Cancer of the breast is the leading form of cancer in women in the United States.  By some estimates, 1 out of 10 women will develop breast cancer at some point in their lives.  A point that is often forgotten is that 1% of breast cancer occurs in men.  Though rates of many other forms of cancer seem to be decreasing, that of breast cancer is on the rise.  Because of the fear associated with this disease, and of the disfiguring surgery often required to treat it, diagnosis is often delayed resulting in severe morbidity and mortality.  The key to successful treatment of breast cancer is patient education and early diagnosis.  Modern techniques allow for aggressive early intervention in breast cancer with good cosmetic results.   

The female breast is composed of lobules of glandular tissue connected by ducts which converge at the nipple.    This is all supported on a connective tissue matrix which suspends the breast from the chest wall.    The breast is drained by abundant lymphatics which drain mostly to the axilla, though areas of the medial breast drain to the internal mammary chain of nodes in the chest.    Breast development and function are under complex hormonal control.  Thus, most of the tumors that develop in the breast are influenced by the female hormones estrogen and progesterone, particularly the former.  Several types of tumors are encountered in the breast and all are common.  Differentiation of the benign tumors and cysts of the breast from the malignant cancers is the challenge of the surgeon. 

Breast tumors develop from the different types of  tissues contained in the breast.  Thus, tumors are encountered of lobular, ductal and connective tissue origin.  Cysts are fluid filled structures that develop from occlusion of  a duct with resultant fluid accumulation.   These cysts are very common, have no malignant potential, may come and go during different menstrual cycles and may cause pain. 

Fibroadenomas are soft, solid, benign tumors of combined connective tissue and glandular origin.   They are often found in conjunction with cysts as part of fibrocystic “disease” of the breast.  These tumors are usually mobile and very discrete within the breast and have occasionally been referred to as a “breast mouse”.   Though they have no malignant potential, differentiating them from other malignant tumors on physical exam at times can be difficult and thus palpable fibroadenomas should be excised. 

Fibrocystic disease is probably a misnomer in that it is so common as to not be a “disease” but rather a condition, and almost a natural consequence of getting older.  This condition begins in early adulthood and is characterized by the development of fibrous scarring, cystic changes, and the development of fibroadenomas and cysts within the breasts.  The affected breast feels finely nodular and may hurt.  Again, the difficulty arises in identifying malignant tumors within a fibrocystic breast which may exist alongside these other benign conditions.  However, the presence of fibrocystic disease may make physical examination and mammography difficult to interpret.    Newer techniques, such as breast MRI are promising to greatly aid in the differentiation between these conditions.

Many other benign breast conditions exist, and an exhaustive explanation of each is not possible here.  To list a few; papillomas, galactoceles and duct ectasia may all cause symptoms which are extremely difficult if not impossible to differentiate from breast cancer short of biopsy.   Any women who notices a palpable mass should seek consultation with a physician.

As previously stated, cancer may develop from any of the cell types present in breast tissue.  Carcinoma in-situ refers to a condition in which cancerous cells are seen in a biopsy specimen but has not yet become invasive.  In the case of Ductal Carcinoma in-situ  (DCIS), left untreated, almost uniformly becomes invasive cancer.  Moreover,  DCIS is frequently multi focal within the breast.  Thus the finding of DCIS warrants aggressive treatment in spite of the pre-malignant nature of this disease.

Much controversy has existed over Lobular Carcinoma in-situ.  This is also a pre-malignant lesion, however many patients found to have LCIS do not go on to develop invasive lobular cancer.  In fact, they more commonly ultimately develop ductal carcinoma and often in the opposite breast.  Many surgeons would recommend a contra-lateral mirror image biopsy in a patient found to have LCIS on initial biopsy.  LCIS should be considered a marker for a patient at high risk for development of invasive cancer at some time in the future.  These patients deserve lifetime close follow up and aggressive management of any mammographic or other suspicious findings.

Two entities deserve special mention.  Inflammatory carcinoma is a very aggressive form of breast cancer that occurs in younger women and typically spreads very rapidly.  Clinically it resembles an inflammatory process in which the involved breast becomes red, inflamed, tender, hot and painful.  The treatment involves combinations of radiation, surgery and chemotherapy as to be described below, however the prognosis is much worse because of the aggressive nature of the disease.

Cystosarcoma Phylloides is a rare variant of fibroadenoma.  These are extremely large benign fibrous tumors but have a tendency to recur after excision.  On rare occasion, these tumors may degrade to a malignant variety and behave like an aggressive cancer. 

