Tag: breast lump

Posted on

Breast Self Examination

Dear Dr. B: I have been doing breast self-examination (BSE) for many years. But recent recommendation by the Canadian Task Force on Preventive Health Care has confused me. Can you please tell me whether I should continue to do BSE? And what is the Task Force’s exact recommendation? Yours, Ms. Confused.

Dear Ms. Confused: My recommendation would be to continue to do breast self-examination. If we are going to ask women to discontinue with BSE then we should ask the public to stop having rectal examination for detection of rectal and prostate cancer, we should stop doing PSA tests, we should stop checking moles, we should ask men not to examining their testicles for tumour – well I can go on and on.

Unfortunately, medicine is not a perfect science. That is why evidence based medicine is not popular with physicians who have to deal with sick and anxious patients face to face. Common sense and sense of responsibility dictates that we should continue to examine and check our bodies for any obvious abnormalities.

Of course, conducting unnecessary invasive tests without adequate clinical indication is not acceptable. But BSE is inexpensive and non-invasive test requiring no high tech machinery.

What did the Task Force recommend?

1. Women aged 40-69 years should not do BSE, as there is a fair evidence of harm and no evidence that it saves lives.

2. Women younger than 40 and older than 70 – no recommendation was made as there is lack of sufficient evidence to evaluate the effectiveness of BSE in this age group.

What are the recommendations based on?

The Task Force reviewed several large studies and failed to find any evidence that BSE prevents death from breast cancer. In fact, the studies show that women who do BSE visit doctors more often for evaluation of benign breast disease, and have higher rates of benign breast biopsy results. This inflicts anxiety and pain not only to patients but to their families as well.

Is this a big price to pay to rule out breast cancer?

Breast cancer is the most frequently diagnosed cancer among Canadian women. Breast cancer accounts for 30 percent of all new cancer cases diagnosed each year, says the Task Force article in the Canadian Medical Association Journal. Each year, 25 percent of women with diagnoses of breast cancer die.

Well, you be the judge. Each woman has to decide what is important for her. It is your body and you should have full control over it. If you are going to do regular BSE then make sure that you learn the right technique. Information pamphlets and videos are available at the Canadian Cancer Society office (Phone: 529-8015).

Early detection of breast cancer requires three tests: BSE, clinical examination of the breasts by a physician or a trained nurse, and mammography. None of these tests are hundred percent accurate in detecting early breast cancer. Therefore, many physicians, including myself will follow the dictum that a breast lump is malignant until proven otherwise. I would rather remove a benign lump then miss a breast cancer!

Ms. Concerned, I hope this answers your question. If you are going to continue to do BSE then make sure that your technique is correct.

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

Posted on

Breast Pain

Fear of cancer makes Susan seek help when she discovers a lump in her breast.

“Fear is not an unknown emotion to us,” says Neil Armstrong, the first man to walk on the moon.

“Just as courage imperils life, fear protects it,” says Leonardo da Vinci.

It is this protection women look for when they visit their physician with a breast lump.
The scenario of fear and protection leads to frequent office visits, multiple negative needle and surgical biopsies, and sometimes-more anxiety and more fear.

In fact, only 10 to 20 percent of biopsies of breast lumps show cancer. But this is necessary if we are to treat every breast lump as malignant until proven otherwise.

In the last column, we discussed about fibrocystic changes in the breast and the pain associated with this condition. Susan wants to know how this condition is treated.

Painful breasts can be cyclic (associated with menstruation) or non- cyclic. Two thirds of the women have cyclic pain and one- third experience non-cyclic pain.

First step in the management of this problem is to rule out cancer. This is done by history, physical examination, needle biopsy and if indicated, by mammography. If there is a persistent lump after all this then surgical removal becomes necessary. A pathologist’s report will give a definitive answer.

This process will help reassure 85 percent of the women. Their pain is not significant enough to require more than regular painkillers or anti-inflammatory medications. The remaining 15 percent will continue to have severe pain, which will affect their lifestyle and warrant more than regular painkillers.

This is where we are long on drug choices but short on effective uncomplicated therapy.

Here is a list of substances tried: birth control pills, progesterone, bromocriptine, danazol, thyroid hormones, tamoxifen, vitamins A, B-complex, and E, diuretics (water pills), prostaglandin inhibitors, iodine, primrose oil, restriction of methylxanthine (coffee, chocolate), and the list goes on.

In young women in their 20s, the birth control pill may be helpful as it provides a stable amount of hormones each month.

Bromocriptine (a prolactin hormone antagonist), and danazol (a synthetic anti-estrogen) have been found to be helpful to large number of women but these drugs have significant side effects. Side effects of bromocriptine are – nausea, headaches, and dizziness. Side effects of danazol are – loss of menstruation, weight gain, acne, hirsutism, and voice change.

Other popular remedies advocated are the use of primrose oil, iodine, and restriction of chocolates, and caffeine containing substances. Whether the benefits obtained are real or psychological is debatable. But the use of or restriction of these substances have no side effects and in fact may be beneficial for other reasons!

