Types of Breast Changes

Lumpiness Breast Changes Due to Your Period Single Lumps Nipple Discharge

Finding Breast Changes

Mammograms Getting Your Mammogram Results What a Mammogram Can Show Lumps (or "mass") Calcifications Are Mammogram Results Always Right? Changes That Need More Follow-Up

Breast Changes During Your Lifetime That Are Not Cancer

Getting a Second Opinion

Follow-Up Tests to Tell You More

Ultrasound Biopsies Types of Biopsies       Fine-Needle Aspiration Core Needle Biopsy Surgical Biopsy Getting Your Biopsy Results       Benign Changes Atypical Ductal Hyperplasia (ADH) or Lobular Carcinoma In Situ (LCIS) Cancer Cells Found in the Lining of the Ducts (Ductal Carcinoma In Situ or DCIS) Cancer That Is Invasive

Finding the Support You Need

For More Information

Chart 1: Possible Mammogram Results and Follow-Up Care

Chart 2: Possible Biopsy Results and Follow-Up Care

About Your Breasts

Breast Basics

The breast is a gland that produces milk in late pregnancy and after childbirth.

What are breasts made of?

• Each breast is made of lobes.
• Lobes are groups of milk glands called lobules.
• Lobules are arranged around thin tubes called ducts.
• Ducts carry the milk to the nipple.
• These lobules and ducts make up the glandular tissue.

What is the lymphatic system?

The breasts also contain lymph vessels, which carry a clear fluid called lymph.

• The lymph vessels lead to small, round organs called lymph nodes. Groups of lymph nodes are found near the breast in the underarm, above the collarbone, in the chest behind the breastbone, and in many other parts of the body.
• The lymph nodes trap bacteria, cancer cells, or other harmful substances that may be in the lymphatic system. Their job is to make sure harmful substances are safely removed from the body.

Back to Top Types of Breast Changes

Breast changes occur in almost all women. Most of these changes are not cancer. However, some breast changes may be signs of cancer. Breast changes that are not cancer are called benign. For more information on benign breast changes that are more likely to happen during certain times of your life, see Breast Changes During Your Lifetime That Are Not Cancer.

Lumpiness

Most women have some type of lumpiness in their breasts. Some areas may be more dense than others and can feel lumpy in an exam. What you are feeling may be glandular breast tissue.

Breast Changes Due to Your Period

Many women have swelling, tenderness, and pain in their breasts before and sometimes during their periods. You may also feel one or more lumps during this time because of extra fluid in your breasts.

Because some lumps are caused by normal hormone changes, your health care provider may suggest watching the lump for a month or two to see if it changes or goes away.

Single Lumps

Single lumps can appear at any time and come in various types and sizes. Most lumps are not cancer, but your health care provider should always check the lump carefully. He or she may do more tests to make sure the lump is not cancer. See Chart 1: Possible Mammogram Results and Follow-Up Care for more information about these types of lumps.

Check with your health care provider if you notice any kind of lump. Even if you had a lump in the past that turned out to be benign, you can't be sure that a new lump is also benign.

Nipple Discharge

Nipple discharge is common for some women. It is fluid that comes from the nipple in different colors or textures. Usually, it is not a sign of cancer. For example, birth control pills and other medicines, such as sedatives, can cause a little discharge. Certain infections also cause nipple discharge. However, for women who are going through or have passed menopause, nipple discharge can be a sign of cancer.

See your doctor if you have nipple discharge for the first time, or a change in your discharge's color or texture. He or she may send a sample of the discharge to be checked at a lab.

Back to Top Finding Breast Changes

There are two ways to find breast changes:

• Clinical breast exams--a breast exam done by your health care provider
• Mammograms --an x-ray of your breasts

One way to find breast changes is with a clinical breast exam done by your health care provider. He or she will check your breasts and underarms for any lumps, nipple discharge, or other possible changes. This breast exam should be part of a routine medical check-up.

The best tool for finding breast cancer is a mammogram. A mammogram is a picture of the breast that is made by using low-dose x-rays. It is currently recommended that women over age 40 receive a mammogram every 1 to 2 years.

Some women check their own breasts for changes. If you find a change, it's important to call your health care provider for an appointment. Make sure to watch the change you found until you see your provider. But a breast self-exam and a clinical breast exam are not substitutes for mammograms.

Mammograms

Mammograms are used for both screening and diagnosis.

A screening mammogram is used to find breast changes in women who have no signs of breast cancer. Most women get two x-rays of each breast.

