Question 1

Why do I need mammography and ultrasound?

Accepted Answer

Mammography and Ultrasound are complementary exams. Some information obtained on mammography cannot be obtained on ultrasound and vice-versa. For instance, calcifications are seen better on mammography whereas lymph nodes are better evaluated on ultrasound. So women over 40 years of age often need both tests to complete an accurate diagnostic workup for a breast mass.

Question 2

When should I do a self breast exam?

Accepted Answer

The best time to do a self-exam is in the few days after your period when the breast is less tender and lumpy. If you have undergone menopause or a hysterectomy, you can pick any day of the month that’s easy to remember such as the 1st of the month or the day you get your monthly salary.

Question 3

Why do I keep getting repeated abscesses?

Accepted Answer

Repeated breast abscesses can occur in diabetics, smokers and patients with a compromised immune system eg in HIV, patients on steroids and immunosuppresive medications. Some of the conditions mentioned here such as IGM, Zuska's disease and TB can also cause repeated abscesses that do not respond to standard treatments. Abscesses that occur outside the setting of pregnancy and breast feeding, or those that recur after treatment, should be seen by a breast specialist.

Question 4

Is it normal to get some sticky fluid from the nipple?

Accepted Answer

A small amount of sticky whitish or green- brown discharge from the nipple that is seen when your press or stimulate the nipples, is normal. Just like skin cells are shed from time to time, dead cells lining the ducts are shed and get liquified, collecting in chambers behind the nipple. When you press around the nipple, this fluid comes out. If  your breast discharge is new or unusual, you should see a breast specialist.

Question 5

Is breast cancer painful?

Accepted Answer

Breast cancer most often presents as a painless breast lump. Women often ignore early signs of cancer as the lump does not hurt. Cancer can cause pain once it involves nerves in the area or may cause discomfort from stretching of surrounding tissues. You should not ignore a breast symptom such as swelling or a lump, because it isn't painful.
Breast Pain, described here as 'cyclical mastalgia" is not a warning sign or risk factor for breast cancer.

Question 6

How do I know if I have breast cancer?

Accepted Answer

In the early stages, a woman with a painless breast lump, may not have any changes to appetite, weight or wellbeing. Symptoms of breast cancer include but are not limited to
1) A lump in the breast or armpit 
2) Change in shape size or feel of the breast
3) Nipple discharge
4) Retraction (pulling in) of the nipple 
5) Dimpling of the skin of the breast
6) Thickening or redness of the skin of the breast
7) Rash around the nipple or areola
A lot of these signs can overlap with those of benign  (non cancerous) breast condition. It is hence important to get yourself examined by a specialist and not try to diagnose yourself at home.
Eary breast cancer can exisit even in the absence of any of the symptoms above in which case it is usualy picked up by mammography or other imaging.

Question 7

Why do I need mammography and ultrasound?

Accepted Answer

Mammography and Ultrasound are complementary exams. Some information obtained on mammography cannot be obtained on ultrasound and vice-versa. For instance, calcifications are seen better on mammography whereas lymph nodes are better evaluated on ultrasound. So women over 40 years of age often need both tests to complete an accurate diagnostic workup for a breast mass.

Question 8

Is breast cancer hereditary?

Accepted Answer

Around 5-10 percent of breast cancers can be attributed to known genetic mutations. Upto 20 percent cases may be familial even if no mutations are known or found. The vast majority of patients who have breast cancer, have no family history and are called 'sporadic'.

Question 9

How can I prevent breast infections and abscesses?

Accepted Answer

If you are breast feeding, breast feed and regular intervals. If the baby does not take a proper feed from one side, empty the breast manually or using a pump. This avoids stagnation of milk. Avoid cracked nipples as they act as pathways for bacteria to enter the breast tissue. Quit smoking and avoid tobacco as they increase risk of breast abscesses.

Question 10

How can I prevent breast infections and abscesses?

Accepted Answer

If you are breast feeding, breast feed and regular intervals. If the baby does not take a proper feed from one side, empty the breast manually or using a pump. This avoids stagnation of milk. Avoid cracked nipples as they act as pathways for bacteria to enter the breast tissue. Quit smoking and avoid tobacco as they increase risk of breast abscesses.

Question 11

Is breast cancer painful?

