Breast Cancer Resources

American Cancer Society® Guidelines for Breast Health
Breast Discharge
Breast Lumpiness
Breast Pain
Brest Self-Examination (BSE)
Core Biopsy
Compression
Cysts
Dense Breasts
Fibroadenoma
Fibrocystic Changes
Lymphedema
Microcalcifications

The American Cancer Society® Guidelines for Breast Health

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The American Cancer Society® regularly issues screening (early detection) guidelines for various cancers to provide guidance to women and health care providers on the methods and tests available, appropriate screening intervals, and new developments. In May 2003 the ACS published an update of its 1997 guidelines for breast cancer screening. The new guidelines are based on a careful review of all studies of the various methods used in the early detection of breast cancer. These breast cancer early detection guidelines represent the most current scientific evidence and expert opinions. These include breast self-exams (BSE), physical breast examinations by doctors, mammograms, and newer technologies, including ultrasound and MRI.

The American Cancer Society’s® Recommendations

• Yearly mammograms are recommended starting at age 40
• Clinical Breast Exams (CBE) should be part of a periodic health exam, about every three years for women in their 20s and 30s and every year for women 40 and older
• Women should know how their breasts normally feel and report any breast change promptly to their health care provider. Breast Self-Exam (BSE) is an option for women starting in their 20s.
• Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (i.e., breast ultrasound and MRI), or having more frequent exams.

 

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Breast Discharge

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Some women experience a clear to milky color discharge from their breasts right before the start of their monthly cycle or at the beginning of their menstrual period. This type of discharge is not unusual. It may also be noticed after sexual stimulation or when women begin taking estrogen supplements. The medications listed on this page have also caused some women to experience breast discharge. An occasional small amount of discharge from both breasts is not abnormal. However, if this discharge continues throughout the month, comes from only one breast or has any evidence of blood, contact your physician.

 

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Breast Lumpiness

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The breasts are very complex glandular organs that consist of 15 to 20 lobes that radiate from the nipples. These lobes further divide into 20 to 40 lobules that contain 10 to 100 alveoli where the milk or fluid is produced in the breast. This whole glandular structure is changing constantly because of the stimulation of estrogen and progesterone hormones on the breast tissue. When the stimulation begins after the menstrual period, the breasts respond by beginning to fill with fluid. Each breast will produce and store between 15 to 30 ccs (3 to 6 teaspoons) of fluid in the ducts during the month. This causes a feeling of lumpiness, especially right before a menstrual period. The hormonal influence also causes extra layers of cells to be produced in the ducts.The combination of these two causes an increase in the size of the breasts and possibly tenderness or pain.

Some drugs routinely prescribed by a physician can cause some women to experience lumpiness, fullness and tenderness in the breast tissues. This type of lump feels very similar to those produced by hormonal changes in the body. The changes are not harmful but the causes may confuse you or your physician.

When you check your breasts before your menstrual period, they will feel differently than at the end of your period. Therefore, it is very important to examine your breasts on a regular basis at the same time of the month; the best time is at the end of the cycle. The increase in cells and fluid in the breast will often cause them to feel lumpy. If you find a lump in the breast, feel the opposite breast in the same area for a similar change. If one is found, you probably have discovered a normal hormonal change. It is safe to wait and go through a menstrual period and re-check the same area. If the area is smaller or softer at your second self-exam, then it has been stimulated by hormonal changes that are normal. If the lump has not become softer or smaller, a physician will need to evaluate the area. Every women has a normal pattern or lumpiness and bumpiness in her breast tissues. Only through regular self-exams can a women get to know this pattern of lumpiness in her own breasts. A physician examining the breasts once a year will not be able to learn the individual patterns of breast lumpiness.

 

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Breast Pain

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Breast pain is very common. Most women experience some degree of pain, tenderness or aching. For some women the pain is mild and barely noticeable. However, other women may find the pain very uncomfortable, causing annoyance and anxiety. Breast pain may be experienced in both breasts, only one breast or in a specific area of a breast.

There are several causes for breast pain. The most frequent cause is cyclical hormonal changes. Normal breasts responses to the surge of estrogen just before the menstrual period include: tenderness, shooting pain, aching and increased generalized lumpiness. These responses occur about one week prior to menses and usually dissipate with the end of your menstrual cycle. Women may experience cyclical pain in both breasts, although some may find one breast is more painful than the other. Many times hormonal replacement therapy will simulate natural hormonal responses and therefore cause breast pain.

