Q: I have nipple discharge, should I worry?

A: It depends on what kind of nipple discharge you have. If you are on contraceptive pills, antihypertensive drugs or are using major tranquilizers such as thorazine or have been breast-feeding during the past year, your nipple discharge is hormone or drug induced. In other words, these conditions increase the level of prolactin, which causes nipple discharge. This occurs in both breasts and is often colorless or milky in appearance.

If you are not using any medications, you may be experiencing a condition called galactorrhea. This excessive or spontaneous milk flow may be due to a small tumor in the brain, which causes increased level of prolactin. This tumor can easily be removed by surgery.

In contrast, if your nipple discharge is spontaneous, persistent and occurs only in one breast and is bloody, then you may have to worry about the presence of a tumor. Fortunately, the majorities of these tumors are benign in nature and are called intraductal papillomas. Only 4% of cases are representation of a malignant tumor in mammary ductal system. Your physician can easily evaluate the cause of your nipple discharge and plan your optimal therapy.

Q: I occasionally experience pain in my breasts. Do I need to be worried about breast cancer?

A: It depends on how old you are and what type of pain you are experiencing. Breast pain is often called “mastalgia” and varies in severity and frequency. Mastalgia is the result of three different conditions; the most frequent type is cyclical pain, related to the menstrual cycle. The other two conditions are non-cyclical. Cyclical pain occurs before menstruation and continues until the period ends. This pain is the result of the influence of hormones on breast tissue, the breasts become tender and the level of discomfort varies in women from vague to complete intolerance. The exact reason of how hormones cause breast pain is not clearly understood, there is some evidence that stress affects the frequency and severity of breast pain by its impact on hormones. Cyclical breast pain can be felt differently and often disappears after menopause. Women who undergo hormone replacement therapy may still continue to experience breast pain. Breast pain may also be the first sign of pregnancy.
The other less common form of mastalgia is non-cyclical pain. This pain has no relation to the menstrual cycle and is generally felt in one spot of the breast. The most common reason for noncyclical pain is history of trauma to the breast.

The third kind of breast pain is not related to breast tissue, it is commonly experienced in the middle of the chest and has no relation to hormones. This pain is induced by joint inflammation in the chest midline (arthritis), called costochondritis. The severity of this pain changes by taking a deep breath. Other causes of non-breast pain can be attributed to neck arthritis or vein inflammation within the breast area, known as Mondor’s Syndrome.

Overall, breast pain is rarely associated with cancer. The simplest approach to breast pain management is the use of a supportive bra, anti-inflammatory medications, and pain analgesics. There is no generally agreed treatment for mastalgia, a qualified physician should individually evaluate every case.

Q: My mother is suffering from breast cancer and my aunt recently died of ovarian cancer. Am I at risk? Do I need genetic testing?

A: Naturally, you have strong family history of cancer and you are at higher risk to develop cancer compared to the general public. However, family history alone cannot reliably determine an accurate risk of hereditary cancer. Other risk factors should be taken into consideration and your risk for cancer needs to be determined by qualified professionals who have special training in risk assessment and genetic counseling.

The majority of breast cancers are sporadic (non-hereditary) and are not associated with any known risk factors. Only a small percentage of breast cancers are genetic; BRCA1 and BRCA2 are the primary causative genes for hereditary breast and ovarian cancer. Individuals who carry these genes are at increased risk for cancer development.

Genetic testing is an appropriate method for diagnosing hereditary cancer risk and you may benefit from the information provided by this test. However, there are still many unanswered questions about interpretation of BRCA test results. It should be noted that a negative BRCA test result does not entirely exclude the possibility of having another breast cancer gene and the risk of subsequent cancer development.

Positive results should be carefully balanced against available risk reduction modalities and appropriate measures should be taken to choose the best option on an individualized basis. Early identification of hereditary breast and ovarian cancer provide an opportunity for selection of the best available preventative plans. These options include increased surveillance, chemo-prevention and prophylactic surgery.

