Doctor’s Corner
BREAST problems are a common reason for patients to visit their doctor and many would be worried about having breast cancer.
But only one in 10 patients referred to surgical clinics have a cancer — the remainder have a variety of conditions going under the general title of “benign breast disease”.
Many of the conditions that this term encompasses are not truly diseases but rather aberrations of normal development — involution of the breast that occurs from puberty to old age.
It is important to realise that breast problems do not only affect women, but men also.
Men, however, feel embarrassed most of the times to approach a doctor concerning breast problems.
In fact, many people do not know that breasts are present in both males and females!
They are modified sweat glands that are just more pronounced/developed in women than men because of hormonal influences.
But there are situations when the male breasts become just as pronounced as in women like in long-standing liver disease, such as seen in alcoholics, when the man develops what is called gynaecomastia.
Common symptoms are pain, cyclical or non-cyclical — ie pain related to menstrual periods.
Cyclical pain is usually in the early phase of the cycle, with intensity gradually worsening to reach a peak just before menstruation, easing with the start of the period.
The whole breast may feel engorged, tender and heavy. Physical contact can be unbearable which often leads to psychological distress.
The pain may be in one or both breasts.
Infections, trauma and others may cause non-cyclical pain but it is often difficult to identify a specific cause of non-cyclical pain.
Breast lumps usually cause a lot of distress to patients, especially when they are afraid that the lump may be because of cancer, which only occurs in very few cases.
The potential diagnoses depend on whether it is a part of a diffuse lumpiness or a single discrete isolated lump. Other features that may influence the diagnosis are whether the lump is painful or not and the age of the patient.
Until recently, it was obvious that any breast abnormality that can be felt should undergo an “excision biopsy” — ie cutting out the lump in case it could be a cancer.
A recent major change in management has been a shift from this approach to use physical examination, radiological imaging (mammography) and fine needle biopsy (a small needle is inserted into the lump and a very small piece cut out and taken for laboratory investigation) — the triple approach.
However, mammography is of little value in a woman under 35 years of age because the breasts are frequently too dense for small lumps to be seen.
For women unsuitable for mammography, ultrasound offers a useful tool for evaluating these “lumpy” problems. Lumpiness can be present on its own but is frequently associated with cyclical breast pain.
In common with pain, it is a manifestation of the cyclical changes that go on in the female breast during the menstrual years. A variety of descriptive terms have been applied to it: fibro-adenosis, cystic mastopathy, fibrocystic disease and cystic mastitis.
The common causes of a discrete single lump may be a fibro-adenoma (a tumour originating from the glands with large amounts of fibrous tissue) or cysts, which all form a well-defined lump. Of course, the possibility of a cancer always has to be ruled out.
Women are encouraged to undertake regular self-examination, which may draw attention to the possible presence of a lump or other changes in the breast.
If the breast is divided by an imaginary line into four quadrants, the upper-outer quadrant is the most affected, so special care should be taken during self-examination to check this part.
The majority of women who have fibro-adenomas are young and have them in the early years after menarche. These lumps feel firm, movable and sometimes tender.
With cystic disease, the occurrence is usually at a slightly late stage of life than fibro-adenomas — after 35 years of age and through to menopause.
A cyst is a closed sac containing fluid, having a distinct membrane, and is probably caused by the same influences, mostly hormonal, causing other cyclical breast changes.
The cyst usually feels soft, movable and occasionally tender, but sometimes the total opposite. The cyst can feel tender, firm/hard and not movable.
If the lump is suspected to be a cyst, then the doctor may do a needle aspiration — ie he will try to draw out the fluid from the lump. But if the lump fails to disappear completely after the aspiration, then the doctor may suggest re-evaluation after a few weeks using the same or other techniques.
We will, in the following few weeks, look at many other diseases or problems of the breasts such as causes of nipple discharge, infections of the breasts, problems of breastfeeding and breast cancer.
Everyone, males included, should do regular self-examination of their breast.
It is also important to note not all breast lumps are cancers. There are many other causes of breast lumps and pain that are not cancers, so do not get alarmed.
Just relax and go see your doctor as soon as possible.
