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"I Feel a Lump. Now What?"
Our step-by-step guide to what to do next if you suspect breast cancer.
Step 1: See Your Doctor
Your suspicious finding needs to be thoroughly checked out, so make an appointment with your doctor. What's reassuring is that 90% of women under age 55 who detect a lump turn out not to have cancer. Here's what to expect checkup day:
"I kept thinking I was too young."
- Clinical breast exam. Your doctor, using his fingers, locates your lump and also feels for certain clues. If the mass is soft, movable, and has a smooth oval or round circumference, it's more likely to be a cyst—a harmless, fluid-filled sac. If it's firm and fixed with irregular borders, it's more worrisome. Either way, your doctor needs to confirm what was felt. So, usually within the next week, you'll be scheduled for one or all of the following tests.
- Diagnostic mammogram. Unlike a routine screening mammogram—which takes less than 15 minutes, involves just two views of breast tissue, and should be a yearly ritual for all women over age 40—a diagnostic mammogram takes about twice as long. Because your lump needs to be looked at from lots of different angles, your breast is compressed between two plastic plates in additional uncomfortable ways during the exam. The squeeze will feel less severe if you take an over-the-counter pain medicine, such as ibuprofen, at least 30 minutes beforehand.
- Ultrasound. Women under age 50 tend to have dense breast tissue that doesn't always show up well on mammograms, so if you're premenopausal, chances are you'll need an ultrasound. The exam uses high-frequency sound waves to create images and typically takes less than 30 minutes. "It's especially good at distinguishing a benign, fluid-filled cyst from a solid mass," says Katherine B. Lee, M.D., a breast specialist at the Cleveland Clinic Breast Center. After squirting gel on your breast the technician presses a wand all around the tissue, which is pretty painless.
- MRI (magnetic resonance imaging). If neither the mammogram nor the ultrasound yields clear results, you may need an MRI, which provides a 3-D view of your breast. You receive an injection of dye that helps highlight abnormalities. Then you lie on your stomach inside a tube-like "capsule" for 20 minutes. You may be able to listen to music. If you're prone to claustrophobia, ask for anti-anxiety medicine.
Five years ago Becky Cwiek, a 43-year-old mother of two from Brighton, Michigan, felt a grape-size lump in her breast after taking a shower. "I wasn't too worried. I told myself it must just be a cyst." Instead, it was an aggressive form of cancer that was caught early enough to treat successfully—all because Becky didn't blow off her discovery. "On the one hand, I was so sure it was nothing, but on the other, I did make an appointment to have it checked out right away."
Step 2: Get Ready for a Biopsy
Reality check: Just because your doctor wants a tissue sample doesn't mean you have cancer. As many as 77% of the 1 million breast biopsies performed each year in the U.S. turn out to be benign, according to a recent study. But if the images of your lump leave doubts about a diagnosis, a biopsy is the only way to be certain. Depending on how big your lump is, where it's located, and how suspicious it seems, you'll need at least one of these three procedures:
"It didn't hurt at all."
- Fine needle aspiration. This quick test, which can be performed in a doctor's office, is often done if your mass looks like a fluid-filled cyst. A superfine needle is inserted into the lump. If it's clearly a cyst, the fluid removed is non-bloody and easily drained. When there's any doubt, the removed tissues or cells are checked for cancer. If there's a pathologist on the premises to analyze the sample, you can have an answer in as little as 10 minutes (otherwise, you'll have to wait overnight). Expect to feel a prick and some pressure while the needle is inserted and the growth is located.
- Core needle biopsy. If the lump looks solid, you'll go straight to this test, which takes up to 45 minutes and is done in a hospital on an outpatient basis. First, your skin is numbed with an injection, then a surgeon inserts a special-tipped, hollow-core needle into your lump and surrounding area at least three times to remove small cylinders of tissue. In some cases the surgeon uses ultrasound to guide the needle, in others X-rays are used—either way, you'll have some temporary bruising and soreness and possibly a little permanent scarring at the needle entry points.
- Excisional biopsy. This is just what it sounds like: a cut in the skin in order to remove the entire lump and surrounding tissue so they can be looked at under a microscope. It's usually same-day surgery done with local anesthesia, but most experts view it as the last resort since it causes soreness and scarring, and doesn't always spare you from another surgery if cancer is found. "It's warranted only in rare cases, such as when a core biopsy is inconclusive," says Nora Hansen, M.D., director of the Lynn Sage Comprehensive Breast Center at Northwestern Memorial Hospital.
Forty-four-year-old Belinda Smith had an X-ray-guided core needle biopsy last year. The mother of two, who lives in Orlando, lay facedown on a table with her breast placed in an opening; the table then rose so the radiologist could work underneath her. "It was like a mechanic working on a car," she says. A mammography unit compressed her breast while computer images helped pinpoint the area to be biopsied. "It was so cutting edge," says Belinda, who admits the process left her "worn out and achy the next day." Her biopsy revealed a small, early-stage cancer that was treated with a breast-sparing lumpectomy and a brief course of radiation.
