What to do when you finda breast lump
“IS this cancer?” is the first thought that comes to mind when one discovers a lump in the breast.
The next action, which is almost like a reflex, is to Google ‘breast lump’, which inevitably leads to more anxiety.
Actually, over 80% of lumps felt will eventually be found to be benign (non-cancerous) after being investigated. Therefore, the first thing to do should be to consult a breast surgeon.
Whenever a breast problem is assessed, the approach used is a ‘triple assessment’ encompassing clinical assessment, imaging (scan) and histopathological examination (biopsy).
During the initial consultation, the doctor will first obtain a full history of the presenting symptoms. Any significant previous medical history and family history will be assessed as well to assess the risk profile of the patient. This will be followed by a physical examination.
If the clinician is male, there will always be a female chaperone throughout the examination.
Most patients will be anxious and uneasy during their first breast examination but will soon be put at ease by the professionalism shown by the doctor.
Only a lump more than 1cm is palpable by hand – anything smaller is difficult to detect unless it is extremely superficial.
Step two of the triple assessment is imaging.
For women below 40, an ultrasound will be the first choice.
This is a very simple procedure carried out by a radiologist and is painless and radiation-free. It will usually take about 20-30 minutes for a complete breast examination.
Women above 40 will be advised to do a mammogram and sometimes an adjunct ultrasound as well.
The reason why the mammogram is reserved for older women is related to breast density – the younger the woman, the denser the breast. This density will make the mammogram image appear very “white” and make interpretation of any underlying lesion difficult.
The main things to look for in the mammogram for suspected cancer would be pleomorphic microcalcification (tiny white dots in a tight cluster made up of different shapes and sizes), architectural distortion of the breast tissue and abnormal density.
Ultrasound, on the other hand, is good for assessing the size, echogenicity (content nature), margin and vascularity (blood flow) of the particular lump.
It is also used to visualise the presence of enlarged or abnormal-looking axillary lymph nodes.
After the scan, if the lump is confirmed to be solid or semi-solid, the patient will be advised to do a biopsy where the doctor removes a few thin strips of tissue from the lump, which will be then sent to a laboratory for microscopic confirmation of the nature of the tissue (benign or cancerous).
The most commonly performed biopsy these days is the core biopsy under ultrasound guidance. This is because direct visualisation of the biopsy process with the ultrasound prevents any potential sampling error and also facilitates more tissue sampling from different parts of the lump.
Once the triple assessment is done, the nature of the lump can be now determined accurately.
The breast surgeon will then advise on the next plan of action.
For benign lumps sometimes, conservative management is recommended as 30% may eventually grow smaller and disappear over time.
For larger lesions – anything more than 3cm – as they may cause breast, distortion surgery is usually recommended.
If the lump is cancerous, the surgeon will advise the patient regarding treatment, which is usually surgery as the primary course of action, followed by adjuvant therapy, such as chemotherapy, radiotherapy, targeted therapy and hormonal therapy.
For some patients, chemotherapy is recommended before surgery to reduce the size of the tumour.
The most common myth about breast cancer surgery is that the whole breast must be removed (mastectomy). This is not true – most times the patient can be treated by breast-conserving surgery, coupled with radiotherapy.
When mastectomy is indicated in certain cases, reconstruction of the breast is always an option.
This article is contributed by Dr Tan Gie Hooi, Consultant Breast and Oncoplastic Surgeon, ParkCity Medical Centre.