"I found a lump: Now what?"
by Dr. Robin Williams

You are standing in the shower and you just happen to remember that it is time to perform your self-breast exam. Hmm! What's this? That wasn't there before. You ignore it and a couple of weeks later, you feel the same lump. This time you think that it may even be larger. What do you do now?

First, calm down and take a deep breath. Eighty percent of breast lumps are ultimately found to be benign. Many women have lumpiness in both breasts due to benign fibrocystic changes. However, a single, obvious lump that you can feel in the breast should not be ignored.

The first step is to visit your primary physician for a clinical breast exam. Many questions regarding risk factors for breast cancer will be asked such as age of first menstruation, age of first pregnancy, age at menopause, family history of breast cancer or other cancers, and personal history of breast cancer or other cancers. If you are premenopausal, you may be asked when the lump appeared in reference to your cycle, and whether or not it got smaller after your cycle. Other questions will concern use of birth control pills and hormonal replacement. Following this complete history will be a thorough breast exam including the axilla (under the arms) and the neck.

The best tool for assessing breast lumps, outside of the physical exam, is the mammogram. Mammography is more sensitive in postmenopausal women because the breasts contain more fatty tissue and are not as dense. An ultrasound may be utilized initially, especially in a premenopausal woman, because the breast tissue is denser. Mammography is often coupled with an ultrasound when trying to determine whether a lump is cystic or solid. Although mammography is our best tool, still up to 15% of breast lumps are not detected by this technique.

The next step in the assessment of a breast lump is usually a referral to a specialist such as a general surgeon. Once again you will have to answer a number of questions followed by a physical exam. The only way to determine if the lump is benign or malignant is by removing all or some of the lump and examining it under a microscope. This biopsy can be done in several ways. For a palpable (able to feel) lump, a needle aspiration or core biopsy can be performed in the office. If the information from this technique is inconclusive, the biopsy would then have to be performed in the operating room. This would involve removing the entire lump or a portion of the lump, depending on its size.

If it is reported that the lump is benign (not cancerous), that is great! Remember though, it is still important to continue those self-breast exams, clinical breast exams and screening mammography. If the report returns that the lump is malignant, then what are the options for treatment?

Surgical management of breast cancer involves either a modified radical mastectomy or breast conservation. A modified radical mastectomy is removal of the entire breast as well as the lymph nodes in the axilla. Breast conservation is removal of the lump followed by removal of the lymph nodes under the arms. After breast conservation, one must also undergo radiation treatment to that breast in order to control recurrence. The need for chemotherapy or tamoxifen is determined by the size of the lump, the presence of cancer within the lymph nodes, the responsiveness of the tumor to estrogen and progesterone, and premenopausal vs. postmenopausal status.

A state of the art component of breast conservation is the sentinel lymph node biopsy. This procedure involves injecting dye into the tumor bed and tracking its flow to the lymph nodes in the axilla. The lymph node containing the dye is removed and examined under the microscope. If there is cancer in this lymph node, then a formal lymph node dissection is performed. If there is no cancer in the lymph node, then a lymph node dissection may not be necessary, thereby decreasing morbidity. This procedure is the wave of the future.

A modified radical mastectomy and breast conservation are equally effective. There is no difference in the five-year survival rate. However, there are some instances when breast conservation cannot be performed. These instances include 1) two or more tumors in separate areas of the breast, 2) persistent positive margins after lumpectomy, 3) diffuse malignant appearing calcifications of the breast on mammogram, 4) prior therapeutic irradiation to the breast, 5) pregnancy, and 6) collagen vascular disease (scleroderma or lupus).

If a mastectomy is performed, the option for reconstructive surgery should also be discussed. Reconstruction can be performed immediately following mastectomy or in a delayed manner after recovering from the mastectomy. There are several different techniques that can be used. The best reconstruction for you is determined after discussion with your plastic surgeon.

Screening guidelines for breast cancer as established by the American Cancer Society are as follows. Self breast exams should begin at age 20 and continue once a month for the rest of your life. Clinical breast exams by a physician should be done every 3 years between the ages of 20 to 40, then every year after age 40. Routine screening mammography should begin by age 40, unless otherwise indicated. A mammogram should be performed every 1 to 2 years between 40 to 49. Beginning at age 50, a mammogram should be performed annually. Early detection is the best tool we have in the fight against breast cancer!!

About the Author
Robin Williams, M.D., FACS, received her Bachelor of Arts in Chemistry from John Hopkins University in Baltimore, Maryland and her Medical Degree from University of Maryland School of Medicine in Baltimore, Maryland. She did her surgical residency under the tutelage of Dr. LaSalle Lafall at Howard University in Washington, D.C. She is in private practice in Nashville, Tennessee where she serves on the faculty of Meharry Medical College. She is also the president of the Nashville NBLIC II Coalition and has recently become a member of the NBLIC II National Steering Committee.