Step 3: Understand Your Lab Results
Biopsy results usually arrive in dribs and drabs over the course of days or even weeks. Together, they make up your pathology report—a document that can seem like it's written in a foreign language. But if you do have cancer, you'll want to make sense of it, since it's key for deciding what treatments will be best. A "translation" of important answers your report contains:
The Fine Print on a Benign Biopsy
- What type of cancer do I have? You'll probably find it described in one of the following ways:
DCIS (ductal carcinoma in situ): About 20% of new cancer cases are this noninvasive type, which arises in the ducts or tubes that carry the milk to the nipple and hasn't traveled to other parts of the body. Nearly all women diagnosed with DCIS can be cured.
IDC (invasive ductal carcinoma): The most common kind of breast cancer, it starts in the ducts, invades fatty tissue of the breast, and can spread to other parts of the body. Still, more than 97% of women with early-stage IDC overcome it.
ILC (invasive lobular carcinoma): About 10% of invasive breast cancers start in the glands (lobules) that produce milk. ILC is often found at a later stage than IDC because the milk glands are deeper in the breast tissue than the ducts, which makes ILC harder to detect by touch and mammogram.
- How aggressively is it growing? You can tell by your cancer's "grade," which is on a scale of I to III. A "I" has the slowest-growing, least aggressive cells; III spreads the fastest.
- What's the hormone receptor status? Some breast cancer cells have hormone receptors—molecules that allow estrogen or progesterone (or both) to activate the cells. The good news is that several new therapies block the hormones from reaching the receptors.
- Does the cancer contain the HER2 gene? Tumors that are HER2-positive tend to grow rather fast, spread quite quickly, and may need more aggressive, specialized treatment.
- What stage is the cancer? To describe how big the cancer is and how much it has spread, doctors use a scale of 0 to IV. The lower the number, the less extensive the cancer. More tissue may need to be removed (and lymph nodes tested) before you learn your cancer's stage.
Don't breathe a sigh of relief: Some types of noncancerous lumps increase your chances of breast cancer in the future. In a study of 9,000 women, those whose benign biopsies revealed excessive or atypical cell growth were four times as likely to develop cancer in the next 15 years as those whose biopsies showed no abnormalities. "'Negative' is not a complete answer," says Stuart Schnitt, M.D., director of anatomic pathology at Beth Israel Deaconess Medical Center in Boston. "Ask for details and find out if you should have more frequent examinations and mammograms or consider preventive drug therapy."
Step 4: Explore Your Treatment Options
You may be anxious to "get the cancer out," but it's important to obtain a second opinion. "It could make a big difference in your chances of a cure," says Michael Sabel, M.D., an author of a University of Michigan study that found that 52% of women who sought additional input received new advice. Ask your local hospital for the names of breast cancer specialists. Once you have a second opinion you can choose your treatment, which typically will include some of the following elements:
Chemo Jitters, Conquered
- Surgery. Depending on the size and extent of your lump, your doctor may suggest breast-conserving therapy, in which your cancer is removed but most of your breast tissue is saved. If mastectomy (removal of your whole breast) is recommended, having a procedure to reconstruct your breast at the same time can ensure the best cosmetic results—and potentially spare you a second surgery. But only 24% of breast surgeons refer their patients to plastic surgeons to discuss options, according to a University of Michigan Medical Center study. "By federal law, breast reconstruction is a medical benefit that must be covered," says lead study author Amy Alderman, M.D. "So speak up and ask your doctor to refer you to a plastic surgeon."
- Radiation. Typically it's administered for six or seven weeks via an X-ray machine, but there's a newer one-week treatment that delivers radiation directly to the site of the tumor. Called partial breast irradiation, a widely used form is MammoSite. Apart from fatigue, there are few side effects associated with either type of radiation.
- Chemotherapy. Even women with early stage breast cancer benefit from chemo—they live longer, according to a recent study. Treatments, via an intravenous drip, typically are every two to three weeks for three to six months. Thanks to new drugs, nausea can be avoided. Hair loss and fatigue, however, are common side effects. So is "chemo brain"—memory and attention losses that may last 10 years afterward.
- Drug therapy. If your cancer is hormone-receptor-positive, you may benefit from tamoxifen, raloxifene, letrozole, or anastrozole, meds that help reduce the chance of a cancer comeback by 50%. Women with early-stage HER2-positive cancers can halve their recurrence risk with trastuzumab, a drug that's administered intravenously once every three weeks for a year.
Before leaving for her first chemo treatment early in 2006, Lisa Vitantonio, a 48-year-old retired nurse from Chagrin Falls, Ohio, began furiously cleaning her house. "My husband begged me to stop since we were late," she recalls. "I kept delaying. I was scared." But it turned out she was so well cared for she sometimes mused that her chemo appointments were her "spa" days. "I would lie on a comfortable lounger in a pleasant room for five to nine hours. Staff would come in to make sure everything was fine and to see if I needed anything," she recalls. "I read, slept, journaled, and watched movies."
Copyright © 2007. Used with permission from the October 2007 issue of Family Circle magazine.
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