Surgical Facts

Breast Problems and Breast Surgery

Every women should be concerned about breast lumps. The reason is simple: Although most breast changes are harmless, they can be an indication of breast cancer - one of the leading causes of death in women.

Every women carries with her the risk of breast cancer. Finding a breast lump can be a frightening event, and the thought of having cancer can certainly be overwhelming. But here are the real and welcome facts: Most breast lumps are benign, and if breast cancer is found early it is usually curable. The key to early detection is monthly breast self-examinations as well as periodic breast examinations by your doctor and periodic mammograms (breast x-rays).

Facts You Should Know..........

More than 90 percent of all breast lumps are discovered by women themselves.

The majority of all breast lumps are benign (noncancerous).

Breast and lung cancer are leading causes of death from cancer in American women.

About one women out of ten (10 percent of all women) will develop breast cancer at some time in her life.

Breast cancer cannot be prevented. But with monthly breast self-examinations (BSE) and periodic professional breast exams and mammography, breast cancer can be detected early and treated properly.

The Normal Breast.........

Many women do not examine their own breasts because they simply don't know what to look or feel for. Understanding the normal anatomy of the breast will help you understand the difference between a lump and normal tissue that is sometimes "lumpy". You should also bear in mind that your breasts are not exactly alike, and that few breasts feel perfectly smooth.

• Chest muscles, directly under the breast, extend from the breastbone up to the collarbone and armpit. During your breast self-examination, you can often feel these muscles as well as your ribs.

• Lymph nodes, are small, kidney-shaped glands that are linked in chains throughout the body. They act as lines of defense, or filters, against the spread of infection. There are two chains in and around the breast - the larger chain extends up into the armpit and the smaller one reaches deep to the breastbone.

• Mammary glands, are located throughout the breast. These produce milk during pregnancy and breast-feeding. They empty into a system of ducts that extends to the nipple.

• Fibrous tissue, encases and supports the entire breast. The more fibrous tissue present, the firmer the breast feels.

• Fatty tissue, is present in varying amounts according to weight and age. The more fatty tissue present, as in more mature women, the softer the breast feels.

Changes in the Normal Breast.........

From the onset of puberty and throughout life, the breast is constantly changing. Awareness of changes that normally occur will help you recognize any abnormal changes, thickening, or lumps that you might find during your monthly breast self-examination.

• Puberty: Growth of the breast begins before the onset of menstruation and it is controlled by female hormones.

• Menstrual Cycle: Under the influence of the female hormones, estrogen and progesterone, breasts swell with fluid, most notably during the week before menstruation. Lumps that are tender may appear during this time and should decrease or disappear in the week following the menstrual period - the best time to examine your breasts.

• Pregnancy: Breast changes, including tenderness, occur very early and continue throughout pregnancy. Mammary glands and ducts enlarge, making the breast about one third larger. The breast generally resumes its former size and shape once breast-feeding stops. There is no evidence at this time that prolonged breast-feeding offers any protection against cancer.

• Menopause: Mammary glands and ducts begin to decrease in size with the onset of menopause. Supporting fibrous tissue usually thins and slackens, and the breast may become less firm, and may sag with age.

• Weight Change: Because breasts contain fatty tissue, they increase or decrease in size as your weight changes.

Benign Lumps (Noncancerous Lumps).........

Any noticeable change, thickening, or localized swelling in your breast that wasn't there before may be a lump. Most breast lumps are benign, and most women will experience a benign lump sometime in their lives. The following are common benign breast problems that appear as lumps.

• Fibrocystic "disease": The most common cause of breast lumps in women age 35 to 50, and is responsible for 80% of all breast operations performed. This condition, which is not an actual disease, is probably caused by the mammary glands, ducts, and fibrous tissue overreacting to normal hormonal changes. As a result, multiple pockets of fluid (called sacs or cysts) develop, and an increase in fibrous tissue may form. In some instances, a lump may consist only of fibrous, rubbery tissue ( a condition called mammary dysplasia). Tenderness and lump size commonly increase during the week before menstruation and decrease a week after. Fibrocystic disease usually disappears after menopause.

• Simple Cysts: A variety of fibrocystic disease, are either single or multiple fluid-filled sacs. With simple cysts, there is no significant increase in fibrous tissue. Tenderness and lump size often fluctuate with the menstrual cycle.

• Fibroadenoma: A single solid tumor, is composed of fibrous and glandular tissue. It occurs most frequently in women between 18 and 35, and is usually moveable when felt. Although it is not usually tender, premenstrual tenderness can occur. Nearly all breast tumors in women under age 25 are fibroardenomas.