Breast cancer is often classified into many subtypes based on predominant cell type, microscopic appearance and other factors which are irrelevant to the purpose of  this discussion.  However references to comedocarcinoma, papillary carcinoma, scirrhous carcinoma, mucinous carcinoma and others may be found during your quest for information.   Other than for statistical analysis and classification purposes, these distinctions do not alter diagnosis or treatment.

Who gets Breast Cancer?

Breast Cancer is the leading cause of death of women 40-45 years of age in the United States.  The incidence rises with increasing age above 40, however cases may occasionally occur in younger women.  This is particularly true in women who have first degree relatives (mother or sister) who have had breast cancer.  Thus, family history of breast cancer is considered to be a risk factor for an individual woman developing this disease at some point in her life.  However this is not a directly inherited trait, like brown eyes, for example.  Only that the likelihood of developing breast cancer is increased in a women whose mother, sister or perhaps grandmother had breast cancer.

Recently, 2 genes have been identified, mutations of which have been linked to the development of breast and ovarian cancer.  These genes have been identified in some patients in whom there is a strong family history of this disease.  It is now possible, though not routine, to test for the presence of these genes in the family members of patients with breast cancer and, thus identify those individuals who are at a high risk of developing breast cancer.  However, it is still unclear what to do with the results of a positive test.  Certainly, this would warrant very close surveillance of these patients.  Some have advocated prophylactic bilateral mastectomy with immediate reconstruction in these patients.  This is obviously a very aggressive approach that is not likely to be acceptable to many such patients.  Genetic counseling is certainly warranted for the first degree relatives of patients with breast cancer who are found by genetic testing to carry mutations on these genes.  Of note, is that many male patients with breast cancer have been found to be carriers of these genetic mutations.  Strategies for using this information is still evolving.

Breast cancers are known to be hormonally sensitive, particularly to estrogen.  Thus, early age of menarche, or first menstruation, late age of first pregnancy, and late age of menopause are all considered to be risk factors for the development of breast cancer.  Increased incidence of breast cancer is also seen in women who have never been pregnant.  The common factor in all of these women is prolonged exposure of the breasts to estrogen without the interruption of this exposure that pregnancy produces.  The incidence of breast cancer has been found to be higher in women of upper socioeconomic groups in the developed world because of the tendency towards later marriage and later parenthood.  Additionally, nuns have been found to have a higher incidence of breast cancer. 

There has been much controversy over whether use of oral contraceptives is a cause of breast cancer.  Birth control pills are hormonal preparations which trick the body into thinking it is already pregnant thereby preventing ovulation.  Earlier birth control pills used high concentrations of estrogen continuously throughout the cycle and thus, an increased incidence of breast cancer was found among women who had used these products for a long period of time.  Current preparations use lower doses of estrogen with a combination of progesterone in varying doses.   This achieves the same effect of preventing ovulation while reducing the exposure of the body to unopposed estrogen.  It is currently believed that these preparations do not increase the risk of developing breast cancer.  Periodically, conflicting data appears in the medical literature but the latter at present still seems to hold true.

Estrogen preparations used in post-menopausal women to prevent osteoporosis probably do increase the risk of breast cancer to some degree.  However, the doses used are smaller and these medications are obviously started later in life.  The decision to take estrogen after menopause has to be weighed in consideration of the risks of osteoporosis versus the risk of breast cancer in against all other factors.

Pregnancy is a tremendous stimulator of breast cancer growth again under hormonal influence.  A woman who is diagnosed with breast cancer during pregnancy must give strong consideration to termination of the pregnancy and immediate commencement  of treatment of the breast cancer.  Conversely, a woman under treatment for breast cancer should not get pregnant until treatment is complete and an appropriate disease free interval is achieved.  Obviously, these are very difficult decisions.

Caffeine use has been linked to the development of fibrocystic breasts and fibroadenomas.  Most patients with this condition do not have a history of excessive caffeine intake. I have noted in my practice patients who had severe fibrocystic disease or very large fibroadenomas who were excessive coffee or cola drinkers.  There is no linkage between cancer development and caffeine intake.

What are the symptoms of Breast Cancer?

The most common presenting  symptom of breast cancer is a palpable mass in the breast.  This is often found by the patient herself or her husband. Any palpable mass in the breast should be considered suspicious and should prompt a visit to the doctor.  Occasionally women will present to the doctor for a nipple discharge. 

