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Breast

Breast Cancer

Breast cancer occurs when abnormal cells in the breast grow in an uncontrolled way.
Breasts are made up of lobules and ducts surrounded by fatty and connective tissue. Lobules produce breast milk and ducts carry milk to the nipple.1

There are several different types of breast cancer.

  • Ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS) are non-invasive breast cancers that are confined
    to the ducts or lobules of the breast.1
  • Invasive ductal or lobular carcinoma is an invasive breast cancer that starts in the ducts or lobules of the breast and can spread into the breast tissue.1 Invasive breast cancer may be confined to the breast and lymph nodes in the armpit (early breast cancer) or may have spread outside the breast to other parts of the body (secondary breast cancer).1,2
  • Paget’s disease of the nipple is a rare form of breast cancer that affects the nipple and the area around the nipple (the areola) and is commonly associated with an invasive cancer elsewhere in the breast.1
  • Inflammatory breast cancer is a rare form of invasive breast cancer that affects the lymphatic vessels in the skin of the breast, causing the breast to become red and inflamed.1

The symptoms of breast cancer depend on where the tumour is in the breast, the size of the tumour and how quickly it is growing.1

Breast changes that may indicate breast cancer include:

  • a new lump or lumpiness, especially if it’s only in one breast3
  • a change in the size or shape of the breast3
  • a change to the nipple, such as crusting, ulcer, redness or inversion3
  • a nipple discharge that occurs without squeezing3
  • a change in the skin of the breast such as redness or dimpling3
  • an unusual pain that doesn’t go away.3

There are a number of conditions that may cause these symptoms, not just breast cancer. If any of these symptoms are experienced, it is important that they are discussed with a doctor.

A risk factor is any factor that is associated with an increased chance of developing a particular health condition, such as
breast cancer. There are different types of risk factors, some of which can be modified and some which cannot.

It should be noted that having one or more risk factors does not mean a person will develop breast cancer. Many people
have at least one risk factor but will never develop breast cancer, while others with breast cancer may have had no known
risk factors. Even if a person with breast cancer has a risk factor, it is usually hard to know how much that risk factor
contributed to the development of their disease.

While the causes of breast cancer are not fully understood, there are a number of factors associated with the risk of developing the disease. Some of the risk factors for breast cancer include:

  • being a woman1
  • increasing age1
  • having a strong family history of breast cancer1
  • having a breast condition such as a personal history of breast cancer, DCIS or LCIS
  • a number of hormonal factors, child-bearing history, personal and lifestyle factors.4

Diagnosis of breast cancer involves the triple test. This includes:

  • a clinical breast examination1
  • imaging tests – which may include a mammogram or ultrasound
  • taking a sample of tissue (biopsy) from the breast for examination under a microscope.1

Other tests, such as blood tests or bone scans, may be done if symptoms suggest that breast cancer has spread outside the
breast.1,2 Magnetic resonance imaging (MRI) may be suggested to assess extent of disease in some cases.

Treatment and care of people with cancer is usually provided by a team of health professionals – called a multidisciplinary team.

Treatment for breast cancer depends on the stage and type of the disease, the severity of symptoms and the person’s general health. Treatment usually involves surgery to remove part or all of the affected breast, and removal of one or more lymph nodes from the armpit. Breast reconstruction may be available for women who have the whole breast removed (mastectomy). Radiotherapy, chemotherapy, hormonal therapies, and/or targeted therapies, may also be used.1

Research is ongoing to find new ways to diagnose and treat different types of cancer. Some people may be offered the option of participation in a clinical trial to test new ways of treating breast cancer.

People often feel overwhelmed, scared, anxious and upset after a diagnosis of cancer. These are all normal feelings.

Having practical and emotional support during and after diagnosis and treatment for cancer is very important. Support may be available from family and friends, health professionals or special support services.

In addition, State and Territory Cancer Councils provide general information about cancer as well as information on local resources and relevant support groups. The Cancer Council Helpline can be accessed from anywhere in Australia by calling 13 11 20 for the cost of a local call.

Breast Cancer Screening

Screening refers to tests and exams used to find a disease, like cancer, in people who do not have any symptoms. The goal of screening exams, such as mammograms, is to find cancers before they start to cause symptoms. Breast cancers that are found because they can be felt tend to be larger and are more likely to have already spread beyond the breast. In contrast, breast cancers found during screening exams are more likely to be small and still confined to the breast. The size of a breast cancer and how far it has spread are important factors in predicting the prognosis (outlook) for a woman with this disease.

BreastScreen Australia is the national breast cancer screening program. It provides free screening mammograms at two-yearly intervals for women aged 50-74 with the aim of reducing deaths from breast cancer in this target group, through early detection of the disease.

