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Frequently asked questions about breast lumps |
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Women and Home Magazine, October 2011
The simple answer is no! just like you don’t wait to see if the rattle in your car goes away before heading to the garage, if you notice an abnormality in your breast it is important to get it checked out soon. Most lumps are completely normal and are a result of the hormonal changes that go on in your breast during your menstrual cycle. These will change during the month, which is why it is so important to get to know your breasts by examining them regularly (once a month just after your period). Then it is easy to spot whats normal and whats not.
We have done really well in the past twenty years raising awareness about the risks of getting breast cancer, and emphasising the importance of good breast health. It does mean that sometimes, if a women feels a lump, she can be terrified that it is cancer. And it is important not to be afraid.
Most lumps in the breast are a result of the normal changes of hormones in your breasts, either throughout your cycle, or as you get older. If you are young it is common to develop benign firm lumps called fibroadenomas, and later on developing cysts or areas of denser tissue in the breast are often a normal results of aging. The purpose of getting your breasts imaged or seeing a breast specialist is to differentiate these common lumps from lumps that are at risk of being cancer. You can also discuss your risk factors and develop a screening schedule individualised to your risk.
The first way to put your mind at risk is to know that more than 70% of all patients with breast problems do not have cancer. It is also important to know your own risk. We know that a family history of breast cancer or a personal history of cancer or radiation increase your risk of developing breast cancer. Other factors such as drinking too much or obesity (particularly later in life) increase your risk of breast cancer, as well as the contraceptive pill and hormone replacement therapies. However, 75% of all cancers develop in women with no risk factors at all, so the only way to be sure is to be seen by a specialist and ensure correct imaging and diagnosis.
The only way to know exactly what type of lump it is, is to have imaging (mammogram or sonar) and a core needle biopsy of any abnormality carried out by a specialist radiologist.
General Practitioners are excellent at general practice and the best person to look after your health long-term. They are often the doctor who gets to know you best over the course of your life. When you have a particular problem, however its often best to see a specialist who has expertise in that area such as breast. Once you are seen by a breast specialist, they will refer you to a radiologist who is also skilled in breast imaging. This ensures a diagnosis will not be missed. The most important part of medicine is having a team of doctors looking after your health who speak to each other, and this includes your GP. It is good to have regular check-ups with your GP even if you are being seen by specialists.
When you visit a breast specialist, you are not just going to discuss your current problem, but chat about your general health and history. It is important to identify risk factors and potential health issues for the future, not just focus on one part of your health. If you do have a lump or abnormality identified, the next step is imaging. No doctor has X-ray fingers, so any clinical examination is always accompanied by imaging. This is an ultrasound of the breast plus a mammogram if you are over 35 years old (under 35 years the breast is often too dense to rely on mammograms to see problems).
If there is a lump present, the radiologist may wish to do a core needle biopsy. This is best done by the radiologist because they use X-ray or sonar guidance. The old technique of Fine Needle Aspiration (FNA) should not be used because it can be inaccurate and not give enough information to the doctor. It is also rare to require a full surgical biopsy in theatre and it is often not the best method of diagnosing cancer as it affects further treatment.
The specialist breast surgeon or radiologist may be concerned about the lump or mass they see, but no diagnosis can be made for certain without a tissue sample taken by biopsy. This takes 48 hours to test at least. The most important thing to remember is that breast cancer is not a death sentence, nor is it an emergency. By the time a cancer is palpable it has been present in your breast for more than five years. There is never a requirement for an emergency mastectomy, and often the best treatment for breast cancer is to begin with chemotherapy before considering surgery. So even if there is cancer present, you have time to consider your options, time to take advice or seek another opinion.
When it’s your turn for a mammogram…
The debate around what age to have mammograms rages throughout the world, and the decisions are usually based on health economics. The USA has now suggested 50 , Sweden still maintains 40. In our unit we suggest 40 is the age to start with mammograms and ultrasounds. Please have them done at units that specialize in digital mammography. Mammograms should be done once a year and can be done in provincial units. Going for a mammogram is like wearing a seat belt when driving a car, it does not prevent an accident but protects you if in an accident.
If you have a family history on either your father or mothers side you should be extra vigilant. Family history translates to a family history of breast and other cancers. You can choose your friends but not your family. If you have family members who either have bilateral breast cancers or are diagnosed with breast cancer before the age of 40, or have ovarian cancer, you may have a specific genetic mutation for breast cancer. Testing family members with breast or ovarian cancer for BRCA 1 and 2 can be done on patients with documented cancers but patients must be seen by a genetic councillor first.
The radiation used for a mammogram is at a very small dose. Over the years of developing better medical care, this dose has got even lower (fifty times less). This does not mean there is no risk however, but in a new study from America this year, they concluded that the benefit of detecting cancer early and treating it saved more lives (by a factor of 100) than the risk of getting cancer due to a mammogram. The dose of radiation one receives when having a mammogram is so small that you can be exposed to a larger dose as background radiation in a shopping mall or on an airplane.
If you are at very high risk of breast cancer and have to start having mammograms before the age of 40, your breast specialist may advise you to have an MRI instead which involves no radiation and can be better for younger breasts.
All cancer is treatable and there are good options for management and cure irrespective of the size when it is found. When breast cancer is detected early, before it invades tissues outside the breast, the survival rate is as high as 95%.
Breast cancer that has not invaded into the breast tissue but is still in the ducts (known as carcinoma in-situ) has a 99% cure rate. Often surgery alone is appropriate treatment. If a small cancer invades into the breast tissue but does not spread to the glands it also has a very good prognosis. The treatment of cancer is tailored more and more to the ‘personality’ of the cancer: how it behaves and what it responds to, not the size alone.
When cancer is confined to the breast it is easier to treat and be sure of a cure. Patients do not die of cancer when it is confined to the breast. It is the spread of cancer of the brain, bones, liver and lungs which will eventually cause problems. The aim of breast cancer awareness and screening is to catch cancer early before it can escape the breast, breakthrough the lymph glands under the arm (the security guards of the breast) and spread from there to the rest of the body like a wave of terrorists that can hide away and reappear in the future.
Many of the more aggressive types of treatment for breast cancer such as chemotherapy are based around catching and killing these spreading cells. Even if the cancer has spread to bones, up to 75% of patients will be alive in five-years after diagnosis.
Even though there is a lot of information available about breast cancer risks and reducing your risk, up to 75% of women who get breast cancer have no history in the family of breast cancer, and none of the risk factors we know about. The lifetime risk of breast cancer in South Africa is not known but worldwide it is 1 in 8. Whilst all cancer is treatable and potentially curable, of course it is better to pick up cancer as early as possible, and part of that is learning to be breast aware. Remember to go for screening mammography and sonar after the age of forty every year, and get your GP or a breast specialist to examine you once a year too. Being breast aware also means learning to love your breasts, and getting to know your body. You may be the best person to pick up when something is wrong with your body if you learn what is normal for you and what is not.
For further information or advice contact 0860 233 233 or breasthealth@netcare.co.za
About us:
Dr Carol Ann Benn and Dr Sarah Rayne are specialist surgeons with an interest in breast disease. They work at both Helen Joseph Breast Unit and the Netcare Breast Care Centre in Johannesburg. They are also both lecturers in the Department of Surgery at University of the Witwatersrand, and are passionate about breast health, working to educate and advise healthcare professionals and the public.
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