Nipple discharge may be caused by a variety of entities, however, if the discharge is bloody an underlying malignancy should be suspected.  Nevertheless, benign entities such as papillomas in the duct may also cause a bloody nipple discharge.  Clear, milky, or greenish discharge may be associated with a variety of benign conditions and rarely is secondary to underlying carcinoma.

A hard mass in the armpit may be a presenting sign of breast cancer in some women but this is a later finding and portends axillary nodal involvement. Other changes such as skin dimpling and nipple inversion that was not previously present may be related to an underlying tumor.  Erosion of the skin with an underlying mass or a mass that is fixed to the chest wall muscles are late findings and fortunately are uncommon presenting symptoms in this day and age except in women who ignore a mass until it exhibits these frightening characteristics.  I cannot stress the importance of seeking medical attention for any palpable breast mass enough.  Treatment for early breast cancer is effective and often cosmetically acceptable.  Treatment of late stage breast cancer is usually ineffective, toxic, disfiguring and generally unpleasant.

Today, because of better patient education, more women are obtaining annual mammograms and often present to the surgeon with mammographic abnormalities.   The typical “suspicious finding” is that of “clustered pleomorphic microcalcifications”.  However, only 10% of biopsies done for this finding yield cancer or carcinoma in-situ.  Nevertheless, it is wiser to biopsy a small lesion which has a 10% chance of being positive than to wait and see if it grows or changes and ultimately have to treat a later stage of breast cancer.  Unfortunately, some women have very dense breast tissue which may obscure microcalcifications or exhibit widely dispersed diffuse microcalcifications which may be very difficult to interpret mammographically.   Newer techniques such as breast MRI are showing promise in differentiating benign from malignant lesions particularly in patients with these difficult to interpret mammograms.  

Currently it is recommended that all women have a baseline mammogram done at age 35 and then annually starting at age 40. 

What is the treatment of Breast Cancer?

The first step in treating breast cancer is proper diagnosis.   A palpable mass may be diagnosed by fine needle aspiration (FNA) of cells which are then fixed on a slide and examined by a cytopathologist.  If a diagnosis of malignant cells is returned one may then proceed to definitive treatment as to be described below.  This is a painless office procedure done with local anesthesia and a small needle.  Unfortunately, frequently the yield of cellular material with a fine needle is often insufficient to make a clear cut diagnosis. 

A mass which can easily be found on physical exam and in which FNA fails to yield a positive diagnosis should undergo biopsy.  Even if the mass is almost certainly a fibroadenoma, the presence of this mass  may make continued follow up of the patient difficult and subtle changes may be missed.

Palpable cysts or cysts deep in the breast that are not palpable but are large enough to aspirate with ultrasound guidance should be aspirated and the fluid sent for cytology if it is blood tinged.  On occasion malignancy will be diagnosed in this manner.  If the cyst disappears completely and does not return within the following 1 to 2 months, no further treatment is required.  Cysts that rapidly recur should be removed as they may in fact be malignant or at least make follow up of these patients difficult.

If there is no palpable mass but only “suspicious” mammographic findings, either a needle localization breast biopsy or a form of stereotactic guided breast biopsy may be performed.  A needle localization biopsy requires that a radiologist place a needle into the lesion in question using mammographic or ultrasonographic guidance.  This part of the procedure is generally done in the X-ray suite of the hospital.  The patient is then brought to the operating room and the tissue surrounding the tip of the needle is excised.  This generally can be done with local anesthesia and intravenous sedation but may require general anesthesia for deeper lesions or larger lesions.  The excised tissue is then X-rayed to assure that the specimen contains the area considered suspicious on mammogram.  Finally, the tissue is examined by the pathologist under a microscope to determine the diagnosis.

Stereotactic biopsies come in several forms.  They all involve the use of a special X-ray table and a computer.  The X-ray table allows the patient to lay comfortably face down with the breast hanging through a hole in the table.  Beneath the table is a special compression paddle which fixes the breast rigidly in space while allowing a portal for completion of the biopsy.  Two X-rays are then taken at different angles and the computer can compute coordinates in three dimensional axes for the location of the lesion in question.     These coordinates are then transmitted back to the procedure table and the biopsy device is thus moved into position for the biopsy.  There are three basic types of biopsy devices which can be used depending on the particular characteristics of the lesion to be biopsied.

