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Woman and doctor 

 

Most breast lumps are not breast cancer and will never develop into breast cancer. The safest approach to all breast lumps however is to always get a lump examined by a medical professional. In fact no matter how often you examine breasts as a doctor or check your own breasts as a patient, it can’t be assumed that the breast lump is of no concern. A clinical examination together with a simple non-threatening non painful investigation called an ultrasound or breast sonar (done by a radiologist, with a mammogram if over 35 years) is the easiest way to tell what the breast lump could be.

Many years ago we used to categorise breast masses according to the age groups where they occurred, but this can be confusing.  A far safer approach is to look at how breast masses are seen with ultrasound (breast sonar).  We want to emphasise that it is most important to determine that the lump is not a cancer.  The triple assessment of a clinical examination, either sonar and/or a mammogram should be obtained as well as a core needle biopsy if required.

Solid masses

Fibroadenoma

These are highly mobile round, smooth, firm lumps usually found in a young woman’s breast (the teenager and the girl in her early twenties). It is sometimes called the breast mouse because it is so mobile and ‘runs’ from the examining hand.  Sometimes they do occur in older women but not often. Fibroadenomas come from the lobules (milk tissue) and react to female hormones like the other breast tissue they develop from.

Most fibroadenomas get noticed around 1-2cm in size but they can grow to even more than 5 cm. Women who have one, often find more when they start looking and it’s not uncommon to find lots, and in both breasts. A fibroadenoma is quite innocent, and almost never related to cancer. Having a fibroadenoma doesn’t even increase your risk of cancer. If the doctor is sure your lump is a fibroadenoma (after confirming it on ultrasound and a core needle biopsy result because clinical exam alone can be wrong in half of all cases) it can be left well alone if it is not bothersome. It may disappear spontaneously.

If the fibroadenoma becomes painful, if it gets bigger than 3cm (that makes it a giant fibroadenoma) or if you are worried about it, it can be removed with surgery from a cut around the nipple. However remember that surgery leaves both scars on the skin and in the breast tissue and can make breast investigations later in life more difficult to read.

If you already have a fibroadenoma and are pregnant, during pregnancy and lactation you can expect the size may vary but they will not interfere with breast feeding or milk coming in.  Calcified fibroadenomas are sometimes found in the elderly women as a hard discrete mobile lump that can be easily seen on a mammogram.

 

Cystosarcoma Phyllodes (Phyllodes Tumour)

Phyllodes tumours (PTs) take their name from the Greek word phyllon which means ‘leaf’ because of their leaf-shaped growth pattern. They can also behave like plants which are difficult to root out, like a weed in the garden. Unlike fibroadenomas, when they grow in the breast, they don’t form a neat shell around the outside, but instead they grow into normal breast tissue. That means when they are removed with surgery, if a rim of normal breast tissue is not taken out too, little bits can be left behind. Like the roots of a weed, they will cause the lump to grow back, often more aggressively than before.

Phyllodes do have a risk of a recurrence even if they are benign (non-cancerous), but they also have a risk of spreading or recurring if malignant (cancerous). The type of tumour and its risk to recur or spread (metastasise) can only be determined once it has been removed and examined microscopically. Once the grade of a Phyllodes tumour is established, you’ll need to undergo a second surgical procedure to ensure you have clear margins of disease- free tissue of 1-2 cm, followed by reconstruction. The reconstructive options depend on many factors. If you’re large-breasted and the tumour is relatively small, reconstruction can be done in a similar way to a breast reduction. If the tumour is large and most of your breast needs to be removed, the reconstruction will be more extensive and involved.

Unlike ‘normal’ breast cancer there are no identified risk factors for having a Phyllodes tumour, nor does there seem to be a genetic predisposition. And unlike ‘normal’ breast cancer which arises from the glandular elements of the breast, these are tumours of the connective tissue within the breast tissue. Malignant Phyllodes tumours don’t spread like breast cancers to lymph glands and usually just recur locally, however the more aggressive tumours can spread to the lungs and liver. Some can be so large (up to 30 cm in size) that complete removal of the breast and part of the chest wall is required

Because doctors don’t encounter Phyllodes tumours all that frequently, they are often misdiagnosed as benign fibroadenomas, the most common kind of breast masses that occur especially amongst younger women. Breast masses should never be brushed off as ‘harmless fibroadenomas’ and that is why most diagnoses today should only be undertaken by a specialist radiologist with the use of an ultrasound.

