Do I need an MRI?
Because breast MRI is more sensitive than mammogram or ultrasound, it is more likely to lead to unnecessary procedures (false positives). Current guidelines suggest that the benefit of extra sensitivity outweighs the risk and costs of screening MRI if you are at very high (above 20% lifetime) risk of developing breast cancer. MRI may also be indicated to assess women newly diagnosed with breast cancer but not yet treated. And MRI is sometimes useful as an addition to other imaging for difficult diagnostic situations. Your breast surgeon can tell you if MRI is right for you.
The American Society of Breast Surgeons' Consensus Statement
Can thermography replace mammography for screening?
Trials of thermography show that it is not accurate enough to replace mammography. Unfortunately this promising technology has not yet been shown to be of any additional diagnostic or surveillance value in the war on breast cancer.
Do I have a breast cancer gene?
In general, genetic abnormalities leading to an increased risk for developing breast cancer, are extraordinarily rare. Of all women diagnosed with breast cancer, only 5%-7% of those can be attributed to an underlying genetic abnormality. Typically, these women will themselves have or have multiple family members with premenopausal diagnoses of breast and/or ovarian cancer. In addition, the BRCA abnormalities may manifest as early onset prostate cancer, pancreatic cancer, or melanoma. Breast surgeons and genetic counselors can determine your personal risk and advise whether it is worth pursuing genetic testing in your case.
Have a worrisome family history like that described above.
Are diagnosed with any type of breast cancer at less than 50 years of age.
Are diagnosed with a breast cancer that does not possess the estrogen, progesterone and HER2 receptors (triple negative breast cancer) at less than 60 years of age.
Are of Ashkenazi Jewish heritage. (It is well documented that women of this ethnicity have a 6 times increased risk for carrying a BRCA mutation.)
Have had breast cancer in both breasts or have had 2 different cancers
See www.nccn.org for a more complete list of indications for testing.
The American Society of Breast Surgeons' Consensus Statement
What can I do to lower my risk of breast cancer?
Exercising, maintaining your ideal weight, not smoking, and minimizing alcohol are important for your overall health. In addition, these things can have a modest impact on lowering your risk of breast cancer. But tamoxifen and raloxifene (Evista) will cut your risk at least in half–much more in some cases. Your provider can calculate your specific risk (at, for example, www.cancer.gov/bcrisktool/), and advise you whether the benefits of preventive medications outweigh the costs and the risks of side effects in your specific case. They usually will if your 5-year risk is more than about 2%.
Do I need to make my reconstruction choices before my initial breast cancer surgery?
You are never required to make reconstruction decisions before the initial breast surgery. Many women find these decisions overwhelming and prefer to first “get rid of” their cancer, deferring reconstruction decisions to a later, perhaps calmer, time. However, if you are having a mastectomy as your initial surgery, delayed reconstruction means living for a while without your breast, which some women find unbearable. Also, some plastic surgeons achieve much better cosmetic results with immediate, as compared to delayed, reconstruction.
If I need radiation therapy for my cancer, can I have immediate reconstruction?
There is no contraindication to radiotherapy after reconstruction. Some types of reconstruction may be affected by the radiation and may require corrective surgery in the future. This is something you should discuss with your breast surgeon and plastic surgeon when weighing reconstruction options.
Should I find out if my breast tissue is dense?
Every time you have a mammogram, your breast density is referred to in the radiologist's mammogram interpretation. There are 4 categories of breast density, from fatty replaced breast tissue (category 1) to extremely dense breast tissue (category 4). Dense breast tissue can make detecting breast cancer more challenging. Dense breast tissue also slightly increases the risk of developing breast cancer. For women with dense breast tissue, additional breast imaging, such as whole breast screening ultrasound, may be recommended. Your physician or healthcare provider can discuss your breast tissue density with you and what it means for you.
View more on breast density (video presentation by Dr. Kevin Hughes)
How do breast surgeons work with plastic surgeons for breast cancer patients?
