Breast Health

Anatomy

The human breast is composed of three components: fat, fibrous tissues, which give the breast its shape, called Cooper's ligaments, and mammary glands which produce milk. As one ages, the percent of fat increases in the breasts. The glands of the breasts are constructed in segments called lobules that drain to the nipple. These lobules are oriented radially from the nipple, like spokes of a wheel. The breast is very responsive to hormones, as is readily evident during the menstrual cycle and with pregnancy. The breast is primarily fed through blood vessels coming from below the breast bone, called the internal mammary artery. It then drains to the armpit, where lymph nodes filter fluid and help defend the body against infections and the spread of breast cancer.

Breast Pain

Painful breasts, called "mastodynia", is a common condition. Mastodynia frequently occurs around the menstrual cycle and is related to hormonal fluctuation. In addition, the breast ducts may enlarge and fill with fluid forming a "cyst" which can grow as large as a golf ball. Most women develop cysts at some time during their life. These are benign and have no malignant potential. If rapid growth of these cysts occurs, exquisite tenderness can result. Immediate relief can be obtained by a simple needle aspiration in the office by your physician. At other times, the fibrous portion can become more dense, incorporating the enlarged ducts to result in diffuse discomfort. This does not respond to needle aspiration. However, women can have significant relief decreasing caffeine intake, wearing a good support bra, and by using vitamin E 800 mg per day and evening primrose oil 500 to 3000 mg per day. It is generally recommended that a woman starts on one of these pills every day for one to two months and see the response. Following that, a gradual tapering to around the menstrual cycle can be accomplished. (If you are on multiple medications, please consult your physician regarding the use of these medications.) Mastodynia is rarely a sign of cancer since only 3% of all breast cancer present as pain. However, if a woman notices a lump with pain, this should be evaluated

Cysts

A cyst occurs in the breast when the ducts enlarge and fill with fluid. A condition called "fibrocystic disease" is a common entity in younger women and is NOT a true disease, but rather a change. Cysts are not harmful, but occasionally can cause pain. However, they can present in a similar fashion to a malignancy. If you notice a prominent lump, this should be immediately evaluated by your physician. The diagnosis would include either a mammogram and/or ultrasound. The diagnosis can be confirmed in the clinic by a simple needle aspiration. Cysts often fluctuate with the menstrual cycle. Treatment of fibrocystic disease and breast cysts include limiting caffeine intake (coffee, tea, colas, chocolate), wearing a supportive bra to prevent stretching of the breast ligaments, taking over-the-counter anti-inflammatories, use of vitamin E 800 mg a day or evening primrose oil 500 mg a day. (Please consult your physician regarding these medications.) If these do not provide adequate relief, birth control pills can control the hormonal cycle. Women who have dense breasts often complain of having a "lumpy" feel. It is these women in particular that should perform monthly self exams so that they can identify which lumps are changing. Within the fibrocystic condition, dense growth of fibrous tissue can occur resulting in a solid marble, which is smooth, movable, and is called a "fibroadenoma". Again, this can be confused with a malignancy and should be immediately evaluated by a physician.

Lumps

The texture of the breast is often lumpy. Eight out of ten breast lumps are benign or non-cancerous. These occur as your breast changes in response to diet or other influences, such as hormones. Prominent lumps can sometimes be visible. Lumps of the breasts fall under cysts, benign fibroadenomas, or cancer. Occasionally, an infection in the breast or a clogged milk duct can also feel like a nodule. Because of the 20% risk of breast malignancy, any prominent lump should be immediately evaluated by your physician who will likely order a mammogram and/or an ultrasound to start the work-up.

Mammography

A mammogram is simply an x-ray of the breast. As technology improves, so does the quality of these images resulting in finding cancers at an earlier stage. The x-ray is taken by flattening the breasts to provide a precise image. Areas of calcification or densities cast shadows on the film which can be readily identified. Mammograms are 85% sensitive at picking up cancer. However, 15% of cancers are not visualized by mammogram, making self exams and physician exams critical in these scenarios. A baseline mammogram is generally recommended at age 40. Annual mammograms are recommended to start at age 50, if one is not a high risk patient. (See Breast Cancer Prevention to define who is at higher risk.) If there is a first degree relative with breast cancer, mammograms are recommended to start ten years prior to the relative's age of diagnosis. (ex. Mother with breast cancer at age 40, mammograms should start on the daughter at age 30.). Annual mammograms allows your physician to notice subtle changes quickly and can prompt further workup if necessary. A patient may be asked to return for additional images if the radiologist feels that one area needs reexamination. Mammograms are given a grade 0 through 5, based on how concerning the image appears. A Grade 0 requires additional imaging, grade 1 being benign, and grade 5 highly suspicious. Mammograms can now be utilized to guide minimally invasive biopsies called stereotactic biopsy of these mammographic calcifications. This is currently available at the Dekalb Clinic and at Kishwaukee Community Hospital.

