Benign Breast Conditions
What is benign (fibrocystic) breast disease?
It is not unusual for a woman to develop one or more cysts in her breasts, nor is it unusual for a woman to have generally lumpy breasts. These are benign (noncancerous) lumps. Opinions differ about whether the presence of these lumps should be called a disease. Some refer to this condition as benign breast disease or fibrocystic disease. Others argue that the lumps are not a disease at all but simply normal fibrocystic changes in the breast. Because opinions differ, there is little data on what percentage of healthy women have benign lumps in their breasts. These conditions are, however, very common, and women are more likely to undergo such changes as they age.
What should I do if I feel a lump in my breast?
If you discover any lump, bump, or general lumpiness in or around your breast tissue, visit your doctor promptly. The lump will be evaluated to see if it is cancerous or benign. Don't panic and assume it is cancerous. The odds are that it is a harmless fibrocystic condition and not a cancer. In most instances, such lumps are benign.
Does having a fibrocystic breast condition increase my risk of breast cancer?
Yes, but generally only if a woman has one of two conditions: proliferative breast disease or atypical hyperplasia. Most women who develop cysts or lumps will not develop cancers, because the changes in their cells are not proliferative. Often proliferative cell changes are not noticeable on physical examination of the breasts and only rarely appear on mammograms.
How should fibrocystic lumps be treated?
If you do find a lump, you will first want to visit your doctor. He or she will recommend the appropriate treatment, which is, most generally, to do nothing. If, after a breast examination, the physician is not entirely sure that a lump or bump is of the usual harmless kind, a biopsy may be ordered. A biopsy may also be ordered if a screening mammogram shows some shades, shadows, or speckles that appear suspicious or that were not visible on a previous mammogram. Sometimes removing fluid from a cyst by needle (needle aspiration) will show that the lump is not a problem. If the lump does not go away completely after needle aspiration, the physician may order a core or surgical biopsy to find out what the tissue around the lump or cyst looks like.
If I do develop a benign breast condition, will I want to be more rigorous about screening for breast cancer?
Even if your doctor tells you that your lumps are the normal, harmless kind and that you don't need to do anything about them, you may want to adopt a more rigorous screening approach than before. Also, as you age, your breasts will be more likely to show signs of benign breast disease. Changes in the consistency of the breast tissue-such as the development of cysts or lumps—are reasons to schedule an annual physical examination of the breasts. Click here to learn what to expect from a CBE.
Breast self-examinations—long touted as a way to catch early-stage cancers—have been shown to be ineffective for this purpose. They are, however, effective in catching benign lumps and cysts. If you are prone to fibrocystic breasts, you may want to learn the correct procedure for breast self-examinations, so you can monitor any changes in your breast tissue. Click here to go to BSE page.
What is proliferative breast disease?
Proliferative disease, or hyperplasia, is characterized by an overgrowth of cells in the inner lining of the milk glands. If the lining has an extra layer of cells but each of the cells looks ordinary, the condition is called proliferative disease without atypia, sometimes abbreviated PDWA. If the extra cells are irregular or look odd, the condition is called atypical hyperplasia. If the odd-looking cells are several layers thick and are beginning to fill up the tiny hollow space of the milk duct, the condition is called ductal carcinoma in situ (DCIS). DCIS is a precancerous condition rather than a form of benign breast disease. Pathologists do not always agree about what distinguishes a thickly overgrown atypical hyperplasia from a barely noticeable carcinoma in situ. The difference is one of degree and remains open to debate.
Does proliferative breast disease increase my risk of breast cancer?
Yes. The presence of proliferative breast disease without atypia is a risk factor. Within 10 years of diagnosis, women who have these cell changes develop breast cancer nearly twice as frequently as women who do not have the condition. In actual numbers, women with PDWA might have a two percent higher absolute risk of cancer over the next decade (one extra woman out of 50) than a woman with no breast disease diagnosed by biopsy, no matter how old she is at the time of the diagnosis.
Atypical hyperplasia is a stronger risk factor for breast cancer than PDWA. Between 10% and 15% of women who have proliferative breast disease will also have the cell irregularities that signal atypical hyperplasia. (That's around three percent of all women who need a biopsy to resolve a suspicious mammogram, or around five of every 10,000 women having first-time mammograms.) Of 20 women with identified atypical hyperplasia, one extra woman may develop breast cancer over the decade following diagnosis.
What percentages of biopsies show evidence of precancerous conditions or of proliferative breast disease?
Around two percent of all first-time mammograms detect a condition that should be examined by biopsy. This rate is somewhat lower for women under 50 and somewhat higher for women over 60. Approximately one biopsy in 5–10 biopsies will identify an invasive breast cancer, which is usually an early-stage cancer that can be treated successfully. Again, for all biopsies, the frequency of cancer diagnosis is lower for younger women and higher for older women. For approximately 10% of biopsies, the pathologist will identify a precancerous condition (carcinoma in situ). The remaining 60–80% of biopsies ordered after a first-time mammogram will find either no particular cell changes or some type of abnormal cell change that caused the mammogram to look unusual. Among these abnormal cell changes, two-thirds will be classified as conditions that have little or nothing to do with the risk of breast cancer, because the cell changes are not proliferative.
