Should You be Worried About Nipple Discharge?

To drink or not to drink - Cordoba, Spain. (Dr. Noorali Bharwani)
To drink or not to drink - Cordoba, Spain. (Dr. Noorali Bharwani)

“Nipple discharge is benign in most instances and is the third most common breast-related complaint, after breast pain and breast mass,” says an article in the Canadian Medical Association Journal (CMAJ May 19, 2015).

About 50 per cent of women in their reproductive years have nipple discharge, which are physiological. This kind of discharge is usually from both breasts, milky, green or yellow fluid expressed from multiple nipple duct openings and often associated with nipple stimulation. Usually these patients do not require surgery if the ultrasound and mammogram is normal. Discharge may spontaneously disappear.

Nipple discharge you should be worried about are spontaneous and often from one breast. It may arise from a single duct or be associated with a breast lump or new skin changes. It can be bloody, serous (clear thin plasma fluid), green or black.

About 15 per cent of these patients will have breast cancer. About 50 per cent of these patients will have benign intraductal papilloma (benign growth in the duct), and 20 per cent will have ductal ectasia.

Ductal ectasia of the breast (also known as mammary duct ectasia or plasma cell mastitis) is a condition in which the lactiferous breast duct becomes blocked or clogged. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal women.

Intraductal papillomas are benign growths of the nipples in women close to menopause. They are usually single. Generally they are not seen on mammography. Surgical excision is indicated to rule out malignancy. These papillomas are the most common cause of bloody nipple discharge.

What can be done for women with nipple discharge?

Women with nipple discharge should be investigated. Mammography (sensitivity may be decreased in younger patients) and retroareolar ultrasonography should be performed in all cases of pathologic nipple discharge. Galactography, and more recently, magnetic resonance imaging, can be helpful in identifying an involved duct or papilloma. Patients with a palpable mass or a mass identified on imaging should undergo needle biopsy to exclude carcinoma, says the CMAJ article.

Milky discharge in patients who are not pregnant or lactating (galactorrhea) is often due to medications. Milky nipple discharge from both breasts is appropriate during pregnancy and lactation, and it can last up to one year after delivery or after breast-feeding has stopped.

In patients who are not pregnant but are lactating should have prolactin levels checked to exclude endocrine disorder (> 20 ng/mL). Medications such as:

  • Psychotropics, antihypertensives (e.g., reserpine, methyldopa, verapamil),
  • Opiates, prokinetics (e.g., metoclopramide) and
  • H2-blockers (e.g., cimetidine) can cause galactorrhea.

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Breast Lumps Should Not Be Ignored

Breast lumps are very common. Breast lumps appear in women and men. They may appear in children. But mostly the breast lumps appear in adults. A breast lump is always an important clinical finding – never to be ignored. It is also a source of anxiety for the patient and his or her family. The first thing they want to know is, “Doctor, is this cancer?”

Investigations of a breast lump starts with a history and physical examination. Physical examination is best done between seven to 10 days from the first day of the menstrual cycle. The clinical history will establish how long the lump has been present. Whether there has been any change. And if there is a previous history of breast biopsy or breast cancer.

Risk factors for breast cancer will be noted (patient’s age and family history). It is important to remember, absence of risk factors does not decrease the probability of cancer.

Careful examination of the breasts will confirm the presence and establish the character of the lump. Hard, irregular, tethered, fixed or painless lump may be suggestive of cancer. Axillary (armpit) and neck areas are checked for lymph glands. The predictive value of physical examination (to say whether the lump is benign or malignant) in experienced hands is about 75 percent.

Mammograms in younger women are not very helpful. But after mid-30s the value of mammography increases. Quite often mammography can clarify the nature of the lump. It can also detect non-palpable lumps.

The overall level of sensitivity of mammography in palpable breast cancers may be no more than 82 percent. It may be even lower in premenopausal women. A negative mammogram in the presence of a persistent lump does not exclude malignancy.

Fine-needle aspiration biopsy done in the office can establish whether a breast lump is solid or cystic. When the lump is solid, cells can be aspirated for examination under a microscope. If fluid is obtained during aspiration and the lump disappears then it is a cyst.

In a cystic lump, if the fluid is not bloody then no specimen needs to be sent for examination and no further investigation is necessary. Bloody fluid may be suggestive of cancer and should be sent for microscopic examination.

Fine-needle aspiration biopsy should provide satisfactory specimen for microscopic examination in 90 percent of the cases with an accuracy rate of 95 percent to detect presence of cancer cells.

When physical examination, mammography, and microscopic examination of aspirated specimen indicate cancer then the probability of this being confirmed by surgery is more than 99 percent. If all three tests are negative then the lump being cancerous is less than one percent.

Core-biopsy, where a bigger sample (a core of tissue) is taken from a breast lump, has 90 percent predictive value for breast cancer. A negative biopsy may make it unnecessary to do an open surgical biopsy.

Ultrasound of the breast lump is an alternative method to distinguish a cyst from a solid lump. Ultrasound is useful when a non-palpable lump is seen on a mammogram.

Nuclear medicine techniques (Miraluma scan) have been used to evaluate breast cancer. Its predictive value for cancer is around 80 percent for a palpable lesion and 50 to 70 percent for a non-palpable breast lump found on mammography.

Whenever reasonable doubt remains about cancer (since none of the tests have a one hundred percent accuracy rate), a surgical open biopsy is undertaken. Only about one in every five to 10 breast biopsies leads to a diagnosis of cancer. But every breast lump should be investigated thoroughly.

