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Breast health

Why am I experiencing nipple discharge? Should I be concerned?

Various factors may contribute to nipple discharge, a leaking of liquid from the breast that is generally colorless or milky in appearance. Women who have been breastfeeding for the past year may have nipple discharge. It can also be hormone or drug induced from taking birth control pills or contraceptives, blood pressure medications and major tranquilizers such as Thorazine. These conditions and medications increase the level of prolactin, a hormone produced by the pituitary gland. High levels of prolactin cause nipple discharge to occur in one or both breasts.

Galactorrhea is another cause for nipple discharge, especially for women who are not taking any medications. Also, a small brain tumor may also increase prolactin levels, resulting in excessive or spontaneous milk. This tumor can be removed by surgery.

Conversely, you should be concerned if you’re experiencing a persistent, spontaneous and bloody discharge that occurs in one nipple. A tumor may be present. Fortunately, most of these tumors, called intraductal papillomas are benign. Only 4% of such cases represent a malignant tumor in the mammary ductal system.

If you are experiencing unusual breast nipple discharge, make an appointment with your physician. They can easily evaluate the cause and plan your optimal therapy.

What should I do if I find a lump in my breast?

If you found a lump in your breast, you may begin to worry about breast cancer. Most breast lumps are benign in nature.

The breasts are glands primarily made of fat and mammary ductal-lobular units. They are considered a vital part of the female reproductive system and are constantly affected by hormones. Breasts can also be a symbol of a woman’s sexuality. Like tree branches, the lobules produce milk, with the ductal units delivering it to the main breast ducts opening to the nipple.

The size of the breast is genetically determined and has no correlation to the incidence of breast cancer. Breasts may change in size due to menstrual cycles and pregnancy, with older women experiencing breast atrophy, causing the breasts to appear less full.

The texture of breast tissue varies from person to person and being familiar with your breast texture and appearance can help with identifying significant changes in a timely manner.

Please see your health care provider if you have a palpable lump or any other changes that feel different from your other breast. Keep in mind, that it is difficult to reliably rule out the possibility of cancer through only a clinical examination. To better determine the nature of a breast lump, ask your physician to have the lump sampled with a biopsy procedure. The biopsy will be examined by a pathologist. Having knowledge about the nature of our breast disease will release your anxiety and accelerate the course of therapy.

What are the symptoms of breast cancer?

  • New lump in the breast or under the arm
  • Changes in consistency of the breast, hardening of the breast
  • Change in size/contour of the breast
  • Skin or nipple retraction
  • Nipple discharge that is unilateral, bloody or clear
  • Inflammatory breast cancer can look like a breast infection with skin redness, warmth and thickening

Remember that many breast cancers have no symptoms, that is why screening is very important.

What should women ask their physician when discussing breast health?

The most important question a woman can ask her physician is “What is my personal risk for breast cancer?” Mammograms aren’t enough. It’s important for physicians to know about other factors, including if a close relative has been diagnosed with breast cancer.

When doctors do not have relevant personal information about a patient’s risk of developing breast cancer, the benefits of early detection and prevention can be lost. Without this knowledge, physicians may not consider referring the patient for appropriate cancer risk assessment and possible DNA genetic testing, screening mammograms and breast MRI at an earlier age. It is the patient’s right to understand his or her own cancer risk and to make choices based on this information.

What kind of conversations should parents have with their children about breast health?

It is important for parents to have conversations about cancer, including breast, ovarian and other forms, with their children. If anyone female or male family member has had disease, tell your adult children need to know as much information about this as possible. If possible, put the information in writing so it can be shared with other family members as needed.

Sharing information about your family’s history of cancer with your children may be awkward or cause you to bring up sad memories, but remember it could have life-saving consequences. Pass it on as a part of your family’s story, just like you do with the humorous or heroic episodes in your family’s past.

We know heredity plays a role in a woman’s risk of breast cancer. For example, women who have a close relative—mother, sister, aunt or cousin—who develops breast cancer before menopause have an exceptionally high risk for developing cancer themselves. Other factors that increase a woman’s risk of breast cancer include being over the age of 50 or having history of breast biopsy with atypical hyperplasia. This is the kind of information women should be bringing up with their doctor when they get their annual check-up, even if the doctor doesn’t ask.

Mammography and screening for breast cancer

When should a woman begin screening mammography?

All major medical groups that are involved with women's health recommend that a woman begin annual screening at age 40. If a woman is at higher risk, alternate screening protocols can be initiated for that patient.

There is no way of completely preventing breast cancer at this point, so your best defense is early detection, which significantly improves prognosis. That is why screening mammography is so important. Digital mammography can show small lesions sometimes years before the patient might feel a lump in the breast.

What is 3D mammography and what are its benefits?

3D mammography, or digital breast tomosynthesis, is a breast imaging modality approved by the FDA for clinical use in February 2011. The UF Health Breast Center – Jacksonville is one of the first facilities to offer this service in Northeast Florida. This technology has proven to be an extremely useful tool for early detection of breast cancer, and when used in the screening population, can decrease the number of patients who have to come back for additional mammographic views because of something seen on the traditional screening mammogram.

From the patient's perspective, there is no significant change from having a typical mammogram. The machine takes additional cross-sectional images of the breast while in compression, but this only takes a few seconds to complete. The radiologist can then view reconstructed 1mm thin slice images of the breast.

