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Breast Health

In June 2007, our guest expert in Le Club's Ask the Expert was Dr. Pamela Lenkov, MD, CCFP.

Pam is a specialist in family medicine, with a sub-specialty in preventive oncology. She works in cross-appointment at The Henrietta Banting Breast Centre at Women's College Hospital in Toronto, the Department of Preventative Oncology at the Toronto Sunnybrook Regional Cancer Centre (TSRCC), and the Health Services department at the University Of Toronto.

She works with these breast diagnostic services, conducts follow-ups of patients with previous diagnoses of breast cancer, and evaluates patients felt to be at high risk, based on individual, familial and hereditary genetic risk.

Pam has received awards for both academic achievement and, more recently, for teaching duties as a Lecturer in the Department of Family and Community Medicine (DFCM) at the University of Toronto. In 2007, she received the Award for Excellence in Teaching of Clinical Clerks and Residents at U of T.

Here are Pam’s answers to your questions about Breast Health:

 

Q: My mother has had breast fibroids for many years. I find now that I am getting older (39) I am experiencing some of the same symptoms my mother experienced and have, in fact, been told I have one in my left breast. How often should I have my breasts examined and is there any treatment for this condition?  


A: I believe that you may be referring to fibroadenomas of the breast. These are amongst the most common solid lumps found in women. In general, simple fibroadenomas are not considered to be precancerous. They usually require a minimum of two years of follow-up with clinical breast exam and breast imaging. The specific follow up plan would be tailored to the individual patient.

With respect to treatment of fibroadenomas, there are several indications for surgical removal. Some of these are: increasing size, unusual features on breast imaging and/or biopsy, and the individual patient’s preference.

 


Q: My mother (aged 79) was recently diagnosed with metastatic breast cancer. The cancer has spread to the lymph nodes under her arms.  She will be having a partial mastectomy followed by radiation.  There is no other family history of breast cancer.  Do I now have a family history of breast cancer (I am 51)?  Or, does her age at diagnosis mean that this is an age-related cancer only?

A: Dealing with a diagnosis of breast cancer in a close family member can be very challenging in many ways. In this case, you have very reasonable concerns as you now have a family history of breast cancer in that your mother, a first degree relative, has been diagnosed with postmenopausal breast cancer. I have been given no additional information with respect to your family history.

If your mother is the only case of cancer in your family, then, based on her age at diagnosis of 79, it is likely that her cancer would be considered a sporadic event and you would not be considered at ‘high risk’ of breast cancer based on that family history. Your personal risk, which would also include additional details such as your reproductive and breast history and your age, can be addressed individually with your physician.

 



Q:  It is interesting to me that, despite having relatively small breasts (and I do mean small) my breast tissue is considered dense, thereby increasing my risk of developing breast cancer. I am almost 60.  Can you comment about this?


A: Breast “density” is a description of the amount of fibroglandular tissue noted on mammography. It is not specifically correlated neither with the size of the breasts nor with the quality of the breast texture on breast examination.

In general, younger women have denser breast tissue on mammography and postmenopausal women (not taking HRT) have “fattier” (i.e. less dense) breast tissue on mammograms. There are always exceptions, however, and in fact, at age 70, approx 25-30 percent of women can still be found to have a breast density of 50 percent. There is evidence that women with extremely dense breasts on mammography do have an additional breast cancer risk.

 


Q: This question has probably been raised before, but I have heard so many conflicting reports about mammograms. Are they required when women reach age 40? What are some of the alternatives?

A: Mammography is currently considered the ‘gold standard’ for breast cancer screening. At the present time, there is no recommended alternative. The Ontario Breast Screening Program (OBSP) recommendations are for mammograms every two years for all women ages 50-74.

The OBSP does recommend annual screening between those ages for certain subsets of women such as those with a family history. However, some guidelines such as those of the American College of Radiology, and the US Preventive Services Task Force recommend beginning from age 40 and continuing either annually or every one to two years.

 


Q:  My sister got breast cancer at 42, and it spread to the liver two years later; she passed away at aged 44.  Every year I have a medical check up using ultrasound. I am now 47 and have never had a mammogram before, although I have had ultrasounds.  Do you think that's enough, or do you have any other suggestions?

A: I am saddened by the loss of your sister. The answer to the above question can help with your query. In addition, ultrasound is considered an excellent diagnostic tool with which to evaluate abnormalities found on breast examination and/or mammography. But at this time, it is not recommended as a standard screening imaging procedure.

