Many women, at some point of their life, will have a breast lump or an abnormal mammogram diagnosis. This would then be followed up with additional testing to confirm that the lump or abnormal area is not cancerous. In many cases, additional mammograms or other imaging techniques can help rule out the possibility of cancer.

When these tests are inconclusive and cancer cannot be ruled out, a woman will need to undergo a biopsy. A biopsy is a procedure that involves removing cells or tissue from a suspicious area of the breast and then examining them under a microscope. Unfortunately, is still the only definitive way to confirm if an abnormality is cancerous or not.

Depending on the situation, different types of biopsies are performed. These are the two main types of biopsies used to diagnose breast cancer:

• Needle biopsy
• Surgical biopsy

Needle biopsies

In needle biopsy, a needle is used to aspirate (draw out) fluid or tissue from a breast lump. Compared to a surgical biopsy, a needle aspiration leaves no scarring, and is less invasive and quicker to perform. However, unlike surgical biopsy, needle biopsies cannot remove the entire lesion and misdiagnosis may occur.

Needle procedures are performed in doctors’ offices, clinics, surgical centers and hospitals. There is little preparation needed for these procedures. Recovery is generally quick and uncomplicated from these procedures. Most patients are able to resume normal activity almost immediately afterwards. Pain is minimal and can usually be managed with an over-the-counter pain reliever.

Needle biopsy procedures include the following:

Fine Needle Aspiration

Fine needle aspiration is only recommended for suspicious areas that can be felt (palpable masses). It is also done as a quick method to obtain sample of a breast lump felt during a clinical breast exam.

Performed under local anesthesia, the surgeon uses a fine hollow needle that is attached to a syringe to extract fluid from a cyst or cells from an abnormal area of the breast. The needle used in this procedure is very small (smaller than those used to draw blood). Several insertions are usually required to obtain an adequate sample. The procedure takes a few minutes and is often done in a doctor's office. There is no incision and a very small bandage is put over the site where the needle entered.

Advantages

• Fine needle aspiration is the easiest and fastest method of obtaining a breast biopsy, and is very effective for women who have fluid filled cysts.
• Does not involve any incision and is relatively painless, inexpensive and quick to perform.
• Minimal chance for complications such as infection or bruising.
• Can be accurate when performed by an experienced doctor.
• For women whose abnormal area was considered unlikely to be cancer at initial evaluations, a benign test result means they will likely avoid a surgical biopsy.

Disadvantages

• The evaluation can be incomplete or inaccurate because the tissue sample is very small. Fine needle aspiration can miss a cancerous tumor and take a sample of normal cells instead. When used alone, up to about 10% of breast cancers may be missed. The effectiveness of this procedure depends not only on the skill of the surgeon or radiologist who performs it, but the breast cytopathologist who specializes in examining individual cells.
• Fine needle aspiration only provides limited information about the tumor.

Note: Because of these potential inaccuracies, a fine needle aspiration that does not find cancer may need to be followed up with another type of biopsy, like a core needle or surgical biopsy.

Core needle biopsy

This procedure is similar to fine needle aspiration, but the needle is larger, enabling a larger sample to be obtained from the breast. It can be used on both suspicious areas that can be felt (palpable masses) and those that can only be seen on a mammogram (nonpalpable masses). Core needle biopsy may also provide a more accurate analysis and diagnosis than fine needle aspiration because tissue is removed, rather than just cells. Because it is both accurate and does not involve surgery, it is often the biopsy of choice for women.

During the procedure, the doctor uses a small amount of local anesthetic to numb the skin and breast tissue around the suspicious area. Three to six needle insertions are needed to obtain an adequate sample of tissue. A clicking sound may be heard as the samples are being taken and the patient may feel some pressure, but should not feel pain. The procedure takes a few minutes and no stitches are required.