Accepted Answer

Breast cancer most often presents as a painless breast lump. Women often ignore early signs of cancer as the lump does not hurt. Cancer can cause pain once it involves nerves in the area or may cause discomfort from stretching of surrounding tissues. You should not ignore a breast symptom such as swelling or a lump, because it isn't painful.
Breast Pain, described here as 'cyclical mastalgia" is not a warning sign or risk factor for breast cancer.

Question 12

Is breast cancer painful?

Accepted Answer

Breast cancer most often presents as a painless breast lump. Women often ignore early signs of cancer as the lump does not hurt. Cancer can cause pain once it involves nerves in the area or may cause discomfort from stretching of surrounding tissues. You should not ignore a breast symptom such as swelling or a lump, because it isn't painful.
Breast Pain, described here as 'cyclical mastalgia" is not a warning sign or risk factor for breast cancer.

Question 13

Is breast cancer surgery painful?

Accepted Answer

We follow the Enhanced Recovery After Surgery  (ERAS) protocl for all our breast cancer surgery. Pain is minimised if well controlled early in the surgical treatment. Towards this goal
1.You may be started on medications that reduce pain on the night before surgery.
2.Local anaesthetic in the form of nerve blocks around the surgical area are routinely used for early pain control.
3.Anti-inflammatory medications and paracetamol are used in regular doses after surgery. 
With this protocol most of our patients are surprised that when they wake up from anesthesia, they have minimal to no pain. They are able to site up shortly after surgery and able walk on the same day. Read more about ERAS here.(undefined)

Question 14

How should I prepare for a mammogram?

Accepted Answer

On the morning of your mammogram, take a shower but do not apply talc or anti-perspirants as they can show up on a mammogram.
 
Carry all old mammography or breast ultrasound reports, films or CDs you may have.
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You do not need to fast before the exam and you should be able to drive yourself back and forth from the test. If you're anxious, you may have a friend accompany you.

Question 15

When is the best time to do a self-breast exam?

Accepted Answer

The best time to do a self-exam is in the few days after your period when the breast is less tender and lumpy. If you have undergone menopause or a hysterectomy, you can pick any day of the month that’s easy to remember such as the 1st of the month or the day you get your monthly salary.

Question 16

Can a breast cyst or fibroadenoma convert to cancers?

Accepted Answer

Simple cysts and fibroadenomas do not convert to cancers. The important thing is that a diagnosis of a breast lump as a cyst or fibroadenoma should be accurate. Occasionally breast cancers can resemble such conditions on imaging and a needle aspiration or biopsy may be needed for confirmation. Once confirmed to be benign these conditions are either observed or treated if they are symptomatic, but not due to risk of malignancy.

Question 17

Should I undergo FNAC or core/trucut biopsy?

Accepted Answer

FNAC only samples a few cells from a breast lesion. Often sampling is inadequate or yields only blood cells or fat. Reports may describe abnormal cells (atypia) which may ot may  not represent cancer. FNACs can also cause higher number of 'false negative' reports which can cause delay in diagnosis and treatment. A core needle biopsy which samples pieces of tissue instead of cells, gives a higher accuracy of diagnosis. The procedure is done under local anesthesia in the clinic without necessitating surgery for diagnosis. We hence prefer core biopsy over FNAC.
https://www.youtube.com/watch?v=-yQLdr6IvAw

Question 18

Can I continue to breastfeed if I have an infection?

Accepted Answer

Yes, Most of the time the bacteria causing a breast infection are already living in the baby's mouth. So you would not pass on the infection to the baby. If you are taking an antibioitic, verify if this antibiotic is safe for the baby if it enters breastmilk and watch for side effects such as diarrhea in the baby. If you have undergone surgical incision and drainage for the absvess, your surgeon will advise you when it is safe to resume breast feeding.

Question 19

Can I avoid chemotherapy after surgery?

Accepted Answer

Chemotherapy is one of the pillars of breast cancer treatment. However not every breast cancer patient may need chemotherapy. If you have a tumour is small, has not spread to lymph nodes, is ER+ PR+ i.e. hormone receptor positive and HER2 negative, you may may benefit from a genomic risk assessment of your tumor. These commercially available tests include Oncotype Dx, Mammaprint, Endopredict and others.
If such testing demonstrates your tumor to be at low risk of recurrence, you may be prescribed endocrine therapy alone for 5-10 years. Adding chemotherapy in  such situations may provide little or no additional benefit. Contact us (mailto:punebreastcare@gmail.com?subject=Opinion about need forchemotherapy)for more information on the topic

Question 20

Can I continue to breastfeed if I have an infection?