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Breast Cancer in Young Women

It is quite common to see young women with breast lump worrying about cancer. This worrying should not be underestimated nor it should be blown out of proportion. Breast cancer in young women is uncommon. Again, one has to define what is young.

Definition of “young” is defined by different researchers as patients younger than 30, 35, 40 or even 50 years. This limits the amount of information you can gather because the number of cancers in each age group is not that high.

Here are few points to remember about young women who present with a breast lump.

Epidemiological studies in the U.S. show that 2.7 per cent of all cases of breast cancer occur in women ages 35 or younger and 0.6 per cent in women younger than age 30. According to a collective review article on this subject in the Journal of the American College of Surgeons (June 2008), women diagnosed at age 35 and younger tend to present at a more advanced stage of breast cancer and have poorer 5-yeare survival than older pre-menopausal women.

There are several concerns to be taken into consideration when a young woman is diagnosed with breast cancer. She will be worried about fertility, she will go into early menopause from the treatment and there will be psychological and emotional toll on the family, especially young children. The young lady will face a significant challenge to maintain her image and sexuality. The young patient needs to be treated as a whole and not as “just another patient with breast cancer.”

These days all patients (what ever their age or illness) are treated by multidisciplinary teams. The teams take into consideration all anxieties which may affect a patient’s treatment and outcome. But certain patients require special care and attention because of the uniqueness of their illness. Young women with breast cancers fall into that category.

Can we predict which young woman will get breast cancer?

The review article says there is currently no accurate tool for predicting breast cancer risk in young women. A Swedish population-based study found 48 per cent of women younger than 40 had a family history of breast or ovarian cancer. Another study has shown that breast cancer is less common in African-American women than Caucasian women but African-American women develop breast cancer at an earlier age and has worse prognosis than Caucasian women.

Why do young women present with later-stage breast cancers?

One of the reasons is that this population group is not screened as vigorously as the older women. Screening mammography is not recommended for women under 40 (low sensitivity and specificity due to dense breasts) and in fact it is controversial to screen women before the age of 50. In the last few years, some studies have discouraged women from doing breast self-examination (BSE). They argue that BSE leads to unnecessary biopsies.

The review article says, “Currently, it is recommended, although not specifically supported in the literature, that women with a family history of pre-menopausal breast cancer should begin mammographic surveillance 10 years before the age that their relative (i.e. mother, sister) was initially diagnosed.”

Some studies recommend doing an ultrasound alone or in combination with mammography to evaluate a breast lump in a young woman. There are other modalities being tried, such as digital mammography and MRI and these methods are showing promising results when one or more test are combined to evaluate a breast lump in a young woman.

The bottom line is, any suspicious dominant breast mass be biopsied even if the tests are negative. This principal applies whether the woman is young or old. Breast cancer in young women is uncommon but a breast lump in that age group should not be ignored but be thoroughly investigated.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Breast Lump Evaluation

A breast lump in a woman or a man is an important clinical finding – never to be ignored. It is also a source of anxiety for the patient and his or her family.

The usual questions are: What is it doctor and what investigations are required to check for cancer?

Investigations of a breast lump starts with a history and physical examination. Physical examination is best done between seven to 10 days from the first day of the menstrual cycle.

The clinical history will establish how long the lump has been present. Whether there has been any change. And if there is a previous history of breast biopsy or breast cancer.

Risk factors for breast cancer will be noted (patient’s age and family history). Absence of risk factors does not decrease the probability of cancer.

Examination of the breasts will confirm the presence and establish the character of the lump. Hard, irregular, tethered or fixed, or painless lump may be suggestive of cancer. Axillary (armpit) and neck areas are checked for lymph glands. The predictive value of physical examination (to say whether the lump is benign or malignant) in experienced hands is about 75 percent.

Mammograms in younger women are not very helpful. But after mid-30s the value of mammography increases. Quite often mammography can clarify the nature of the lump. It can also detect non-palpable lumps.

The overall level of sensitivity of mammography in palpable breast cancers may be no more than 82 percent. It may be even lower in premenopausal women. A negative mammogram in the presence of a persistent lump does not exclude malignancy.

Fine-needle aspiration biopsy done in the office can establish whether a breast lump is solid or cystic. When the lump is solid, cells can be aspirated for examination under a microscope. If fluid is obtained during aspiration and the lump disappears then it is cystic.

In a cystic lump, if the fluid is not bloody then no specimen needs to be sent for examination and no further investigation is necessary. Bloody fluid may be suggestive of cancer and should be sent for microscopic examination.

Fine-needle aspiration biopsy should provide satisfactory specimen for microscopic examination in 90 percent of the cases with an accuracy rate of 95 percent to detect presence of cancer cells.

When physical examination, mammography, and microscopic examination of aspirated specimen indicate cancer then the probability of this being confirmed by surgery is more than 99 percent. If all three tests are negative then the lump being cancerous is less than one percent.

Core-biopsy, where a bigger sample (a core of tissue) is taken from a breast lump, has 90 percent predictive value for breast cancer. A negative biopsy may make it unnecessary to do an open surgical biopsy.

Ultrasound of the breast lump is an alternative method to distinguish a cyst from a solid lump. Ultrasound is useful when a non-palpable lump is seen on a mammogram.

Nuclear medicine techniques (Miraluma scan) have been used to evaluate breast cancer. Its predictive value for cancer is around 80 percent for a palpable lesion and 50 to 70 percent for a non-palpable breast lump found on mammography.

Whenever reasonable doubt remains about cancer (since none of the tests have a one hundred percent accuracy rate), a surgical open biopsy is undertaken.

Only about one in every five to 10 breast biopsies leads to a diagnosis of cancer. But every breast lump should be investigated thoroughly.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!