• Papillomas: Small, wart-like growths in the lining of a mammary duct near the nipple, which can produce a clear or bloody discharge from the nipple.

Other Conditions.........

Mastitis: Also known as infection of the breast, occurs when bacteria enter the mammary ducts through the nipple, usually as a result of suckling during breast-feeding. Localized pockets of infection (abscesses) appear as tender, warm lumps.

Trauma: An injury to the breast, may result in blood accumulation (hematoma) or destruction of fatty tissue (fat necrosis). Both conditions can appear as lumps. No evidence exists that injury causes cancer.

Malignant Lumps (Cancerous Lumps).........

Malignant lumps are usually single, hard, and painless. They develop most often from mammary ducts or glands, and are most commonly found in the upper, outer portion of the breast. Unlike benign lumps, cancerous lumps continue to grow in an uncontrolled manner, and in time will spread beyond the breast. The risk of developing breast cancer increases if you've had breast cancer before, if you have a family history of the disease, or if you've had a previous biopsy indicating a precancerous condition. In general, the risk of breast cancer rises with age, and is higher if you give birth for the first time after age 30 or if you never give birth. Breast cancer is decidedly a woman's disease - less that one percent of all breast cancers occur in males. Many authorities think that reducing fat intake can help reduce the chances of breast cancer.

• Early Breast Cancer: A small tumor less than an inch in size, located in the breast only. It's important to realize that even an "early" cancer may have been growing for several years before becoming large enough to be felt. Women who examine their breast each month, visit their doctor for periodic breast examinations, and have periodic mammography are most likely to detect an early breast cancer. Each year in the United States, 150,900 women are diagnosed as having breast cancer. Early diagnosis and proper treatment give these women a better chance of being alive and well in the future.

• Advanced Breast Cancer: A large tumor that has spread from the breast to the lymph nodes. Once this occurs, the chance for cure is reduced, even with surgical removal of the breast and lymph nodes. Of the 44,000 American women who die each year from breast cancer, many could have been diagnosed and treated earlier with regular examinations.

• Disseminated Breast Cancer: Means that cancer cells may have spread not only to the lymph nodes but to other areas of the body as well, commonly the bones, lungs, and liver. Cancer cells usually spread through the lymph system and bloodstream. Unfortunately, the cure rate is low.

The simple 1-2-3 of Breast Self-Examination.........

• At the Mirror: Stand in front of your mirror. First, view your breasts with your hands relaxed at your sides, then with hands clasped behind your head, Look for a lump, dimpling, rash, or puckering of the skin or nipple. Repeat with hands on your hips, flexing your chest muscles. Then, gently squeeze each nipple between your thumb and forefinger, checking for a sticky or obviously bloody discharge. A drop or two of clear or milky fluid is normal.

• In The Shower: Wet, soapy skin makes this step easier. Raise your left arm overhead and mentally divide your entire breast into a series of vertical or horizontal strips. Hold the middle fingers of your right hand flat against your left breast. Starting at the center of your armpit, press straight down and move your fingers in small, circular motions. Use light, medium, and deep pressure in each spot to probe the entire depth of breast tissue.

• Lying Down: Put a pillow under your left shoulder to help flatten the breast evenly over your chest. This allows you to examine the breast tissue by pressing against the firm chest wall. With your left arm above your head, begin at the armpit and make three small circles, each about the size of a dime. Use light, medium, and deep pressure. After each series of circles, move one finger's width along the strip and begin again. Cover the entire breast.

Your Medical Evaluation.........

Combining monthly BSE with periodic mammography and professional breast exams is your best insurance that if a breast change does occur, it will be detected, diagnosed, and treated as early as possible. Your medical history, a physical exam, and diagnostic tests will help your health care professional evaluate any changes.

• History: A medical history can help your health care professional determine your risk of cancer. You may be asked about menstrual history, prescribed medications, family incidence of breast cancer, and any previous breast lumps or changes.

• Physical Exam: Your doctor will examine your general health, while focusing on the condition of your breasts. Using firm finger pressure, your health care professional will try to detect the location and size of the lump, as well as determine whether any neighboring lymph nodes are affected.

• Ultrasound: By directing painless sound waves at your breast, ultrasound produces images of your breast tissue. This diagnostic test is sometimes recommended to help your doctor distinguish between a solid and fluid-filled lump.

