Breast concerns account for about three percent of female visits to a primary care provider. The most common symptoms accounting for these visits are breast lumps and breast pain. Because breast cancer is the most common malignancy in women in the United States, affecting one in eight women over their lifetime, women with breast problems often fear the worst. However, studies have shown that only about 3.5 percent of women reporting a concern have cancer; most problems are benign. Evaluation of a breast concern requires a systematic approach. For example, if the concern is a lump, does it change in size, tenderness, or consistency at any point in the menstrual cycle. Examination of the breast should include assessing breast symmetry, noting any skin changes like dimpling, and evaluation of the nipple for discharge or inversion. The exam should also include evaluation of lymph nodes in the neck, above and below the clavicle (collarbone), and in the axilla (armpit).
If a mass is present, it is more likely to be malignant if it is hard or has indistinct margins, is fixed to the underlying structures or skin (meaning it is not freely moveable), or if it is associated with skin dimpling or nipple inversion. It is more likely to be benign if it has discrete, well-defined margins, has a soft or rubbery consistency, or if it changes with the menstrual cycle. However, because clinical findings can be unreliable, any mass should be evaluated with mammography and possibly ultrasound as well. In women under age 30, mammography may be less effective because younger women tend to have denser breasts making mammography technically difficult.
Breast pain is common. Over 50 percent of women will experience breast pain at some point in their lifetime, however breast cancer rarely causes breast pain. Breast pain may adversely affect sleep and quality of life. Over 65 percent of women with breast pain report that the level of pain correlates to their menstrual cycle. The long-term prognosis for women with diffuse, often bilateral breast pain, is excellent. In one study that followed women with breast pain for almost five years, less than two percent developed breast cancer. Treatment for breast pain includes a well-fitting bra that offers lift, support, and compression, and minimizes excess motion. Reducing caffeine intake is often suggested for breast pain, however strong evidence for this is lacking. Anti-inflammatory medications may be helpful and tamoxifen, which is used to treat estrogen-positive breast cancer, is often recommended for breast pain associated with the menstrual cycle. Other treatments include over-the-counter (OTC) medications like Vitamins E and B6, oil of chaste tree or chasteberry, flaxseed, and acupuncture.
Nipple discharge is seen in five to 15 percent of women with breast cancer. If the discharge is unilateral, mammography is often recommended even in the absence of a detectable mass. If it is happening in both breasts, thyroid and visual field evaluations should be performed to look for the possibility of a pituitary mass (the pituitary gland, located in the front of the brain, is the central control center for the endocrine system which includes lactation). Lastly, all women should see their Ob/Gyn doctor for an annual breast exam and possible mammography. Talk to the gynecologist about when to start annual mammograms as the recommendations keep changing.
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