Any features on ultrasound that are not typical should result in a core needle biopsy, which involves a small biopsy done under local anaesthetic.  ALL masses, irrespective of diagnosis, should be followed up 6 months later by an ultrasound. Furthermore any masses that grow, or are larger than 3cm, should always be excised

 

Fat necrosis

Severe injury to the breast (from a motor vehicle accident or being punched in the breast) can cause fat necrosis. It is also seen after some breast reduction operations. The problem is that fat necrosis feels like a hard irregular lump, which can feel a lot like a mimic breast cancer.  The only way to tell the difference is through a mammogram and core needle biopsy which will usually help tell the difference. There is no treatment required for this problem, surgery is not advisable, and once the investigations have confirmed that the lump is fat necrosis, reassurance and watching it doesn’t get bigger or change is all that is needed.

 

Breast hamartomas (Fibroadenolipoma)

This is not a common breast lump, and not the first thought of most doctors. Hamartomas of the breast are normally painless breast lumps which are softer and larger. They have been called a ‘breast within the breast’ because they contain all the different types of tissue found in a breast. This may account for some diagnostic confusion especially if an FNA is performed, as the cells are difficult to differentiate from abnormal cells. It is normally possible to confirm diagnosis with a core biopsy rather than an FNA. Even on a mammogram these lumps have a distinct picture showing an easy to see lump separated from normal breast tissue by a thin white margin. If clinical examination and core needle biopsy do not fully explain the lump, a surgical removal is recommended.

 

Fibroadenosis (and cyclical breast pain)

Breasts alter cyclically with the different stages of the menstrual cycle.  In the week prior to menstruation, the breast normally increases in size and sometimes becomes nodular, with pain. This can mimic a breast mass.

This is normally called ‘fibroadenosis’ but we think this term can be confusing and misleading sometimes because represents what is going on inside the breast at a tissue level but the process is normal. Breasts are uniquely different to palpation, some are smooth, some are nodular and the term should not be used as if this is abnormal or a disease of the breast.

All breasts have a certain amount of fibrosis (connective tissue) and adenosis (gland or milk tissue) and disease should be attributed to a woman with breast symptoms. If concerned, a breast ultrasound can aid the clinician in determining whether this is a mass or just nodularity.

 

Cystic masses

Breast Cysts

Breast cysts are masses that might look and feel like a lump but actually they are fluid-filled sacs within the breast. No one knows why they form but it can be due to the hormonal or structural changes in the breast that happen as you get older. Cysts usually occur in the premenopausal women in the years after childbirth and breast feeding (thirty-five to fifty years) and they develop in about 5% of women. They might be single or multiple, but often they are only picked up on mammogram or sonar. The most important information about pure breast cysts is that they do not cause cancer and they are no associated with cancer. They are easily diagnosed using sonar (ultrasound) and can be aspirated with a fine needle (FNA).  The fluid is usually yellow or greenish and there can be up to 20mls.

Provided there is no blood (red or black) in this fluid and that there is no residual lump remaining after the aspiration, no further treatment is necessary.  If there is blood or a residual lump, further evaluation is mandatory.  This takes the form of sending the aspirate for cytology (it is a good principle to send all aspirates for cytology) and then to biopsy the residual mass if present under radiological guidance or to excise it surgically.

 

Galactocele

This is simply a cyst, found only in breast feeding women that contains retained milk but has no signs of bacterial infection.  It can be treated by needle aspiration of the cyst and suppression of milk. Uncommonly surgical excision can also be performed if necessary.

There is no definite symptom which means that you definitely have breast cancer. Most of the symptoms which are related to breast cancer are also present with non-cancer problems, so it is important not to panic if you develop a problem but to ensure you get it checked out.

If you have breast cancer will you feel a lump?

Most breast cancer present as a lump in the breast. Often women are surprised by the unexpected appearance of a lump and are unsure whether to get it investigated. No matter how sudden or how the lump feels, it is very important to see your doctor. Cancer lumps often feel hard and craggy and grow steadily in the breast. Eventually the cancer will spread to the lymph glands causing hard lumps to be felt under the arm too.

Approximately ten per cent of breast cancers present without a lump, and in fact when you do feel a lump in your breast, around 80-85% of those are benign. Most lumps felt in the breast are not cancers but might be cysts or masses known as fibroadenomas.

Cancer can show up without a lump, and if you experience some of these other symptoms you should also get checked out:

  1. Change in the size and shape of the breast
  2. Thickening of the skin of the nipple or ulceration
  3. Eczema of the nipple, itching or scaly patches
  4. Nipple turning inwards
  5. Thickening or dimpling of the skin of the breast
  6. Lumps noticed under the arm

Is breast cancer is painful?

