TOPIC: Benign Breast Disease -- Cancer is Not Your Only Risk
Images of thousands of pairs of breasts float through my mind these days. I suppose if I were a man, this would be quite understandable, but since I’m not, let me explain. One of my dearest “sisters” wrote me a while back telling me that her annual mammogram was found to be abnormal this year. Well, needless to say, both of us immediately thought the dreaded “C” word, as I’m sure most women would and do. After many sleepless nights, we found out that cancer was not her problem. She was diagnosed with something called “Benign Breast Disease.” Upon doing further research so that I could be of some assistance and support to her through this ordeal, I realized how little I knew (and how little information was available) on this particular topic. So, in her honor, and for your edification, I would like to use my editorial this month to discuss Benign Breast Disease (BBD).
When we women do think about the health of our breasts, it is most often in connection with our cancer risk. We are all pretty familiar with the statistics that say that one in nine (or one in eight, depending on the study you’re reading) women will fall victim to breast cancer in her lifetime. What no one ever tells us is that as far as our health is concerned, benign breast disease is far more common and can be equally as serious, distressing and disfiguring. As many as 90% of women will contract some sort of BBD (on a microscopic level) and it is actually palpable (can be seen and/or felt) in as many as 50%. It was really puzzling to me that since our risk of these problems is much greater, why we hear so little about it. Even after doing my research, I’m still confused about why so few people discuss this and so few physician make women aware of it. I suppose it’s because the topic can be quite confusing.
Benign breast disease encompasses so many different conditions, from relatively painless and non-threatening ones to disease processes that are not only connected to a greater risk of breast cancer, but can be life-threatening and disfiguring all by themselves. In this editorial, I will try to step you through the major categories of benign breast disease, from least to most threatening. Hopefully, by the end, you will be much more aware of these problems and seek attention promptly if you experience any of the symptoms. Unfortunately, as I said, most women will contract BBD, but they will be so worried that it is cancer, they will be reticent to have the proper testing done. And leaving some BBD conditions untreated can cause unnecessary loss of breast tissue or even the entire breast. So, let’s go through this gently, but thoroughly.
The least serious (but not least problematic) of the benign conditions is something generically called Breast Pain. This pain is poorly understood, but is generally thought to be attributable to an increased sensitivity of breast tissue to normal levels of hormones. It often appears with no warning, may continue for several months, and then disappear as suddenly as it came. Or it can be felt every month around the time of menses for some women. A surprisingly high percentage of breast pain is actually caused by chest wall arthritis and/or muscle overuse or strain. If it is found to really be breast pain, and not chest pain, the normal course of treatment includes powerful hormones prescribed for one year or more. In addition or in substitute, a woman can try abstinence from caffeine, though this is not as effective as hormone treatment. Adding 400-800 IU of vitamin E may help as well. Supportive or sports bras are also recommended. Though this condition is exceedingly hard to treat, it is not life-threatening and it almost always disappears entirely when a woman enters menopause.
And so we come to those benign conditions that can actually be seen or felt. There are three categories, increasing in seriousness. They are: (1) Non-Proliferating Lesions, (2) Proliferating Lesions Without Atypia, and (3) Atypical Ductal Hyperplasia (ADH). I will discuss each in turn and the various conditions found in each category. I will also attempt to keep the technical terminology to a minimum or define it when I have to use it.
1. Non-Proliferating Lesions
(or things that go lump in the night)
The non-proliferating lesions category includes many of those things we women typically call “lumps.” They are: Cysts, Fibroadenomas, Fibrocystic Disease, Fat Necrosis, Mastitis, and Mammary Duct Ecstasia.
Cysts: These are those pockets full of fluid that we women often discover ourselves while doing breast self exams and mistake for cancer. They are most often found in women 35-50 and can be quite painful. These cysts are normally diffuse, ill-defined, and cyclic with the menses. Needle aspiration (some fluid is drawn from the cyst) is usually used for diagnosis. If the fluid is found to be benign, the cyst can be drained and this usually gives instant pain relief. These cysts are not serious and often disappear after menopause all on their own.
2. Proliferating Lesions Without Atypia
Fibroadenomas (benign tumors): These are lumps composed of solid or granular tissue. They are rounded in outline, are easily moveable, and feel rubbery. They are most often found in women under 30 and African American women. They are extremely common and most surgeons prefer to surgically remove them to verify that the lump is benign. Even without removal, about 10% will disappear each year for those who choose to watch them instead of remove them. Again, these lumps are not serious.