Increased surveillance includes regular self and clinical breast exams and mammography. The recommended surveillance for ovarian cancer is transvaginal ultrasound and serum tumor marker CA-125 on either a 6 month or yearly interval. Chemoprevention is another alternative; chemo-preventive agents, such as tamoxifen, reduce breast cancer risk in women with BRCA mutations. Oral contraceptives are also associated with a significant risk reduction in ovarian cancer in BRCA carriers. Prophylactic surgery such a mastectomy and removal of the ovaries also reduce the risk of breast and ovarian cancer. These preventive measures can significantly lower the chance of breast cancer and ovarian cancer in high risk individuals.

Currently, genetic testing requires pre-authorization by many insurance companies, if coverage is denied the patient is ultimately responsible for payment. Federal and state laws have provisions for privacy of patients who undergo genetic testing; these laws prohibit health insurance discrimination as well.

Q: I just had a mammogram which showed areas of microcalcifications. Do I have cancer? What should I do next?

A: It depends on the type of microcalcifications in your mammogram. Fortunately, approximately 80% of microcalcifications are not associated with cancer. Microcalcifications are the result of calcium deposition within different areas of breast tissue and are commonly the result of gradual changes that occur with the aging process. Benign microcalcifications have special characteristics that can be recognized by radiologists. In the absence of significant risk factors for breast cancer, the majority of cases only require regular follow up.

Microcalcifications associated with malignancy are different in shape, size and the pattern of their appearance. Malignant calcifications are small, tightly clustered and follow the pattern of the mammary ductal system. Any suspicious mammographic microcalcifications require tissue sampling by either core needle biopsy or open biopsy. The choice of tissue sampling is often determined by the extent of mammographic calcifications and their location within the breast. If microcalcification is seen only in a small area, the exact location can be identified by image-directed core needle biopsy and the area can be sampled sufficiently. Core needle biopsy is considered a minimally invasive procedure which is easily tolerated and is currently the most common approach for tissue sampling. Core needle biopsy is an office procedure and does not require general anesthesia.

Another method of tissue sampling for mammographically detected microcalcification is called “Needle Localization Excisional Biopsy.” This is an open biopsy procedure which first requires insertion of a wire as a tracer into the suspicious microcalcification area by a radiologist. This procedure is then followed by a visit to the operating room where a surgeon removes the abnormal area and sends the tissue to a pathologist for further analysis. Needle localization excisional biopsy is the preferred procedure in situations where there is more than one area of microcalcification on the mammogram. In this circumstance, the entire area has to be removed in order to better determine the nature of the abnormality within the breast.

Further management and treatment planning depends on the diagnosis rendered by a pathologist. It should also be noted that about 5-10% of core needle biopsies do not provide sufficient tissue samples which are necessary for a pathologist to render an accurate diagnosis. In these cases, needle localization excisional biopsy is the final alternative.

Q: My twin brother was just diagnosed with breast cancer. Can breast cancer occur in men? What are my chances of getting breast cancer?

A: Breast cancer occurs in males however, the incidence is much less than in women. The most common symptoms of male breast cancer are a lump in the breast, abnormality seen in the nipple area and/or nipple discharge. There are also benign lesions such as intraductal papillomas that may present with similar symptoms. Bilateral breast enlargement called “gynecomastia” may reflect endocrine abnormalities related to estrogen metabolism or appear as the result of endocrine therapy for prostate cancer. Rarely, metastatic tumors from other sites such as the prostate can appear as a breast mass in elderly males.

The breast cancer types that are seen in men are of ductal origin and behave similarly to those that occur in women. If male breast cancer is detected at an early stage, survival is comparable to that of women. However, breast cancer in men is often detected at a more advanced stage. This is primarily due to the fact that most men are not aware that breast cancer can also affect them.

The treatment options for men with breast cancer are similar to treatments used in women. Risk factors for male breast cancer include family history of breast cancer, carrying breast cancer genes and estrogen treatment for sex changes. Conditions such as chronic liver disease including cirrhosis, which causes impairment of estrogen metabolism and higher serum estrogen levels may contribute to the development of breast cancer in men.