• Needle Biopsy: This procedure uses a thin needle to extract cells from your lump. If the lump is fluid-filled and your doctor can remove all the fluid, no further treatment may be needed. If the lump is solid, a number of cells can be withdrawn and evaluated under a microscope to learn if the lump is benign or malignant.

• Mammography: Your doctor may recommend mammography. This low radiation x-ray is very successful in detecting the possibility of breast cancer even before a lump can be felt. During mammography, your breast will be flattened against a special device to provide a clear image of all the breast tissue. Then, your x-ray is examined for breast changes that may associated with cancer.

American Cancer Society Recommends:

Age 35-40
One baseline mammogram

Age 40-50
A mammogram every 1-2 years

After Age 50
Yearly mammogram

Understanding Open Biopsy.........

Open biopsy remains the most accurate method of confirming whether a breast change is cancerous. During open biopsy, your doctor removes all or part of your lump for examination under a microscope. The surgery may leave a small scar, but should have little effect on the contour of your breast. Most open biopsies are performed in the hospital on an outpatient basis.

• Plan Ahead: Talk with your doctor before the biopsy to decide on a plan of action in case the lump proves to be malignant. When you sign the consent for the biopsy, you may also choose to give permission for any additional surgery. In this case, your doctor will meet with you ahead of time to discuss possible procedures if treatment must go beyond the biopsy. But if you prefer, you may choose a two-stage process. In this case, the diagnostic biopsy is followed by a waiting period, during which you and your doctor can discuss treatment options if a malignancy is found.

• During Biopsy: If it is possible, your biopsy incision is made along the breast contour to help conceal the scar. When a lump is small and easy to reach, your doctor may remove the entire mass and the surrounding margin of normal cells (excisional biopsy). With a large lump, your doctor may decide to take only part of the affected area (incisional biopsy). After the lump is removed, cells are evaluated under a microscope to determine if the lump is malignant. In four out of five cases, the tissue is benign, and no further surgery is necessary.

• Staging: If the tissue is malignant, special diagnostic procedures will analyze the type of cancer and its stage of development. Staging is a valuable guide in tailoring a treatment plan to meet your individual needs.

Breast Cancer Treatment Options.........

In the past, women had few choices when the learned they had breast cancer. Usually, a Halsted radical mastectomy was performed, which meant removal of the breast, lymph nodes, and chest muscle. Today, because of advances in technology and medicine, women have more choices than before. The three basic type of treatment for breast cancer are local treatment (surgery), regional treatment (radiation therapy), which refers to a specific area of treatment, and systemic treatment (chemotherapy and hormonal therapy), which applies to the entire body. In discussing treatment options and making recommendations, your doctor will consider the type and extent of the cancer, your age, and your medical history.

Surgery.........

The most common operations performed today include modified radical mastectomy, partial mastectomy (including lumpectomy), and simple mastectomy.

• Modified Radical Mastectomy: This is one of the most commonly performed breast cancer operations. In the modified radical mastectomy, the entire breast and a portions of the axillary (underarm) lymph nodes are removed. This procedure differs from the Halsted radical in that the chest muscles are left in place. The modified radical mastectomy is also known as total mastectomy with axillary dissection. Depending on your individual treatment plan, chemotherapy may also be advised. Advantages and Disadvantages: Radiation therapy is not routinely prescribed following a modified radical mastectomy. Another advantage of this procedure is that the chest muscles are retained, so the strength of the arm is not affected. Hand and arm swelling is rare. Also, reconstructive surgery is possible. The disadvantage of the modified radical mastectomy is the removal of the breast.

• Simple Mastectomy: Your doctor may determine you are a candidate for simple mastectomy, also known as total mastectomy. This procedure is less extensive than the modified radical. Only the breast is removed. Chest muscle and axillary lymph nodes remain in place. Advantages and Disadvantages: Simple mastectomy does not include removing the chest muscles, so strength of the arm is not affected. In addition, because this procedure is less extensive than the modified radical, recovery time for simple mastectomy may be shorter. The disadvantage of the simple mastectomy is the removal of the breast.

• Partial Mastectomy: This procedure removes the tumor and a margin of surrounding healthy tissue. Most or all of the axillary lymph nodes are usually removed (axillary dissection), often through a separate incision, to determine whether the cancer has spread into those nodes. Sometimes a "lumpectomy" is performed rather than a partial mastectomy with axillary dissection. The two procedures are similar, but the margin of tissue surrounding the tumor is smaller with a "lumpectomy." With both procedures, radiation (x-ray) therapy is almost always advised as an adjuvant (supplement) following surgery. Chemotherapy may be prescribed as well depending upon the evaluation of the axillary lymph nodes. Advantages and Disadvantages: An advantage of this treatment is that most of the breast is left in place. The disadvantages of this procedure include multicentricity (cancer located in more than one area) and the necessity of radiation (x-ray) treatment following surgery

Other Treatments.........

