Breast Health

Seventy-five percent of all breast cancers occur in women with NO family history of breast cancer. We know that lifestyle choices such as diet, exercise, alcohol consumption and smoking all play a vital role in the development of breast cancer. Before you can understand what is abnormal in breast tissue, it is important to understand the normal structures of the breast. It is the first step in understanding how it functions and how it at times becomes diseased.

Normal Anatomy

Please refer to the diagram below. The breast is covered with skin (8) and it protects the lobules (3) that produce the milk, ducts (6) that carry the milk to the nipple-areola (5) complex (4),, fibrous supportive connective tissue and fat (7). The fat and fibrous tissue varies in every woman accounting for the differences in breast composition. The breast is attached to the pectoralis muscle (2) and then to the chest wall (1).

breast-anatomy[1] The breasts change throughout the life of a woman—from puberty through childbearing years and into menopause. The composition of the breasts will change based upon whether or not the breasts go through cycles of pregnancy, lactation and eventual involution with the ending of the menstrual cycle. Breastfeeding has been associated with a decrease risk of breast cancer, and that link may be due to the “flushing” of cleansing of the ductal cells by the production and expression of human milk.
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Breast Self Exam

Twenty percent of all breast cancers are not visible on mammography. Therefore, if there is one item that you learn from this section on breast health, realize that a true mass in the breast needs to be biopsied or sampled even when mammograms, ultrasounds and MRI’s do not show a lesion. A mass in the breast can present as a ridge, a thickening or even a change in the skin of the breast. Because the breast tissue changes with the menstrual cycle, it is very important to know the architecture of your breast tissue. If you notice a change in your breast you should have it evaluated by your family doctor or gynecologist, who will refer you to a surgeon if necessary. Breast awareness is the key.

What to look for?

Monthly breast self-exam is an important part of sustained breast health. Once a month, the week after your period if you still get your period or the first of the month if you are post menopausal , you should begin the exam by looking in the mirror.

Next, the breast exam can be performed in the shower, using soap and water, or in front of the mirror, using body oil or gel, to help your hands glide over your breasts. It can also be performed lying down, like the diagram below. Begin with one arm over your head using firm but gentle pressure allow the pads of your fingers to glide over your breast moving side to side from the top of the breast to the fold below the breast.

SelfExam1

Check your breasts for:

Skin dimpling
Skin retraction (pulling in or puckering of the skin)
Bulging of the skin,
Inversion of the nipple (the nipple diving in instead of out),
Redness or edema (fluid or thckening of the skin).

What can a mass feel like?

A firm pea
A marble
A thickening or a ridge
Gravel

Use your right hand to examine your left breast and vice versa. Pay special attention to the nipple region feeling for any changes. The exam is then repeated lying on your back checking from the armpit to the breast bone and the collar bone to the abdomen. The nipple can be gently squeezed to see if there is a discharge of fluid.
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Breast Feeding

Is breastfeeding good for your breasts?

The female breast is the vital link to sustaining our species. In our societies, the breasts have become the most visible sign of being female. The fear of breast cancer often over shadows the amazing physiologic function of life sustaining milk production for our young. We often forget the importance of the breast in the nurturing of our offspring. Breastfeeding is using our breasts for their intended purpose! It has significant benefits for mothers and babies.

Breastfeeding has been associated with a decrease risk of breast cancer, and that link may be due to the “flushing” or cleansing of the ductal cells by the production and expression of human milk.
Benefits of breast feeding

FOR MOM

Helps mom lose pregnancy weight
Reduces post partum bleeding by releasing oxytocin ( causes uterine contraction)
Promotes bonding with your baby
Can lower your stress levels
May reduce your risk of some types of cancer (breast cancer)
May protect against osteoporosis later in life

FOR BABY

Protects your baby from gastrointestinal trouble, respiratory problems, and ear infections
Can prevent allergies in your baby
Breast milk contains CCK (Cholecystokinin) sleep hormone
May lower the risk of SIDS (Sudden infant death syndrome)
May boost your child’s intelligence
May protect against obesity later in life
May protect your baby from childhood leukemia
May protect your baby from developing type 1 diabetes
May protect preemies from infections and high blood pressure later in life