Breast surgeons and plastic surgeons frequently work together. Typically, the breast surgeon will remove the necessary breast tissue and plastic surgeons will perform reconstruction of the removed site.
Do certain breast conditions, such as mastitis, predispose someone to breast cancer?
Mastitis does not predispose you, or make you susceptible, breast cancer. However, other benign conditions (such as such as atypical ductal hyperplasia or lobular carcinoma in situ) are considered indicators of an increased risk for breast cancer. These are usually diagnosed on a biopsy performed for a different reason. If you have had such a diagnosis, you should discuss risk-reducing options with your surgeon.
What kind of masses can be found directly under the nipple?
Any type of breast mass, either benign or cancerous, can be found directly under the nipple. The tissue below the nipple is still breast tissue, so anything that can be found elsewhere in the breast can be found under the nipple as well. Most commonly we see benign masses such as cysts and fibroadenomas. Papillomas (growths within the ducts that may cause nipple discharge), as well as other less common types of masses may be seen in this location. Cancers can also occur directly beneath the nipple. Finding a lump directly under the nipple doesn't necessarily mean it’s cancer, but it also doesn't mean it can should be ignored. If you have a breast mass, consult your healthcare provider.
How do physicians address several different lumps in one breast?
Breast specialists will typically keep track of different lumps in one breast found on physical exam by using specific notations and measurements. Traditionally, this involves looking at the breast like a round clock, with the nipple in the middle. The position of the lump is estimated as if you were telling time; for example, the mass could be at two o’clock position or the six o’clock position. We also measure the distance the lump is away from the nipple, as well as the size of the mass. Often, if a mass is felt on physical exam, this would be followed up with an ultrasound. The ultrasound indicates the shape of the mass as well as features such as whether the edges of the mass appear smooth or jagged. A follow up breast exam or ultrasound exam becomes important in tracking whether the lumps have changed over time.
Why do I need a surgical biopsy if my core biopsy did not show cancer?
A core biopsy can be extremely helpful in determining the type of tissue present in a lump or abnormality on breast imaging. If, however, the suspicion is high enough and there is concern that the results of the core biopsy do not match the findings on physical exam or breast imaging (called a discordant core biopsy result), your surgeon may recommend that the entire area of concern be removed to make sure that there is no cancer. Furthermore, some core biopsy samples may show abnormal cells, called atypia. If a core biopsy shows atypia, it may indicate the presence of cancer in nearby tissue. A larger sampling of tissue will be recommended. A careful discussion with your surgeon will help you determine your need for a surgical biopsy.
Why shouldn’t I just have my lump surgically removed to see if it is cancerous?
Not all lumps are cancerous. There are many causes of breast lumps and bumps. Because surgery itself has a potential for complications, surgery for a clearly benign (noncancerous) “lump” is not indicated in many circumstances. And if the “lump” is malignant (cancerous), the diagnosis of cancer is best made by a core needle biopsy rather than by removing the lump to prove that it is cancer. Core needle biopsies are accurate, less invasive and do not limit future cancer treatment options. Cancer treatment options, including the use of very effective chemotherapy medications and breast reconstruction, may be eliminated or limited by the use of a surgical removal of a lump.
The American Society of Breast Surgeons' Consensus Statement
Do needle biopsies spread cancer?
There has been no conclusive evidence that a needle biopsy itself will lead to the spread of cancer cells should they be present in the biopsy sample. This type of biopsy has been used to diagnose breast disease for decades. In that time, there has been no increased incidence of breast cancer spreading outside of the breast.
The American Society of Breast Surgeons' Consensus Statement
Does my elderly mother really need surgery to treat her breast cancer?
Because incompletely treated breast cancer can lead to local complications, such as skin ulceration or even invasion into the chest wall muscles and ribs themselves, even for an elderly patient, surgery to remove the primary tumor can be indicated. Furthermore, a patient's advanced age alone does not dictate that no treatment of any kind will be offered. A careful discussion with your surgeon about the various options available for treating breast cancer in an elderly patient will help to clarify the next step. For additional guidance, review our Breast Cancer Late in Life article.