Firstly, a device for a fine needle aspiration for cytologic examination may be utilized. This type of biopsy is usually done by a radiologist, however a negative result on a potentially suspicious lesion is very unreliable and should mandate a repeat biopsy utilizing a technique that obtains tissue for more complete evaluation.

A large needle suction biopsy allows for examination of tissue fragments which can be taken from all directions around the biopsy needle.  This can be utilized for any lesion but is typically used for small lesions which are, nevertheless, too large for biopsy using a tissue core biopsy, to be described next.  This procedure is also often done by the radiologist but the surgeon does these as well. 

Lastly, a device which takes a core of tissue as much as 2cm in diameter can be used to take an intact piece of tissue which contains the lesion in question.  This procedure is done by the surgeon and is usually amenable only to lesions less than 2cm in greatest diameter.

The advantages to all of these procedures over standard needle localization breast biopsy are several.  All are reliable in making the diagnosis of breast cancer in appropriately selected patients.  The procedures are performed in a special procedure room and do not require the use of the radiology suite for needle localization and the operating room for surgery.  They are all easily done with local anesthesia with a little valium given orally before the procedure to help relax the patient.  There is much less surgical dissection required to obtain the biopsy and thus much less post operative pain.  Lastly, the scar is minuscule and since 75% - 90% of these biopsies may be negative, this procedure is much more acceptable to many patients who will not require additional surgery.

Nevertheless, these procedures do have some limitations.  If the lesion cannot be visualized on the X-ray taken by the procedure table it cannot be localized for the biopsy.  Lesions that do not contain calcium or are only very faint on standard mammogram may not show up on the stereotactic imager.  Also, lesions which are too close to the nipple or to the chest wall cannot be biopsied using these techniques.  Women with very small breasts may not be amenable to this type of biopsy because their breast will not hang down enough through the table to be fixed in the compression paddle.  Lesions  much larger than 2cm may not be completely excised by these techniques and the risk is that a focus of cancer or carcinoma in-situ may be missed.  If the performance of a stereotactic biopsy will compromise the integrity of the tissue sample obtained or not assure a complete examination of  the entire suspicious lesion then a standard needle localization breast biopsy should be performed instead. 

Finally comes the decision about what to do if the biopsy is positive for cancer.  There is a long history to the evolution of breast cancer surgery.  A century ago, with improvements in surgical technique, developments in anesthesia and surgical care, attempts were made to improve the likelihood of cure of breast cancer by accomplishing more and more radical surgery.  It has since been established that surgery alone does not cure advanced breast cancer no matter how radical an operation is.  Therefore, modern techniques aim at removing the primary tumor, establishing if nodal metastasis is present, and if so, to what extent, and then using combinations of chemotherapy, radiation, and hormonal therapy to treat “advanced” disease if it is present.

Patients who are found to have a tumor of 2 cm or less without involvement of the nipple, skin or chest wall, and no clinically positive lymph node metastasis on physical exam may be candidates for breast conserving surgery.  The tumor is removed from the breast with a healthy margin of normal tissue and the lymph nodes are removed from the axilla for laboratory examination.  This procedure has good cosmetic results and is acceptable to most patients.  Most importantly, the recurrence rate for cancer is equal to that following more radical surgery.  In patients with small breasts or in the case of tumors close to the nipple, the cosmetic results of this procedure are unsatisfactory and the cancer recurrence rate is higher because of inability to resect an adequate amount of normal tissue surrounding the tumor.

The “gold standard” of breast cancer surgery is the modified radical mastectomy.   This operation involves the removal of the entire breast and the lymph nodes in the axilla, sparing the chest wall muscles.  The wound is then closed primarily without the need for skin grafting.  Immediate breast reconstruction may be undertaken at this time while the patient is still under anesthesia using the techniques discussed below.  This procedure is very well tolerated and most patients leave the hospital within a few days. 

A new technique is evolving in breast cancer surgery which in the future may spare many patients the need for full axillary dissection.  This technique, called radio-guided sentinel lymph node biopsy, uses a radioactive tracer which is injected into the breast to guide the surgeon directly to the sentinel lymph node.  This node is then removed through a small incision, and very carefully examined using special techniques which would be too expensive and time consuming to perform on complete axillary node dissection specimens.  Using these special techniques, it can be determined if the axilla does or does not contain nodal metastasis.   In those patients in whom this result is positive, a complete axillary dissection is then performed.  However, many patients with early stage breast cancer do not have nodal metastasis and these patients are thus spared an axillary dissection.  A complete discussion of this procedure may be found in the Office Procedures section of this web site and I encourage you to visit this page.