Unlike most cancers, breast cancer does not present with pain. That doesn’t mean that if you have a painful lump it can’t be cancer, but it is unusual for pain to be the first thing a women with breast cancer notices. The most common way that women find a breast cancer is when they feel a lump in the breast or notice a discharge from the nipple. In the future, we want breast cancer to be found on mammogram, before there is even a lump, because we know that the earlier a cancer is detected, the better it can be treated.

Is a nipple discharge normal?

It is true that some nipple discharges are very normal- take breast feeding for instance! It is also quite common to get a discharge after breast feeding for a while. Not all nipple discharges are normal however, and they can mean different things. Breast specialists worry particularly with one sided nipple discharges that come from just one place on the nipple what every colour they are, and we also don’t like nipple discharges that have blood in them. The best plan is to get every nipple discharge checked out by a specialist who can help you understand what the problem is, and help you solve it too. Remember not to squeeze your nipples- they can respond by producing or increasing a discharge. If you have been squeezing, the first step to preventing a discharge is by stopping.

What changes in the nipple are related to breast cancer?

There are two particular changes on the nipple which are concerning for breast cancer. The first is an itchy scaly eczematous rash which can develop on the areolar (the coloured part of skin around the nipple) or on the nipple itself. This kind of rash can cause the skin to peel or become red and raw. It is termed ‘Paget’s disease’ and is a spread of cancerous or pre-cancerous cells along the ducts to the nipple where they cause rash or an ulcer.

The second symptom that can develop is an inversion and in-drawing of the nipple. Many women have inverted nipples which are completely normal, but if a nipple suddenly becomes inverted, particularly on one side only, it is cause for concern and should be investigated.

 

Whilst all cancer is treatable and potentially curable it is better to pick up cancer as early as possible. Remember to go for screening mammography and sonar after the age of forty every year, and get your GP or a breast specialist to examine you once a year too. Being breast aware also means learning to love your breasts, and getting to know your body. You may be the best person to pick up when something is wrong with your body if you learn what is normal for you and what is not.

Studies have shown that it is possible to reduce the number of women dying from breast cancer by 45% using very simple measures. These include understanding your risk of having breast cancer based on your personal and family history, and being screened regularly for breast cancer.

What does screening involve?

Early detection is the key to better outcome with breast cancer. If a cancer is picked up very early, the risk of spread is low and there is more likelihood it can be treated with simple measure such as surgery. The later a cancer is picked up, the more aggressive treatment has to be, and the higher the likelihood of dying from the cancer.

There are many measures you can take to pick up cancer early and decrease your risk of dying. It can involve a number of different types of examinations, which include breast self-examination, clinical breast examination by your doctor or breast specialist, mammography, ultrasound (breast sonar), and magnetic resonance imaging (MRI).

Breast Self-Examination

During breast self-examination, a woman takes time to examine her breasts and get used to the way they feel and look. She checks her breast for any differences, which might include a change in the size or shape of the breast, any irregularities in the skin, any changes in the nipple and any lumps in the breast or under the arm. It is a free and easy way for women to get used to noticing any changes in the breast, and we recommend you carry out breast self-examination monthly, at the same time in your cycle if still menstruating, or on the same day each month.

Clinical Breast Examination

A clinical breast examination is an examination of the breasts which is done by a healthcare professional. It includes not only a physical examination, but time spent by the doctor listening to any symptoms or concerns the patient has, and discussing breast health. Although there is little evidence that clinical breast examination plus mammography is better than mammography alone, we believe it is important to keep close contact with your doctor or breast specialist so that you are clear about what to do if you notice a symptom.

Mammogram

Mammography is an examination of the breast using a low-dose of X-rays to look at any abnormalities within the breast. It requires you to stand beside the mammography X-ray machine and place your breast on a pad, where the X-rays will take an image of the breast from at least two views. Studies have shown that annual mammograms significantly reduce the amount of women over the age of 40 years who will die from breast cancer.

Older mammography uses photographic film to record the pictures, but newer better technology allows digital mammography, where the picture is recorded in a computer and can be more carefully looked at. This is particularly useful in women with dense breast and younger women before the menopause (still having periods).

Ultrasound

Ultrasound (breast sonar) is another imaging method to look inside the breasts. It uses high-frequency sound waves to echo back a picture of the structures inside the breast. It can be used to evaluate abnormalities found on clinical examination and mammography, and it is particularly good for looking at breasts of younger women, and looking for infections in the breast.

The accuracy of an ultrasound is highly dependent on the skill of the technician or doctor carrying out the test. That sometimes means that tests need to be repeated or errors in what is seen.