If your recent screening mammogram revealed a breast change since your last one, or if you or your health care provider noticed a change, he or she will probably recommend a diagnostic mammogram. More x-rays are taken during a diagnostic mammogram than a screening mammogram to get clearer, more detailed pictures of the breast. It is also used to rule out other breast problems.

A digital mammogram is another way to take a picture of your breasts. The procedure for having a digital mammogram is the same as a screening mammogram, except that it records the x-ray images in computer code instead of on x-ray film.

Here are mammograms of three different women. Doctors look at these x-rays for any breast changes that don't look normal.

Normal

Benign Cyst (Not Cancer)

Cancer

Getting Your Mammogram Results

If your results were normal, it means the radiologist did not find anything that needs follow-up.

If your results were abnormal, it means the radiologist found:

• A change from a past mammogram
• A change that needs more follow-up

What a Mammogram Can Show

The radiologist will look at your x-rays for breast changes that do not look normal. The doctor will look for differences between your breasts. He or she will compare your past mammograms with your most recent one to check for changes. The doctor will also look for lumps and calcifications.

Lumps (or "mass")

The size, shape, and edges of a lump sometimes can give doctors more information about whether or not it is cancer. On a mammogram, a growth that is benign often looks smooth and round with a clear, defined edge. On the other hand, breast cancer often has a jagged outline and an irregular shape. (See Chart 1: Possible Mammogram Results and Follow-Up Care.)

Calcifications

A calcification is a deposit of the mineral calcium in the breast tissue. Calcifications appear as small white spots on a mammogram. There are two types:

• Macrocalcifications are large calcium deposits often caused by aging. These are usually not cancer. (See Chart 1: Possible Mammogram Results and Follow-Up Care.)
• Microcalcifications are tiny specks of calcium that may be found in an area of rapidly dividing cells. If they are found grouped together in a certain way, it may be a sign of cancer. (See Chart 1: Possible Mammogram Results and Follow-Up Care.)

Depending on how many calcium specks you have, how big they are, and what they look like, your doctor may suggest that you:

• Have a different type of mammogram that allows the radiologist to have a closer look at the area
• Have another screening mammogram, usually within 6 months
• Have a test called a biopsy.

Calcium in the diet does not create calcium deposits (calcifications) in the breast. Calcification

"I used to think whenever a mammogram found a lump or a mass, it was probably cancer--it turns out that most breast changes are not cancer. That's one thing I sure didn't mind being wrong about." Anne, Age 60

Are Mammogram Results Always Right?

No. Although they are not perfect, mammograms are the best method to find breast changes. If your mammogram shows a breast change, sometimes other tests are needed to better understand it. Even if the doctor sees something on the mammogram, it does not mean it is cancer.

Changes That Need More Follow-Up

Sometimes your doctor needs more information about a change on your mammogram. Your doctor may do follow-up tests such as an ultrasound or more mammograms. The only way to find out if an abnormal result is cancer is to do a biopsy. It is important to know that most abnormal findings are not cancer.

Back to Top Breast Changes During Your Lifetime That Are Not Cancer

You might notice different kinds of breast changes at different times in your life. Many of these are caused by changes in your hormone levels and are a normal part of getting older.

Younger women may have more glandular (more dense, less fatty) breast tissue than older women who have stopped having their period (menopause). This kind of tissue is where breast changes usually occur.

Before or during your period, you might have lumpiness, tenderness, and pain in your breasts. The lumpiness and pain usually go away by the end of your period.

During pregnancy, your breasts may feel lumpy, as the glands that produce milk increase in number and get larger. Still, breast cancer has been found in pregnant women, so talk with your doctor if you have questions about any breast lumps.

"Everything changes over time, including your body. The important thing is to work with your doctor to deal with the changes in a calm and sensible way." --Carmen, Age 70

While breastfeeding, you may get an infection called mastitis that happens when a milk duct becomes blocked. Mastitis causes the breast to look red and feel lumpy, warm, and tender. Mastitis is often treated with antibiotics. Sometimes the duct may need to be drained. If the redness or mastitis does not go away with treatment, call your doctor, as you may need further care.

As you approach menopause, your periods may become less frequent. Changing hormone levels also can make your breasts:

• Feel tender, even when you are not having your period
• Feel more dense
• Feel more "lumpy" than they did before

As you age, other breast changes are more common, such as:

• Intraductal papilloma. This is a growth inside the nipple that looks like a wart. It can be removed by surgery without changing the way the breast looks.
• Mammary duct ectasia. As you near menopause, ducts beneath the nipple can become swollen and clogged. This can be painful and cause nipple discharge. The problem is treated with warm packs, antibiotics, and sometimes surgery to remove the duct.