Breast Size

The size of the breast is very often a concern and leads to the surgical reduction (for macromastia) or enhancement micromastia (for) of the breasts. Both operations are very commonly performed, but you must carefully weigh the risks and the benefits of the procedure before you contemplate having the surgery performed on you.
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Breast Reduction

Breast reduction surgery is a procedure that a woman often thinks about for years prior to following through with the actual operation. Shoulder and back pain, as well as the mere large size of the breasts are the main reasons for seeking surgical reduction of the breast volume. When being evaluated for the surgery, it is important to express your desires to the surgeon about what your expectations are as far as the size that you want your breasts to ultimately become. They cannot create your new breasts to your liking if you do not make your wishes known. The surgery takes between 2 and 4 hours to complete. The nipple complex is preserved and every attempt is made to maintain the sensation to the nipple, although occasionally the sensation to that area is changed from the surgery. The scars from the surgery are in the form of an inverted “T.”

During the procedure, the excess breast tissue is removed, the nipple is lifted and the remaining skin and breast tissue are brought around below the nipple to recreate the breast form. It is very important to let the surgeon know what size you want your breasts to be. They will tell you what (around of tissue) needs to be removed in order to comply with the regulations of some insurance companies. After surgery, you may have drainage tubes to remove excess fluid from the surgery. These will remain in the breast for 7 to 10 days, rarely longer. Some patients are kept overnight in the hospital, which should be discussed with the surgeon. The scarring after surgery can range from barely perceptible to scarring that is considered hypertrophic (over growth of scar tissue). It is often difficult to predict how you will scar so you need to be prepared for the scars to be visible. Ask your surgeon to have all of the breast tissue evaluated by a pathologist, as precancerous lesions and cancer cells occasionally can be found in the breast tissue that was removed.

What symptoms come from the breast being too large?

Neck pain
Back pain
Shoulder divots (ridges from the bra)
Debilitating discomfort
Skin irritation under the breast

Pre-reduction and Post-reduction

Will I like my new breasts?
Breast reduction surgery is one surgery that has the highest patient satisfaction. Women should wait until after child bearing to have the surgery performed, unless their symptoms are incapacitating. Although breastfeeding is possible after breast reduction, the surgery can block the ducts and make breastfeeding problematic.

What should I do to make sure my breasts are healthy before surgery?
Prior to breast reduction, a screening mammogram of each breast should be performed. In addition, a comprehensive breast health history and clinical breast exam is required.

What are some complications of breast reduction surgery?
Fat necrosis (a noncancerous formation of tissue) can cause calcium deposits and create a mass or lump. Calcium deposits that appear on mammograms are called microcalcifications, which may require a biopsy.

*Knowing this before the surgery, women can be prepared for the potential biopsy in the future. These benign, noncancerous changes are quite minor compared to the overall improvement that breast reduction can provide the appropriate patient.
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Breast Augmentation and Enhancement

Women who contemplate breast enhancement or augmentation should consider the risks and benefits of the surgery. First and foremost, the surgery to enhance the breast tissue is one that should be done as a personal choice and not to “please” someone else. With the exception of Poland’s Syndrome, congenital absence of the breast tissue, the only medical indication for breast augmentation is to create symmetry in a woman undergoing mastectomy (removal of the breast) and reconstruction.

Breast enhancement is a surgical procedure that is done as a same day surgery. The surgery requires general anesthesia, and this is typically the greatest risk of the surgery itself. There are many approaches to placing an implant to enhance the breast, but the most widely accepted method is placing the implant under the pectoral muscle so as not to interrupt the native breast tissue. Implants come in many varieties, from saline (salt water) to silicone gel to a silicone composite gel that does not leak. Several different incisions can be used to place the implants and this should be discussed with your surgeon. The placement of the incision may be altered if you need a lift (mastopexy) in addition to the implant placement.

Infection, implant rupture, capsular contracture (scar tissue around the implant) and leakage of the implant are the main complications of breast augmentation. The incidence of breast augmentation is on the rise around the world. For the most part, it is a well-tolerated surgical procedure. Women contemplating the surgery should carefully weigh the risks and perceived benefits to them prior to undergoing this elective cosmetic procedure.

