What to Do If You Find a Breast Lump or Have an Abnormal Mammogram

Whether you have breast cancer or not, these steps will help you get the best care.

By Beth B DuPree MD, FACS, and Meryl Davids Landau

Photograph: iStock

Step One: Make These Phone Calls

Time Frame: That Day

    * Call #1: Your ob-gyn: This doctor knows your history and breasts, and can help you through this process. Tell the receptionist that you found a lump or got a call that your mammogram is abnormal, not just that you need an appointment. The doctor may ask you to come in or may refer you right away for imaging studies or just send you to a breast specialist.
    * Call #2: A breast surgeon: Ask your doctor’s office to call the specialist directly, which may get you in faster. You may be asked to have additional mammographic views or a breast ultrasound before your visit. Even if the lump proves malignant, though, there’s usually risk if you can’t be seen for a few weeks. (But if you have sudden skin changes associated with a mass, tell your doctor since there is a rare but aggressive form of cancer called inflammatory breast cancer that requires urgent attention.)
    * Call #3: Your insurer: Especially if you’re in an HMO, your insurance company may require that you see a gynecologist or an internist before the specialist. If you don’t get a referral at the beginning, you might be denied coverage for needed treatment later. You need to know what your plan will cover and if there are restrictions about where you can receive care.

Step Two: Prepare for Your Appointment

Time Frame: Days to a Few Weeks

    * Write down details about the lump: how hard it is, whether it is painful, whether it moves when you touch it, its size (compared with a pea’s, for instance), and whether the size has changed. Plus: where you were in your menstrual cycle or sequential hormone therapy when you found it.

    * List the prescription medications, over-the-counter drugs, and all supplements you take regularly. (A variety of medications can cause lumpiness.)

    * Pick up your past two years’ worth of mammograms if they were taken at a different center. Be certain to have the actual films and the written reports for both mammograms and an ultrasound if you have had one.

    * Outline a brief medical history, especially previous breast lumps or abnormal mammogram findings. It is important to note any previous breast biopsies and the results from them, specifically atypical lesions.  Note any family history of breast or ovarian cancer in both your father’s and mother’s families.

Step Three: Get Evaluated

Doctors diagnose breast cancer by the "triple test": physical exam, imaging, and biopsy. If you’re at a comprehensive center that does it all, plan to be there much of the day.

The Exam

The breast surgeon will manually examine all breast tissue and lymph nodes. You will be examined sitting up and lying down. If the doctor can’t find the lump, move into the same position you were when you felt it. 

Imaging: Mammogram and Breast Ultrasound

You may have one or more types of imaging (ultrasound, mammogram or, less frequently, MRI). Which one you have first depends mostly on your doctor’s suspicions about the type of lump, and may also depend upon when your last mammogram was performed.

Mammography is the only breast cancer screening tool for the general population, though high-risk women are sometimes screened with MRIs as well. Digital mammography, which allows for better imaging in women with dense breasts, has begun to replace the familiar “film screen” mammography for screening.

A mammogram done for diagnostic purposes provides views that magnify or compress specific regions of the breast. This will likely be ordered if there is a mass or if your screening mammogram shows microcalcifications (tiny calcium deposits) and/or dense tissue.

Because tumors can be diagnosed only via biopsy, you probably won’t get a definitive diagnosis immediately after imaging unless this is a feature offered by a comprehensive breast center.

Mammogram

    * In addition to the two basic views of each breast, the technician will take additional images of the area where the lump was found. The technologist may press on the spot with a compression paddle and also magnify the area to see if it has irregular borders  or if the density disappears with compression. The radiologist will also look for microcalcifications, which can be associated with cancer. (Note: Not all cancers produce microcalcifications and not all calcifications indicate cancer.)
    * Results ready: Immediately to a few days
    * A mammogram can confirm a discrete  mass but not definitively diagnose a malignancy (that’s why you’ll need a biopsy), so the radiologist will write up a detailed summary and send a report to you and/or your doctor.
    * Ask your doctor when you should expect results. To avoid waiting, request that they be given by phone or sent via e-mail.
    * If your mammogram doesn’t show a mass, don’t be surprised if you’re sent for an ultrasound. Up to 20 percent of breast cancers are not seen on mammography, but only a small number will elude both mammography and ultrasound.  If you feel a mass and the mammogram and ultrasound are both read as normal, you still need to see a breast surgeon. There are some cancers that will not be detected by either test!

After imaging, you’ll be referred for a biopsy which may be performed by either a breast surgeon or breast radiographer. It is important to see a surgeon to establish a relationship so that he or she can evaluate your breast before the area is changed from a biopsy.

Ultrasound

    * To evaluate a palpable lump or to look for a density found on a mammogram. An ultrasound may be able to determine if a mass is a fluid-filled cyst or a solid.
    * Results ready: Immediately to a few days
    * If it’s a fluid-filled cyst: Your doctor may suggest that nothing be done right away, because the cyst may deflate on its own through your next menstrual cycle. But if the cyst is large, it can be aspirated with a small needle. (If the fluid is green, it is usually discarded)  (See "Biopsy," below.) If you leave the cyst alone, watch to see whether it enlarges over the next few weeks; if it does, request an aspiration to be sure it is a cyst. Many women prefer to have the cyst drained so that they do not have to feel it.
    * If it’s not a simple cyst aspiration, a biopsy will be required.