This is incredibly helpful for detecting early breast cancer, especially in those patients with dense breast tissue. When we report mammograms, we are required to comment on breast tissue density, and this is assigned using four categories from almost entirely fat density to extremely dense. Dense glandular tissue can easily obscure the margins of a cancer, because the mass and the surrounding normal tissue can have a similar density. In addition, patients with extremely dense breast tissue are at increased risk of developing breast cancer.

What is the difference between a screening mammogram and a diagnostic mammogram?

The main difference is that a screening mammogram is only meant for women who have no symptoms related to the breasts. If there are any symptoms detected by the patient or suspicious findings by the referring physician, then the patient must be scheduled for a diagnostic study. This means that the radiologist will do whatever imaging is necessary to fully evaluate the symptom. This might include special mammographic views, tomosynthesis, ultrasound or MRI. This might also involve breast surgical consultation. Remember that if you feel a lump in your breast, a negative mammogram does not necessarily exclude the possibility of an underlying malignancy and further workup may be warranted.

Genetic counseling

Who should go through genetic counseling and testing for breast cancer?

The National Comprehensive Cancer Network guidelines recommend genetic testing for people who are diagnosed with breast cancer at an early age, 50 years of age or younger. It also recommends genetic testing for the following:

  • Women with triple-negative breast cancer before age 60
  • Women with breast cancer and a family history of breast cancer in a close blood relative before age 50
  • Women with breast cancer and a family history of ovarian cancer in a close blood relative
  • Individuals with breast cancer and also a personal history of other cancers
  • Women with ovarian cancer at any age
  • Men with breast cancer
  • People who don’t have cancer but have a strong family history of breast and/or ovarian cancer at a young age, or family history of multiple other cancers
  • Family members with a known cancer susceptibility gene should all undergo counseling and possible testing
  • High-risk populations such as women of Ashkenazi Jewish descent with family or a personal history of breast and ovarian cancer should be tested regardless of age

Will my insurance premiums go up based on the results of genetic testing?

Federal law (GINA: Genetic Information Nondiscrimination Act) prohibits discrimination based on results of genetic testing. This means that insurance companies cannot raise your premiums, or drop clients based on genetic testing results. These results cannot be considered a pre-existing condition and employers or schools cannot discriminate against a person based on genetic testing results.

Second opinion for breast cancer

Why should someone who has been diagnosed with breast cancer seek a second opinion? When should they seek the second opinion?

A second opinion is a suggested and critical first step after a diagnosis. It can be helpful in confirming whether or not the patient has cancer, and if so, exactly what type of cancer. All cancers are not created equally. In our second opinion service, we take many factors into consideration, such as family history, lifestyle and overall health. A second opinion can give the patient a clear understanding of their individual diagnosis and risk factors, so that they can ask the right questions to get the optimal treatment for their specific type of cancer.

Breast cancer treatment

What are my treatment options for breast cancer?

Because breast cancer is a common disease among women with a high survival rate, it is important that the chosen treatment is not worse than the disease.

Treatment options depend on four characteristics of each patient’s particular tumor.

  • The size of the tumor.
  • If there is cancer in the lymph nodes.
  • If there are hormone receptors on the cancer cells.
  • The grade of the tumor — what they look like under microscope. Grade one is well-differentiated, grade two (most common) is moderately differentiated and grade three is poorly differentiated.

A patient's age is also a factor in choosing treatment. Many patients will need some type of surgery. Some patients will also need radiation, chemotherapy and hormonal therapy. Talk to your doctor about what treatment options are right for you.

Is there an advantage in treating breast cancer with proton therapy?

When there is an indication to treat the regional lymph nodes, the heart and lung are at higher risk of radiation exposure compared to treatment of the breast or chest wall alone. Proton therapy results in significantly reduced exposure of the heart and lung to radiation while maintaining the high dose to the target regions. Thus, proton therapy can minimize the risk of side effects without compromising tumor control.

Breast Reconstruction

How do I know if breast reconstruction is right for me? When is the right time to have it?

Any female who will undergo a mastectomy for breast cancer or has undergone a mastectomy in the past is a candidate for breast reconstruction. Before pursuing breast reconstruction, patients should consider their overall health to determine if they’re healthy enough to undergo surgery and if they have the time, since it can take up to a year to complete breast reconstruction.

Immediate reconstruction refers to starting the process of breast reconstruction at the time of a patient’s mastectomy. The breast surgeon will complete the mastectomy, and the plastic surgeon will then come into the operating room (while the patient is still under anesthesia) and begin the process of breast reconstruction. Delayed reconstruction refers to initiating breast reconstruction at a later time, even months or years after a patient has undergone a mastectomy. Both the decision to undergo breast reconstruction and the timing of breast reconstruction should ultimately be the decision of the patient, made with the guidance of a plastic surgeon who specializes in breast reconstruction.

Most breast surgeons will refer a patient to plastic surgery for consideration of breast reconstruction if mastectomy is being considered. Also, even if a patient has had a mastectomy years ago and has completed cancer treatment, a patient's primary care physician can refer a patient to a plastic surgeon for consideration of delayed breast reconstruction. Meeting with a plastic surgeon can help answer any questions and address any concerns a patient may have and help a patient decide if breast reconstruction is the right option for them.