Pain may be aggravated by certain substances in the diet. Caffeine along with the herbs Ginseng and Dong Quai have often been associated with breast pain. Some medications, particularly those used to treat hypertension and heart disease, may cause sensitivity and pain in the breast. Woman who smoke tend to experience a higher incidence of breast pain. The nicotine in cigarettes narrows the blood vessels above the waist in women, contributing to breast pain. Injury to the breast may cause short-term tenderness and pain. Commonly, women will experience some bruising at the affected area. As discoloration decreases, the pain usually subsides. There is no increased risk of breast cancer from trauma.

It is important to provide proper fit and style of brassieres. Experiment with different styles and non-underwire bras to find the one that works best.

Many of our patients have found some relief from their breast pain by using one or a combination of the following suggestions:

• Vitamin E 200-400 I U/daily
• Reduction of caffeine intake
• Anti-inflammatories (Advil, Aleve, Aspirin)
• Eliminate smoking
• Evening Primrose Oil, 3 Capsules/daily
• Very warm compresses
• Decreasing intake of Ginseng and/or Dong Quai

These measures may take up to a month to be effective.

Estimates indicate 90% of women experience some degree of breast pain at some point in their life. Breast pain is not a specific marker for cancer and most commonly is caused by some of the reasons mentioned earlier. This pain may be uncomfortable and disconcerting, but is manageable. Hopefully, this information sheet will be helpful and provide some assistance in your management of breast pain.

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Breast Self-Examination (BSE)

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The following should be performed once a month.

Inspection Exam

• While standing in front of a minor, look at your breast for any changes in appearance. Look for changes such as dimpling of the skin, puckering or swelling or redness of the breast.
• Visual inspection of the breast in this manner should be done with arms over your head, hands placed firmly on the hips pressing downward and leaning forward toward the minor with hands on hips. These three positions allow inspection of the breast at different angles to provide a thorough visual examination of the breast.

Physical Exam

• While lying down on your back, place a pillow under your right shoulder. Rest your right arm above your head.
• With the finger pads of the three middle fingers on your left hand begin performing your exam on your right breast.
• Move over the breast using one of three patterns: (A) Vertical strip - is the method of up and down strokes beginning near the armpit and working toward the center of your chest; (B) Circular - using this pattern begins at the armpit continuing in a circle pattern until reaching the nipple areolar complex; (C) Wedge - beginning at the armpit examining from the outer portion of the breast to the nipple using a spoke pattern until entire breast is covered.
• Customarily the vertical strip pattern of search is considered the easiest to perform and provides for thorough examination of the breast. However, it is important to continue to use the pattern you choose routinely to provide for consistency when examining the breast.
• When examining the breast apply three pressures- light, medium and deep with your finger pads. These three distinct pressures afford the opportunity to discover areas beneath the skin and to the chest wall.
• Now alternate the exam for your left breast.
• It is preferable to do your exam while lying down, however many women choose to do their self breast exam while showering. If this is your choice, soap will assist in the hands gliding more readily across the breast.

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Core Biopsy

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Core Biopsy

This is a procedure in which a small nick is made in the skin after local anesthetic is administered. A needle is then placed into the breast and positioned so that the tip of the needle is centered in the lump or mass. Ultrasound is often used to assure the correct location of the needle. Once in position, the biopsy part of the needle is activated and a distinct sound is heard. The needle is then withdrawn. This part of the procedure may be repeated a number of times in order to obtain an adequate sample to send to the pathologist.

Stereo Core Biopsy

This is a procedure for a small, hard to feel lump, mass, or calcifications. While the breast is compressed, a nick is made in the skin after local anesthetic is administered. A needle is then inserted into the breast and is positioned so that the tip of the needle is centered at the site of the mass or calcifications. Mammographic X-ray views are taken to assure the correct location of the needle. Once in position, the biopsy part of the needle is activated and a distinct sound is heard. The needle is then withdrawn. This part of the procedure may be repeated a number of times in order to obtain an adequate amount of tissue to send to the pathologist.