Cancer can be diagnosed only through an examination of tissue under a microscope, therefore every solid mass or complex cystic mass should be biopsied. Don’t assume needing a biopsy means that you have cancer: More than 60 percent of biopsies in women over 40 turn out to be benign.

Time frame: Many breast centers can schedule your biopsy on the same day or the day after your imaging. A referral to a breast surgeon should occur prior to a biopsy so that your breasts can be examined before the biopsy occurs. This is particularly important if you are diagnosed with cancer so that you have an established relationship with this individual and do not have to go on the hunt for a doctor in a state of panic.

Your doctor will recommend one of the following:

Needle Aspiration
    * If your doctor suspects your lump is a fluid-filled cyst or if it appears to be a complex cyst, a thin needle, often guided by ultrasound, is inserted and the fluid is removed. This may be repeated several times. No anesthesia is required.
    * Results ready: Immediately to two days
    * If the fluid is green, the lump is a harmless cyst. Because aspiration causes a cyst to collapse, your treatment is complete. If the fluid is bloody, it is sent to a pathologist.
This biopsy can sometimes diagnose cancer but cannot determine cancer type or other details that are important for treatment. If the cytology is positive or suspicious, you’ll probably need an US guided vacuum assisted or core needle biopsy.

Minimally Invasive Image Guided Breast Biopsy (considered “best practices” by the 2009 Consensus Conference on Image Detected Breast Cancer) :

Core-Needle Biopsy

    * Under local anesthesia, a narrow needle is inserted multiple times, extracting thin cores of tissue that are sent to a pathologist.
    * Results ready: Within two days

Vacuum-Assisted Biopsy

    * Your breast is anesthetized with a local anesthesia, then a biopsy device is inserted into the breast. By using  ultrasound as a guide, the doctor is able to extract larger cores of tissue. A marker is inserted to serve as a guide back to that area if a cancer is found or to mark the area for the future mammograms. Many masses are no longer palpable after the biopsy. The scar is as tiny as with a core-needle biopsy, but doctors get a lot more tissue to analyze so they’re less likely to miss the cancerous part.
   * Results ready: Within two or three days
   * Vacuum-assisted biopsies can also be performed to evaluate microcalcifications found on mammography. They are done with stereotactic (computer) guidance with the patient lying face down on a special mammography table.
  

Excisional Biopsy

    * Doctors sometimes need to remove the entire lump, especially if other biopsy results aren’t consistent with your doctor’s expectation. If an ultrasound was suspicious for a cancer and the results were benign, there’s always the possibility a benign core biopsy simply missed the cancerous tissue. Excisional biopsies are also indicated for large benign masses, masses under the nipple, masses very near the skin surface and occasionally in women with breast implants. The procedure is usually performed in the operating room under IV sedation and local anesthesia. Occasionally special stains are required for the pathologist to make a correct diagnosis.
    * Results ready: From one to two days to a week

Step Four: Getting the News

Ask your doctor how and when the office will contact you. Think twice about giving your cell number. You don’t want to be driving or in the grocery checkout line if you find out it is cancer. Be specific about whether or not the office can leave a message. Doctor’s offices are very careful about how you health information is disseminated.

Recruit a friend or family member to go with you if you’re getting your results in person. (Many centers want you to come in for results, even if the diagnosis is not cancer.) Whether the results are negative or positive, you’ll need to note some important details of your diagnosis.

If it’s negative:

Get a photocopy of your pathology reports for your files.

Have your doctor carefully explain the results. There’s a whole range of benign, from truly nothing to conditions such as atypical hyperplasia, which put you at risk for future cancer. Understand the symptoms you should watch for, your timetable for any follow-up visits, and when you should schedule your next mammogram. If the biopsy diagnosis is a benign condition that can be associated with a more significant pathology, your doctor may still recommend removing the lump with an excisional biopsy.

If it’s cancer:

Once you’ve gotten the diagnosis, ask your doctor for the following.
    * A photocopy of the pathology report for your files.
    * Answers to the following questions:

What type of cancer is it?  Invasive or non-invasive? (For help reading a pathology report, go to breastcancer.org’s online guide.)
Did it begin in the ducts or in the lobules?
How large is it?
What is the clinical stage (the stage the doctor can assess with a physical exam)?
Is there evidence of invasion into blood vessels or lymphatic vessels?
What additional tests are required before treatment begins?  (MRI, CXR, Bone scan, PET? CT? These will vary based upon the type of cancer and clinical stage.)
How does the doctor perform sentinel node evaluation?
Ask for a referral to a plastic/reconstructive surgeon and a radiation oncologist to help in your decision process.
Can the doctor connect you with a support group?
Is my tumor estrogen-receptor positive or negative? Progesterone positive or negative? Her2neu positive or negative?
Ask if you are a candidate for genetic testing for the BRCA I and II gene. (Risk factors include diagnosis under 40 or 50, Ashkenazi Jewish heritage, family history of ovarian cancer, Hx bilateral breast cancers, premenopausal breast cancers, male relatives with breast cancer.)
Today many women with early-stage breast cancer should request that the biopsied tissue be genetically analyzed. One test, Oncotype DX, examines tumor genes and predicts risk of future recurrence. This crucial knowledge can drive your treatment decisions. This test should only be ordered after your lymph nodes are examined and found not to have tumor cells in them.

Beth B DuPree, MD, FACS, is chair of the Board of Advocates of the American Society of Breast Surgeons and the medical director of the Breast Health Program at Holy Redeemer Hospital in Meadowbrook, Pennsylvania.


This article was taken from "More Magazine".