Breast lump or a swelling in the breast is a complaint frequently encountered by general surgeons. It is a common reason for a female patient to seek surgical help. Due to religious and cultural modesty prevailing in our society, as well as various misinformation, breast diseases are still shrouded in mystery.

What is a breast lump? In my surgical practice the most common question that I face from the patients is, "Is it cancer?". Breast lump has become synonymous with breast cancer. This is far from the truth. I shall try to shed some light on this problem, which I hope will help the female readers and their relatives. Only 20 per cent of breast tumours turn out to be malignant!

Breast lumps which are not cancers: Commonest benign breast lump is called fibroadenoma. It is typically found in young women. It is generally smooth, spherical, painless and very mobile without any attachment to skin or surrounding breast tissue. More than one may be present. It gradually increases in size and may eventually fill the whole breast but usually its size varies between 2-3 cm. During pregnancy fibroadenoma may increase in the size but return to original size after birth of the baby.

Fibroadenoma is usually treated by surgical removal. It is a minor operation commonly done under short general anaesthesia. It is possible to plan the cut in the breast skin in such a way that there is almost no postoperative scar. In case of unavoidable large cuts, it is placed in such a way that the scar is hidden under the clothing. It requires several hours of hospital stay. In patients with other medical problems it may be safer to spend one night in the hospital. In case of superficial fibroadenomas the surgery may be performed under local anaesthesia. It is essential to send the tumour for pathological examination to confirm the diagnosis.

The other common breast lump is called

fibroadenosis
. By definition it is not a tumour. The cause of this condition is too technical to be discussed here but in short it is due to an abnormality in female hormone level. In this condition multiple lumps of various sizes are found in the breast. Typically both breasts are involved, although the lady may complain about one breast only. Lump size may be anywhere between a size of grain to 3-4 cm. The breasts are painful and tender to touch. The pain may become intense at or near the time of menstruation. The pain may radiate to the arm or back, and may be so severe so as to interfere with normal life. In most patients it is the pain that brings them to a surgeon and not the lump. There may be nipple discharge in the form of clear sticky fluid. There is a strong psychological association of this disease.

Fibroadenosis is a disease of the reproductive age. It may be self-limiting, usually disappearing after the first pregnancy. In most patients the disease is of mild form and simple analgesic with adequate explanation usually bring about a relief. In others stronger analgesics may be required during the painful phase. More resistant cases are treated with hormone therapy. Surgery is reserved for extreme cases. A particularly painful cyst or lump is removed under general anaesthesia. As in fibroadenoma it is possible to plan the skin cut to provide best cosmetic results. The most important point to remember from the patient's point of view is the possibility of recurrence, and more than one operation may be required.

Painful breast conditions: It is important to remember that breast cancers are rarely painful.

Commonest painful condition of breast is cyclical mastalgia, or pain in breast during menstruation. The intensity of pain varies from person to person. The exact cause is unknown but it may be due to accumulation of fluid in breast during this particular time. It is most commonly seen in the young ladies. It is self-limiting and usually disappears after marriage and pregnancy. However in some patients it may continue unto middle age. There is a well proven association of this pain with psychological status. Explanation, assurance and an analgesic are all that is required for its treatment.

Breast abscess is a very painful condition seen most often in lactating mothers. Injury to nipple from baby's sucking allows bacteria to enter the breast and produce abscess. The area of the breast become swollen, tender, hot to touch and the skin may take a reddish hue. In very early stage it may be possible to treat breast abscess by antibiotics alone but most patients require surgery to drain the pus. It is done under general anaesthesia and the patient may go home the next day. But she will require repeated dressing till healing is complete.

The painful condition of fibroadenosis has been discussed previously. In elderly post-menopausal women with large breast, minor trauma may lead to a condition called fat necrosis. It is found in the form of an irregular painful lump in one breast. It is sometimes difficult to distinguish it from cancer without making any tests. Because of the age in which it is commonly found, it is mandatory to thoroughly investigate a suspected fat necrosis.