Advantages

• Core needle biopsy is accurate when done by an experienced radiologist.
• Quick, relatively inexpensive and only mildly uncomfortable, it does not involve surgery and only rarely leads to complications, such as infection or bruising.
• Core needle biopsies also provide more important information about the suspicious area, such as the tumor type and tumor grade. Such information helps a patient and her physician plan for treatment.
• For women with a benign test result, it means they will have avoided the more invasive surgical biopsy.

Disadvantages

• This procedure is inaccurate for patients with very small or hard lumps.
• Core needle biopsy can also miss a tumor and take a sample of normal tissue instead when used without the help of stereotactic mammography or ultrasound guidance. Such false negative results occur in up to eight percent of stereotactic mammography or ultrasound-guided core needle biopsies of nonpalpable masses.
• Core needle biopsy may not provide complete information about the tumor.

Good to know!

It is important to remember that even if your doctor tells you that a biopsy is needed, most women who do it do not have breast cancer. In the US, about 1 in 10 women who have biopsies are diagnosed with cancer.

Firstly, not every lump or mammographic change merits a biopsy. Nearly all mammographic masses that look smooth and clearly outlined, for instance, are benign. Your doctor needs to thoughtfully weigh the findings from your physical exam and mammogram along with your background and your medical history before making a recommendation for a biopsy.

The main advantage of needle biopsy is that it allows a diagnosis to be made before any major surgery is done on the breast. If the biopsy result is negative, most patients will have avoided the more invasive surgical biopsy. A needle biopsy is much less invasive and relatively painless compared to surgical biopsy, and can provide much of the information about a tumor for the physician to formulate a treatment plan. However, it is important to keep in mind that a needle biopsy is slightly less accurate than surgical biopsy.

A surgical biopsy is the most accurate biopsy method that is able to provide complete information about tumors. It may also serve as a treatment and may be the only surgery needed to remove a tumor. As a surgical procedure, it is more painful, requires more time to heal and is associated with a greater risk of infection and bruising than a needle biopsy. The procedure may also the look and feel of the breast.

To do or not to do

Given the accuracy and ease of needle biopsy, many women undergo this procedure first. A surgical biopsy would only necessary if the results of a needle biopsy are in question.

Be in control!

No single solution is right for everyone. Each woman should consult with her doctors and her family, weigh the alternatives and decide what approach is appropriate. Being involved in the decision-making process can give a woman a sense of control over her body and her life.

In general, doctors feel it is wise to biopsy any distinct and persistent lump. When it comes to deciding between a needle biopsy and surgical biopsy, there are a number of benefits and risks that must be considered.

If an abnormal mammogram turns up, a breast biopsy is the preferred follow-up procedure even though other options are available. Biopsy has long been considered the “gold standard” in the diagnosis of breast cancer.

Even a biopsy may not be 100 percent accurate. Research has shown that the false-negative rate for core biopsy, a type of needle biopsy, can be as high as 8 percent. Needle biopsies, in particular, are relatively inaccurate compared to surgical biopsies. A core needle biopsy, for example, may miss a cancerous tumor and take a sample of normal tissue instead.

In the case of fine needle aspiration, the evaluation may potentially be inaccurate because the tissue sample taken is very small. When used alone, up to about 10% of breast cancers may be missed. Consequently, when a fine needle aspiration does not find cancer, it may still need to be followed up with another type of biopsy, such as a core needle or surgical biopsy.

What?

A mammography is a process when an x-ray of the breast is taken to detect and diagnose breast disease.

A mammogram can pick up very small tumours, even before they can be detected as a lump. It is used to screen for breast cancer, as well as to diagnose breast cancer. A diagnostic mammogram is used to diagnose breast disease in women who have breast symptoms. Screening mammography is used to look for breast disease in women who are asymptomatic; that is, they appear to have no breast problems.

Mammograms don't prevent breast cancer, but they can save lives by finding breast cancer as early as possible. Finding breast cancers early with mammography also means that many more women being treated for breast cancer are able to keep their breasts. When caught early, localized cancers can be removed without resorting to breast removal (mastectomy).

When?