There is no effective uncomplicated therapy applicable to all women with painful lumpy breasts. There is lack of research on breast pain. But it is important to remember that pain is usually not an indicator of cancer in the breast. And a breast lump is considered malignant until proven otherwise.

Well, Susan, are you better informed now? She smiles and says: Thank you for now, Dr. B!

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

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

Posted on

Breast Pain

Breast pain is a common complain among women of menstruating age.

Susan is no exception. Besides pain, she has lumps in both breasts. Her symptoms are cyclic – associated with menstruation.

Since October is Breast Month, Susan wants her breasts examined. She is worried about cancer.

Susan’s physical examination reveals diffuse lumpy areas in both breasts with one discreet lump (about 3 cm in size) in the right breast. A fine needle aspiration of the lump confirms the presence of clear fluid and the lump disappears.

Susan’s mammogram reveals no suspicious lesions to suggest cancer. She is aware that 15 percent of mammograms fail to detect cancer (false negative).

Therefore, the conclusion is that Susan has fibrocystic changes in her breasts. The old term “Fibrocystic Disease” has now been replaced with fibrocystic changes. It cannot be a disease if the condition is very common, responds to physiological hormonal changes, and disappears later in life.

Women with fibrocystic changes not only suffer from pain but also have significant anxiety about cancer. One can easily miss a malignant lump among the multitude of benign appearing lumps.

Physicians and patients have to be vigilant at all times. The principle of management should be that a breast lump is malignant until proven otherwise.

Dr. B, can you tell me more about the fibrocystic changes of the breasts?

Susan, this condition is known by many different names and encompasses many benign conditions of the breast.

One textbook says that it is virtually impossible to estimate the incidence of benign breast disorders. But it is believed that 50 percent of women experience symptoms of fibrocystic changes at some point in their lifetime.

Usually the symptoms occur in women of menstruating age, with a mean age of 39years and a range of 18 to 67 years.

Solid benign lumps (fibroadenomas) occur in younger women, but cysts occur few years before and after menopause (35 to 60 years).

This condition is associated with a history of premenstrual breast discomfort, irregular menses, and spontaneous abortions; a family history of both benign and malignant breast disease; lack of use of oral contraceptives; a low incidence of obesity; small breasts, and late natural menopause (Breast Diseases by Harris and others).

The cause is unknown. It is likely due to imbalance of the female sex hormones as the condition occurs after the onset of menstruation and rarely appears after menopause.

Dr. B, do fibrocystic changes cause cancer of the breast?

Susan, there is inadequate evidence to suggest that fibrocystic changes lead to cancer of the breasts. Usually the fear is that cancer may be missed in women who have “lumpy” breasts. These women do and get regular breast checkups.

The management of this condition is not easy. We will discuss this next week. In the meantime remember: A breast lump is malignant until proven otherwise.

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

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

Posted on

Breast Lump

Dave and Susan were anxiously waiting for me.

Since her last visit, Susan has practiced breast self examination. She found a breast lump.

Susan is aware that breast cancer is the most common cancer diagnosed in Alberta women. It also accounts for about 21% of all cancer deaths in women (Breast Cancer – The Picture in Alberta: 1998).

Susan came straight to the point. She told me about her breast lump.

“Dr B, do you think it is cancer?”

“Susan, I will have to do some investigations before I can answer your question.”

I started with clinical history. How long the lump has been present? Has any change been noted? Is there a previous history of breast biopsy or breast cancer?

Age is the most significant risk factor for breast cancer in women. At age thirty, the probability of developing breast cancer in the next five years is 1 in 667. At seventy, it is 1 in 65.

Susan is thirty eight. Her risk is 1 in 208.

Any other risk factors? Susan’s sister had breast cancer. It is estimated that less than 10 percent of all breast cancers have genetic predisposition.

Breast cancer may or may not be painless.

A fine needle aspiration biopsy of the lump was required to establish whether the lump is solid or cystic. A cystic lump has a very low probability of cancer. I also arranged a mammogram. This would provide further information on the nature of the lump. It would also pick up smaller lumps which were not felt during the physical examination.

Susan and Dave were made aware that eighty percent of breast lumps are benign in nature but a breast lump is suspected to be malignant unless proved otherwise.

Within a week I had good news for Susan. The needle biopsy and mammogram did not reveal cancer. She was advised to see me seven to ten days after she starts her next menstrual cycle.

Susan arrived as planned.

I gave her another physical examination to see if the lump had changed or even disappeared. The lump was still there.

Unfortunately, none of the tests we do are hundred percent accurate to rule out cancer.

“Doctor, I know this. I have been talking to my sister. What’s next for me? A surgical biopsy?”

Yes. This would entail a surgical procedure under local or general anesthetic.

Susan underwent day surgery as planned. There was no cancer.

I saw Susan again a few weeks later. She was happy and relieved.

“Doctor, what should I do to stay one step ahead of the game?”

Mammography and physical examination are the mainstay of screening in breast cancer (Cancer Screening in 1995; Current Oncology; March 1995).

Susan got ready to leave. I gave her some pamphlets to read.

“Call me if you have any questions,” I said as Susan stepped out of the door.

She smiled and said, “Thank you, doctor!”

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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