In most cases of concern about a potential breast lump, a normal ultrasound along with a negative breast exam is all that is needed. However, if symptoms persist, the patient should be referred to a surgeon with experience in caring for young women with breast problems.
Nipple Discharge
As will be discussed in chapter nine, nipple discharge that occurs on its own, without squeezing, requires medical attention, as it could be an early sign of cancer, except in the case of pregnant women or women who have just given birth.
OTHER BREAST PROBLEMS, such as pain and infection, are treated much the same in all age groups.
The key point to remember is that any new breast change that persists after a woman has completed her menstrual cycle should be reported to her physician. If her doctor is unresponsive to her concerns, she should seek a second opinion, preferably from a breast surgeon.
WOMEN THIRTY TO FORTY
Breast Lumps
Though breast lumps are common in women in their thirties, the good news is most prove to be benign. However, differentiating between benign and malignant can be challenging—generally because breasts in this age group, as with younger women, tend to be lumpy under normal circumstances.
Here, the menstrual cycle plays a role, adding both lumpiness and tenderness just before the onset of menstruation. That said, the best time to do a breast exam or evaluate a lump is five to ten days after the onset of the period.
And the best way to evaluate the seriousness of a nodule is with an ultrasound. If the diagnosis still remains sketchy, a diagnostic mammogram can be both helpful and safe.
This focused mammogram, covering a specific worrisome area, can be distinguished from a screening mammogram, which is done on women forty and over who have not experienced symptoms.
Breast Pain
Though breast pain is common in this age group, it’s rarely associated with an underlying malignancy. Most such pain can be alleviated with over-the-counter anti-inflammatories, as well as caffeine restriction. Pain that is localized in one spot and increases in intensity over one or two menstrual cycles merits medical attention.
Breast Infections
Breast infections in this age group are typically associated with lactation, discussed in chapter four. Infections in non-lactating women usually respond well to antibiotics. Those that don’t, or that recur after initial treatment, should be seen by a breast care specialist.
SCREENING MAMMOGRAMS FOR WOMEN UNDER FORTY
Compared to younger age groups, women in their thirties do have a somewhat higher occurrence of breast cancers. Since their breasts still tend to be dense, small malignancies don’t show up well on mammograms.
For all these reasons, routine screening mammograms are not recommended, and a diagnostic ultrasound remains the first line of defense.
However, there are exceptions: Mammographic screening in this age group is restricted to women who have a first-degree relative (mother or sister) who was diagnosed with breast cancer under the age of fifty. Screening for those women should start ten years earlier than the age at which the relative was diagnosed. For example, if the mother was found to have a malignancy at age forty-five, the daughter would start yearly screening at age thirty-five.
In addition, very high-risk women, such as Angelina Jolie, who had multiple family members with breast and ovarian cancers and who tested positive for the BRCA gene mutation, require more aggressive screening. We follow these women twice yearly in our high-risk clinic, and we start yearly MRI screening at age twenty-five and yearly screening mammograms at age thirty.
Most of these women are also encouraged to consider risk assessment counseling, and in some cases, genetic testing (see chapter eighteen).
OTHER SYMPTOMS in this age group, such as nipple discharge, are managed in much the same manner as with younger women.
WHAT I’D TELL MY DAUGHTER
• The vast majority of breast problems in this age group (birth to forty) will be associated with non-cancerous conditions.
• Still, breast changes merit attention. Persistent or progressive changes need a timely answer.
• When in doubt, get an opinion from a breast care specialist.
THERE IS OBVIOUS OVERLAP when treating breast symptoms in the various age groups. For example, the care of symptomatic women in their thirties is nearly identical to what is offered for patients in their forties. To avoid repetition, we have simply summarized basic treatment in this and the previous chapter. A more detailed discussion of common breast problems is provided in Section II.
However, women in their forties should be aware of these concerns in particular:
Breast Lumps
Any new breast lump in a woman over forty merits concern. The older she is, the higher the probability of cancer. In menstruating women, breast lumpiness is common, but any nodule that persists after completion of a menstrual period requires medical attention. An ultrasound is often the only test needed to determine the nature of the lump. However, if doubt remains, a diagnostic mammogram is the next step. When findings on the mammogram or ultrasound are worrisome, a core needle biopsy (see page 48) will establish an accurate diagnosis.
If all diagnostic studies are negative, a further, two-month re-evaluation is still important, both to reassure the patient and to guard against a possible missed diagnosis of malignancy.
Abnormal Mammograms
The second most common breast problem in this age group is an abnormal screening mammogram. In most cases, additional imaging will eliminate concerns and the woman can return to routine yearly screening.
In the event of a positive finding, a core needle biopsy (see page 47) will provide an accurate diagnosis. If the biopsy is benign, the patient returns to regular screening. However, if the biopsy proves positive, the patient is referred to a breast surgeon.
Nipple Discharge
Nipple discharge is common in over-forty age groups, and squeezing the nipples is the primary cause. It is normal for breast ducts to contain fluid, and it is common for the breast, when squeezed, to produce a drop or more of yellow, green, or white fluid from the nipple. Although this discharge is not worrisome, women are advised not to squeeze their nipples.
However, discharge that occurs spontaneously requires medical attention—though in most cases the event is not related to a hidden breast cancer. Still, we are concerned when the fluid is either clear or bloody. If the discharge is suspicious enough to warrant a biopsy, it usually turns out to be benign, or associated with small, potentially curable breast cancers. For a more detailed discussion, see chapter