Other treatments for breast cancer include radiation (x-ray) therapy, chemotherapy, and hormonal therapy.

• Radiation (x-ray) Therapy: This procedure refers to the eradication or suppression of cancer cells by radiation. Radiation treatment of lymph nodes and the chest area is used after surgery to destroy cells that may not have been removed by surgery. Radiation therapy destroys both normal and cancerous cells. However, since cancer cells grow and divide rapidly, they are more affected by radiation than are many normal cells. Treatment usually takes from four to six weeks, five days a week, often followed by a radiation "boost" one to two weeks later to the area where the tumor was located. An advantage of this therapy is that it usually controls any cancer cells remaining in the treatment area. A disadvantage is the length of treatment. Also, this therapy involves additional expense, and carries some side effects that your doctor will discuss with you.

• Chemotherapy: An example of systemic treatment, chemotherapy employs cancer-killing drugs (usually three or four) that are given intravenously or orally. The course of treatment usually takes nine months or less. Adjuvant chemotherapy enhances surgical treatment when there is a possibility the cancer has spread into or beyond axillary lymph nodes. Also, the risk of the breast cancer recurring may be reduced with this treatment. Disadvantages include side effects which your doctor will discuss with you.

• Hormonal Therapy: Another example of systemic treatment, hormonal therapy is often prescribed when the cancer has been found to be sensitive to female hormones (estrogen and progesterone). By evaluating the estrogen receptor assay, a test with biopsy tissue, your doctor can determine if you are a candidate for this therapy.

After Surgery.........

• Biopsy: Most biopsies go quite smoothly and you'll probably be able to go home the same day or the morning after surgery. If necessary, your doctor will prescribe pain medications to make you more comfortable. Dressings are needed until the incision heals, and a properly fitted bra is recommended for support. Any skin stitches will be removed later in your doctor's office.

• Mastectomy: If you have had a mastectomy, the road to recovery may be difficult, both physically and emotionally. During the first few days in the hospital, a sterile suction device, inserted during surgery, removes fluid that accumulates under the skin. Pain medication is given as needed and the dressing checked and changed. Approximately one to two weeks after surgery, stitches or staples are removed either before your release from the hospital or in the doctor's office. Occasionally, the skin at the incision site may not heal; minimal treatment is usually successful, and skin grafting is rarely necessary. If fluid continues to accumulate under the skin, it can be removed by painless needle aspiration in your doctor's office. In time, the numbness of the chest wall and underarm region will decrease. Arm and hand swelling, although less common, are more troublesome. In some cases, shoulder motion and strength may be slightly limited. This can usually be improved by physical therapy, if the lymph nodes were involved, additional therapy may be recommended by your doctor. It the days following surgery, it's important for you to realize that your life can continue to be as rich and full as ever. Your uniqueness and worth as a person can never be affected by having had breast surgery - a fact affirmed by those who love you and by other women who have had mastectomies. You can find support and counsel from your nurses, doctor, and local agencies such as the Reach to Recovery volunteers of the American Cancer Society. They can help you before and after surgery and suggest where you can be fitted for a comfortable, attractive breast substitute (prosthesis).

• Reconstructive Surgery: Advances in reconstructive surgery have made breast reconstruction an option for most patients. The surgeon builds a new breast using a silicone implant or an implant plus tissue moved from other parts of the body. Your doctor can answer any questions you may have about this surgery.

What about the future?.........

Regular checkups with your doctor will be necessary for all women who have had biopsies or other surgery.

Yearly mammography is recommended following breast cancer treatments to help detect recurrences or new changes before they can be felt.

All breast cancer patients should look at the road ahead, keeping these important facts in mind:.........

Breast cancer is a disease that may recur.

Most recurrences develop within the first 5 years.

Each year that passes without evidence of cancer substantially improves the chances you are cured.

Self-help and support services are available. Ask your doctor, nurse, or social worker for a referral in your area.

All women - not only those women with prior breast lumps, benign or malignant - should learn and practice monthly breast self examination. Early detection is your best protection against breast cancer!

NOTE: The material presented here is provided for informational and reference of the condition stated, and is not intended as a substitute for professional medical care. Only your doctor can diagnose and treat a medical problem.