Nipple Discharge: Milk is of course the commonest nipple discharge, but at times there may be other discharges. A clear fluid may come out during pregnancy and is normal. Fibrocystic disease which has been discussed above, may be associated with a clear or some time greenish dirty discharge. Blood stained discharge is commonly associated with a benign tumour called duct papilloma, but it may also be an indication of cancer. All nipple discharge should be taken seriously and a doctor consulted as soon as possible.

Breast Cancer: It is third most common cancer in the female. Unfortunately there is no statistics for Bangladesh but in the US 100,000 new cases are diagnosed each year. The incidence is lower in countries of Asia and Africa.

Risk Factors: Is any particular group of women at higher risk? Again there is no clear answer. Age is a crucial variable. More than 66 per cent of women with breast cancer are above the age of 50 years and 80 per cent are at least 40 years old. Only 2 per cent of newly diagnosed patients are under the age of 30. Family history also plays an important role. The chances of developing cancer are two to three times higher for women with a close female relative (mother, sister) who has had breast cancer. Factors related to reproductive history which have shown high risk of breast cancer are, early onset of menstrual bleeding, late first pregnancy, late menopause and no pregnancy. Other factors that have been identified are obesity and high socio-economic status.

Diagnosis: Early diagnosis is the key to effective treatment. If detected early it may be possible to completely cure the patient. Most breast cancers are detected by the patient herself. Thus the importance of self-examination by the patient. The self-examination can be done in a few minutes in the bathroom. Since the feel of female's breast vary according to time of menstruation, a particular date in each month should be reserved for self-examination. A routine of once a month is sufficient, if there is any suspicion a surgeon's help should be sought. Carcinoma breast usually presents as a painless, irregular, firm, somewhat fixed lump. There may be associated swellings in the armpit of the same side. Other changes that are suspicious: change in beast shape, contour, dimpling to the skin, retraction of the nipple etc. Some patients because of our social taboos may come to a doctor with late manifestations; like a large tumour fixed to skin or chest wall, breast lump which have ulcerated and smelling very offensive, bone pain, bone fracture, jaundice, fluid in the abdomen etc.

Mammography, a special type of X-ray for the breast, is quite accurate in diagnosing very early cancers which cannot be felt. But it must be emphasized that mammography can never replace examination by a doctor because of the various variables involved.

When there is a suspicion of cancer, biopsy is the only means of confirming diagnosis. Today it is possible to take biopsy by a simple needle prick without cutting the skin (FNAC). Some time when FNAC is doubtful, open excision biopsy under general anaesthesia may be required. It take about 2-3 days for the results to be available. It is possible to obtain biopsy results immediately during surgery by a process called frozen section biopsy. But it requires special equipment.

Treatment: In early breast cancer, surgery is the mainstay of treatment. In most cases the involved breast is removed under general anaesthesia, along with the glands of armpit (total mastectomy). In very early cancers, it may be an option to remove a part of the breast with the cancer (lumpectomy). In that case the patient must be under regular checkup of a qualified surgen. Mastectomy is done under general anaesthesia and blood transfusion may be necessary. It takes about one to one and half hours and the patient can start eating normally in 3-4 hours. Stitches are usually removed between 7-10 days. After surgery almost all patients will require radiotherapy and/or chemotherapy for a certain period as determined by an oncologist (doctors specialized to treat cancer). At present hormone based treatment is also found to be very effective.

In advanced and late cases surgery may be difficult and these patients are initially treated by radiotherapy, chemotherapy, hormone therapy or a combination of them.

After mastectomy, it is possible to reconstruct the breast using artificial materials (mammary implants) or patient's own muscles. This provides an almost normal appearance which may be important for young patients.

Conclusion: Majority of breast lumps are not cancer. Early detection and treatment of breast cancer may ensure long, disease-free life and even complete cure. At present it is possible to plan skin incisions to obtain minimal scar. All the treatments mentioned above are available in Bangladesh and there are many competent surgeons and oncologists to provide these treatments.

The writer is Associate Professor of Surgery, Bangladesh Medical College.