If you are taking hormones, such as hormone replacement therapy (HRT), birth control pills, or injections, when getting your mammogram be sure to let your doctor know. Hormones may cause your breasts to be more dense. This can limit your doctor's ability to read a mammogram.

When you stop having periods (menopause), your hormone levels drop, and your breast tissue becomes less dense and more fatty. You may stop having the lumps, pain, or nipple discharge you used to have. And because your breast tissue is less dense, mammograms can be easier to read. This means doctors are more likely to find breast changes or early breast cancer.

Back to Top Getting a Second Opinion

"I wasn't sure if it was okay to ask for a second opinion... it's good to know that lots of other people are asking. After all, it is my body; I owe it to myself to be sure." --Marie, Age 55

After seeing your health care provider, you may want to get a second opinion from another health care provider. Sometimes, a second opinion may be covered by your health insurance. Many women feel uneasy about asking for a second opinion, but it is very common. Your health care provider will not be surprised or offended if you seek a second opinion. A second opinion might help you feel more confident that you are making the best choices about your health.

Back to Top Follow-Up Tests to Tell You More

Doctors often use ultrasound or biopsies to follow up after finding signs of a breast change.

Ultrasound

An ultrasound uses sound waves to make a picture of breast tissue. This picture is called a sonogram. It helps doctors look more closely at lumps. An ultrasound shows if a lump is solid or filled with fluid (cyst). (See Chart 1: Possible Cysts are usually not cancer. Mammogram Results and Follow-Up Care.) An ultrasound also can help your doctor decide if more tests are needed.

It is important to know that an ultrasound may not find all abnormal changes.

Biopsies

During a biopsy, the doctor removes some cells or tissue, an area of small calcium deposits, or the whole lump. The tissue is sent to a lab where a doctor called a pathologist will look at the cells. He or she checks the cells for cancer or other diseases. Biopsies are usually done on an outpatient basis, meaning you can go home the same day as your test. Biopsies are the only way to find out if cells are cancer.

Types of Biopsies

The most common types of biopsies are:

• Fine-needle aspiration
• Core needle biopsy
• Surgical biopsy

Fine-Needle Aspiration

Fine-needle aspiration only takes a few minutes and can be done in the doctor's office. It is often done when a doctor finds a lump that appears to be a cyst. The doctor tries to remove fluid from the lump using a thin needle and a syringe. If the lump is a cyst, removing the fluid will make it go away. If the cyst returns, it can be drained again. Because cysts are rarely cancer, doctors test the fluid only if it is bloody or if there are other reasons to be concerned. If the lump is solid, cells can be taken out with the needle. These cells are checked for cancer.

Fine-Needle Aspiration

Core Needle Biopsy

This type of biopsy can be done in the doctor's office or hospital. A core needle biopsy is a type of biopsy that uses a needle with a special cutting edge. The core needle is inserted through a small cut in the skin. A small core of tissue is removed. More than one tissue sample can be taken through the same small cut in the skin. This test may cause a bruise but rarely leaves a scar.

During the biopsy, the doctor may insert a guided probe into the area of the breast change. The probe gently vacuums tissue samples from the area.

Sometimes the doctor uses other methods to guide the core needle or probe to the breast change. These include:

• Ultrasound-guided needle biopsy. Doctors use ultrasound to guide the needle during the biopsy. This method is used when lumps are hard to feel on a breast exam or see on a mammogram.
• Stereotactic core needle biopsy localization. A three-dimensional (3-D) x-ray guides a biopsy needle to a lump or other change that cannot be felt on a breast exam. With one type of equipment, you lie face down on an exam table with a hole in it. The hole allows your breast to hang below the table, where the x-ray machine and needle are. Or, special equipment can be attached to a standard mammogram machine to x-ray your breast from two angles.

Surgical Biopsy

A surgical biopsy is an operation to remove part or all of the breast lump. Most of the time, you have the biopsy and go home the same day. Sometimes a doctor will do a surgical biopsy as the first step. Other times, a doctor may do a surgical biopsy if the results of a needle biopsy do not give enough information.

Surgical Biopsy

Sometimes, a needle is used to guide a surgical biopsy. A mammogram or ultrasound is used to find breast changes that cannot be felt. Once the breast change is found, a radiologist puts a needle into the breast so that the tip of the needle is at the area of breast change (called needle localization). Then a fine wire is placed through the needle. The needle may be removed and the wire stays in place. You may be asked to walk to another room or to the operating room for the biopsy. During surgery, the doctor uses the tip of the wire as a guide to what tissue to take out.