 



Q: After having a biopsy one year ago with a negative result, I have recurrent inflammation in my breast. The antibiotic keflex helped four times before, but is not helping now. I have pus discharge from my nipple and my nipple is inverted. That is the reason I had a biopsy. I have pain, but no fever. What is my next option? Surgery?  Thank you.

A: You have a very complex set of symptoms and concerns. Based on the limited information I have been given, I would suggest that you have follow-up as soon as possible with your physician, as the symptoms you describe could potentially be associated with a serious diagnosis.

Certainly, the possibility of an underlying cancer would always need to be excluded in a setting of persistent breast symptoms such as you have described which have failed to respond to treatment. If you have already consulted a surgeon, then your question with regard to the need for surgery would best be addressed by that specialist.

 


Q:  I have very dense, lumpy breasts and over the years have had many cysts.  I am 50 and my doctor has recommended that I have an annual breast MRI in between my annual mammogram and ultrasound, as an additional diagnostic measure.  Although my mother has recently been diagnosed with breast cancer (at age 78, there is no other family history of breast cancer. What do you think about my doctor’s recommendation?


A: It is difficult to specifically individualize a response to your concerns without additional information. In general, neither a history of cysts nor the current presence of breast cysts is considered a specific indication for the addition of MRI to conventional mammography as a screening procedure.

As the only information I have with respect to your family history is your mother’s diagnosis at age 78, it is difficult to delineate your specific risk (see also the answer to the second question). In general, a recommendation for MRI based on family history alone would not be made if your mother’s history is the only case in your family.

 



Q:
When doing my breast self- exams, I always compress my nipples to check for discharge. Is a small amount of clear, sticky discharge normal? I have never been pregnant, and stopped taking oral contraceptives over a year ago.


A: In general, manipulation or squeezing of the nipples to check for discharge is not recommended as part of the breast self-examination (BSE).

This is important because spontaneous discharge (i.e. occurring without manipulation/squeezing) is one of the characteristics of nipple discharge that is considered potentially worrisome (but still, in many cases, ultimately found not to be associated with cancer after investigation).

I would strongly recommend that you consult your physician for the symptoms you describe in order to undergo a breast examination. Your physician can then decide if any additional investigations are warranted.

 



Q: Hi Dr. Lenkov.  I have two questions for you:  Does late menopause increase the risk of breast cancer? What effects do menopause and the fluctuation of estrogen have on fibrocystic breast disease?


A: There are several ‘reproductive’ risk factors for breast cancer. With regard to age at menopause as a potential risk factor, if the average age is considered to be 51, there is a small increased risk of breast cancer, per year, with a delay in age at menopause. In general, with the advent of menopause, the expectation is that for a patient not taking HRT, her fibrocystic breast condition will significantly improve.

 



Q:  I am 36 years old, and have never had a mammogram, but I have had many lumps in both breasts over the years. Once, I had a cyst that was so large that it was aspirated and analyzed by a doctor.

 I have had several ultrasounds on both breasts, and it has (so far) turned out to always be cysts in my breast tissue, not tumors. Usually these shrink and disappear in time. My left breast, however, is almost always tender (has been this way for about 10-15 years) and becomes excruciating just before my period. Is this common, and should I get a mammogram to be sure it's nothing more than cystic tissue? I am afraid of how painful a mammogram might be for me.

And, if it is a cyst, would having it removed give any relief to the tenderness and pain? Are there any treatments you could recommend? I have heard some doctors mention taking vitamin E or cutting down on caffeine.


A: Breast pain involving one or both breasts is an extremely common symptom. In my practice, I have found it to be a common complaint in many of patients in their late 30s and definitely during the 40s until menopause.

Fortunately, breast pain which is long-standing and unchanged in quality and which occurs on a cyclical basis with respect to the timing of the menstrual period is very unlikely to be associated with an underlying cancer. For any patient who is over the age of 30 and who presents with a new (painless or painful) breast lump, even if she has a known history of breast cysts, the appropriate work-up would begin with clinical breast examination.

A decision to proceed next with either aspiration of the lump and/or imaging, which would include both mammography and ultrasound, would be based on the symptom presentation, a full review of the patient’s history including risk factors, and the clinical impression on the examination.

 For many patients with breast cysts and fibrocystic breast condition, reduction or discontinuation of caffeine intake has been associated with a significant improvement in symptoms.

 

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