It is recommended that women get a mammogram once a year, beginning at age 40. If you're at high risk for breast cancer, with a strong family history of breast or ovarian cancer, or have had radiation treatment to the chest in the past, it's recommended that you start having annual mammograms earlier – which you should discuss with your doctor.

Although breast x-rays have been performed for more than 70 years, modern mammography has only existed since 1969. That was the first year x-ray units dedicated to breast imaging were available. With modern mammography equipment used specifically for breast x-rays, very low levels of radiation are used, usually about 0.1 to 0.2 rad dose per x-ray.

Strict guidelines are in place to ensure that mammography equipment is safe and use the lowest dose of radiation possible. Many people are concerned about the exposure to x-rays, but the level of radiation in modern mammograms does not significantly increase the risk for breast cancer.

How?

For a mammogram, the breast is compressed between 2 plates to flatten and spread the tissue. Although this may be uncomfortable for a moment, it is necessary to produce a good, “readable” mammogram. The compression only lasts a few seconds, and the entire procedure for screening mammography takes about 20 minutes.

Most standard mammogram includes two views of each breast taken from different angles. Even if you have a lump in only one breast, pictures will be taken of both breasts. This is so the breasts can be compared, and so that the other breast can be checked for abnormalities. If you've had a mammogram before, the radiologist will compare your old mammogram to the new one to look for changes.

What it shows?

The procedure produces a black and white image of the breast tissue on a large sheet of film that is interpreted by a radiologist. The doctor reading the films looks for several types of changes: Calcifications are tiny mineral deposits within the breast tissue that appear as small white spots on the films, and are divided into 2 categories:

• Macrocalcifications - are coarse (larger) calcium deposits that most likely represent degenerative changes in the breasts, such as aging of the breast arteries, old injuries, or inflammations. These deposits are associated with benign (non-cancerous) conditions and do not require a biopsy. Macrocalcifications are found in about half the women over the age of 50, and in about 1 in 10 women younger than 50.
• Microcalcifications - are tiny specks of calcium in the breast. They may appear alone or in clusters. The shape and layout of microcalcifications help the radiologist judge how likely it is that cancer is present. In most instances, the presence of microcalcifications does not mean a biopsy is needed. Instead, a doctor may advise you to have a follow-up mammogram within 3 to 6 months. In other cases, if the microcalcifications look more suspicious, a biopsy is then needed.

A mass, which may occur with or without calcifications, is another important change seen on mammograms. As with calcifications, a mass can be caused by benign breast conditions or by breast cancer. Masses can be due to many things, including cysts (non-cancerous, fluid-filled sacs) and non-cancerous solid tumors (such as fibroadenomas) but may be cancer and usually should be biopsied if they are not cysts.

A cyst cannot be diagnosed by physical exam nor mammogram alone. To confirm that a mass is really a cyst, either breast ultrasound or removal of fluid with a needle (aspiration) is needed.

If a mass is not a simple cyst (i.e. it is partly solid), then you may have more imaging tests. Some masses can be watched with periodic mammograms, while others may need a biopsy. The size, shape, and margins (edges) of the mass help the radiologist to determine whether cancer may be present.

Your prior mammograms may help show that a mass has not changed for many years, which would mean that the mass is likely a benign condition and help avoid an unnecessary biopsy. Having your prior mammograms available to the radiologist is very important.

A mammogram may show something suspicious, but by itself it cannot prove that an abnormal area is cancer. If a mammogram raises a suspicion of cancer, a small amount of tissue must be removed and examined under a microscope. This procedure is called a biopsy.

FAQ

What are some tips on having a mammogram?