Magnetic Resonance Imaging

MRI is another method of imaging the breast using yet another modern technology. It uses a magnetic field to provide the doctor with a three-dimensional image of the breast. It also requires injection of a dye into your blood, which will help the MRI demonstrate normal from abnormal. It is an expensive test and not often necessary to diagnose abnormalities.

MRI is useful in patients who have inherited disorders such as BRCA genes or a higher than normal risk of breast cancer with ‘difficult to read’ breasts.

When you feel a lump or have a concern that you have developed a breast symptom, the first way to put your mind at risk is to know that more than 70% of all patients with breast problems do not have cancer. The only way to be sure of what is the problem is to be seen by a specialist and ensure correct imaging and diagnosis.

What will happen when I am seen by a doctor?

When you visit a general practitioner or breast specialist you are not just going to discuss your current problem, but chat about your general health and history. It is important to identify risk factors and potential health issues for the future, not just focus on one part of your health. The way to know exactly what type of lump it is or the cause of your symptom is to have your general practitioner or breast specialist to carry out triple assessment. This means that every lump or symptoms is investigated and managed in the same rational manner.

What is triple assessment?

Clinical examination

You doctor will spend some time examining you in order to determine if there is an abnormality. They will look at you to see if there are any breast changes you can see such as skin thickening, nipple changes, or dimples in the breast. After that your doctor will feel the breasts, in the same way as in breast self-examination. They will feel into the axilla and all over the breast looking for lumps or pains. It is also important to look at the nipple carefully, looking for any discharges or abnormalities. Often your doctor will do a full clinical examination to check for any other changes or abnormalities, including taking your blood pressure.

If you do have a lump or abnormality identified your doctor will discuss what that means. No doctor has X-ray fingers, so any clinical examination is always accompanied by imaging which is the next step.

Radiology examination

This is imaging done by a specialist radiologist, and double read by a second radiologist to ensure nothing is missed. Normally this includes a mammogram with at least two views (but sometimes more) and an ultrasound of the breast and armpit. Often in women under 35 years the breast is often too dense to rely on mammograms to see problems so an ultrasound is done alone. Newer methods of diagnosis such as MRI scan may also be useful in some cases.

Pathological diagnosis

If there is a lump present, the radiologist may wish to do a core needle biopsy. This is best done by the radiologist because they use X-ray or sonar guidance. The old technique of Fine Needle Aspiration (FNA) should not normally be used because it can be inaccurate and not give enough information to the doctor. It is also rare to require a full surgical biopsy in theatre and it is often not the best method of diagnosing cancer as it affects further treatment.

This sample will be sent to a pathologist who will cut the sample into small slices and stain them especially to allow easy identification of any abnormalities or cancers.

How soon will I be told if its cancer?

The specialist breast surgeon or radiologist may be concerned about the lump or mass they see, but no diagnosis can be made for certain without a tissue sample taken by biopsy. This takes 48 hours to test at least. The most important thing to remember is that breast cancer is not a death sentence, nor is it an emergency. By the time a cancer is palpable (at 1cm) it has been present in your breast for at least five years.

There is never a requirement for an emergency mastectomy, and sometimes the best treatment for breast cancer is to begin with chemotherapy rather than considering immediate surgery. So even if there is cancer present, you have time to consider your options, time to take advice or seek another opinion.

Breast Cancer staging

Patients often ask what stage their cancer has been diagnosed and how advanced it is. Although this might seem very important, in actual fact the character of the cancer, the way it behaves and reacts to treatment, is more important. For instance, an early stage but aggressive cancer may progress more quickly than a large but laid-back tumour.

Staging is made on clinical and laboratory findings. Staging systems are used to classify breast cancer, so that the doctor can treat the disease with a logical basis and all breast cancers doctors have a common base on which to base treatment plans. The most commonly used staging system is the TNM staging system. It allows doctors at particular centres to compare their results with other centres all over the world. Thus treatment regimens in South Africa can be compared with those in the United Kingdom and United States of America.

The most commonly used staging system is the TNM staging system, with T referring to tumour size, N referring to nodal status and M being used to determine metastatic disease which is when cancer has spread beyond the breast and regional lymph nodes to the rest of the body. Metastases are little islands of tumour cells that have spread from the primary cancer and taken root in distant tissues and organs. It is these metastases that eventually cause death. Doctors detect metastases with various methods.