Accepted Answer

Yes, Most of the time the bacteria causing a breast infection are already living in the baby's mouth. So you would not pass on the infection to the baby. If you are taking an antibioitic, verify if this antibiotic is safe for the baby if it enters breastmilk and watch for side effects such as diarrhea in the baby. If you have undergone surgical incision and drainage for the absvess, your surgeon will advise you when it is safe to resume breast feeding.

Question 21

What can I do to reduce cyclical breast pain?

Accepted Answer

Simple measures you can take include
 
Reduce consumption of caffeine in tea coffee and sodas.
Wear a comfortable, support  bra.
Apply warm or cool compresses when the breasts are painful.
Try vitamin E, evening primrose oil or GLA
See a breast specialist for guidance if you have significant pain.

Question 22

If I have a breast problem, should I undergo a mammogram or an ultrasound?"

Accepted Answer

Mammography and breast ultrasound are complementary tests. One is not necessarily better than the other, as they provide different types of information.
In young women < 40 years of age, we usually start with a breast ultrasound. If needed digital mammography or breast MRI may be used to investigate a problem further.
 
In women over the age of 40 years we start with a diagnostic mammogram. An ultrasound or needle biopsy may be needed to complete the diagnosis.
 
It is best to discuss the problem with a breast specialist or breast surgeon who can guide you about appropriate investigations. If you have a concern and the mammogram is normal, do not let it stop you from seeing a specialist.  Mammography is not perfect and can miss 10-20% of cancers.
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Question 23

When is nipple discharge abnormal?

Accepted Answer

If discharge is bloody or clear watery, it may be a sign or a growth in the ducts thats bleeding or secreting fluid. Such discahrge usually affects onebreast or only one particular duct opening. If you notice that without any stimulation, your bra on one side is wet, or shows blood spots, that imay be cause for concern. If you are not pregnant or breast feeding, but have milky discahrge, this is abnormal as well.

Question 24

What can I do to reduce cyclical breast pain?

Accepted Answer

Simple measures you can take include
 
Reduce consumption of caffeine in tea coffee and sodas.
Wear a comfortable, support  bra.
Apply warm or cool compresses when the breasts are painful.
Try vitamin E, evening primrose oil or GLA
See a breast specialist for guidance if you have significant pain.

Question 25

Could this lump I feel on self-exam be breast cancer?

Accepted Answer

If you find a breast lump, do not panic as most breast lumps are not cancerous.However do not try to diagnose yourself at home. See a breast specialist who can examine you and advise any additional investigations that may be needed for an accurate diagnosis.

Question 26

I have cysts in the breast, what should I do?"

Accepted Answer

There are different types of breast cysts. "Simple cysts" can often be safely observed. They do not convert to cancer nor do they increase risk of breast cancer . "Complex cysts" may need a needle aspiration and occasionaly a biopsy of the wall.
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A cyst may occasionally grow to a large size, be felt by hand and cause discomfort. A needle aspiration can be performed to remove fluid and alleviate the discomfort. Much like a water balloon, a cyst collapses after removal of fluid. Cyst fluid may be sent for testing if needed. A breast specialist can help decide what if anything needs to be done about these cysts. Rarely does a cyst need surgery.

Question 27

Should I undergo FNAC or core/trucut biopsy?

Accepted Answer

FNAC only samples a few cells from a breast lesion. Often sampling is inadequate or yields only blood cells or fat. Reports may describe abnormal cells (atypia) which may ot may  not represent cancer. FNACs can also cause higher number of 'false negative' reports which can cause delay in diagnosis and treatment. A core needle biopsy which samples pieces of tissue instead of cells, gives a higher accuracy of diagnosis. The procedure is done under local anesthesia in the clinic without necessitating surgery for diagnosis. We hence prefer core biopsy over FNAC.
https://www.youtube.com/watch?v=-yQLdr6IvAw

Question 28

What can I do about cyclical breast pain?