Breast Ultrasound

Occasionally, a lump will need to undergo ultrasound. This helps distinguish solid lumps from fluid-filled cysts. These are painless sound waves that are converted in to a visual image of the interior of the breast. The radiologist may request these images to assist in giving the mammogram a "grade". Minimally invasive biopsies can be guided using ultrasound equipment. This procedure is performed by the DeKalb Clinic surgeons using cutting edge technology available at DeKalb Clinic or Kishwaukee Community Hospital.

Breast Nipple Discharge

It is not uncommon for woman to notice nipple discharge at some time during their life. This usually represents a benign finding, but also can be related to tumors of the pituitary, or side effects of medication. The usual types of discharge are white, green, brown, and rarely red. Although most of these are benign, any nipple discharge should be immediately evaluated by a physician. Mammograms and ultrasounds will likely be ordered. Depending on the type of discharge, a biopsy may or may not be recommended.

Breast Cancer Prevention

There is still no convincing data explaining why some woman are more prone to breast cancer. Two breast cancer genes have now been identified, and do dramatically increase a family to the risk of breast cancer. However, 90 to 95% of all breasts cancers over age 50 do not have this inherited risk factor! A landmark study from the National Cancer Institute conducted by the National Surgical Adjuvant Breast and Bowel Project known as NSABP-P1 study, published in 1998, looked at 13,388 women as young as 35 who were considered at high risk for developing breast cancer. By taking tamoxifen (Nolvadex), they could reduce their risk of invasive breast cancer by up to 49%. This pill is taken once a day for five years. The ongoing study is looking at five versus ten years. The next study in progress is comparing tamoxifen against raloxifene (Evista) and eligible women are being entered from the Dekalb Clinic. Being a candidate for these medications include a calculation of a woman's "GAIL" risk assessment which looks at various areas of risk. Higher risk is based on current age, race, age at first menses and first live pregnancy, relatives with cancer, number of biopsies and if they were pre-cancerous. The greatest risk factor is age. As one gets older, the incidence of breast cancer rises. The well published 1 in 9 statistic is based on a woman living to the age of 90. The concern that the incidence of breast cancer is on the rise likely relates to the improved technology for earlier detection. Early detection results in increased chance of cure! Another high risk is family history. 80% of all breast cancers occurring in woman over 50 have no family history! One's history of previous biopsies with pre-cancerous cells also dramatically increases the risk.

Estrogen is a very important female hormone that occurs naturally in the body. Estrogen does not actually cause breast cancer, but it may stimulate its growth, feeding the cancer. Having an early first menstrual period increases one's risk. Becoming pregnant before the age of 30 decreases one risk and the more children a woman has, seems to decrease the risk. These factors all decrease the amount of estrogen exposure to the breast. Although highly debated, environmental pollution, saturated fats, excessive alcohol consumption, obesity, radiation exposure, and lack of exercise have all been purported to contribute to breast cancer. If you would like further information about your risk for developing breast cancer or to calculate your own Gail risk assessment, please call the DeKalb Clinic's General Surgery Department.

Breast Biopsy

If your physical exam, mammogram or ultrasound reveal a suspicious area, your physician may recommend a biopsy. Keep in mind that these biopsies are intended to provide only a diagnosis and not specific treatment. There are four types of biopsies.

In the clinic, a small needle or core biopsy can be performed under local anesthesia. There is minimal bruising. The needle is about the size of a paper clip. Multiple small cores can be obtained. This rarely needs pre-certification. There is almost no recovery time. If malignancy were identified, further treatment would be necessary. The procedure is painless and the results are available in about two business days.
A mammogram-guided biopsy can be done either at Dekalb Clinic or at Kishwaukee Community Hospital. This is for nonpalpable mammogram lesions. It takes 30 to 60 minutes and is done under local anesthesia. The scars are approximately 1/4-inch long. There is minimal bruising. Anywhere from 5 to 15 cores can be obtained. The lump is again sampled or can be completely removed. It does need pre-certification and the recovery time is generally 10 to 60 minutes. Again, the results are available in approximately two business days. Further treatment would be necessary if the diagnosis was cancer.
An ultrasound-guided biopsy can be done at either DeKalb Clinic or Kishwaukee Community Hospital. This is for ultrasound - visible lumps and takes 30 to 60 minutes. It too is similar to the mammogram guided biopsy in all aspects.
The final choice is an excisional biopsy, which is done in the operating room suite. Occasionally, a wire may need to be directed as a road map to identify the area of concern. It typically takes 45 to 60 minutes, done under local anesthesia with IV sedation. The scar is 2 to 3 inches and can result in significant bruising or a possible breast defect. There is minimal to moderate discomfort. It always needs pre-certification. Recovery time is one to seven days. Again, this procedure is not intended to be a breast cancer treatment.