Needle Localization

Getting Your Biopsy Results

On average, you should get your biopsy results from your doctor 7 to 10 days after your biopsy.

The biopsy results will tell your doctor if you have:

• Benign breast changes
• Changes that may increase your chances of getting breast cancer
• Cancer cells in the lining of your breast ducts
• Cancer cells that have spread into nearby breast tissue

Here are more detailed descriptions of biopsy results.

Benign Changes

• Fibroadenomas--Hard, round lumps that feel like rubber
• Fat necrosis--Painless, round, firm lumps
• Sclerosing adenosis--Growths that may contain calcifications and are often painful

Your health care provider will probably suggest that you get follow-up care for these types of benign changes. See Chart 2: Possible Biopsy Results and Follow-Up Care for more information.

Two types of changes that may increase your chances of getting breast cancer

• Abnormal cells found in the breast ducts (Atypical Ductal Hyperplasia, or ADH)
• Abnormal cells found in the breast lobules (Lobular Carcinoma In Situ, or LCIS)

Even though I was scared, I am glad I went for a follow-up to find out what I had. Now my doctor and I can do something about the breast change.--Jackie, Age 63

Atypical Ductal Hyperplasia (ADH) or Lobular Carcinoma In Situ (LCIS)

ADH and LCIS are not cancer. However, having ADH or LCIS in one breast does mean that you have a higher risk of getting cancer in either breast. Your doctor will want to follow your breast health very closely if you have ADH or LCIS. For example, your doctor may suggest that you:

• Get more mammograms or see him or her more often
• Take a drug, called tamoxifen, which has been shown to lower some women's risk of getting breast cancer
• Take part in clinical trials of promising new preventive treatments. In a cancer prevention trial, a large group of people is studied to help find better ways of preventing or lowering the chances of getting cancer.

A very small number of women with LCIS have surgery to remove both their breasts. They do this to try to keep breast cancer from developing. Talk to your doctor about what is best for you. See Chart 2: Possible Biopsy Results and Follow-Up Care for more information about ADH and LCIS.

Cancer Cells Found in the Lining of the Ducts (Ductal Carcinoma In Situ or DCIS)

DCIS is a condition in which cancer cells are only found inside the lining of a breast duct. The abnormal cells have not spread outside the duct to the surrounding breast tissue. Therefore, most women with DCIS are cured with treatment. However, if not treated, DCIS sometimes spreads to other parts of the breast (also called invasive breast cancer). Your doctor may discuss some of these treatment choices for DCIS:

• Getting breast-sparing surgery (the surgeon removes only your cancer and some normal tissue around it) with radiation therapy
• Getting breast-sparing surgery without radiation therapy
• Getting a total mastectomy (surgery to remove the entire breast)
• Taking the drug tamoxifen after surgery and radiation to lower the chances of the cancer coming back

See Chart 2: Possible Biopsy Results and Follow-Up Care for more information about DCIS.

Cancer That Is Invasive

Even if you have breast cancer that has spread to other parts of your breast, finding it early gives you the best chance to get treatment that may save your breasts and your life. It's also true that women with breast cancer that has spread have reasons for hope.

Some women with breast cancer may want to take part in a clinical trial. Clinical trials are research studies to find better ways to treat cancer. Some studies on new cancer-fighting drugs, drug combinations, and ways of giving treatment have already begun to show good results.

For more information about breast cancer and its treatments, call 1-800-4-CANCER for a free copy of What You Need To Know About Breast Cancer or visit www.cancer.gov and search for "breast cancer." (See For More Information.)

Back to Top Finding the Support You Need

It can be scary when you find out about a breast change, get an abnormal mammogram result, or learn you have breast cancer. Many women have found it helpful to:

• Ask friends or loved ones for support. Take someone with you while you are learning about your testing and treatment choices.
• Ask your doctor or nurse to:
  • Help you understand medical terms that are confusing
  • Tell you how other people have handled the types of feelings that you are having
• Contact the organizations listed in For more Information.

Back to Top For More Information

The following organizations can give you more information on mammograms, breast changes, finding breast cancer early, and different breast cancer treatments.

National Cancer Institute (NCI)

You can find out more from these free NCI services:

• Answers to your questions about cancer
• Tips to prevent and screen for cancer
• Informational materials
• Other resources

NCI Online
Web site: www.cancer.gov

This Web site provides current and accurate information from the National Cancer Institute. Through instant messaging (LiveHelp), Information Specialists can answer your questions about cancer and provide help in navigating NCI's Web site. You will find a wide range of cancer information, including:

• Treatment options
• Clinical trials
• Ways to reduce cancer risk
• Prevention and screening information
• Ways to cope with cancer

Centers for Medicare and Medicaid Services (CMS)

CMS provides information about Medicare benefits to pay for screening mammograms.