BreastScreen Australia is targeted specifically at women without symptoms aged 50-74 years. Evidence shows that screening has the greatest potential to prevent mortality from breast cancer for this age group. Women aged 40-49 and 75 years and older, who have no breast cancer symptoms or signs, are also eligible for free screening mammograms.

Two-yearly screening mammograms are the best way for women aged 50-74 years to detect breast cancer early, before there are any signs or symptoms. Early detection in this age group offers women a better chance of successful treatment and recovery.

Screening may result in a 30% reduction in mortality in women aged 50-74 years, but the mortality reduction is less in women aged 40-49 years since the incidence of breast carcinoma at this age is less. The cost effectiveness is also less in women aged 75 years and older, since other causes of death become more common.

Women 40-49 years

Age is the biggest risk factor in developing breast cancer. Around 75% of all breast cancers occur in women over the age of 50. Current research shows that breast cancer screening is most effective in detecting early breast cancer in women aged 50-69 years.

Current evidence indicates that the benefits of breast cancer screening for women aged 40-49 years are not strong enough to encourage all women in this age group to have regular breast cancer screening.

Women in their 40s who have no breast problems are able to have a free screening mammogram through BreastScreen Australia if they wish. However, they are not specifically targeted to attend.

Women 40 years and under

Regular screening mammograms are not recommended for women under 40 years. One reason is that the risk of breast cancer in young women is low compared to that of older women. Also, mammographic screening is not as effective in younger women. As women grow older and approach menopause, their breasts change and become less dense or solid. The tissue of younger women’s breasts is usually more dense than that of older women and can show up as white areas on the x-ray. Breast cancers also show up as white areas on x-rays. This makes breast cancer more difficult to detect in young women. Women under 40 years of age are therefore more likely to have an unnecessary recall for assessment, with all the anxiety associated with this, and sometimes invasive investigations, when there was no cancer there in the first place.

Younger women who notice any unusual breast lumps, pain or nipple discharge should see their doctor immediately. Those who are concerned about their individual risk of developing breast cancer should also seek advice from their doctor.

Mammography is usually referred to as the ‘mammography unit’ used by the radiographer to take the x-ray of the breast. A mammogram is an x-ray picture of the breast that is designed to detect breast cancer.

A screening mammogram can detect small lesions of cancer (as small as a pea or around 1cm). Detecting cancer at this early stage increases the effectiveness of treatments.

Mammographic screening is generally safe for women with implants. There is an extremely small chance that the pressure placed on the implant by the mammography machine could cause the implants to rupture or break.

In women who have implants which have already ruptured or started to leak, it is possible that having a mammogram could increase the amount of silicone or saline (depending on the type of implant) spreading into the breast tissue.

In some women with implants, very small amounts of silicone or saline (depending on the implant) pass through the pores of the implant shell. This is sometimes called ‘bleeding’ of the implant. At present it is not known whether mammography increases ‘bleeding’ of implants.

There is a small chance that mammography will change the shape of the breasts by dispersing the fibrous capsule that often grows around the implant. The breast may feel softer after mammography. However, it cannot be guaranteed that both breasts will be affected equally.

Yes. Breast self examination does not replace the need for a screening mammogram. Breast awareness is an important part of health care. It helps you to learn how your breasts feel normally, so that if you notice any changes or lumps in your breast to consult your doctor as soon as possible.

A screening mammogram can detect small lesions of cancer (as small as a pea or around 1 cm) whereas the size of a cancer detected by physical examination is larger (around 2.5cm in diameter).

Women who perform breast self examination and who are eligible for the BreastScreen Australia program should start/continue to have two-yearly screening mammograms.

While having a family history of breast cancer can increase your risk, it is important to note that nine out of ten women who develop breast cancer do not have a family history of breast cancer.

Australian recommendations are to begin routine breast screening mammography at age 40 for some women who have a strong family history.

See your doctor to discuss any further concerns regarding your family history of breast cancer.

You should generally wait six months after you have stopped breastfeeding to have a mammogram, as the image can be harder to read and you may also experience increased discomfort. If you think you have any symptoms of breast cancer you should see your doctor who may refer you for diagnostic procedures.

From time to time you may find breast changes, such as:

  • a lump or lumpiness;
  • any change in the shape or appearance of the breast such as dimpling or redness;
  • an area that feels different to the rest;
  • a discharge from the nipple;
  • any change in the shape or appearance of the nipple such as pulling in or scaliness (nipple inversion or retraction); or
    pain.

Many women are concerned that a breast change might be breast cancer. Even though this will not be true in most cases, it is very important that all breast changes are carefully investigated. If it is cancer, finding it early will mean a much better chance of effective treatment.

