I Feel a Breast Lump - Now What Do I Do?

Eric P. Melzig, MD
Richmond Surgical

One of the scariest moments for a woman is when she feels a lump in her breast, with the human nature of fearing the worst taking over. Thoughts of a cancer diagnosis become the immediate concern; anxiety then enters the picture, along with the perception of a negative outcome. The good news is the vast majority of breast lumps are benign and harmless. A similar scenario plays out when a woman is informed that her mammogram is abnormal and further imaging is indicated, with the vast majority of mammogram abnormalities being benign.

The evaluation of a new breast lump should begin with a visit to one's primary care physician or gynecologist. Your physician will perform a dedicated history and physical examination with emphasis on factors influencing breast health. Key features of the history include the presence or absence of nipple discharge, pain, or lymph node swelling. Is there redness of the breast associated with the lump? This may indicate mastitis. If one is premenopausal, has the breast lump changed in size and texture over time, and does this correlate to the timing of the menstrual cycle? If nipple discharge is present, is it clear or bloody, and is it spontaneous? Much information can be gleaned from a detailed history, which can be segmented into the below parts:

Risk Assessment

A detailed personal risk assessment will not necessarily dictate treatment of the newly discovered lump but can add perspective. Risk analysis is helpful in planning a long-term approach to breast health and a screening strategy. The salient risk factors, in order of importance, are:  1) personal history of familial genetic mutations (Angelina Jolie's BRCA1 and BRCA2 mutation, for example); 2) personal history of previous breast cancer; 3) personal history of non-malignant proliferative benign disorders (sclerosing adenosis, ductal hyperplasia or atypical ductal hyperplasia, for example); 4) breast density on mammography; 5) family history of breast cancer; and 6) previous radiation therapy to the chest (for example, Hodgkin's disease treatment). The risk factor generating the greatest misconception is a positive family history of breast cancer, with women automatically suspecting doom when they feel a breast lump. Conversely, women with negative family history tend to feel bullet proof. Both concepts are incorrect, as the status of the family history is an important factor, but breast cancer is multifactorial and family history is only one of many risk components. Ultimately, most breast cancer patients have a negative family history of breast disease and the majority of patients with breast cancer (60%) have no identifiable risk factors.

Physical Examination

The breast exam alone can lead to a benign diagnosis without imaging or biopsies. Findings such as mastitis, fibrocystic changes with associated breast thickening, waxing and waning masses associated with one's menstrual cycle, and lesions that are actually in the skin and not in the breast can all be readily diagnosed as benign entities. If the palpable lesion is indeed a true mass on physical exam, then breast ultrasound is the preferred method of evaluation. Ultrasound will distinguish a benign simple cyst from complex cysts and solid lesions. This distinction can lead to an ultrasound-guided cyst aspiration and resolution of this benign lump or it can point to the need for further investigation with additional imaging.

Diagnostic Mammogram

After intake of a patient’s history and a physical exam, a diagnostic mammogram is the next tool for patients aged 35 and older. If less than 35 years of age, the accuracy of a diagnostic mammogram significantly decreases due to the natural breast density of a young woman, as breast density naturally decreases with age. For those under 35, a solid lesion can best be diagnosed with an ultrasound-guided needle biopsy. At this young age, the high percentage diagnosis is a benign fibro-adenoma.

For those over 35, the diagnostic mammogram will yield important information concerning the nature of the mass. Is it smooth or are the borders irregular? Does it create architectural distortion? Are there any other lesions present that are too small to be palpated? The recent introduction of 3D tomosynthesis with mammography adds detection sensitivity. Needle biopsy using mammogram imaging is called a stereotactic biopsy. Imaging with breast MRI is very sensitive in detecting breast abnormalities and is especially helpful in patients with dense breasts. If a lesion is not visualized on mammography, 3D tomosynthesis or ultrasound, then a needle biopsy using MRI image guidance is the preferred diagnostic option.

Multiple well-controlled, large, randomized studies document that annual screening mammography saves lives. As a cancer is evolving, mammography leads to early detection. If the malignant process is diagnosed earlier in its natural history, we are lead to higher cure rates and less severe treatments. Despite some controversy, mammography lowers the risk of dying from breast cancer and should be a mandatory component of every woman's healthcare plan.

It is important to note that men are not exempt from breast cancer. While women account for 99% of breast cancer diagnoses, men are still at risk and 2,000 men per year in the United States are diagnosed. Therefore, men must fight their usual reluctance to seek medical attention and have any breast lumps examined by their physicians.

Do not panic if you find a breast lump on self-exam. Benign diagnoses far surpass malignant diagnoses. Remain calm and consult with your treating physicians. Personal history, physical examination, imaging, and, if required, image-guided needle biopsy will most likely lead to a benign diagnosis, ruling out malignancy.

For further inquiries about breast cancer management and advancements, or HCA Virginia’s Breast Care Network, contact Eric P. Melzig, MD, of Richmond Surgical, at 804.285.9416, or visit their website at richmondsurg.com.