Centers for Disease Control and Prevention (CDC)

CDC conducts, supports, and promotes efforts to prevent cancer and increase early detection of cancer. CDC's National Breast and Cervical Cancer Early Detection Program provides free breast and cervical cancer screening and diagnostic services to women with low incomes.

National Women's Health Information Center (NWHIC)

NWHIC provides a gateway to women's health information. NWHIC is sponsored by the U.S. Department of Health and Human Services Office on Women's Health.

U.S. Food and Drug Administration (FDA)

The FDA has information about mammography on its Web site, including a section for consumers, a list of FDA-approved mammography facilities, and laws about how these facilities are run.

Back to Top Chart 1: Possible Mammogram Results and Follow-Up Care

Conditions	Features	What Your Doctor May Recommend
Cysts	Fluid-filled lumps Usually not cancer Occur most often in women ages 35-50 Often in both breasts Some too small to be felt	Doctors often watch cysts over time or use fine-needle aspiration to remove the fluid from the cyst. Ultrasound may be used to see whether a lump is solid or filled with fluid.
Fibroadenoma	Hard, round, benign growth Feels like rubber; moves around easily Usually painless Often found by the woman herself Appears on mammogram as smooth, round lumps with clearly defined edges Can get bigger when the woman is pregnant or nursing	Sometimes diagnosed with fine-needle aspiration If the fibroadenoma does not appear normal, the doctor may suggest taking it out to make sure it is benign.
Macrocalcifications	Appear on a mammogram as large calcium deposits Often caused by aging Usually not cancer	Have another mammogram to have a closer look at the area A biopsy may be used for diagnosis
Mass	May be round and smooth or have irregular borders May be caused by normal hormone changes	A mammogram and/or ultrasound may be used to see whether a lump is solid or filled with fluid A biopsy may be used for diagnosis
Microcalcifications	Appear on a mammogram as tiny specks of calcium that might be found in an area of rapidly dividing cells If they are found grouped together in a certain way, they may be a sign of cancer.	Have another mammogram to have a closer look at the area A biopsy may be used for diagnosis

Back to Top Chart 2: Possible Biopsy Results and Follow-Up Care

Conditions	Features	What Your Doctor May Recommend
Atypical Ductal Hyperplasia (ADH)	Abnormal cell growth	Getting more mammograms and/or seeing the doctor more often Taking tamoxifen
Cancer	Abnormal cells dividing without control in the breast Could spread to other parts of the body	Surgery Chemotherapy Radiation therapy Hormonal therapy Biological therapy Treatment may depend on the stage of the disease
Ductal Carcinoma In Situ (DCIS)	Cancer cells in the breast ducts Has not spread to other parts of the breast May develop into cancer that spreads to other parts of the breast (invasive breast cancer)	Breast-sparing surgery and radiation therapy (with or without tamoxifen) Breast-sparing surgery without radiation therapy (with or without tamoxifen) Total mastectomy (with or without tamoxifen)
Fat Necrosis	Painless, round, firm lumps Formed by damaged fatty tissue May occur after surgery to the breast Often occurs in response to a bruise or blow to the breast, although a woman might not recall being injured	Sometimes removed with surgical biopsy because it can look like cancer
Fibroadenoma	Hard, round, benign growth Feels like rubber; moves around easily Usually painless Often found by the woman herself Appears on mammogram as smooth, round lumps with clearly defined edges Can get bigger when the woman is pregnant or nursing	Sometimes diagnosed with fine-needle aspiration If the fibroadenoma does not appear normal, the doctor may suggest taking it out to make sure it is benign
Intraductal Papilloma	Growth inside the nipple that looks like a wart May cause nipple discharge	Surgery to remove the growth
Lobular Carcinoma In Situ (LCIS)	Abnormal cells found in the lobules Not cancerous but associated with a greater chance of getting cancer in either breast in the future	Regular check-ups to look for signs of breast cancer Tamoxifen may be suggested Evaluation of breast cancer risk by your doctor
Sclerosing Adenosis	Too much tissue growth in lobules Can contain calcifications Often painful Changes usually very small but can produce lumps	Clinical breast exam Annual mammogram More tests if breast changes are noted on breast self-exam, clinical breast exam, or mammogram

More information on these conditions can be found on www.cancer.gov or by calling 1-800-4-CANCER.

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