Post-core Biopsy Instructions

• The biopsy site and Steri-Strip should be kept dry for the first 24 hours.
• The ice pack you have on top of the pressure dressing is reusable. You may remove it when you arrive home and place it in the freezer. If discomfort should arise, you may place it inside your bra over the dressing.
• Remove the pressure dressing the next morning after the biopsy.
• Remove the Steri-Strip five (5) days after the biopsy. You may bathe your breast carefully with the Steri-Strip in place. Be careful not to loosen it. If the Steri-Strip should happen to come off before it is supposed to, you should then apply a clean Steri-Strip to the biopsy site. You might try taping a piece of plastic wrap over the biopsy area before bathing to keep it dry.
• We have applied a topical antibiotic ointment on top of the Steri-Strip, unless you indicated a possible allergy to it. You may apply antibiotic ointment to the biopsy site as needed; it promotes better healing of the site.
• You may have discomfort, and you may have some bruising where the needle entered the skin, or where the breast was compressed during the biopsy. Applying moist heat 24 hours after biopsy will help with bruising.
• If you need medication for discomfort, take acetaminophen products such as Tylenol only, no aspirin or ibuprofen. DO NOT TAKE ASPIRIN FOR 24-48 HOURS!
• You may return to work or other activities on the day of your biopsy as long as no heavy lifting or strenuous physical activities are required. On the day following your biopsy, all activities, except swimming, should be well tolerated.
• Watch for excessive bleeding, pain, redness around the biopsy site, or fever. If any of these occur, please call our office.
• Someone from our office will try to call you on the morning after your biopsy. If you have any questions or problems that arise after your biopsy, please call our office at (865) 584-0291.
• It generally takes 48 hours to get a report from the Pathologist. We will call you as soon as we receive it.

Follow-Up After Biopsy

Your doctor has discussed with you how and when you are likely to receive your results. At the time you receive your results, they will be explained to you and a recommendation for one of the following options will be made and the reason explained; 1) Follow up with X-rays and/or ultrasound; 2) Repeat needle or mammotome biopsy; 3) Surgery

Follow-up after a benign biopsy is very important. Your biopsy procedure consisted of a needle which only sampled a portion of the abnormality. There is a small but definite risk that the area sampled is not representative of the area as a whole. If your biopsy result is benign (non-cancerous), it is of vital importance that you continue with your follow-up visits as recommended to you to confirm the original diagnosis. You share responsibility in keeping your follow-up appointments since we may not be able to contact you if you move or if your notification gets lost in the mail.

Please do not hesitate to ask any questions you may have about your follow- up examination.

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Compression

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Many patients have asked why there has to be so much compression for a mammogram. The issue of compression is a sensitive one. Here are some facts to keep in mind:

• Compression spreads out normal breast tissue, enabling the Clinical Breast Radiologist to detect smaller lumps.
• Compression immobilizes the breast, resulting in exquisite detail on the mammogram again enabling the Clinical Breast Radiologist to identify the smallest abnormalities related to any early cancer.
• Compression decreases the thickness of the breast, which results in a smaller dose of radiation.
• Compression helps in pulling the breast tissue forward away from the chest wall, resulting in a mammogram which includes the maximum amount of breast tissue. If it is not included in the mammogram, the Clinical Breast Radiologist won’t see it!
• Compression results in brief discomfort, but no matter how uncomfortable you may feel, it has never been shown to damage the breast tissue.

We realize that many of our patients have breast tenderness which can be worsened by the mammogram. We make the following recommendation:

• Schedule your mammogram for the week following your menstrual cycle; the time when breast tenderness is normally the least.
• If you have severe, unremitting tenderness, take Tylenol or ibuprofen just before your arrival.
• Please inform the Mammography Technologist if you are experiencing pain while she is positioning the breast for the mammogram. Our Mammography Technologists are more than willing to work with you to minimize any discomfort in having a mammogram.

Despite our best efforts, we know that most patients experience discomfort during the mammogram. The discomfort should be brief. If any pain is experienced, you are encouraged to bring it to our attention so we can work with you, or reschedule the mammogram when your overall tenderness is less.

Bruising is an unusual but known complication of mammography, and tends to occur more frequently in elderly patients with fragile blood vessels in the skin; this is not detrimental to the breasts. Compression, no matter how uncomfortable it may be, does not damage the breasts.

We appreciate our patients’ willingness to undergo an annual examination for early detection of breast cancer, and we want to work closely with you to make that experience as comfortable as possible.

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Cysts

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Breast cysts are fluid-filled collections enclosed by a membrane. They are not related to cancer! The special cells in the membrane lining the cyst are responsible for making the fluid and they can also absorb this fluid. Therefore, a cyst can get larger, stay the same, get smaller or go away by itself. If cysts appear on the mammogram, they can change the way the mammogram looks from year to year.

The cysts in the breast are usually not related to cysts elsewhere in the body (such as on the ovary or in the skin). If a breast cyst is close to the skin and large enough, or hard, it can be felt with our fingers. Often with breast ultrasound, we see many more cysts than we are able to feel. Not all the lumps we feel in the breast will be cysts! Breast tissue is normally lumpy. So often we are just feeling normal breast lumpiness when we encounter that “pebbly” texture. Breast ultrasound is invaluable in telling us what we are feeling.