Many women elect to have breast reconstruction done immediately at the time of mastectomy.  There are two basic techniques of breast reconstruction most widely used today.  The first, is with the use of a tissue expander placed under the pectoralis major muscle at the time of breast cancer surgery.  Tissue expanders are essentially just specialized balloons.  Over several weeks following the surgery, the tissue expander is slowly inflated with saline in successive office visits.  This results in stretching and expansion of the overlying skin and subcutaneous tissue.  At a later operation, the tissue expander is removed and a saline breast implant is inserted.  Specialized techniques may then be utilized to reconstruct the nipple if so desired.  

The second technique involves creation of a large flap of tissue from the abdominal wall muscles, subcutaneous tissue, and skin.  This flap of tissue is then rotated up and tunneled under the skin so as to recreate the breast mound.  The nipple can then be reconstructed using the same techniques mentioned above.  Occasionally, a flap may be created using a muscle from the back with its overlying skin and subcutaneous tissue.  The choice of which flap to use has mostly to do with the patients body habitus and with the surgeons preference.  Either of these procedures may be done at the time of initial cancer surgery or in a delayed fashion several weeks or months afterwards. 

Radiation therapy is often utilized in the treatment of breast cancer.  What many patients do not seem to readily understand is that radiation, like surgery, only treats local disease, while chemotherapy, to be discussed shortly, is for the treatment of disease that may have already spread to other areas of the body.  Radiation is lethal to normal tissues as well as malignant cells, therefore, it is not possible to administer high doses of radiation to the whole body in an effort to eradicate metastatic disease.  However, radiation may be very useful, often in conjunction with surgery, in the control of locally advanced disease.  This is particularly true in the case of patients with tumors that involve underlying chest wall muscles or with extensive axillary metastasis.   Cells are most vulnerable to radiation during cell division.  Since cancer cells divide more rapidly than normal cells, they are preferentially destroyed by radiation.  Additionally, normal cells are more easily able to repair themselves following exposure to radiation.  The radiation oncologist can capitalize on these subtle differences by varying the dose of radiation and exposing the treated area to several relatively small doses over many different treatments.  There is no systemic toxicity associated with radiation treatments.  One does not lose their hair or become incapacitated.  There is however, often local irritation, or thickening of the skin and subcutaneous tissue of the irradiated.  Patients should not have tissue expanders placed in an area to be irradiated as this often results in formation of a hard capsule around the tissue expander with severe scarring and a very unsatisfactory cosmetic result. 

Chemotherapy may be necessary in patients with nodal metastasis, distant metastasis or locally advanced disease, such as in the case of a large tumor or one which involves the chest wall musculature.  Historically, chemotherapy was offered only to pre-menopausal women because it was found that after menopause there was no improvement in cure rates or survival in these women.  Additionally, post-menopausal women suffered greater and were less likely to tolerate the toxicity associated with chemotherapy.  Currently, with newer agents, chemotherapy is regularly given to all patients with advanced disease as defined above.  The choice of which agents to use is dependent on the type of tumor, its stage, number of nodal metastasis, and of course, the patients underlying condition.

I’ve been intentionally vague in describing which patients are candidates for different types of surgery, radiation and chemotherapy.  This is because these decisions must, to some degree customized to each individual patient.  In any one patient several options may be appropriate.  Proper treatment of breast cancer is a team effort requiring consultations with the surgeon, radiologist, oncologist, radiation specialist, pathologist, cytopathologist and, of course, the patient.

What is the Prognosis?

Prognosis for patients suffering from breast cancer depends largely on the stage of the disease.  Additionally certain tumor factors may play a role in determining the predictive aggressiveness of the tumor.  Breast cancer, like other solid organ tumors are staged based on three parameters; tumor size, lymph node metastasis, and distant metastasis.  Some may find the foregoing confusing; if so, skip it. It will not be on the test.  Tumor size is graded as follows:

TIS:  no infiltrating cancer, carcinoma in situ

T0: no demonstrable tumor

T1: Tumor of 2cm or less without skin or chest wall involvement

T2:  Tumor 2 - 5 cm but no skin or chest wall involvement

T3:  Tumor > 5cm but no skin or chest wall involvement

T4:  Tumor any size but with skin involvement or chest wall involvement

Nodal metastasis is graded as follows:

N0:  No clinically palpable axillary lymph nodes

N1:  palpable but mobile, non-fixed axillary nodes

(N1a if lymph node metastasis is expected, N1b if not suspected to be malignant)

N2:  palpable fixed axillary nodes

N3:  palpable nodes in a nodal basin other than the axilla; i.e. above or below the clavicle

Metastasis is graded as follows:

M0: no distant metastasis present

M1: radiologic evidence of distant metastasis is present

Using this data the stage of disease is graded by the following: 

Stage 1: T1, N0 or N1a, M0

Stage 2: T1, N1b, M0;  T2, N0, M0; T0, N1b, M0; T2, N1a, M0; T2, N1b, M0

Stage 3:  Any T3 with any N, M0; Any T4 with any N, M0; Any T with N2 or N3, M0

Stage 4:  Any T with any N, M1

The above refers to clinical preoperative staging and may be upgraded or downgraded depending on the findings at the time of surgery.

I do not wish to quote numbers here in terms of cure rates and survival predictions.  Suffice it to say that early stage breast cancer, stage 1 and stage 2 is a potentially curable disease with appropriate surgical and medical management.  Even patients with advanced disease can expect to achieve sustained survival with appropriate, aggressive treatment.  Certain other factors, which the tumor may possess may be considered to improve or worsen prognosis independent of the stage of disease.

As stated previously, breast tumors are often responsive to female hormones.  This is because they have receptors for the female hormones, estrogen and progesterone.  These may be expressed to a varying extent on individual tumors, and the presence of high concentrations of these receptors, particularly those for estrogen, portends a more favorable prognosis.  Patients with estrogen and progesterone receptor positive tumors may respond well to treatment with tamoxifen, an anti-estrogen medication.  More on this to follow.

Other tumor factors have been identified which affect prognosis however, presently do not alter therapy.  These are reflective of the abnormal behavior of the tumor cells and relate to the rate at which these cells are dividing.  Thus, tumor cells which have an abnormally high content of DNA, improper numbers of chromosomes, or high percentage of cells in a dividing phase all have a worse prognosis.

Tamoxifen is an anti-estrogen medication that works by competing with estrogen binding sites on cells that contain estrogen receptors.  It has long been observed that breast cancer growth is stimulated by high estrogen activity, particularly in pre-menopausal or pregnant women.  Historically, many women with breast cancer were treated by removal of the ovaries, and in some cases the adrenal glands, another source of estrogen, as well.  With the discovery of the estrogen receptor protein and the drug tamoxifen these operations have fallen out of favor.  Traditionally , tamoxifen has been used in the treatment of breast cancer in post menopausal women only.  Recently, it has come to light that this drug is effective in pre-menopausal women as well and may be used in conjunction with other breast cancer treatment modalities.  In addition, it has recently been found that this medication may be effective in prophylaxis against breast cancer development in patients with high risk.  Women on tamoxifen should not get pregnant or breast feed while taking the medication.  Additionally, tamoxifen may promote ovulation and interfere with birth control pills.  Appropriate precautions should be taken while on this medication.  Other side effects of the medication include increased incidence of uterine tumors, deep venous thrombosis and disturbances of vision that may be permanent.  These side effects occur with low incidence, but the risks need to be weighed against the benefits when considering taking this medication over a long term. 

Prevention and Early Diagnosis

As I have stated several times in this dissertation, early stage breast cancer is a treatable and potentially curable disease.  The most important factor in making an early diagnosis is aggressive surveillance.  Currently, it is recommended that all women have a screening mammogram about the age of 35.  Subsequently, a mammogram annually after the age of 40 will detect >90% of clinically undetectable yet suspicious lesions.  Any suspicious lesion should be biopsied to rule out carcinoma.  Fibroadenomas and cysts may also be picked up on mammogram and treated as necessary.  Ultrasound is very useful in delineating cysts from fibroadenomas.

All women after the age of 35 should routinely examine their breasts.  It is far more common for a female patient, or her husband, to be the first to notice a new lump in the breast than it is for a lump to be detected on physical exam in the physicians office for the first time.   Breast consistency changes during the menstrual cycle and therefore, self examination is most accurate following menstruation when the breasts are no longer engorged.  Any new mass or lump warrants investigation.

After the age of 40, women should have their breasts examined by their physician on an annual basis. 

I hope I have answered more questions than I have created and that I have not unduly alarmed anyone.  As always, I encourage any interested party to contact me via E-mail or telephone with questions that you may have.