If I have a mastectomy can I save my nipples?
The progression of breast cancer surgery over the last several decades has been quite remarkable. It used to be quite a physically disfiguring operation. At that time, skin and muscles from the chest wall, as well as many lymph nodes, were removed, leading to a significant physical deformity and lifelong disability for the patient. Currently, however, there are many circumstances where a skin-sparing mastectomy is possible, and in some cases even a nipple- sparing procedure will be possible. The specific circumstances will depend on many factors, including the location and type of breast cancer present. A careful discussion with your surgeon can help determine if you are a candidate for this type of procedure.
Will I get lymphedema?
Several factors increase a patient’s risk of developing lymphedema. These include having a larger number of lymph nodes removed, having a history of prior axillary surgery or axillary radiation, infection following breast or axillary surgery, and obesity. Sentinel node biopsy, or removal of only one or a few lymph nodes, has a lower incidence of lymphedema than removal of a larger number of nodes, as with a full axillary dissection. Women who have full axillary dissection have about a threefold increase in the incidence of lymphedema (5%-20%) when compared with those having sentinel node biopsy alone (2%-7%).
Shouldn’t I have bilateral mastectomies?
There is no medical evidence that a woman with one-sided breast cancer has any survival advantage by having her non-affected breast removed, except for those women who have tested positive for one of the hereditary breast cancer genes. They may be at an increased risk of developing breast cancer in the non-affected breast.
Will I need chemotherapy?
Size of the tumor
Grade of the tumor cells
Estrogen and progesterone receptor status
HER2 receptor status
Age of the patient
Evidence of lymph node involvement
Results from genomic testing
Breast cancer treatment is highly individualized. Therefore, consultation with a medical oncologist who deals with breast cancer is recommended.
Should I get a second opinion about my breast cancer treatment?
A second opinion is useful when any of the details of a woman's breast cancer treatment are unclear or not adequately explained to the patient's understanding or satisfaction. Even if the opinions are basically the same, sometimes just hearing the same information presented in a slightly different fashion by a different physician is helpful in clarifying the treatment plan and giving the patient some peace of mind. Many institutions have multidisciplinary breast cancer conferences that meet regularly to discuss new cases of breast cancer, and this serves as an internal type of second opinion. Unless specified by a patient's insurance company, second opinions are not mandatory.
What are my reconstruction choices after mastectomy?
One type involves placing an expandable implant under the chest wall muscle. This implant can then be gradually “inflated” following healing of the skin incision. The expander is replaced by a permanent implant later in a second operation.
The other type of reconstruction involves moving tissue from one area of the body to the chest wall to create a new “breast” mound.
Both of these methods can be done after the completion of the mastectomy or at a later date, but most often the initial stages of these reconstructions are begun immediately following the mastectomy at the same setting. There are advantages and disadvantages to each method. They should be discussed fully with your breast surgeon and reconstructive surgeon before making the decision that is best for you.
How should I screen for breast cancer if my breast tissue is dense?
The American Cancer Society and National Comprehensive Cancer Network (NCCN) recommend that women with very dense breast tissue speak with their healthcare providers about the risks and benefits of combining screening mammography with breast MRI. Mammography is the only screening imaging method for breast cancer shown to decrease mortality. However, in select high-risk populations (such as women whose lifetime risk of developing breast cancer exceeds 20% or women with a genetic predisposition to breast cancer) supplemental screening with breast MRI or ultrasound can be beneficial. MRI does have a high sensitivity of detecting breast cancers, but it is also expensive and requires IV contrast dye. In addition, it has not been shown to reduce breast cancer mortality rates. Ultrasound is noninvasive but is dependent on who performs the exam, which can often lead to “false alarms” requiring further evaluation. Therefore, screening for dense breast tissue should consist of a clinical breast exam and screening mammogram, followed by a discussion with your healthcare provider to see if any other imaging studies are recommended for you.