Micromastia (genetically under developed) and post partum ptosis or “sagging” of the breast tissue are the major reasons women seek breast enhancement. Thousands of women undergo breast augmentation annually around the world and the numbers are on the rise. Surgical enhancement can be a safe procedure and should be performed by a board certified plastic and reconstructive surgeon. The implants should be placed behind the muscle in order to not affect future breast imaging.
Are breast implants safe?
Breast augmentation has come under tremendous scrutiny over the years. The controversy over the safety of silicone breast implants has created a stir in the medical and legal communities. Silicone implants were used for reconstruction and breast enhancement from 1962 until 1992. The fear of leakage, capsular formation and systemic autoimmune diseases had silicone implants taken off the market for 14 years, from 1992 to 2006. We are now, since November 2006, able to use silicone implants not only in reconstruction after breast cancer, but for the augmentation of micromastia in a healthy breast. There have been no studies linking breast implants with an increased risk of breast cancer or other breast diseases. The National Cancer Institute actually has published data to show a lower risk of breast cancer among patients with breast augmentation. (Women choosing to have implants on average have small breasts and overall lower body fat, which is likely the link to the decreased risk.)

Are implants associated with connective tissue disorders?
There was concern over the association of breast implants and the development of autoimmune diseases. A review of several large epidemiological studies of women with and without implants indicates that autoimmune or connective tissue diseases, such as lupus, scleroderma or rheumatoid arthritis are no more common in women with implants than those in women without implants. (FDA website)
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Benign Breast Disease

Breast disease can be divided into two main categories—benign (noncancerous) or malignant (cancerous).

One of the challenges for physicians is determining what breast problems stem from cancer and therefore require aggressive treatment, and what problems are not cancers and can be treated appropriately as such. This process often requires evaluation by a physician’s clinical exam in conjunction with mammography, ultrasound and MRI.

Most often a biopsy (small sample of tissue) is removed to confirm a diagnosis. Some noncancerous conditions are easily diagnosed and treated without a biopsy, but if there is ever a question, a biopsy is mandatory.
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Breast Pain

Breast pain, mastalgia or mastadynia, was the chief breast complaint in one study of HMO patients (1) and resulted in 47 percent of the patient visits for breast related issues. For most patients, breast pain is not incapacitating, but is an area of concern that does need to be given appropriate attention.

In order to affectively treat breast pain, the cause of the pain must be determined. The first step in the diagnosis and treatment of breast pain is a comprehensive history and physical. The first step is to rule out the life threatening condition of an underlying breast cancer or a significant breast infection.

Inflammatory Breast Cancer or Mastitis?

A mistake a woman can make is overlooking an acute change in her breast that she thinks is a breast infection and is actually an aggressive form of breast cancer called inflammatory breast cancer or IBC. Cancer is a rare cause of breast pain, but the fear of an underlying cancer diagnosis is usually the reason medical evaluation is pursued. IBC is a very aggressive from of breast cancer that may show up literally without warning. Urgent medical/surgical evaluation is needed. Although infections in the breast are far more common, cancer must be ruled out.

Signs and symptoms of IBC:

Rapid change in the breast
Breast color change (red, purple, pink or bruised
Thickness or heaviness
Edema (fluid in the breast tissue)
Warmth
Pain, tenderness or itching
A lump may or may not be present
Skin looks like orange peel
Swollen lymph nodes under the arm pit
Nipple flattening or inversion
Mastitis (infection)
Breast skin redness
Fever >38.3 C or 101 F
Edema or swelling in the breast
Overall fatigue or tiredness
Pain or tenderness
A lump may or may not be present that is red
Tender lymph nodes under the arm
Pus may drain from the breast
Any of these symptons can occur in women who are breast feeding and have an infection. They are not diagnostic of cancer but need to be evaluated to make certain that it is an infection and not cancer.

How is the diagnosis made?

Your doctor will ask you specific questions about the onset of the symptoms and then examine your breasts and arm pits.

You will likely be placed on an antibiotic by mouth while the diagnosis is being made, in case it is an infection. Antibiotics may be used for a 3 to 5 day course before a biopsy is performed to see if there is improvement in the breast tissue. If an infection has progressed to a point where there is a collection called an abscess, surgical drainage with a needle or incision may be necessary.