Breast cysts can appear at any age — in teenagers to 90-year-olds. However, we find the most cysts in 40-year-olds. This implies that cysts are related to the increasing hormone irregularity at this age, but this is not the whole story, as they are still seen in women with no hormonal stimulation. We do see more cysts in postmenopausal women on synthetic hormone replacement (estrogen) then in those women who are not taking hormones after menopause. We know of nothing in the diet that affects cyst formation or growth. There is a common misconception that caffeine causes cysts. This is not true! Caffeine may cause breast discomfort, but will not cause cysts.

Often, a woman will notice a sore spot in her breast and start touching that area more carefully. Because breast tissue is normally lumpy, sometimes it will feel like there is a lump in that sore spot. Our patients (and sometimes their doctors) often assume that they have the pain from a cyst in that area. While pain and cysts are often indirectly connected (both can be caused by hormones), the vast majority of cysts do not cause pain, and the vast majority of breast pain is not related to cysts!

Breast ultrasound is the best way to evaluate breast cysts because it is so very sensitive to seeing fluid in the tissues. It tells us if the lumps we feel are cysts or solid, or just normal breast tissue. It shows us cysts that are even smaller than 1/8 inch. Only breast ultrasound can tell us if a lump we are feeling on physical exam is a cyst or if a nodule we see on the mammogram is a cyst. Breast ultrasound also has the ability to show us the lining of the cyst and its contents. If these meet our requirements for a simple cyst, it is guaranteed to be unrelated to cancer. If the lining is irregular or there is debris in the cyst, the ultrasound is not sufficient to evaluate the cyst and the fluid needs to be aspirated (drawn out with a needle) to examine the fluid itself under a microscope. Even in this situation, the vast majority of complex cysts will be unrelated to cancer. The debris is usually caused by the lining cells falling off into the fluid and releasing particles and gooey protein contents.

Cyst aspiration is a quick and simple procedure when done with ultrasound guidance. The skin is numbed with a topical anesthetic, and a needle is quickly inserted. Suction is applied and the fluid is drawn into a syringe. Most cysts will disappear and never return. Some cysts (less than 25%) will come back, but that does not mean that there is anything wrong with the cyst. Cyst aspiration is done for diagnostic purposes, as described above, and also for relief of discomfort that may be caused by a cyst and/or anxiety from cysts that can be felt.

Having cysts does not mean that you have “fibrocystic disease.” Cysts are so common that almost every woman will have some at some point in her life. It does not mean that she is at a higher risk for developing cancer. Many of our patients need multiple cyst aspirations every year when they visit us, but after a few years the number of cyst aspirations decreases.

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Dense Breasts

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This section describes the meaning of the term “dense” breast on a mammogram. Radiologists describe a mammogram as having a dense pattern if they see more white than gray on the mammogram. The reason this is important is that lumps are more difficult to see on a dense (white) mammogram. Here at the Knoxville Comprehensive Breast Center, we routinely supplement dense mammograms with physical examination and ultrasound to make up for the lowered sensitivity of the mammogram in the case of the dense breast. The following questions are frequently asked by our patients:

Am I abnormal if I have dense breasts?
No. The density of the breast is an individual characteristic like hair color or height. Young women tend to have dense breasts, but 25% of young women do not have dense breasts. Older women tend to have more of a fatty, or low density, mammogram, but 25% of older women will have extremely dense breasts. Women often convert from dense to intermediate to low density during the course of their lifetime, but it occurs at a different rate and at a different time for each woman. The density of the breast reflects the amount of fibroglandular tissue in the breast relative to the fatty tissue. Also, the amount of fluid retention in your breast at the time of the mammogram can affect the density. Density can therefore change with pregnancy, lactation, menstrual cycle, weight gain/loss, hormone use, surgery, radiation therapy and age. Having dense breasts does not mean you have fibrocystic disease! Please refer to the section on fibrocystic changes if you have more questions about that.Back To Top

Are my dense breasts caused by diet?
No. As discussed above, your individual characteristics and hormonal status can affect your breast density. Losing weight may increase your breast density if you lose more than 20 pounds, but individual items in your diet do not significantly affect breast density.

If the mammogram is less sensitive for dense breasts, do I still need yearly mammograms?
Yes. Although the mammogram of a dense breast may not show lumps as clearly as the ultrasound, it is still the best way we have of looking for microcalcifications. Most microcalcifications are part of normal aging in the breast. If microcalcifications are present in a tumor, they can be the smallest, earliest sign of some cancers that we can identify. Fortunately, they show up on mammograms better than on any other test we have available to us today, no matter how dense the breast is! For that reason, we still recommend yearly mammograms in women age 40 and up and, in certain situations, in younger women.