In response to your inquiry about your risk for development of breast cancer, it is clear that you are at higher risk compared to the general population. It is likely that you share very similar genetic backgrounds with your brother and you are more susceptible to be affected with similar diseases. It is critical that you undergo appropriate risk assessment by referring to a qualified physician and plan a comprehensive surveillance follow up program in order to ensure early detection of this disease.

Q: I am a newly diagnosed breast cancer patient and my surgeon wants me to choose between total axillary dissection and sentinel lymph node biopsy. What is the real difference between these two procedures?

A: Axillary lymph nodes are the lymph nodes that are located under your arm. They are small and round structures that are part of the immune system and are designed to protect the body against disease. They are also the site of tumor metastasis. This means that when breast cancer spreads, axillary lymph nodes are the first place that the tumor cells reside. The status of tumor spread into the lymph nodes is the most well-established predictor of the outcome of breast cancer patients. It also directs the extent of therapy. Presence of tumor cells in axillary lymph nodes requires more aggressive therapy. Assessment of the presence or absence of tumor cells in axillary lymph nodes requires surgical sampling of the nodes. This can be achieved either by removal of the entire axillary lymph nodes called total axillary dissection or by removing the first few nodes known as sentinel lymph node biopsy. Totally axillary dissection is occasionally associated with the some degree of morbidity such as lymphedema and/or pain or altered sensation. Lymphedema is swelling caused by the build up of lymph fluid, and causes a sensation of heaviness and discomfort to the patient.

Sentinel lymph node biopsy involves removal of only a few lymph nodes. Sentinel lymph nodes are identified by a tracer such as blue dye or radioactive material which is injected by a surgeon around the original tumor. The idea is to identify which lymph nodes the breast tumor drains into. The sentinel lymph node is analyzed by a pathologist to determine if any tumor can be found. When there is evidence of tumor cells in the sentinel node, the surgeon proceeds to total axillary dissection.

Sentinel lymph node biopsy is less invasive than total axillary dissection and is associated with minimal morbidity. Sentinel lymph node biopsy is now gradually replacing total axillary dissection and in experienced hands, it has been found to adequately predict the state of axillary lymph nodes in about 95% of cases. This surgery is new and is still under investigation. If you decide to undergo sentinel lymph node biopsy, please make sure that the procedure is performed by a surgeon who has sufficient experience in the procedure.

Q: I am a 60-year-old woman and have done self-breast exams every month for the last ten years. Last month I was diagnosed with a 2 cm breast cancer lesion, which was found by my doctor during a routine visit. How did I miss the cancer? What is the value of a breast self-exam?

A: Your story is not unique. Many women experience the same level of disappointment when they develop breast cancer despite their personal efforts in following the established recommendations. A self-breast exam is one of those casually developed recommendations as a life saving modality. Currently, there is no scientific evidence to support the highly exaggerated value of breast self exams.

Several clinical trials, including the famous Shanghai study in 1997, have clearly shown there is no association between practice of a self-breast exams and an improved mortality rate from breast cancer. In this study 267,040 women from 520 industrial workplaces were randomly divided between those who were instructed to perform self-breast exams versus those who did not. These women were followed for the development of breast cancer and for death from breast cancer. The study results indicated the incidence of breast cancer cases was approximately equal in the two groups. In addition, it was found that individuals who did develop cancer in the self-breast exam group were not diagnosed at an earlier stage and the breast lesions were not smaller compared to the other group. Furthermore, the mortality rate in the two groups was the same.

This finding has been supported by other studies such as the one conducted by the World Health Organization. These studies show that breast self-exams are not a very effective tool to detect breast cancer. It is clear that by the time one finds a lump, the cancer has been in the breast for many years and a few months in earlier detection does not make a huge difference in the clinical outcome.

A self-breast exam alone does not save lives, however when combined with a yearly clinical breast exam by a qualified physician may increase the chance of detecting small tumors. Detection of smaller size tumors allows better cosmetic results if a woman chooses the option of conservation therapy. At the present time, the best approach to detect early stage breast cancer is to undergo a yearly mammogram and a clinical breast exam. Self-breast exams alone may create a false sense of security and delay referral for yearly clinical breast exams.