Inflammatory Breast Cancer or Mastitis

Alternatively, a tissue biopsy may be performed initially if the suspicion of cancer is high as this is necessary to make the diagnosis of breast cancer. (For the treatment of IBC, see Breast Cancer Treatment Options.)

Mastitis or breast infection is common in nursing mothers, and is easily treated with oral antibiotics, warm compresses and continued nursing or expressing of the milk. Rarely does an abscess need to be surgically drained.

Causes of Breast Pain

Non-Breast causes

Chest wall muscle strain
Costochondritis (inflammation of the rib joints)
Chest wall injury/rib fracture
CAD (Coronary Artery Disease)
Gallbladder disease
GERD (Gastroesophageal reflux disease)

Breast Causes

Mastitis
Cyst
Trauma
Mondors disease (inflamed vein)
Medication related
Prior breast surgery
Inflammatory breast cancer (IBC)
Scar tissue
Duct ectasia (dilated duct)

When does the pain occur?

Most breast pain is caused by changes in the level of active estrogen in the body. In determining the cause of breast pain, the pain quality, frequency and consistency of the pain must be determined. In order to treat the pain the underlying cause must be determined. Once an evaluation to exclude cancer is performed, the pain needs to be characterized to help to define the appropriate treatment.

True breast pain is usually within the central and upper regions of the breast. Musculoskeletal pain tends to be found between the breasts as they attach to the chest wall and toward the arm where the pectoral muscle attaches to the shoulder at the armpit. Non-breast causes of pain can usually be identified with a thorough medical history and clinical examination. Once you determine that the pain is coming from the breast, you need to figure out the pattern of the pain.

Is the pain non-cyclic (random) or cyclic (related to the menstrual cyclic)?

Non-cyclic

Constant or intermittent pain
No relation to menstrual cycle
1/3 of all breast pain
Complaint of women later in life
Unilateral and localized
May be related to excess body fat
Excess estrogen production
Unknown causes

Cyclic

Menstrual cycle related pain
Upper Outer Quadrant (UOQ) most involved
Radiates to axilla /arm
Diffuse / bilateral
Unknown causes

How can I get rid of my breast pain?
Once you determine the nature of the pain (cyclic vs. non cyclic), the treatments can be straightforward. If the cause of the pain cannot be determined and it is of unknown cause, oftentimes reassurance and supportive measures will alleviate the breast symptoms.

Cyclic Breast Pain

REASSURANCE that it is not cancer
Supportive measures
Bra mechanics
Heat / Cold therapy
Breast massage
Relaxation Techniques
It is normal to have these monthly changes

What other treatments are available?

Decrease dietary fat
Evening Primrose Oil -EPO
EPO 1.5 gm twice a day
Danazol,
Bromocriptine,
Tamoxifen
Dostinex

For severe breast pain that is non-cyclic and is negatively impacting a woman’s life, there are additional lifestyle changes and medications that can help to treat the symptoms. A decrease in overall dietary fat intake can greatly improve the severity of breast pain. Excess fat in our diet leads to excess circulating estrogen and therefore, stimulation of the breast tissue (2). Evening primrose oil (EPO) (gamma linoleic acid) restores the abnormal fatty acid profile in breast tissue, therefore decreasing the sensitivity of breast ductal cells to steroid hormones such as estrogen. Recommended dosages are 1.5 grams twice a day and it may take up to three months to see a decrease in the pain. If you have a seizure disorder, discuss this with your doctor as EPO can increase your susceptibility from seizures (5).

There are several different medications that are reserved for treatment of breast pain of the most severe form. When a woman complains, “Cut off my breasts I cannot stand the pain any longer,” there are medications that can be prescribed. Danazol, Bromocriptine, Tamoxifen and Dostinex may be used, and this treatment should be directed by a breast surgeon or gynecologist who is familiar with the risks as well as the benefits of each medication as the side effects can be quite significant.

Some suggested treatments have not been proven.

Caffeine restriction has been suggested to alleviate breast pain, but to date no randomized studies have proven that it makes a difference (4).Vitamin E, B1 and B6 have not been proven to improve breast pain when tested against placebo (sugar pills) (3).

