only need one or two of the treatments.
If you need surgery, there are two types that we perform, a lumpectomy (breast conservation surgery) or a mastectomy. The type of surgery recommended will on the size of the lump in relation to the size of the breast. Those who have mastectomies should be offered breast reconstruction, either at the same time as the cancer operation or in the delayed setting. Two types of reconstruction are usually discussed; implant reconstruction or using your own body tissue such as your back muscle (latissimus dorsi) or using your tummy fat (DIEP reconstruction).
Other forms of treatment including chemotherapy, radiotherapy, and endocrine therapy will be discussed and offered according to the characteristics of the cancer. Sometimes, chemotherapy is given first before surgery (neo-adjuvant chemotherapy).
Depending on the cancer type, you may also need an operation to the armpit (axilla) where a few (or all glands) will be removed to check the presence of any cancer cells. This is normally done at the same time as the breast operation.
You will have a breast care nurse who will help you through your treatment. She will be your point to contact whenever you need help or advice.
Q. There’s a history of breast cancer in my family. Do I need to take special precautions?
A. Whether you need to take special precautions depends on who has had breast cancer in the family, their ages, and the number of family members affected. Sometimes, you may be recommended to have a mammographic follow-up, or if you are deemed eligible, you may be referred by the breast clinic to the local clinical genetics unit for discussion regarding having the genetic test. This is usually only applicable to those assessed to be at high risk of developing breast cancer. If you have any concerns, please see your GP.
Q. I am in my 50s, should I have a regular mammogram?
A. The incidence of breast cancer increases with age. Therefore, women between the ages of 50 and 70 years are automatically invited to attend the National Breast Screening Program to have a mammogram, which happens every three years. Recently, women aged 47 and 73 have been included in the program and this has started in certain areas in the country. After the age of 70 you will stop receiving screening invitations. However, you can ask to continue to have mammograms by contacting your local screening unit.