Q: I have a 1.5 cm cancer in my right breast. I would like to undergo breast conservation therapy and keep my breast, but my surgeon advises me to remove both of my breasts. I am only 55 years old and the only one in the family with breast cancer. Do I really need such a drastic therapy?

A: The answer to your question is simply no. You are right in your decision to remove your right breast cancer by a surgical procedure called “lumpectomy” followed by radiation therapy. The overall long therm outcome of this approach is the same as if you totally remove your breast via “mastectomy”. In respect to your other breast, you are now at slightly higher risk compared to the general population to develop a new cancer in your left breast. However, in the absence of any detectable abnormality in this breast and without any other significant risk factor, it is not justified to consider a preventive/prophylactic mastectomy.

Bilateral prophylactic mastectomy is a disfiguring procedure and often is associated with an adverse psychological impact. In addition, despite general assumption this procedure does not totally eliminate the possibility of developing breast cancer. Surgically, it is not possible to remove all the breast tissue by the procedure and the reports in the literature have demonstrated that prophylactic mastectomy does not guarantee a lifetime breast cancer risk-free status. Therefore recommending a bilateral prophylactic mastectomy should be based on a well-balanced risk-benefit analysis by a team of qualified physicians and with complete acceptance from the patient.

Bilateral prophylactic mastectomy, especially if it is not followed by reconstructive/plastic surgery is a life-changing experience and should not be considered because of induced fear to the patient or because of any financial incentive. On the other hand, bilateral prophylactic mastectomy is an effective tool in management of very high-risk individuals such as those who carry breast cancer genes. These women will definitely benefit from this preventive measure. Remember, however, that if you choose breast conservation therapy for your right breast cancer, you need to undergo regular clinical breast exams and mammography in order to reduce the chances of missing any recurrence or new cancer in either of your breasts.

Q: I am a newly diagnosed breast cancer patient recovering from my surgery. I am told that I need chemotherapy. What is the benefit of chemotherapy?

A: Chemotherapy is administration of anti-cancer drugs, which are designed to destroy tumor cells. This is a systemic therapy, which may result in a better outcome in breast cancer patients. However, the degree of benefit from chemotherapy is different in different patients. The age of the patient, the type of the tumor and the presence or absence of lymph node involvement influence the degree of benefit from chemotherapy. In addition, when the tumor spreads beyond the lymph nodes and shows distant metastasis, the type and the effect of chemotherapy may change. Generally, chemotherapy is given after surgical therapy and often to those patients whose tumors are aggressive and the lymph nodes contain tumor cells.

Another form of chemotherapy called neoadjuvant chemotherapy is given before surgery and after making the diagnosis of cancer by a needle biopsy. The added advantage of this approach is that we can find out whether the tumor cells are sensitive to chemotherapy, which is important information for optimal management. In addition, neoadjuvant chemotherapy may result in reducing the size of the tumor, which impacts the options for surgical therapy. Smaller sized tumors are more amenable to lumpectomy in women who would otherwise need a mastectomy.

In your case, you apparently have already undergone surgical therapy and your physician has determined that because of the characteristics of your cancer you need chemotherapy. At this point, it is critical that you learn about the nature of your cancer, the stage of your disease and ask your physician to provide you with a realistic picture of the risks and benefits of the therapy that he/she has designed for you. This is the only way that you can make a decision that feels right for you. You may also consider getting a second opinion. Based on the available evidence, the treatment of breast cancer is somewhat subjective. You are entitled to consult with other experts aside from your own physician and explore other options. There are always new ways of treating breast cancer and you may benefit from different alternatives.

Q: “What should I do if I find a lump in my breast?”