The following are useful suggestions for making sure that you receive a quality mammogram:

• Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.
• Use a facility that either specializes in mammography or does many mammograms a day.
• If you are satisfied that the facility is of high quality, continue to go there on a regular basis so that your mammograms can be compared from year to year.
• If you are going to a facility for the first time, bring a list of the places, dates of mammograms, biopsies, or other breast treatments you have had before.
• If you have had mammograms at another facility, you should make every attempt to get those mammograms to bring with you to the new facility so that they can be compared to the new ones.
• On the day of the exam, don’t wear deodorant; some deodorants contain substances that can interfere with the reading of the mammogram by appearing on the x-ray film as white spots.
• You may find it more convenient to wear a skirt or pants, so that you’ll only need to remove your blouse for the examination.
• Schedule your mammogram when your breasts are not tender or swollen to help reduce discomfort and to assure a good picture. Try to avoid the week just before your period.
• Always describe any breast symptoms or problems that you are having to the technologist who is doing the mammogram. Be prepared to describe any pertinent medical history such as prior surgeries, hormone use, and family or personal history of breast cancer. Also discuss any new findings or problems in your breasts with your doctor or nurse before having a mammogram.
• If you do not hear from your doctor within 10 days, do not assume that your mammogram was normal. Call your doctor or the facility.

What to expect when getting a mammogram?

• Most private health plans cover mammogram costs, or a portion of them. Low-cost mammograms are available in most communities. Call the local hospital or the National Cancer Society for information about facilities in your area.
• Having a mammogram requires that you undress above the waist. A wrap will be provided by the facility for you to wear.
• A technologist will be present to position your breasts for the mammogram. Most technologists are women. You and the technologist are the only ones present during the mammogram.
• The whole procedure takes about 20 minutes. The actual breast compression only lasts a few seconds.
• You may feel some discomfort when your breasts are compressed, and for some women compression can be painful. Try not to schedule a mammogram when your breasts are likely to be tender, as they may be just before or during your period.
• All mammogram facilities are now required to send your results to you within 30 days. Generally, you will be contacted within 5 working days if there is a problem with the mammogram.
• Only 1 or 2 mammograms of every 1,000 lead to a diagnosis of cancer. About 10% of women who have a mammogram will require more tests, and the majority only need an additional mammogram. Don't be alarmed if this happens to you. Only 8% to 10% of those women will need a biopsy, and 80% of those biopsies will not be cancer.
• Women aged 40 or older should get a mammogram every year. You can schedule the next one while you're there at the facility and/or request a reminder.

Is mammography really an effective way to detect cancer?

Mammograms aren't perfect. Normal breast tissue can hide a breast cancer, so that it doesn't show up on the mammogram. This is called a false negative. And mammography can identify an abnormality that looks like a cancer, but turns out to be normal. This "false alarm" is called a false positive. To make up for these limitations, more than mammography is needed. Women also need to practice breast self-examination (BSE), get regular breast examination by an experienced health care professional (“clinical breast examination”), and, in some cases, also get another form of breast imaging, like ultrasound or MRI scanning.

Is it risky to do a mammogram due to radiation exposure?
The risk of contracting breast cancer by radiation exposure due to mammography is very low. Risk estimates from an annual two view mammography over 10 consecutive years of 100,000 women aged 40 years, result in more than 8 breast cancers during the lifetime of these women. The benefit-to-harm ratio is estimated to be 48.5 lives saved per 1 life lost to radiation exposure. However, the benefits need to be taken into account to balance the discussion of risks. The potential benefits outweigh the risk.

Differences between screening and diagnostic mammograms:

Screening Mammograms

• Routine
• Annual or as recommended
• Asymptomatic (no signs of cancer)
• Family history of breast cancer
• Fibrocystic breasts

Diagnostic Mammograms

• Not routine
• As needed
• Symptomatic: breast pain or tenderness; lump or mass; nipple discharge
• Personal history of breast cancer
• Previous abnormal mammogram or abnormal physical exam
• Breast implants
• Previous breast biopsy or surgery

What?

Magnetic resonance imaging (MRI) uses powerful magnetic fields and radio waves that are fed into a computer to generate three-dimensional images of breast tissue.

MRI highlights the differences in water content and blood flow between tissues, and because tumors tend to have more blood flow than surrounding tissues, MRI is an effective tool for visualizing tumors. In some instances technicians administer contrast agents to patients in order to further improve image quality.

When?

