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Breast Cancer
What to do if you have a breast lump?
I remember when I was a medical student, the Professor of Medicine saying, “You have your eyes to see, your ears to listen and your hands to feel”. It was true then to make a diagnosis and it’s true today.
Breast cancer is diagnosed in over 13,000 Australian women each year and over half of those cases are because women who are very cautious and aware of their breasts saw or felt something was different.
Dr Helen Zorbas, the Director of the National Breast and Ovarian Cancer Centre says “Women can be breast aware by getting to know the normal look and feel of their breasts through everyday activities, like feeling them whilst showering , looking at them in the mirror whilst dress and you know, there is no right or wrong way to check your breasts, the important thing is just to do it.”
What do you do if your think there is a problem?
If you notice, don’t panic but go along and see your GP.
• A new lump, especially if it’s only in one breast.
• A change in size or shape of the breast.
• A change in the nipple such as redness, a crust forming, ulceration or an inversion.
• A discharge from the nipple.
• If the breast skin is red or dimpled and if you have a pain that doesn’t go away
Each year you’ll join over 350,000 women each year, who do the same thing but what you need to keep foremost in your mind is that in 95% of cases, those changes will not be cancer.
The correct way to get the right diagnosis
The best plan of action for your doctor to assess the changes that you note is called: The Triple Test.
Not every woman will need the three tests but each test must be performed in sequence until an absolute diagnosis of the changes is made. Breast checks should be done by experienced professionals and my advice is always to go to established centres in each state until a positive diagnosis is made.
The first test: Personal History
Your doctor takes your personal and your family history and examines your breast. Your story about the nature of your breasts is so important in setting the scene for what is to follow:
Do you have Hormonal Lumps?
The ebb and flow of hormones during a monthly cycle, when on the Pill or on Hormone Replacement Therapy (HRT) creates lumps within the breast. Usually they come and they go but, nonetheless are the most common reason why women will see their doctor.
Could you have a Breast Mouse?
Another problem, especially in younger women is a single hard lump that is hard to feel because it scurries around an area of the breast. It’s called a fibro adenoma. Once properly diagnosed they are often left alone and only removed if they increase in size and concern a woman.
Are you troubled by Breast Cysts?
Cysts are fluid filled sacs found more commonly. In women who are 35-50 years or in those taking HRT, cysts in the breast tissue may form. If they cause pain or form a lump which stays around, the fluid in it is drained using a fine needle and the lump disappears.
Family history
What is the family history of breast cancer?
One in twenty women inherits a gene which increases the risk of breast cancer. Even with that gene, many women won’t get the disease which the doctors say means that the information in the gene has not been expressed.
If several close, blood relatives on the same side of the family have breast cancer your risk increase. There is an even greater increase in risk if they are very close relatives, such as a mother or sister and the risk increases if your relatives were younger when their cancer was diagnosed.
This concerning situation is uncommon and women who report it are referred to a genetic counsellor who will help them sort out the family history, dissect it carefully and plan a program for the future. Examination of your breasts helps your doctor plan the vital next step in diagnosis and differentiate the various causes. Sometimes the advice will be to come back in a month or so for a reassessment but will never be this response, “I’m not worried and neither should you be.”
The Second Test: Taking a picture
To take the step towards diagnosis further the usual tests are Mammography and Ultrasound. Many women will need both to make a diagnosis.
Mammography is a soft tissue, low dose x ray of the breast which is used to evaluate tiny tumour, even as small as a grain of rice. Mammography can be used as a screening in women with no signs of breast cancer.
An Ultrasound uses sound waves to form a picture of the internal tissues of the breast. It is more accurate than mammography and is therefore very valuable in assessing breast changes in younger women where the natural glandular activity makes them very dense which makes it hard for the mammogram to locate possible cancerous images.
Ultrasound is especially valuable in identifying cysts, where the inside of a lump appears to be hollow.
The Third Test: Taking a Biopsy
If your breast changes or lump are not caused by hormonal changes or by a cyst, you may need to go a step further and have an aspiration or core biopsy of the tissues within the breast to be absolutely sure of the cause.
A fine needle biopsy takes a small sample from the breast but sometimes a larger one is needed by the pathologist and that’s when a core biopsy is done under local anaesthetic control.
The value of the triple test is to establish evidence of a change but in more difficult cases more sophisticated tests are needed.
More Difficult Cases
• MRI or Magnetic Resonance Imaging is increasingly being developed to find smaller and smaller tumours.
• Nuclear Medicine is where a tiny amount of radioactive material is injected into a vein and if a lesion is present it then collects and images are taken to isolate the cancer.
• Computer Axial Tomograms or CT scans are a complex series of images taken within the body for all sorts of different angles to locate the cancerous changes.
• PET Scans use a computerized image of the metabolic activity of the body tissues.
If these facilities are not available and that is often true in parts of Australia which are isolated sometimes the lump is fully excised to be tested by the pathologist. If there is a cancer, the specialist will move to the next step.
This plan of action is not ideal because if a full biopsy proves the lesion or the lump is not cancer, a disadvantage is that the scar which is left behind often makes future assessments of the breast, so much more difficult. Where ever you live in Australia, ask your doctor the best place to go to obtain the right diagnosis and the best advice.
What if it is cancer?
Don’t freak out because recent research shows 88% of women are still alive five years from diagnosis and that the cancers are being diagnosed at much earlier stages where they are the most curable.
What if you have early breast cancer?
The aim is to remove the diseased tissue from the breast and also the arm pit which contain the main lymph glands and destroy cancer cells which have passed into the body. Treatment plans will vary!
They will vary from woman to woman because each person is different and so is the pathology of their cancer.
Discuss your options with your specialist.
Give yourself time to make the decision! Although the word ‘cancer’ strikes fear to the heart, believe it or not, you do have the time to think and talk about it so that you make the right choice.
Share your load with others. Don’t lock it in!
In any stressful situation, we only take aboard about 25% of what we are told so it’s vital that you go prepared to each of your consultations. Take your partner or a dear friend. Bring a pen and write down what you’re told. Some people even bring a tape recorder.
Should I have Breast Conserving Surgery or Mastectomy and what about radio therapy?
For the most part, the risks of dying from the cancer are the same with breast conserving and mastectomy.
Breast conserving surgery
This means the cancer, tissue around it and the lymph nodes under your arm are removed and it is your option if the cancer and the tissue around it are small enough to leave the rest of the breast intact and leave you an acceptable look.
It’s also important if it’s what you want.
Mastectomy
This is removal of the entire breast, together with the nodes in the arm pit. It happens:
• When the cancer is large.
• It is in more than one place in the breast.
• If it has come back again after earlier removal and you had radiotherapy at that time...Radiotherapy can only be used once on the breast region
• It’s what you want.
Radiotherapy
Radiotherapy is used to destroy any remaining cancer cells in the breast, the chest wall or the arm pit. Radiotherapy is recommended after breast conserving surgery. Sometimes used on the chest wall after mastectomy and with both surgeries to the armpit and the lower neck.
Its use is to:
• Reduce the risk of the cancer coming back in the same breast.
• Less chance of more surgery happening.
• A better chance of surviving the cancer.
Not everyone goes ahead with radiotherapy even though it’s almost always indicated. Services in Australia especially, in the bush, are lagging behind what is considered basically acceptable in other parts of the world. However, my view is to always have radiotherapy even if it means travelling long distances.
Dr John D’Arcy March 2009
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