A: Breasts are glands that are continuously under the effects of hormones and are considered an integral part of a women’s reproductive system and are a symbol of her sexuality. Breasts are primarily made of fat and mammary ductal-lobular units. Like branches of a tree, the lobules make milk and the ductal units deliver it to the main breast ducts which open to the nipple. The size of the breast is genetically determined and it has no relation to the incidence of breast cancer. Breasts undergo changes in size during the menstrual cycle and pregnancy and undergo atrophy during old age. Breast tissue generally has a texture that varies from person to person, familiarity with your breast texture and appearance can help to identify any significant changes in a timely fashion. Any palpable lump or any other change in your breast requires attention of your physician. Fortunately, the majority of breast lumps are benign in nature. However, it is difficult to reliably exclude the possibility of cancer by clinical examination only. The best way to determine the nature of a breast lump is for you to ask your physician to have the lump sampled by a biopsy procedure and have the biopsy examined by a pathologist. The knowledge about the nature of your breast disease will eliminate your anxiety and will accelerate the course of your therapy.

Q: What are the signs and symptoms of breast cancer?

A: Breast cancer presents itself in a variety of shapes and forms. The most common presentation of breast cancer is the appearance of a palpable breast mass. The mass can be found by the patient and/or partner or by a physician during physical exam. It is frequently irregular and firm in palpation and occasionally can be fixed to the underlying tissue. Rarely breast cancer is associated with breast pain. Unilateral bloody nipple discharge may occasionally be the first presentation of breast cancer; other signs include nipple retraction, skin ulceration, and a change in the color of the skin of the breast or a change in shape of the breast. In advanced cases, there are palpable nodules in the armpit which represent axillary lymph node involvement by the tumor.

Breast cancer can also be non-palpable and seen only by screening mammography and/or ultrasound. Regardless of how an abnormality is detected, the lesion has to be appropriately sampled and examined by a pathologist. Palpable breast lesions can be sampled by “Fine Needle Aspiration Biopsy” which involves insertion of a small needle into the mass used for retrieval of cellular material for further microscopic evaluation. This is the most cost effective procedure to sample a breast lesion and also has the advantage of providing a rapid bedside diagnosis. Fine Needle Aspiration Biopsy has to be performed and interpreted by an experienced pathologist. Another minimally invasive sampling procedure is “Core Needle Biopsy” which uses a larger size needle and is often used for non-palpable breast lesions. Core needle biopsy provides a tissue diagnosis and requires a wait period for the results. Occasionally surgical biopsy is further required to establish an accurate diagnosis of a breast mass. When the diagnosis of breast cancer is established it is important for the patient to understand the course of her/his disease and to find the best options for therapy. It is imperative to find the most knowledgeable team of breast physicians who understand the value of a multidisciplinary approach to breast cancer.

Q: I Have Just Been Diagnosed With Breast Cancer, Will I Have To Loose My Breast?

A: Planning of breast cancer therapy is influenced by many factors: these include the size, the type, and other characteristics of the tumor as well as the choice of the patient. Traditionally mastectomy, which is the removal of the entire breast, was the only surgical approach as the initial therapy. In recent years however, this trend has changed. Clinical trials by distinguished scientists both from Europe and the United States with over 20 years of clinical follow up have shown that patients undergoing conservation therapy experience the same outcome as those who choose mastectomy.

Conservation therapy involves removal of the tumor with a rim of normal breast tissue called “lumpectomy” followed by radiation therapy. Conservation therapy is particularly suitable for small tumors and for patients who choose to keep their breast. Conservation therapy has to be managed by a team of knowledgeable physicians who are able to remove the entire tumor with clear surgical margins and also offer the state of the art radiation therapy. For large tumors, it may be essential to involve an oncologist to consider pre-surgical chemotherapy in order to shrink the tumor before surgery. This approach is associated with a better chance of removal of the entire tumor and a better cosmetic result.

In a small percentage of cases, such as the presence of several foci of tumor in a breast or if a patient cannot tolerate radiation a mastectomy may still be the only option for surgical therapy. Women with very large tumors and very small breasts may not be a suitable candidate for breast conservation therapy. Other barriers to conservation therapy are related to regional, racial, or socioeconomic bias, lack of radiation therapy facilities or the surgeon’s personal preference for mastectomy.

Making the right choice is your right. This is only possible if you are empowered with sufficient knowledge about your breast cancer in order to make an informed decision. You need to fully discuss your options with your physician by asking the right questions.