Breast pain, for the most part, can be successfully treated with reassurance and supportive measures. One of the main reasons medical intervention is sought is to make sure there is no underlying breast cancer.

References

1. Mastalgia — Breast pain was the most common breast complaint a retrospective review of office visits for breast related issues. Forty-seven percent of breast-related visits were for the evaluation and treatment of breast pain. Barton et al. evaluated 2400 women over 10 year period (All enrolled in HMO) Ann Int Med 1999; 130: 651-657

2. Boyd et al randomized 21 women to low-fat diet (15 percent fat) vs. generalized diet (>36 percent fat). 90 percent in low-fat group had decreased breast pain vs. 22 percent in generalized group (p=.0023). Lancet, 1998; 2: 128-132

3. Surgery 1985; 97: 490-494

4. Surgery 1990; 107: 549-55

5. Surgery, 1982; 91: 263-267
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Nipple Discharge

Discharge from the nipple can be very concerning and there are a few basics that you need to know.

If a discharge is found on one side, is clear or bloody and comes out without stimulation, then evaluation by a breast surgeon is needed.

The breasts are created to produce milk, therefore it is normal for fluid to come from the breasts. The white milky substance produced in the breasts that occurs when a woman is not breastfeeding can be associated with other causes, therefore you need to be evaluated by your gynecologist if the white, milky fluid comes form your breasts when you are not breastfeeding.

If the fluid is green and only comes out of the nipple with stimulation, then is most likely the normal process of duct lubrication. It usually occurs in both breasts.

Nipple discharge needs to be evaluated with mammography, ultrasound, possibly a breast MRI and possible a ductography. If the discharge is concerning to your physician, a biopsy of the duct will be needed.
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Skin Change

Another sign that is often ignored is a change in the skin of the breast. Inflammatory breast cancer (IBC) is a type of aggressive breast cancer that my show up with the only abnormality being edema, or fluid in the breast, redness and/or pain. The diagnosis of IBC is made with a tissues biopsy. If you notice any of these changes, you should see a physician as soon as possible since infection and cancer are the two causes of this breast change and both require physician intervention fro treatment. (www.ibchelp.org)

My nipple has changed and looks funny?
There is a relatively rare (less than 1 to 2 percent) form of breast cancer called Paget’s disease. Although you could have eczema of the nipple, Paget’s disease must be considered. The first symptom is usually an eczema-like rash. It is a sign of a cancer underlying the nipple complex. It can be red, oozing or crusty. It is often not seen on the mammogram or ultrasound and often is found only with a biopsy.
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Breast Mass

Have a lump in your breast ?You wake one morning and find a lump in your breast.

Welcome to the roller coaster of breast disease. However, this process need not be frightening, as you are in control and you determine where you are going. What you need now is information.

Where do you begin this daunting task?
The most important thing to do is to get the answers to all of your questions. A mass in your breast will require further evaluation. An ultrasound is often required to further characterize a mass as solid, requiring biopsy, or cystic which may or may not require aspiration. A mammogram will be needed if you are over 35 or if your doctor feels it is appropriate to evaluate the mass.

There are also microscopic findings on mammograms, called microcalcifications, which may require spot magnification views (also known as a diagnostic mammogram). Depending upon the findings of your radiologic studies, you may be referred to a surgeon or radiologist for a biopsy or aspiration if it is felt to be a fluid filled cyst.

Most procedures to biopsy the breast can be performed in an outpatient setting, which will allow you to have the procedure performed more quickly. Oftentimes, an ultrasound or mammogram is used to guide your surgeon to the abnormal area of your breast.

If the lump in your breast is not apparent on any studies, it still needs to be evaluated and likely require a biopsy to determine whether it is or is not cancerous. Remember, 20 percent of all cancers are not seen on mammograms or ultrasounds; therefore, palpable masses with negative X-ray studies need to be thoroughly evaluated.

The bottom line with an abnormal mammogram, ultrasound, MRI or palpable mass is that a tissue biopsy is the gold standard to determine whether the mass is benign (not cancer) or malignant (cancer). If your questions are not adequately answered, get a second opinion.
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