If you notice a breast change or experience a breast symptom you should see your doctor without delay. A doctor will do a clinical breast examination and refer you for further tests such as a diagnostic mammogram or ultrasound if needed. These tests require a doctor’s referral and may be performed in a private radiology practice or a public hospital.

Magnetic Resonance Imaging (MRI) makes use of strong magnetic fields and radiofrequency pulses to generate sectional images of the body in any plane and is especially useful in examinations of soft tissue.

It is an important tool for working with diseases such as cancer. Unlike other imaging modalities (X-ray and CT scans), MRI does not use ionising radiation. MRI of the breast is not available at BreastScreen Australia, but is available through public, private hospitals as well as private diagnostic imaging providers in a large number of locations around Australia.

Since 1 February 2009, the Australian Government has been funding Medicare rebates for annual MRI breast scans for women. To be eligible for the rebate you must be a female who is less than 50 years of age, with no current signs or symptoms of breast cancer, who has been identified as at high risk of breast cancer due to family history or genetic mutation.

Source: Australian Government Department of Health

Breast Biopsy

Once a breast lump or breast abnormality has been detected, your doctor may want to conduct a breast biopsy. This procedure involves taking sample tissue from the suspicious area to determine whether the breast lump is cancerous.

While the thought of having a breast biopsy might be frightening, the results can provide reassuring peace of mind. Remember, the vast majority of breast biopsies do not turn out to be breast cancer. And a biopsy is currently the only way to achieve an accurate breast cancer diagnosis.

There are various breast biopsy options to consider. The choices range from an open surgical procedure to new minimally invasive techniques. Be sure to understand your biopsy options and talk with your doctor to determine the procedure that is best for you.

Stereotactic Biopsy

Stereotactic biopsies use mammography (x-rays) to locate breast abnormalities, while ultrasound biopsies use high-frequency sound waves to create breast tissue images.

In a minimally invasive breast biopsy using stereotactic imaging, a patient lies face down on a special table with her breast protruding through a hole in the table’s surface. The breast is lightly compressed to immobilize it throughout the biopsy procedure. The table is connected to a computer that produces detailed x-ray images of the abnormality to be biopsied. Using these images, the doctor guides a special sampling device (for example, biopsy probe) to collect tissue specimens.

Ultrasound Guided Biopsy

Minimally invasive breast biopsies using ultrasound imaging are performed on patients in an upright or reclined position. Using a hand-held transducer, a doctor will move the device back and forth across the breast to generate clear images of the abnormal breast tissue. While viewing the images on a computer monitor, the doctor will guide a small probe into the breast to retrieve sample tissue specimens.

In a core needle biopsy, the physician makes a small skin incision through which a needle is inserted into the lesion to obtain sample tissue. The hollow spring-loaded device is “fired” repeatedly into the abnormality to collect a sufficient amount of breast tissue for analysis. Usually, 4 to 6 samples are taken (4 to 6 insertions). This biopsy procedure is performed in an outpatient setting or doctor’s office without general anaesthesia or stitches.

Fine Needle Aspiration (FNA) is a biopsy procedure that uses a thin needle on a syringe to draw fluid and/or cellular material from a breast abnormality. Thus, Fine Needle Aspiration provides information about cellular material, whereas the other tissue biopsy procedures allow tissue within the abnormality to be compared to surrounding tissue for a more accurate diagnosis. Fine Needle Aspiration is most often used to aspirate, or drain fluid, from benign (non-cancerous) fluid-filled cysts. However, the extracted fluid can be examined by a pathologist to confirm whether the abnormality is benign or requires further testing.

Fine Needle Aspiration biopsy procedures are generally performed by a physician in his or her office. If the breast lump is small and cannot be felt, the procedure can be performed using stereotactic or ultrasound imaging guidance. During the procedure, a long, thin needle is inserted through the breast into the abnormality for sample extraction. Because the needles used for Fine Needle Aspiration biopsies are smaller than needles used to draw blood, local anaesthesia is not required.

Gynaecomastia

Gynaecomastia is a condition in which firm breast tissue forms in males. The breast tissue is usually less than 4cm inches across and is located directly under the nipple. Gynaecomastia may be present on one side or on both sides. This condition may make the breast tender.

Some men and boys have fat on their chests that makes it look like they have breasts. This condition is called pseudo-gynaecomastia (false gynaecomastia). It is not the same thing as gynaecomastia.

Gynaecomastia is usually caused by changes in hormones at puberty or as part of aging. Hormones are chemicals produced by the glands of the body, such as the thyroid gland, the testes and the ovaries. Gynaecomastia may be caused by changes in the balance of 2 hormones, oestrogen and testosterone. In rare cases, gynaecomastia is caused by prescription drugs, over-the-counter medicines, illegal drugs, tumours or disease.