MRI does not replace mammography or ultrasound imaging of breasts. Instead it provides a powerful supplementary tool for detecting and staging breast cancer. In addition to its role as a diagnostic tool, researchers are investigating whether breast MRI may be useful in screening younger women at high risk of breast cancer.

For example, MRI is particularly good for detecting very small tumors and therefore can be used after a suspicious spot has been detected by mammogram or ultrasound to determine whether the cancer has spread further in the breast or into the chest wall.

MRI is also especially useful for detecting tumors in women with breast implants (which can interfere with mammogram rays), and in women with dense breast tissue. This last point makes MRI a particularly desirable addition for women at high risk of developing breast cancer who are more likely to begin screening at a younger age, when breast tissue tends to be denser.

How?

The best MRI technique involves the use of a special "breast coil". During an MRI, you lie still and are moved in and out of a narrow tube as the machine creates images of your body. If you're claustrophobic, being confined within an MRI machine for up to an hour can be difficult. Some facilities have an open MRI machine to avoid this problem, or you may be given a mild sedative.

The value of MRI for breast cancer detection remains uncertain. Some doctors believe MRI can distinguish a breast cancer from normal breast gland tissue better than other techniques. But MRI is expensive and requires highly specialized equipment and highly trained experts. Relatively few MRI centers exist, especially outside of major cities. Even at its best, MRI produces many uncertain findings. Some radiologists call these "unidentified bright objects", or UBOs. MRI also cannot detect calcifications. Finally, MRI can dislodge certain metal devices, such as pacemakers, in some people.

FAQ

When is MRI useful?

It is unlikely that MRI will be used as a general screening tool for breast cancer. It may, however, prove useful in:

• Evaluating a woman who has a palpable mass that isn't visible with ultrasound or mammography
• Assessing a lesion in the densely glandular breast of a young woman
• Screening a young woman who is at high risk for cancer because of a significant family history of breast cancer or an abnormal breast cancer gene

What are the advantages of MRI?

• MRI is sometimes used successfully in women who have breast cancer cells in an underarm lymph node, but have no breast mass that doctors are able to feel or see on a mammogram. In these cases, where mastectomy is typically recommended, MRI can help find the precise site of the cancer's origin within the breast. Finding the cancer's precise origin can expand a woman's treatment options from only mastectomy to include lumpectomy plus radiation.
• MRI can help determine if a cancer is limited to one area of the breast, or if it is "multicentric" and involves more than one area. Knowing this affects treatment choices, since mastectomy is necessary for multicentric disease. This is particularly useful for women with invasive lobular cancer, which has a tendency to be diffuse or multicentric.
• MRI is good for looking at scar tissue. It can evaluate a significant change in the lumpectomy site.
• MRI scanning can detect leakage from a silicone-filled breast implant, since it easily distinguishes silicone gel from surrounding normal breast and chest wall tissues.
• In the case of metastatic breast cancer, MRI can evaluate other parts of the body. A woman who has progressive back pain, or who develops new weakness or numbness in the arms or legs (not just hands or feet), can have an MRI scan of her back. The scan can help identify serious conditions such as the possible presence of a spinal tumor or brain metastasis.

When doctors screen for breast cancer, they look for signs of disease in women without symptoms; they should be part of every healthy woman's routine. Today, three screening tests are routinely done for breast cancer:

• Breast self-examination (BSE)
• Clinical breast examination (CBE)
• Mammography (MMG)

Other screening procedures also include:

• UltraSonography (USG)
• Magnetic Resonance Imaging (MRI)
• Positron Emission Tomography (PET)
• Electrical Impedance Scanning (EIS)
• Scinti-Mammography
• Thermography

Strategy

Breast self-examination

• From 20 years old onwards

Clinical Breast Examination

• From 20 years old onwards- 3 yearly
• From 30 years old onwards- Annually

Screening mammogram - initiated by patient and physician

• From 40 years old onwards
• Annually

What?

Ultrasonography or ultrasound is an imaging method that uses high-frequency waves to image the breast or other parts of the body.

