Questions and answers on breast cancer
GUIDELINE 1. INVESTIGATION
OF A BREAST LUMP THAT CAN BE FELT |
A lump can be felt in my breast. What should happen next?
First, be aware that finding a lump is common and that most lumps are not due to cancer. However, any new lump must be investigated to find out what it is.
The investigation should start with your doctor asking about your medical history, doing a complete physical examination and usually also ordering a diagnostic mammogram. An ultrasound examination can also be valuable, especially to distinguish between cysts (harmless fluid-filled sacs) and other kinds of abnormalities.
These steps may be all that is necessary to rule out cancer, especially if your doctor is experienced in breast examination.
What sort of questions will my doctor ask me?
You will be asked how long it has been since you first noticed a lump, whether it has changed at all (for example, whether it has grown bigger or changed in texture), and whether you've noticed any skin changes or irritation.
You will also be asked about possible risk factors. These are things that might increase your chance of having breast cancer at some time in your life. Your risk is higher if:
- you are older. Risk increases with age;
- you have had breast cancer before;
- you have had a breast biopsy in the past that showed some abnormality or
- you had radiation treatment for Hodgkin's disease in childhood.
Your family's health history can also contribute to your risk of getting breast cancer. The risk is higher if there is a "strong" history of breast cancer in your family. You have a strong history if the person with cancer was your mother, sister or daughter. The risk rises if more than 1 person in your immediate family had breast cancer, and if their cancer was found before menopause or before they were 50 years of age.
Although these factors are associated with an increased risk, don't be too concerned if some of them apply to you. It may reassure you to know that most women with the common risk factors don't get cancer.
What will my doctor look for during the physical examination?
During the examination, the doctor is looking for signs that the lump is either "benign" (non-cancerous) or "malignant" (cancerous).
The armpit and the area above your collarbone will be examined to see if the lymph nodes are enlarged. These lymph nodes are sometimes called "glands." Swollen lymph nodes can be one of the first signals of a spreading cancer. The skin of the breast and the nipple will also be examined for any irritation, rash, dimpling or other abnormality that cancer can sometimes cause. Fluid leaking from the nipples unless it is blood-stained is usually not related to cancer, especially if it occurs in both breasts.
The lump itself will be felt to see if it can be moved within the tissue and whether its edges seem smooth or rough. Smooth, rounded lumps that move easily are much less likely to be cancerous. Lumps due to cancer are usually, though not always, painless.
What is a diagnostic mammogram? Do I need to have one?
A diagnostic mammogram is an x-ray of the breast and is recommended when there is reason to suspect cancer. Because younger women (generally less than 35 years old) have denser breast tissue, mammography is less helpful in this situation.
Diagnostic mammography is more thorough than regular "screening" mammography. It includes extra compression to "push" normal breast tissue out of the way and give a clearer image of the suspicious area. If tiny flecks of calcium (microcalcifications) are noticed, magnified views will be taken since these flecks are sometimes associated with cancer.
If there is any doubt about what the mammogram shows, it is recommended that 2 individuals experienced in reading mammograms should interpret the results. For an accurate diagnosis, a high-quality mammogram is important. To ensure high quality you should check that your centre is accredited by the Canadian Association of Radiologists.
However, even when all the best procedures are followed, cancer is not always visible on a mammogram, which means that a normal result is not absolute proof that there is no cancer.
I have gone through all these steps, but my doctor still cannot rule out cancer. What is the next step?
More tests may be necessary. Your doctor may suspect that the lump is actually a harmless cyst (a sac filled with fluid). This is a common condition. If a cyst is suspected, an ultrasound examination or a technique called "fine-needle aspiration" can help confirm the presence of a cyst.
In fine-needle aspiration, a very thin needle is inserted into the lump. If the lump is fluid-filled, the needle will draw out the fluid. If it is blood-stained it will be sent for testing. If not, you can be certain that it is only a cyst, and no further testing or treatment will be required.
What if the lump is solid and contains no fluid?
If fine-needle aspiration doesn't draw out any fluid, the lump may still be a harmless, solid fibrous growth. The needle can retrieve cells from the lump for further examination under the microscope. Sometimes, this is enough to reach a clear diagnosis.
If the answer is still unclear, further investigation will be needed. Your doctor can use a larger needle to draw out some tissue from the lump. This is then examined under the microscope to see if there are any cancer cells. This procedure is called a "core biopsy." Your doctor may be able to locate the lump by feel; if not, a mammographic or ultrasound "picture" of the lump is used as a guide to make sure the needle goes to the right place.
If cancer is still suspected, a "surgical biopsy" is done, in which the whole lump is removed for examination under the microscope. To make sure of getting it all, some of the surrounding normal tissue is also taken.
What about other
diagnostic techniques
such as thermography,
light scanning and magnetic resonance imaging (MRI)?
Thermography, which detects the tumour's heat, and light scanning, which shows the tumour by shining a light through the breast tissue, are inaccurate and not recommended for diagnosis.
The value of MRI is still being investigated. Right now, it is not a routine part of the diagnostic process.
I have a breast implant. Should
I not have some of the tests?
You can and should have the same tests (and treatments, if necessary) as everyone else. However, special techniques may be necessary to get a good mammographic image of a breast with an implant.
Will all these tests be done
by my doctor?
Reliable results depend on the skill and experience of the people who do the tests and interpret the findings. Not all doctors have the required experience and skills and not all tests are available in every location.
Depending on these factors, you may be referred to different specialists for some or all of the tests you'll need. No matter who does the investigation, the goal is to reach a reliable diagnosis using the fewest possible procedures as quickly as possible. While this goes on, you should expect to be kept fully informed. Don't hesitate to ask any questions you may have.
Are any more follow-up tests needed if my lump is found
to have no cancer?
It depends on the type of lump you have. For some lumps in which the diagnostic test results were difficult to interpret, your doctor may wish to schedule follow-up tests to be on the safe side. When the diagnosis is straightforward, however, no further tests are needed.
What if my lump turns out to be cancer?
In this case, you will have more decisions to make. Together, you and your doctors will decide which kind of surgery is best for you and whether you need other treatment such as radiotherapy, chemotherapy or hormonal therapy. Guidelines 3, 4, 6, 7 and 8 in this booklet will help you with these decisions.
Above all, don't feel rushed into taking action. This is a difficult time, and it is normal to feel anxious. A delay of 1 or 2 weeks will have no significant effect on the outcome and will give you time to gather information and talk things over frankly and openly with your doctor. Don't be afraid to ask questions or to ask for any additional support you need. Family and friends can be especially important at this time.