Accepted Answer

Simple measures you can take include
 
Reduce consumption of caffeine in tea coffee and sodas.
Wear a comfortable, support  bra.
Apply warm or cool compresses when the breasts are painful.
Try vitamin E, evening primrose oil or GLA
See a breast specialist for guidance if you have significant pain.

Question 29

What if I find something on my self-exam?

Accepted Answer

If you find a breast lump, do not panic as most breast lumps are not cancerous.However do not try to diagnose yourself at home. See a breast specialist who can examine you and advise any additional investigations that may be needed for an accurate diagnosis.

Question 30

Can I take medicines to dissolve cysts and fibroadenomas?

Accepted Answer

Some fibroadenomas and cysts will shrink and resolve on their own especially in women nearing menopause. In young women they may increase in size during puberty, pregnancy and breastfeeding, under influence of norma femalel hormones. As there is no 'imbalance' or hormones to be corrected, no medical treatements are usually advised for these conditions.

Question 31

What is inflammatory breast cancer?

Accepted Answer

'Inflammatory breast cancer' is a specially aggressive type of breast cancer. Tumor cells block lymphatic channels of the breast skin causes redness and thickening of the skin of the breast, resembling inflammation. The diagnosis is often confused with mastitis and treated with multiple courses of antiobiotics causing delay in diagnosis. If inflammation of the breast does not respond to antibiotics, you should see a breast specailist. A tissue biopsy is important for a diagnosis in such cases.

Question 32

What genetic defects can cause breast cancer?

Accepted Answer

80-90% of hereditary breast cancer is caused by mutations in BRCA1 or BRCA2 gene. TP53, PTEN,CDH1, ATM, CHEK2 and PALB2 are other genes responsible for familial cancers.

Question 33

Can a breast cancer spread due to a breast biopsy?

Accepted Answer

No, it is a common myth that a needle may disturb tumor cells and cause them to spread. This myth has been dispelled by several studies. If cancer cells get displaced into the surrounding environment they do not remain viable to implant. In fact patients who have cancer diagnosed on needle biopsy have better survival outcomes than women who directly undergo surgery.

Question 34

Why do women get breast pain around menopause?

Accepted Answer

Menstrual cycles may become irregular around menopause. Ovulation may not occur. The cyclial painful changes that occur in the breast can become exaggerated. Often these painful symptoms subside when menopause is complete. Women are advised to continue annual screening mammography after 40 years and discuss any unusual breast symptos with a breast surgeon.

Question 35

Why do women get breast pain around menopause?

Accepted Answer

Menstrual cycles may become irregular around menopause. Ovulation may not occur. The cyclial painful changes that occur in the breast can become exaggerated. Often these painful symptoms subside when menopause is complete. Women are advised to continue annual screening mammography after 40 years and discuss any unusual breast symptos with a breast surgeon.

Question 36

Can a BRCA mutation be inherited from the father?

Accepted Answer

Yes ,risk of breast cancer risk can be inherited with equal probability from the mother or father. Paternal uncles, aunts, cousins and grandparents also contribute to your family hisotry.

Question 37

At what age should  I start mammography and how often should I do it?

Accepted Answer

We usually advise women to come in for a baseline screening mammogram at age 40 years. After a review of your risk factors and a clinical exam, a personalized screening strategy is prepared for you. Women over the age of 40 years women are usually advised mammography every 1-2 years. After the age of 50 years, the test is advised annually. If you have a strong family history or known genetic risk, you may need to start screening earlier and use other tools besides mammography. Consult a breast specialist who can guide you appropriately.

Question 38

Can a breast cancer spread due to a breast biopsy?

Accepted Answer

No, it is a common myth that a needle may disturb tumor cells and cause them to spread. This myth has been dispelled by several studies. If cancer cells get displaced into the surrounding environment they do not remain viable to implant. In fact patients who have cancer diagnosed on needle biopsy have better survival outcomes than women who directly undergo surgery.

Question 39

Does removal of a fibroadenoma cause scars and deformity ?

Accepted Answer

Most fibroadenomas can be and should be removed through hidden scars around the pigmented area of the areola. Scars in the armpit or in the crease where the breast attaches to the chest wall also hide well. As these are "pushing growths" that do grow into surrounding normal tissue, removal does not cause volume loss. The surrounding tissue that has been pushed away, falls into the space created on removal. Use of absorbable sutures instead or remoable sutures or staples, also minimises scars.

