Breast

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.

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

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.

• 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