Sometimes tests are needed, and sometimes they’re not. Your doctor will ask you questions about your symptoms, such as how long you’ve had the breast tissue, and whether or not the area is tender. Your doctor will also ask you about the illnesses you have had in the past, the medicines you take, and other matters relating to your health. Then you will have a physical examination.

Whether you need tests depends on your age and what your doctor learns from your history and physical examination. If you are a teenager, you probably will not need more tests, since gynaecomastia is common in teenage boys. As many as 65% of 14-year-old boys have gynaecomastia. The breast enlargement usually goes away on its own in 2 or 3 years. However, younger boys and adult men with gynaecomastia may need to have some tests, because it is more possible that some kind of disease is causing the problem.

In most cases, no treatment is needed. Your doctor will probably want to check the size of your breast tissue every few months. In 90% of teenage boys, gynaecomastia goes away in less than 3 years.

Sometimes the problem can be solved if you stop taking a medicine that is causing gynaecomastia or stop using an illegal drug that is causing the problem.

Occasionally, medicines may be used to treat gynaecomastia, especially if tenderness is a problem. The medicine will make the extra breast tissue go away. Rarely, surgery may be necessary to remove the extra breast tissue.

Treatment is necessary if gynaecomastia is caused by a disease or a tumour. If it is due to a disease, the disease itself will need to be treated.

Probably not. Breast cancer is very rare in males. Your doctor will probably be able to tell whether the lump is cancer. Lumps caused by cancer are usually not underneath the nipple, but breast tissue from gynaecomastia grows in this area. Breast cancer feels different than the breast tissue of gynaecomastia. With cancer, there sometimes is dimpling of the skin or a bloody discharge from the nipple. If there is any question that you have cancer, you will need to have a mammogram and a biopsy.

Nipple Discharge

Alternative names

Discharge from breasts; Milk secretions; Lactation – abnormal; Witches milk; Galactorrhea

Definition

This symptom involves abnormal discharge from the nipple(s)

The likelihood of nipple discharge increases with age and number of pregnancies.

While a milky nipple discharge is rare in men and in women who have never been pregnant, it does occur. When it does, it is likely to be caused by some underlying disease, particularly when accompanied by other changes in the breast(s).

It is relatively common in women who have had at least one pregnancy. A thin yellowish or milky discharge (colostrum) is normal in the final weeks of pregnancy.

The nature of the discharge can range in colour, consistency, composition, and may occur on one side or both sides.

“Witch’s milk” is a term used to describe nipple discharge in a newborn. The discharge is a temporary response to the increased levels of maternal hormones. The discharge should disappear within 2 weeks as hormone levels dissipate in the newborn.

Other nipple discharges can be bloody or purulent (containing pus), depending on the cause.

  • Breast abscess (most common in lactating women)
  • Trauma can cause discharge from both breasts
  • Drugs such as cimetidine, methyldopa, metoclopramide, oral contraceptives, phenothiazines, reserpine, tricyclic antidepressants, or verapamil
  • Prolactinoma (prolactin-secreting tumour in the brain)
  • Intraductal papilloma (a small noncancerous growth in the duct of the breast)
  • Ductal ectasia

The medical history will be obtained and a physical examination performed.

Medical history questions documenting a nipple discharge in detail may include:

  • Could you be pregnant?
  • Are you breast-feeding?
  • What type of drainage is there?
    • Does it look like milk (even though you are not breast-feeding)?
    • Does it look bloody?
    • Does it look like pus?
  • Is the drainage from both breasts?
  • How much drainage is there?
    • Enough to stain the lining of the bra?
    • Enough to soak through the bra?
    • Does the discharge occur spontaneously, or only when expressed?
  • Do you perform breast self-examination? How often?
  • What medications do you take?
  • What other symptoms are also present? Especially, is there:
    • Fever
    • A breast lump
    • Breast pain
    • Headaches or change in vision

The physical examination will include examination of the breasts for lumps or other abnormality.

  • Breast biopsy (if a lump is present)
  • Cytologic study of discharge (a study of the cells in the discharge)
  • Mammogram or ultrasound
  • Blood test for serum prolactin

References

  1. Cancer Australia. Guide for women with early breast cancer. Cancer Australia, Surry Hills, NSW, 2012.
  2. National Breast and Ovarian Cancer Centre. Guide for women with secondary breast cancer. National Breast and Ovarian Cancer Centre, Surry Hills, NSW, 2010.
  3. Cancer Australia. Breast changes. http://canceraustralia.nbocc.org.au/breast-cancer/awareness/breast-changes [Accessed July 2012].
  4. Cancer Australia. Breast cancer risk. http://canceraustralia.nbocc.org.au/breast-cancer/about-breast-cancer/breast-cancer-risk [Accessed July 2012].