Question 40

How do you treat Idiopathic Granulomatous mastitis (IGM)?

Accepted Answer

Whenever we suspect IGM, we try to avoid surgery and diagnose the condition on core needle biopsy. We use a protocol that involves medical management with steroids and abscess aspirations whenever needed to minimize pain, scarring and deformity. Treatment may often need several months and close supervision for prevention of complications from steroid use. Patients need counselling and emotional support during treatment. T

Question 41

Will I need radiation after breast cancer surgery?

Accepted Answer

Need for radiation is determined by the type of surgery you have, the size of the tumor and whether it has spread to the lymph nodes.
1) Radiation is advised in nearly all cases if the type of surgery is a "lumpectomy for breast cancer" or "breast conservation surgery".
2) Radition is also used in locally advanced cancers which are large in size and those that have spread to the lymph nodes
3)Radiation may be omitted in certain small tumors of favorible biology in elderly patients. 
To know if your case benefits from radiation, contact us (mailto:punebreastcare@gmail.com?subject=Do I need radiation for my breast cancer?)for an opinion.

Question 42

How can I prevent cracked nipples?

Accepted Answer

Avoidi harsh soaps that cause drying of the nipples. Y
ou can use purified lanolin creams between feeds.
Apply few drops of milk to the nipple and air dryi the nipples. 
You can also use nipple shields are measures that can be used to prevent cracked nipples.

Question 43

How can I prevent cracked nipples?

Accepted Answer

Avoidi harsh soaps that cause drying of the nipples. Y
ou can use purified lanolin creams between feeds.
Apply few drops of milk to the nipple and air dryi the nipples. 
You can also use nipple shields are measures that can be used to prevent cracked nipples.

Question 44

For Breast Cancer Surgery is a mastectomy better than lumpectomy?

Accepted Answer

Patients often believe that the cancer can come back in the remaining breast after lumpectomy, but cannot recur after mastectomy. Truth is although most patients will never develop a recurrence,  a cancer can recur in the chest wall or skin flap after a mastectomy or in the remaining breast after a lumpectomy. Regardless of which surgical approach is taken, routine follow-up with your breast surgeon or oncologist is a must.
 
After a breast surgeon has evaluated you for breast cancer, you may be a offered a the choice between lumpectomy+ radiation and a mastectomy.
The choice is only offered if the cancer lends itself safely to be treated by either options. This means that you will not be offered a lumpectomy if the tumor were not suitable for that treatment eg. if the tumor involved multiple areas of the breast.  However when the choice is offered to you, your survival will not be affected by the surgical treatment you choose, as long as you complete all treatments advised. Not completing radiation after lumpectomy has high risk of recurrence.
When making the decision between lumpectomy and mastectomy discuss the following with your breast surgeon.
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1) Need for radiation: Radiation is almost always given after a lumpectomy, whereas it can be av

oided in certain cases after a mastectomy.
2) Options for reconstruction after mastectomy: A mastectomy may not be a mutilating surgery, often the skin and nipple areolar complex can be preserved at the time of surgery and the breast is removed and replaced with  an implant or a flap.
3) Plan for surveillance / follow-up after surgery: Routine mammography for the treated side is necessary after a lumpectomy. If you undergo a mastectomy, mammography is needed for the opposite side. The side of the cancer is followed with clinical exam alone
4) Possibility of genetic/ hereditary breast cancer: In cases of known BRCA mutations, a bilateral mastectomy may be offered over the choice of lumpectomy and radiation. If you opt for a lumpectomy in this situation, annual MRI is also advised for surveillance given the higher risk of recurrence.
5) Expected cosmetic outcomes of either approach: Aesthetic outcomes of both approaches may be satisfactory. Sometimes patients opt for a bilateral mastectomy with reconstruction for symmetry. In cases of a lumpectomy, a symmetrization procedure may be offered for the opposite side. Radiation also affects long-term appearance of the breast.
 
It is important for the woman to be comfortable with the decision she makes. It is also important for family members to help the patient make her own decision and notjudge them for the choices they make.

Question 45

Why do women get breast pain around menopause?