Fibrocystic Disease: This condition is also known as chronic cystic mastitis and mammary dysplasia. The general term fibrocystic disease (FCD) does not refer to any distinct category, but is rather a generic term used to describe benign changes that do not fit in the other categories. Again, like fibroadenomas, these are lumpy or granular breasts. These lumps are most often seen or felt around the nipple, areola or upper quadrant of the breast. FCD is most often responsible for the lumpiness and tenderness that some women experience during mid-menstrual cycle. It is most commonly found in women approaching middle age. Ingestion of caffeine is thought to contribute to FCD, so eliminating caffeine may help. Vitamin E therapy is also used in treating FCD. This is another non-serious, but annoying, benign breast disease and these breast changes usually disappear on their own after menopause.
Fat Necrosis (or Lipoma): These are lumps or growths in the breast that are composed primarily of fat encased in fibrous tissue. They are generally painless, round, and firm. Fat necrosis is most commonly found in obese women with large breasts and it sometimes can be the result of injury or trauma to the breast. These lumps do not become cancerous and they need not be removed. Since they are painless, the most common treatment is no treatment.
Mastitis (commonly known as Breast Infection): This is the benign breast disease that most women are already familiar with because it is quite common in nursing mothers. Mastitis develops when a common bacteria (called Staphylococcus Aureus) enters the breast through tiny cracks in and around the nipples (caused when babies nurse) although this too can be the result of injury to the breast. The symptoms include: redness, tenderness, painful swelling of the breast or nipple, swollen glands in the armpit, fever, a yellowish discharge from the nipple, and fatigue. Mastitis is generally minor and heals by itself within a few days. Acetaminophen can help with the pain and swelling; also a few leaves of raw cabbage placed in the bra next to the skin can relieve the discomfort. However, if symptoms persist for more than a few days or if the fever rises, a course of antibiotics may be necessary. Women who ignore these symptoms have found that the area will form an abscess (walled off collection of pus). It then becomes a very serious condition requiring admission to the hospital and antibiotics delivered intravenously. If left untreated long enough, the abscessed area or even the entire breast may need to be removed.
Mammary Duct Ecstasia (Periductal Mastitis): This condition is the most frequent cause of nipple discharge in pre-menopausal women. It can occur with or without pain, but it is almost always associated with a serous gray, greenish or bloody discharge. Normally only one ductal system in one breast is involved, though ecstasia may be bilateral. It, like primary mastitis, is an infection caused by bacteria when the ducts below the nipple become clogged. The bacteria can progress further than one duct and lodge itself deep into the breast tissues. It causes degeneration of the ducts which is what is responsible for the discharge. A course of antibiotics and warm compresses is usually the first level of treatment. If this does not resolve the infection, surgery to remove the ducts then becomes necessary. This condition most often occurs in women nearing menopause. It can be both serious and painful and cause a good deal of breast disfigurement. Breasts left disfigured by the removal of the ducts are suitable candidates for reconstructive techniques like implants and tissue relocation.
(a little more frightening lumpy things)
Some of these conditions still include “lumps” like the first category. This category includes: Intraductal Papillomas, Sclerosing Adenomas, Changes due to Pregnancy, and Cyclic Changes.
Intraductal Papillomas: These are small, wartlike growths that result from the overgrowth of milk duct cells found in women nearing menopause and are another of the most common causes of nipple discharge. These warts may be solitary growths or be found in multiples. It is typically very difficult to determine whether these growths are benign or malignant and so most surgeons choose to remove them. Women with intraductal papillomas usually develop more of them and/or go on to develop breast cancer. If a woman chooses not to have them removed, the typical treatment includes reducing the amount of fluid the body retains before the menses. One way is to limit the amount of dietary salt and another is to take prescribed diuretics (or “water pills”). Elimination of caffeine and addition of Vitamin E is also recommended. It has also been found that reducing the amount of fat eaten and reducing alcohol consumption can help the liver process hormones more effectively and since hormones are implicated here, this can be helpful. Papillomas are serious and should be watched carefully since they have a three-to-four-fold increase in cancer risk.
3. Atypical Ductal Hyperplasia (ADH)
Sclerosing Adenomas: These are just another type of lump. They are caused by excessive growth of lobule tissue (the distal or far ends of the ducts). They are usually detected by mammograms and often confused for cancer. They are painful, but non-palpable. Treatment includes removal or careful monitoring.
Changes due to Pregnancy and Cyclic Changes: This is just a catch-all category for benign breast changes. These can include or not include lumps, swelling or pain. Any changes to the breasts should be checked and monitored and classified if possible. There is no specific treatment option for this category. Treatment depends on symptomology.