Part of the staging is to perform certain tests to determine whether the cancer has spread (M):

  • X-ray chest for lung spread
  • X-ray bones and bone scan for bony spread
  • Brain scan for brain metastases (MRI)
  • Abdominal ultrasound (sonar and CAT scan for liver spread)
  • Blood tumour markers (these should be used as a serial assessment, not as individual values).

There are four stages of cancer:

  • stage one and two cancers are early;
  • stage three cancers are locally advanced (large breast cancers greater than 5cm) and
  • Stage four cancers have spread to elsewhere (M+).

It is your right to know as much as you want about the cancer, ask about new treatments and remember that your time with your doctor is just that: YOUR TIME so take as much time as you need during a consultation. It is your body and your life so become involved with your health.

Nude female torso with medical instruments

Any woman (and even men) can get breast cancer which is why it is so important to know about the disease and know about all potential treatments. It is often not clear why some people get cancer and others do not, and the more we learn about the disease, the better we get at curing it.

What is cancer?

It is natural in life that we are all born, we grow and we all eventually die. The cells that make up our bodies are just the same. They have a life cycle which involves multiplying, growing and eventually dying in a process called ‘apoptosis’. In cancer, some of the cells of the body will misbehave and do not carry out the normal cycle. They will continue to grow and multiply but they will not die. Eventually they will spend all of their time multiplying and none of their time working as a normal cell does so that they grow into a tumour. This tumour invades the normal cells and makes new blood cells to feed its growth. It is out of control.

Eventually the tumour decides to break up and uses the bloodstream and lymphatic cleaning system of the body to travel to distant parts of the body, such as the brain and the bones, the liver and the lungs. There these small cancer cells will settle and begin to multiply in their new position, destroying the normal functional tissue in that area. These are called ‘metastases’ and the increase in these tumours will eventually lead to death.

Is breast cancer common?

Breast cancer is the most common cancer to affect women worldwide. There is no adult woman, population or culture that is free from the risk of getting breast cancer. The rates of cancer vary throughout the world, from one in 8 women in the United States to much less in Japan and the Far East. There are not accurate statistics for the prevalence of breast cancer in South Africa, but we think they may be similar to those in the United States because we have a similar diet and lifestyle.

Breast cancer is also the most common cause of cancer death for women in the world today although there has been a dramatic decrease in cancer deaths over the past forty years due to increased awareness and increased screening of women.

Who gets breast cancer?

Anyone with breast tissue can suffer from breast cancer, it even affects men. Women of every age are at risk, even including young women in their 20s or 30s. Breast cancer has been seen in girls of nine years old. Your risk of getting breast cancer increases with your age, so as you get older you become more and more likely to get breast cancer. A woman less than 40 has approximately 1 in 230 risk of getting breast cancer rising to 1 in 29 after the age of 65.

It doesn’t matter what race or culture you are, all groups suffer from breast cancer. Women of all walks of life are at risk, whether rich or poor, healthy or unhealthy, insured or uninsured. Most women (more the three quarters) do not even have risk factors that put them at high risk of breast cancer. It depends on whether your cells decide to stop behaving and start multiplying irregularly and progressively.

Many women who get breast cancer ask “Why me? What did I do to cause this?” It is very normal to ask this type of question, but the answer is: Nothing. There is no single cause of breast cancer and no single event that will bring it on. There is nothing any women does or doesn’t do which causes breast cancer. It is an unfortunate event of life which we work to lessen through early diagnosis and treatment.

How treatable is breast cancer if caught early?

All cancer is treatable and there are good options for management and cure irrespective of the size when it is found. When breast cancer is detected early, before it invades tissues outside the breast, the survival rate is as high as 95%.

Breast cancer that has not invaded into the breast tissue but is still in the ducts (known as carcinoma in-situ) has a 99% cure rate. Often surgery alone is appropriate treatment. If a small cancer invades into the breast tissue but does not spread to the glands it also has a very good prognosis. The treatment of cancer is tailored more and more to the ‘personality’ of the cancer: how it behaves and what it responds to, not the size alone.

Do chances of survival drop (by how much?) if caught later?

When cancer is confined to the breast it is easier to treat and be sure of a cure. Patients do not die of cancer when it is confined to the breast. It is the spread of cancer of the brain, bones, liver and lungs which will eventually cause problems. The aim of breast cancer awareness and screening is to catch cancer early before it can escape the breast, breakthrough the lymph glands under the arm (the security guards of the breast) and spread from there to the rest of the body like a wave of terrorists that can hide away and reappear in the future.

Many of the more aggressive types of treatment for breast cancer such as chemotherapy are based around catching and killing these spreading cells. Even if the cancer has spread to bones, up to 75% of patients will be alive in five years after diagnosis.

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