Accepted Answer

Menstrual cycles may become irregular around menopause. Ovulation may not occur. The cyclial painful changes that occur in the breast can become exaggerated. Often these painful symptoms subside when menopause is complete. Women are advised to continue annual screening mammography after 40 years and discuss any unusual breast symptos with a breast surgeon.

Question 46

At what age should I start mammography and how often should I do it?

Accepted Answer

We usually advise women to come in for a baseline screening mammogram at age 40 years. After a review of your risk factors and a clinical exam, a personalized screening strategy is prepared for you. Women over the age of 40 years women are usually advised mammography every 1-2 years.  After the age of 50 years, the test is advised annually. If you have a strong family history or known genetic risk, you may need to start screening earlier and use other tools besides mammography. Consult a breast specialist who can guide you appropriately.

Question 47

What causes Galactorrhea or abnormal milk discharge?

Accepted Answer

Certain medications that increase prolactin levels can cause galactorrhea. These include some antacids, antidepressants, antipsychotics, anti-hypertensive and estrogen containing drugs. Abnormalities in thyroid and other hormones can also cause galactorrhea. Rarely galactorrhea may be caused by a tumor in the pituitary gland. A breast surgeon can do a hormonal workup and advise you to see an endocrine specialist if needed.

Question 48

I have nipple discharge but why is  my mammography/ ultrasound normal?

Accepted Answer

Certain conditions like intraductal papillomas and ductal carcinoma in-situ are microscopic, cell level changes in the duct lining. They often do not cause a mass or calcifications, so mammograms and ultrasounds may be normal. If you have abnormal discharge you should see a breast surgeon even if your imaging is normal.

Question 49

How should I prepare for a mammogram?

Accepted Answer

If you are healthy premenopausal and undergoing a  regular screening mammogram, try to schedule your test in the week after your menstrual period when the breasts are less tender. Do not apply deodorants, talcum powders and antiperspirants around the breast or armpits before your exam, as the salts contained in these may cause “specks” to appear on the mammogram. You do not need to fast for the exam and no IV or contrast is needed for the test. Remember to gather your previous mammography and ultrasound reports as well as images on films or CDs. Decisions in reporting involve comparison with images from prior years and noting changes over time. Any prior breast biopsy or surgery reports should also be made available to the radiologist reading your mammogram. If you’re anxious, take a friend or family member to accompany you.

Question 50

Why not just remove a lump to get a diagnosis?

Accepted Answer

“Excisional Biopsy” i.e. removal of a breast lesion as a first step in diagnosis is a very common but wrongful practice. Diagnosis of most breast problems can be made with a high level of confidence by performing a core-needle biopsy under local anesthesia in the OPD. 1)Several breast problems may not need surgery at all, and a needle biopsy can avoid unnecessary surgery.
2)If you have cancer that is picked up on excisional biopsy, you’ve undergone incomplete surgery. This is because  a cancer operation involves more than just removal of a lump. Repeat surgery is needed to obtain clean margins and for lymph node staging.
3)If your tumour would have benefitted from chemotherapy to shrinking it prior to surgery, this opportunity is lost.
4)Scars from the excisional biopsy may not allow skin-preservation and optimal aesthetic outcomes at the subsequent cancer operation.
For all these reasons, a needle biopsy should be done first. Surgery should be performed only if it is actually required at all; and the right operation should be performed knowing what the diagnosis we intend to treat.

Question 51

Is chemotherapy painful ?

Question 52

Why not just remove a lump to get a diagnosis?

Question 53

Who is a close blood relative when considering family history?

Question 54

How to prevent pain from mammograms?

Question 55

How to prevent pain from mammograms?

Question 56

How to prevent pain from mammograms?

Question 57

How should I prepare for a mammogram?

Question 58

Can breast cancer occur during pregnancy and breast feeding?

Question 59

Can breast cancer occur during pregnancy and breast feeding?

Question 60

Should I get a cyst removed?

Question 61

Why is an abscess wound not stitched up?

Question 62

Should I get a second opinion on my biopsy report?

Question 63

I have large breasts- will breast reduction help decrease pain?

Question 64

I am 25 years old, should I undergo mammography?"

Pune Breast Care

Dr Pranjali Gadgil

Breast Surgeon in Pune, Maharashtra, India