(OK, this is the one that should really worry you)
This category only includes one condition or diagnosis. It is called Atypical Ductal Hyperplasia or ADH.
ADH: This is the most serious of the benign breast disease categories. Atypia is used to describe how “abnormal” cells appear when viewed under a microscope. Normal breast cells have no atypia; in other words, all the breast cells look identical. If some cells look different from nearby cells, they are said to be atypical. This is an early warning sign that cancer may be on its way. Atypia itself is not cancer; all it really means is that cells in an area are misbehaving or overgrowing. This condition is known as proliferative; i.e., there is an increase in the growth of ductal epithelial cells or cells that line the ducts of the breast. This category shares some similarity to the features of ductal carcinoma and brings with it a significant increased risk of breast cancer.
And now that I’ve discussed all the major categories of benign breast disease, here is some information on which of these should be of greatest concern to you because of their breast cancer risk. Breast changes and their relative cancer risk are as follows:
No Increased Risk:
While I have tried to be as thorough as I can in this editorial, I could not possibly cover all the information concerning these benign breast diseases. Nor have I elected to cover breast cancer itself, as there are literally hundreds of thousands of books, articles and other resources on that topic. However, if what I’ve given you here is insufficient, I would like to point you to the following resources for additional information, assistance and support on both the benign breast conditions and breast cancer itself:
Cysts, Fat Necrosis, Mammary Duct Ecstasia, Fibroadenomas, Fibrocystic Disease (FCD), Mild Hyperplasia, Changes due to Pregnancy and Cyclic Changes, and Mastitis.
Slightly Increased Risk (1.5 to 2 times):
Sclerosing Adenomas, Moderate/Severe Hyperplasia, and Papillomas.
Moderately Increased Risk (5 times):
Atypical Ductal Hyperplasia (ADH)
The Komen Foundation (Breast Health)
College of American Pathologists (CAP) – Public Interest: Health and Wellness
And just in case there are any men out there who've read this far (and for your information too, ladies, to pass on to the men you love), I would like to state that BBD does not just affect women. Like breast cancer, it can also occur in men although it is very rare. In men's case, the most common BBD is called Gynecomastia (Pubertal or Adult). Simply expressed, this condition is an excessive development of breast tissue in men. Although it is not serious, it can be embarrassing and/or distressing. There are treatments available for it. I direct you to the first resource listed above for more information regarding this BBD and breast cancer in men.
As an aside, I would also like to offer you this warning. We all are already strongly encouraged to get annual mammograms after the age of 40. And I’m sure most of you are responsible enough to heed this advice. However, many testing centers will tell you that if you do not hear back from them, this means that your mammogram was normal and you have nothing to worry about. I strongly encourage you to ignore this and call your testing center or your physician and ask for the results of your mammogram. I am hearing from quite a few women who have been the victims of never having been notified about abnormal mammograms. Testing centers and physicians are very busy people; test results have been known to get lost or misfiled. And the longer you go without proper diagnosis and treatment, the more serious any potential condition will get. What could have been handled with a routine course of antibiotics may brew unnoticed until much more serious and drastic action must be taken. Breasts have been lost to negligence. Please, call your physician and ask for test results (this applies to all testing done, not just mammograms). It only takes a moment and you will feel much better upon hearing someone shuffle through your files and state unequivocally that your mammogram was normal. And if your physician finds these types of confirmation calls annoying, well then, I suggest you find yourself another physician.
I hope that by reading this, you have become more aware of what benign breast disease is and what the symptoms and treatments for these conditions are. As I said, my “sister” and I were totally unaware of all this and totally unprepared for it as well. My objective in presenting it to you has been with the hope of saving you the distress and fear that she and I have felt. Though cancer is often more serious, BBD is more common. I hope that if you are stricken with one of these conditions, you will understand that treatment is available for some and that catching them early can save you much pain and disfigurement or loss. Good luck in this and in all your journeys.
Author’s Note: My thanks to the owners of the web sites I mentioned above where I found most of the information and statistics for this editorial. And my prayers are with you, my sister, for a positive outcome to your pain and suffering.
Disclaimer: The information provided in this editorial is for informational purposes only and the author cannot make guarantees of accuracy or the application of this information to any specific individual, nor does she support nor discourage any particular treatment modality. Diagnoses and treatments should be obtained and/or be recommended only by a qualified healthcare practitioner. All patients are encouraged to speak to their doctors first before making any significant changes to their healthcare regimen.