Are there any resources to help make my “new” me my “best” me?
Many local and national organizations can provide resources and support regarding body image issues that you may experience during and after the treatment of breast cancer. The Internet is also a great source for free online information and resources. Many hospital systems and cancer centers now have cancer nurse navigators, nurses who are trained to help newly diagnosed cancer patients through their journey and can often assist in a supportive role helping patients find these resources.
Below is list of several national organizations and their contact information; the local chapters can be found through the national offices:
The American Cancer Society – www.cancer.org
- Susan G Komen for the Cure – www.komen.org
- National Cancer Institute – Cancer Information Service – www.cancernet.nci.nih.gov
- Cancer Care, Inc – www.cancercare.org
- Living Beyond Breast Cancer – www.lbbc.org
- Young Survival Coalition (women with breast cancer under age 40) – www.youngsurvival.org
How often should I get specialized testing, such as a PET scan, CT scan, or bone scan?
PET scans, CT scans, and bone scans are specialized radiological exams that are typically ordered by your physician if there is a concern for spread of the breast cancer to other parts of the body (metastatic disease) based on specific symptoms such as new localized bone pain or new abdominal swelling. These tests can also be used to track the progress or assess the response to the treatment of metastatic breast cancers. These expensive tests use ionizing radiation and are not needed to screen patients with early breast cancer.
Does a breast MRI show axillary lymph nodes?
A breast MRI does show axillary lymph nodes. There are currently new studies assessing the ability of MRI to distinguish between benign and metastatic (cancerous) lymph nodes based on the appearance and certain characteristics of the nodes as seen on MRI. However, to date there is no concrete evidence that MRI can diagnose metastatic nodal disease and definitive node biopsy with pathology evaluation is considered the standard.
How do physicians keep track of several different lumps in the breast on breast imaging?
Much like on physical exam, physicians often refer to a mass in terms of its “o’clock” position and its distance away from the nipple. If a lump has been biopsied, a titanium or ceramic clip can be left behind to mark the spot that was biopsied. These clips come in different shapes such as a ribbon shaped clip, or a circular clip. The shapes of the clips are easily seen on mammograms and help keep track of the breast areas that have been biopsied.
Can women who use wheelchairs have mammograms?
Absolutely yes! Women who use wheelchairs can and should have mammograms according to the same guidelines as any woman regardless of her ability status. There are some things that a patient who uses a wheelchair can do ahead of time to make sure that her mammogram goes more smoothly and in a timely fashion. Some tips include:
- Calling the mammogram facility ahead of time to make sure they will be able to accommodate a patient using a wheelchair and to have any special items needed the day you will be there.
- Wearing a 2 piece garment for ease of changing.
- Having someone else available to come with you to the appointment.
- Arriving, if possible, in a wheelchair with detachable arms, as the wheelchair arms will often need to be removed to perform the mammogram. If not, you may need to be transferred to another wheelchair.
Can a patient who uses a wheelchair have a core needle (minimally invasive) breast biopsy?
Yes, this is possible. Core breast biopsies can be done multiple ways depending on what the lesion is and how it is best seen on imaging. Ultrasound guided core needle biopsies are usually done with a patient laying down on a table on their back. The patient using a wheelchair may require transfer to a table for the procedure. For stereotactic breast biopsies (mammogram based biopsy) and MRI guided biopsies, patients are usually required to lay flat on their stomach with their arms above the head. Again, getting in the correct position and transfer from the wheelchair to the biopsy table for the procedure may require assistance but this is not a contraindication to core needle breast biopsy. There are some stereotactic breast biopsy units, called upright units, where the patients may have the stereotactic breast biopsy in a sitting position or on a stretcher. Your physician will be able to discuss the specifics about the type of biopsy and biopsy equipment you may require.