What should I do if I am diagnosed as having proliferative breast disease or atypical hyperplasia?
If you are diagnosed as having proliferative breast disease without hyperplasia, many specialists recommend regular physical examinations of the breasts and, depending on your age and profile, regular mammograms.
For women who have atypical hyperplasia, many breast specialists recommend annual mammograms and twice-yearly physical examinations of the breasts. Because the condition is a strong marker for an increased risk of breast cancer, a woman might want to discuss the pros and cons of risk-reduction options with her doctor. In a clinical trial to measure the effectiveness of tamoxifen (an estrogen-blocking medicine) in preventing breast cancer among higher-risk women, the women who had atypical hyperplasia and took tamoxifen developed breast cancer less than one-fourth as often as the women in the control group. Another medicine, raloxifene, is being studied to find out if it also lowers the risk of breast cancer.
Tamoxifen
Tamoxifen is a prescription drug that has been used for 20 years in the treatment of women with breast cancer. The drug has recently been proved to reduce the risk of developing breast cancer among women at high risk of the disease.
The National Cancer Institute enrolled 13,000 high-risk women in a clinical trial. Half of them received tamoxifen and half did not. The women in the tamoxifen group developed breast cancer 49% less frequently than the women who did not receive it over a five-year period. The risks and benefits of long-term treatment are not yet known.
Women were eligible to join the study if their risk of getting breast cancer within five years was at least as high as the risk for an average 60-year-old woman (a 5-year breast cancer rate of 1.7%). Risk factors used to estimate the presence of a high breast cancer risk included:
- age
- history of lobular carcinoma in situ (a noninvasive breast cancer)
- multiple biopsies, especially if the diagnosis was atypical hyperplasia
- number of first-degree relatives with a history of breast cancer
- age at first birth and age when periods began
Tamoxifen is not for all women because of the risk of serious and potentially fatal side effects. The side effects seen in the tamoxifen trial included a higher rate of endometrial cancer, pulmonary embolism, and deep-vein thrombosis among the women who took tamoxifen. These problems were expected, because tamoxifen acts like estrogen in many ways. Women in the tamoxifen group had fewer spinal and hip fractures, an effect also expected from an estrogen-like drug.
If you think you are a candidate for tamoxifen, schedule an appointment with your doctor or with a breast specialist, if there is one in your area. You can then review your risk factors and weigh your own risks and benefits for taking tamoxifen.
If I am diagnosed as having proliferative breast disease, should I worry?
Obviously, you'd rather not have any abnormal breast condition at all, even if it's benign. However, knowing about the proliferative changes would put you in a fortunate minority of women. Nearly one-third of all women will develop a proliferative overgrowth during her lifetime, but few will ever be aware of that condition. Knowing about such a condition alerts you to your risk. You can counteract that risk by getting annual or biannual physical examinations of the breasts and, depending on your age and profile, more frequent mammograms. Decisions about screening for breast cancer should be made by you in conjunction with your doctor.
How common is proliferative breast disease?
Nearly one woman out of three has some proliferative overgrowth at some time, but few of them ever find out about it. This condition does not cause a lump and is rarely visible on a mammogram. The only way we know that 25–30% of women have these changes is through autopsy studies on women who died for reasons unrelated to breast cancer. Because proliferative disease—with or without atypia—sometimes regresses and goes away on its own, more women are likely to have some of these changes at one time or another than current estimates would indicate.
How is proliferative breast disease discovered?
The women who do learn that they have proliferative disease or atypical hyperplasia generally do so by accident: their mammograms contain calcifications or other irregularities. Although calcium is generally found in bones and blood, tiny speckles of calcium sometimes migrate into other tissues as well. When calcifications do appear in breast tissue, they more commonly appear in the cells that are the least average. For example, such deposits are found more frequently with atypical hyperplasia than with PDWA, more frequently with proliferative disease than with nonproliferative disease, and so on. And even though proliferative cell changes themselves don't show up on mammograms, the calcifications are visible on mammograms. This is an extremely lucky circumstance, because doctors are then able to identify an increased risk of cancer by way of a secondary consequence of the condition. This alerts women to the fact that they have a higher risk of breast cancer. If you are diagnosed as having this condition, you will probably want to adopt a more rigorous schedule for screening for breast cancer. Most women who have a current proliferative condition but are not aware of it are less likely to be careful about annual breast exams. Of course, most of them will not develop breast cancer or a precancerous condition over the next several decades in any event, but a few may miss the opportunity to identify a precancerous change when it first occurs.
