Breast lump and breast pain are two common presenting signs and symptoms of breast cancer. However, the presence of breast lump or breast pain does not necessarily indicate the presence of cancer. Most breast lumps, especially in the young, will eventually be proven to be benign; and most breast pain, especially the cyclical ones, will eventually be proven to be hormonal in origin. This does not mean, however, that breast lump and/or breast pain can just be ignored. Any breast lump or breast pain warrants closer examination.
Breast lumps or masses in the breasts can either be benign (non-cancerous) or malignant (cancerous). Many women will notice lumps in their breasts especially in the week before and after menstruation. Majority of these lumps are benign and are commonly just due to the natural change in the architecture of the breast in response to the changing hormones of the body. However, all of these lumps need to be examined by a medical professional; more so if the lumps are hard, large, fixed, matted, and accompanied by skin changes like skin dimpling, skin ulceration, and nipple retraction.
There are a number of reasons that can cause breast pain in women. These can include hormonal changes, pregnancy, lactation, menopause, infection, and, occasionally, cancer. Most breast pain can be attributed to hormonal changes in the body. This type of breast pain is usually cyclical in nature and commonly felt on both breasts. Cyclical breast pain is rarely due to cancer but it does not exclude the presence of breast cancer.
When to seek consult
- Any breast lump especially those that are hard, large, fixed, or matted
- Breast lump or breast pain that is associated with the following:
- skin dimpling
- skin ulceration
- skin redness and warmth
- nipple retraction
- nipple discharge
- axillary (underarm) lymph nodes or mass
Evaluation and management of breast lumps and breast pain
All women are encouraged to examine their breasts every month in a systematic way. This is best done a week after the first day of menses.
- First, with hands placed on the waist, the breasts should be inspected in front of the mirror for symmetry and for any skin changes like skin dimpling, nipple retraction, redness, or any other lesions.
- Second, with both arms raised, the breasts should be inspected for the same lesions.
- Third, squeeze both nipples and look for any fluid that comes out of it.
- Fourth, while lying down and with the left arm raised, the right hand should palpate the entirety of the left breast for lumps and masses. This should be done in a systematic manner going radially, spirally, or top-to-to-bottom, with the aim to cover all the areas of the breast. The palpation should be able to cover the area from the collarbone to the lower breast fold and from the mid-sternum to the axilla. Do the same thing for the other breast.
- Fifth, while standing upright, palpate both breasts again. Some women do this step while in the shower to facilitate palpation while the skin is wet.
Aside from monthly self-breast examination, breast lumps and breast pain should be examined further by a medical professional (Family doctor or Gynecologist). For women aged 30 years and older, breast lumps are examined by doing a mammogram, which involves taking x-rays of the breast while it is being compressed flat by a machine. For women younger than 30 years old, an ultrasound or an MRI of the breast is recommended. The difference in the diagnostic tests according to age groups is based on the consistency of the breast. Breasts of younger women are more fibrous and would be imaged better by an ultrasound or MRI, whereas breasts of older women are more fatty and can be adequately imaged by a mammogram.
The management will then depend on the results of the imaging studies. These imaging studies have a scoring system, the Breast Imaging-Reporting and Data System (BIRADS), which categorizes the findings according to how likely they appear to be benign or malignant. Depending on the BIRADS score, a significant breast finding can either be observed serially every 6 months to 1 year or explored further through a tissue biopsy. A low BIRADS score points more to a benign finding and is recommended to just be observed serially. A high BIRADS score points more to a malignant finding and is recommended to be biopsied to ascertain whether it is malignant or not. The biopsy result will then identify whether the mass is malignant or benign. Malignant masses have to be removed surgically (with or without chemotherapy). Benign masses can be observed or can be removed depending on the preference of the patient and the judgement of the doctor.