Following the breast biopsy, a visit with your physician to go through the pathology results is necessary. Frequently, a six-month mammogram will be ordered to identify changes from scarring from the procedure, or to make sure the lesion has not returned.

Breast Cancer

500 American women were diagnosed today with breast cancer! 40,000 women will die this year. 2 million survivors are alive!

If you, or someone you love, have the misfortune of the diagnosis of breast cancer, all nationally recognized options are readily available for you in the local community. These are all considered equivalent treatment from a cancer standpoint.

A first option is a lumpectomy, which preserves the breast and removes the abnormal tissue. Anywhere from 15 to 25% of the breast can be removed. The cosmetic result is often excellent, although a slight defect may be noted. To prevent recurrence of a breast cancer, this is always followed by radiation therapy, where your breast is x-rayed to kill any remaining cancer cells. This is typically given in five brief treatments per week for six to seven weeks (about 35 treatments). The Illinois Regional Cancer Center in Dekalb can provide this treatment. You and your surgeon will discuss if your tumor is amenable to lumpectomy.
A mastectomy removes the breast down to the chest muscle. Radiation treatment is NOT required. The Woman's Health and the Cancer Rights Act of 1998 required insurance companies to cover breast reconstruction after mastectomy. Immediate reconstruction results in the best cosmetic results, as well as the patient's psychological benefit. However, delayed reconstruction can also provide good cosmetic results. Several options are available and can be determined by your physician and plastic surgeon. These reconstruction options are generally used in conjunction with mastectomy and are listed below.
1. The options include a breast implant, which is a saline (salt water) filled pocket below the skin,
2. A tummy tuck operation, (Transrectus abdominus myocutaneous flap = TRAM flap) where the tissue below the umbilicus is tunneled up to reconstruct the breast in a subsequent nipple is remade, or
3. Tissue from the back (Latissimus dorsi flap) can be rotated anteriorly. Patients have had this done locally and have been extremely happy with their cosmetic results. Immediate reconstruction allows you to remain in your normal clothes as well as bathing suits, without concern for sometimes heavy or hot prostheses.
4. If an external prosthesis is desired, the DeKalb Surgery Department can offer advice regarding the purchase of these appliances.

Regardless of the breast cancer operation, the armpit nodes would need to be sampled. This helps identify the stage of the tumor and the need and/or aggressiveness of the choice of chemotherapy.

Sentinel Node Biopsy

An exciting new frontier in the area of breast surgery is treatment of the sentinel or "gatekeeper" node. Excellent data is starting to be accumulated that the breast likely drains to two or three nodes first, prior to advancing to the higher nodes. Identification of these first nodes will then allow a closer scrutiny of these nodes for cancer cells. Identification of the sentinel nodes is done by the use of a very low dose radioactive material and blue dye, at the time of the cancer operation. Two or three nodes are then removed and sent to the pathologist for special evaluation and careful scrutiny. This changes the stage of the patient 15% of the time, resulting in more aggressive treatment course. Our physicians have been doing this for over one year and have had excellent results. In addition, the remainder of the lymph nodes are being removed as is the standard of care in the United States to identify any other nodes that could have cancer cells. Eventually, once large scale studies have been performed, resection of just the sentinel node will likely be all that is necessary. This will reduce the side effects of removal of the armpit including armpit numbness, mild pain, and the less than 5% chance of arm edema or swelling.

Follow-Up For Breast Cancer

Followup for breast cancer is usually done either from the oncologist, or the surgeon. In the first year, more frequent examinations are required, generally every three months. At one year, other tests may be ordered, such as a chest x-ray, blood work, and/or a CAT scan, as determined by your physician. Continued close monitoring using mammograms would also be necessary.

The Future

Given the advent of modern technology, breast cancer is no longer the scary diagnosis it once was. The options are varied and provide many woman with an acceptable alternative. In conjunction with Kishwaukee Community Hospital, DeKalb Clinic's General Surgery department has obtained the most advanced equipment to date and actively provides training and education to assist in the diagnosis of breast conditions. The options listed above are continually improved, tested, and evaluated. They are all approved by the FDA. These approaches and information listed above are acknowledged and accepted for breast pathology and are routinely used around the country in state-of-the-art breast centers.

Pledge

We, the breast surgeons of DeKalb Clinic, are dedicated to solving your breast issues in a caring and compassionate fashion. We will do our best to alleviate your fears in a sensitive and timely manner, while offering a full array of the most modern breast cancer workup and treatment modalities here in the comfort and convenience of your own home town!