Is it dangerous to have dense breasts?
No. Having dense breasts does not mean you are at a higher risk than anyone else of developing breast cancer. If you have dense breasts, however, you have a higher chance of a lump not showing up on your mammogram. This can be compensated for by a thorough breast examination and breast ultrasound. The ultrasound detects lumps hidden by overlapping normal breast tissue on the mammogram. It does this in two ways. First, it shows the breast in a straight line from the skin to the chest wall with no interference from what might be on top of or next to an area of interest. The mammogram is a composite picture, with overlap from side-to-side or top- to-bottom, but the ultrasound shows us a cross-section with no overlap.

Also, the ultrasound looks at a different physical property of tissue: its fluid content, not how X-rays pass through tissue. Fluid-filled structures show up darker than surrounding tissue on ultrasound, instead of the same shade of white as the surrounding tissue on a mammogram.

What if my doctor feels a lump and it doesn’t show up on the mammogram?
This is not a rare situation. The ultrasound is an excellent way to check if a physical finding is not showing up on the mammogram because it is part of normal lumpy breast tissue or because it is hidden by dense breast tissue. As discussed in question #4, ultrasound detects abnormalities by difference in fluid content. Ultrasound is exquisitely sensitive to fluid and routinely shows up cysts that don’t show up on the mammogram. Ultrasound also often shows us solid (not fluid-filled) lumps that don’t show up in mammograms of dense breasts. The ultrasound characteristics of these solid lumps have been shown to be very accurate in predicting which lumps are suspicious in certain situations. The imaging of solid lumps is still slightly less reliable than that of cysts, and additional follow-up or biopsy is sometimes necessary. If the ultrasound doesn’t show a cyst or a solid mass, it often shows which anatomical feature of normal breast tissue is causing the lump that is felt. Ultrasound is extremely reliable in this situation as well, as long as it is performed by an experienced specialist, such as those at The Knoxville Comprehensive Breast Center. We hope this removes some of the mystery associated with the term “dense breasts.” If you should have any further questions, please contact one of the breast imaging professionals at The Knoxville Comprehensive Breast Center.

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Fibrocystic Changes

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Fibrocystic changes, a term used by physicians and pathologists, describes a number of non-cancerous conditions occurring in the breasts. These conditions are found in the breasts as lumps or masses which occur and change with the menstrual cycle and may be accompanied by pain and tenderness. Previously, the term "fibrocystic disease" was used to describe the process and was falsely implicated as a risk factor for cancer. However, at least 50 percent of all women have irregular feeling, lumpy breasts. Furthermore, studies have shown that as many as 90 percent have microscopic fibrocystic changes.

These changes are a normal response to the hormonal stimulation of the breast tissue and do not represent a "disease" process. Thus, the term "fibrocystic disease" is not an accurate description of the changes. Fibrocystic changes do not increase the risk for cancer. The term is commonly applied to any change that is not cancerous. Because there is no exact clinical definition, ask your physician precisely what type of changes have been found in your breast tissue if you receive the diagnosis of fibrocystic changes.

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Lymphedema

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Lymphedema is a condition involves swelling of the soft tissues of the arm or hand. The side effect that can begin during or after breast cancer treatment. It isn't life threatening, but it can last over a long period of time. The swelling may be accompanied by numbness, discomfort, and sometimes infection.

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Microcalcifications

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Microcalcifications are some of the diagnostic markers our Radiologists, who are Breast Imaging Specialists, look for while evaluating your mammogram. Most often, microcalcifications represent a benign process. Only a small percentage is indicative of cancer. In order to evaluate them, we often get additional magnification views.

Microcalcifications are seen in the soft tissues of the body, including the breast, in which there are many benign structures that can calcify. One of the most common reasons for breast microcalcification development is dietary intake.

Unfortunately, some cancers also produce microcalcifications which can be one of the very first signs that a small breast cancer may be present. By looking at the size, shape, and distribution of the microcalcifications, the Clinical Breast Radiologist can detect whether these microcalcifications may indicate a possible malignancy. Sometimes it can be difficult to differentiate benign from suspicious microcalcifications on the mammogram. After careful review of the images, the Clinical Breast Radiologist will make one of several recommendations. If the microcalcifications are felt to be benign, short-term follow-up examinations will be recommended. When the microcalcifications are indeterminate, other recommendations are made including ultrasound, breast MRI, or possible tissue sampling. In the event that the Clinical Breast Radiologist feels that tissue is needed for a diagnosis, a stereotactic biopsy in the office may be recommended.

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