Fibrocystic Breast Changes
Fibrocystic changes occur in at least half of women and are uncommonly associated with the development of breast cancer. However, the primary importance of diagnosing benign breast disease is to rule out more serious conditions, including breast cancer (Sugg 2014; Alvero 2015; Jones 2011; Vaidyanathan 2002).
Unfortunately, benign breast conditions are often misdiagnosed since each woman’s breast anatomy is different and mammography cannot identify all structures with complete precision. Thus, a woman with a benign breast lump may need other diagnostic procedures potentially including ultrasound, aspiration, and biopsy to exclude malignancy (Amin 2013; Miltenburg 2008; Jones 2011). Thyroid hormone irregularities, particularly hypothyroidism, should also be ruled out in women with fibrocystic breast conditions, as low thyroid function may be related to fibrocystic changes and the progression of breast cancer (Stoddard 2008; Patrick 2008; Smyth 2003).
Manual Breast Examination
A clinical manual breast exam (performed by a doctor) is often an early step in assessing breast symptoms. This exam involves palpating the breasts for lumps, and determining if discharge can be expressed. However, a manual breast examination will rarely be able to detect early-stage breast cancer and cannot be used in isolation to clearly differentiate among different benign breast disorders (Miltenburg 2008; Onstad 2013).
Women may perform breast self-exams to detect changes in their breasts. Fibrocystic breast tissue may feel thick, lumpy, or rope-like in texture, and the lump(s) are mobile and do not feel stuck to surrounding tissue. Lumps caused by fibrocystic breast conditions may become larger before each menstrual period and shrink after the menstrual period is over. Breast pain may occur in both breasts, and this pain may fluctuate throughout the menstrual cycle or remain constant. The most important consideration for women who examine their own breasts is to take note of changes in appearance or texture of breast tissue and to promptly report those changes to their health care provider, who can advise whether additional evaluation is necessary (NLM 2013; Scott-Conner 2015; NBCF 2012; Mayo Clinic 2013a).
Ultrasound is often the only imaging study used to evaluate breast lumps in younger women. Ultrasound does not expose the patient to radiation. Instead, ultrasound uses sound waves to investigate the anatomy of the breast (Jones 2011; Miltenburg 2008; Gucalp 2014; NLM 2014).
A mammogram is an x-ray–based imaging procedure of the breasts. There are two types of mammogram: screening and diagnostic. Screening mammograms are performed on women with no signs or symptoms of abnormalities, and are meant to detect early-stage breast cancer. Diagnostic mammograms are used in women who have signs and symptoms of breast abnormalities in order to help differentiate cancer from benign conditions such as fibrocystic changes (NCI 2014). As a tool for detecting cancer, mammography is most useful in postmenopausal women. Younger women and those taking hormone replacement therapy often have dense breast tissue, which makes mammogram images less helpful. By themselves, mammograms do not identify all cases of cancer: follow-up of all imaging studies by means of cyst aspiration or biopsy is usually necessary for conclusive diagnosis (Miltenburg 2008; Evans 2002; Jones 2011; Onstad 2013).
One downside of mammograms is they expose women to a small amount of radiation (Jones 2011). Although not appropriate for all women, alternatives to mammography are available. Women interested in reading about breast cancer screening using mammography alternatives can refer to the Life Extension magazine article Breast Cancer Screening Alternatives.
Breast Imaging Reporting and Data System (BI-RADS)
Physicians use a system called BI-RADS (Breast Imaging Reporting and Data System) to classify breast abnormalities. The BI-RADS score can provide an estimate of breast cancer risk and also guide further management. The BI-RADS system is applicable to both ultrasound and mammogram (Kim 2008; NCI 2014). The BI-RADS system classifies a breast nodule according to six features (Heinig 2008). Based on these six features, the radiologist provides a BI-RADS score from 0 to 6, with a higher score denoting a higher risk that the mass is cancerous, and a score of 6 indicating biopsy-proven cancer.
Table 3: BI-RADS Scoring
In women who receive a BI-RADS score of 4 or 5 after mammography or ultrasonography, a breast biopsy is often required (Eberl 2006; Kennedy 2011). There are several forms of breast biopsy available:
Fine needle aspiration. Fine needle aspiration is the least invasive type of breast tissue biopsy (Wesola 2013). In this procedure, the physician inserts a narrow gauge needle into the breast, removing a small sample of cells for analysis. Fine needle aspiration has a very low rate of complications and is associated with minimal discomfort. However, it requires a high degree of expertise on the part of the physician performing the procedure (Ljung 2001; Breastcancer.org 2015; Kaur 2007) and has become less favored than core needle biopsy in many breast cancer centers (Zervoudis 2014).
Core needle biopsy. A core needle biopsy is more invasive than fine needle aspiration and is associated with greater discomfort, though it has a low rate of complications. Some researchers prefer core needle biopsy, and it may be a more reliable method for distinguishing between in situ and invasive breast cancer compared to fine needle aspiration (Zervoudis 2014; Verkooijen 2002). Core needle biopsy is usually the first biopsy procedure used to evaluate breast lumps that cannot be easily palpated manually (Willems 2012; Al-Sobhi 1999; Verkooijen 2002).
Image-guided biopsy. If a mass that needs to be biopsied cannot be easily observed or localized, then the physician performing the biopsy may use imaging techniques to help guide the needle. A biopsy guided by mammography is called a stereotactic biopsy, and ultrasound imaging can be used to perform an ultrasound-guided biopsy (Huang 2014; BreastCancer.org 2015).
Surgical biopsy techniques. In cases where fine needle aspiration or core needle biopsy are inconclusive or provide results that are suspicious for cancer, incisional biopsy or excisional biopsy may be indicated (ACS 2014).
- In incisional biopsy, a physician uses manual instruments to cut through the skin and remove a piece of the suspicious tissue for examination. This procedure may be performed under sedation (BreastCancer.org 2015).
- Excisional biopsy is a surgical procedure performed under local anesthesia in which the entire area of suspicious tissue is removed. This procedure may be performed under sedation (ACS 2014; BreastCancer.org 2015).