The female breasts may be expected to undergo hormone-controlled enlargement at puberty, and later in pregnancy, and the glandular part of the breast undergoes involution (shrinkage) after the menopause. The breast can also be affected by many different diseases, with common symptoms being pain, nipple discharge or retraction, or the formation of a lump within the breast.
is much more common than cancer, particularly in young women, and includes acute inflammation of the breast (mastitis); abscess formation; and benign breast lumps, which may be fibroadenosis – diffuse lumpiness also called chronic mastitis or fibrocystic disease – in which one or more fluid-filled sacs (cysts) develop.
Women who are breastfeeding are particularly prone to mastitis, as infection may enter the breast via the nipple. The process may be arrested before a breast abscess forms by prompt treatment with antibiotics. Non-bacterial inflammation may result from mammary duct ectasia (dilatation), in which abnormal or blocked ducts may overflow. Initial treatments should be with antibiotics, but if an abscess does form it may need to be surgically drained.
Duct ectasia, with or without local mastitis, is the usual benign cause of various nipple complaints, with common symptoms being nipple retraction, discharge and skin change.
Lateral view of female breast showing internal structure and chest wall.
Breast lumps form the chief potential danger and may be either solid or cystic. Simple examination may fail to distinguish the two types, but ASPIRATION of a benign cyst usually results in its disappearance. If the fluid is bloodstained, or if a lump still remains, malignancy is possible, and all solid lumps need histological (tissue examination) or cytological (cell examination) assessment. As well as having their medical and family history taken, any women with a breast lump is advised to undergo triple assessment: a combination of clinical examination, imaging – mammography for the over-35s and ultrasonography for the under-35s – and fine-needle aspiration. The medical history should include details of any previous lumps, family history (up to 10 per cent of breast cancer in Western countries is due to genetic disposition), pain, nipple discharge, change in size related to menstrual cycle and parous state, and any drugs being taken by the patient. Examination involves inspecting the breasts, noting position, size, consistency, mobility, fixity, and local lymphadenopathy (glandular swelling). The nipples are examined for the presence of inversion or discharge. Fine-needle aspiration and cytological examination of the fluid, ULTRASOUND, MAMMOGRAPHY and possible BIOPSY are diagnostic tools, their use depending on the patient's age and the extent of clinical suspicion that cancer may be present.
The commonest solid benign lump is a fibroadenoma, particularly in women of childbearing age, and is a painless, mobile lump. If small, it is usually safe to leave it alone, provided that the patient is warned to seek medical advice if its size or character changes or if the lump becomes painful. Fibroadenosis (diffuse lumpiness often in the upper, outer quadrant) is a common (benign) lump. Others include periductal mastitis, fat NECROSIS, GALACTOCELE, ABSCESS, and non-breast-tissue lumps – for example, LIPOMAS (fatty tissue) or SEBACEOUS CYSTS. A woman with breast discharge should have a mammograph, ductograph, or total duct excision until the cause of any underlying duct ectasia is known. Appropriate treatment should then be given.
most commonly – but not exclusively – occurs in postmenopausal women, classically presenting as a slowly growing, painless, firm lump. A bloodstained nipple discharge or eczematous skin change may also be suggestive of cancer.
The most commonly used classification of invasive cancers split them into two types, ductal and lobular, but this is no longer suitable. There are also weaknesses in the tumour node mestastases (TNM) system and the International Union Against Cancer (UICC) classification.
The TNM system – which classifies the lump by size, fixity and presence of affected axillary glands and wider metastatic spread – is best combined with a pathological classification, when assessing the seriousness of a possibly cancerous lump. Risk factors for cancer include never having had a baby, first pregnancy over the age of 30 years, early MENARCHE, late MENOPAUSE and positive family history. The danger should be considered in women who are not breast feeding or with previous breast cancer, and must be carefully excluded if the woman is taking any contraceptive steroids or is on hormone-replacement therapy (see MENOPAUSE).
Screening programmes involving mammography are well established, the aim being to detect more tumours at an early and curable stage. Pick-up rate is five per 1,000 healthy women over 50 years. While regular two-view mammograms could reduce mortality they might also cause distress because there are ten false positive mammograms for each true positive result. In premenopausal women, breasts are denser, making mammograms harder to interpret, and screening appears not to save lives. About a quarter of women with a palpable breast lump turn out to have cancer.
This is complex so all options should be carefully discussed between surgeon or oncologist and the patient and, where appropriate, her partner. Locally contained disease may be treated by local excision of the lump, but sampling of the glands of the armpit of the same side is generally advised to check for spread of the disease, and hence the need for CHEMOTHERAPY or RADIOTHERAPY. Depending on the extent of spread, simple MASTECTOMY or modified radical mastectomy (which removes the lymph nodes draining the breast) may be required. Follow-up chemotherapy, for example with TAMOXIFEN (an oestrogen antagonist) much improves survival. Certain women with early breast cancer, whose cells contain large amounts of a protein called HER2, may benefit from the MONOCLONAL ANTIBODY DRUG trastuzumab and from AROMATASE INHIBITORS.
As well as the physical treatments provided, women with suspected or proven breast cancer should be offered psychological support because up to 30 per cent of affected women develop an anxiety state or depressive illness within a year of diagnosis. Problems over body image and sexual difficulties occur in and around one quarter of patients. Breast conservation and reconstructive surgery can improve the physical effects of mastectomy, and women should be advised on the prostheses and specially designed brassieres that are available. Specialist nurses and self-help groups are invaluable in supporting affected women and their partners with the problems caused by breast cancer and its treatment.