When?

If you're under age 30, your doctor may recommend ultrasound before mammography to evaluate a palpable breast lump. Mammograms can be difficult to interpret in young women because their breasts tend to be dense and full of milk glands. (Older women's breasts tend to be more fatty and are easier to evaluate). In mammograms, this glandular tissue looks dense and white—much like a cancerous tumor. Some doctors say that locating an abnormality in the midst of dense gland tissue can be like finding a polar bear in a snowstorm. Most breast lumps in young women are benign cysts, or clumps of normal glandular tissue.

Ultrasonography may be used to detect and classify breast lesions in the following types of women:

• Women with dense breasts
• Women with fibrocystic breast disease
• Women with a lesion that cannot be well classified with mammography alone
• Young women with masses
• Pregnant women with masses
• Women with silicon breast implants
• Women who refuse exposure to x-rays (mammography)

Doctors also use ultrasound to guide biopsy needles precisely to suspicious spots in the breast, without radiation exposure. Ultrasound is not a substitute for a screening mammogram. Its value as a general screening test for breast cancer is unproven.

How?

Ultrasound sends high-frequency sound waves through your breast and converts them into images on a viewing screen. Ultrasound complements other tests. If an abnormality is seen on mammography or felt by physical exam, ultrasound is the best way to find out if the abnormality is solid (such as a benign fibroadenoma, or cancer) or fluid-filled (such as a benign cyst). It cannot determine whether a solid lump is cancerous, nor can it detect calcifications.

You will be asked to undress from the waist up and put on a medical gown during the test. During the test, you will lie on your back on the examining table.

A water-soluble gel is placed on the breast and a hand-held device (transducer) that directs the sound waves to the breast tissue. The transducer is moved over the surface of the breast to create a picture. The test is then repeated for the other breast, if necessary.

FAQ

How to prepare for the test?
Since you need to remove your clothing from the waist up, it may be helpful to wear a two-piece outfit. On the day of the test, do not use any lotions or powders on your breasts.

How the test will feel?
The number of people involved in the test will be limited to protect your privacy. You will be asked to raise your arms above your head and turn to the left or right as needed. There is no discomfort from the ultrasound device.

What abnormal results mean?
Distinctive patterns may indicate:

• Cysts
• Benign lesions
• Malignant lesions (breast cancer)

What are the risks?
There are no risks associated with ultrasound. It involves no exposure to radiation.

What?

Scintimammography (nuclear medicine breast imaging) is a supplemental breast exam that may be used in some patients to investigate a breast abnormality. A nuclear medicine test is not a primary investigative tool for breast cancer but can be helpful in selected cases after diagnostic mammography has been performed. Nuclear medicine breast imaging involves injecting a radioactive tracer (dye) into the patient. Since the dye accumulates differently in cancerous and non-cancerous tissues, scintimammography can help physicians determine whether cancer is present.

When?

Scintimammography is especially useful for women with dense breasts, which are typically found in younger women before a menopause. As dense breast tissue is hard to interpret with a conventional mammography, scintimammography is an imaging technique that can reduce the occurrence of false positives that lead to unnecessary biopsies. Compared to a standard mammogram, some studies have shown that a scintimammography test has an accuracy rate of as high as 90%. However, this technique is not meant as a substitute to mammogram or other tests, but used in conjunction with them.

How?

A very small amount of radioactive isotope (tracer) is injected into a vein in the arm or foot, much like taking a blood sample. Once injected, the tracer then travels throughout the body via the bloodstream and can be seen by a group of special detectors, called gamma cameras, "marking" certain biological processes to locate a tumor. No special preparation is required before the test and it takes about 30 minutes to complete.

FAQ

Who is a suitable candidate for scintimammography?

As this imaging technique is not a screening tool for breast cancer, it is appropriate for certain patients after a physical breast exam, mammography, and ultrasound are performed. It can help determine a suspicious breast abnormality that would otherwise require a biopsy to confirm.

These patients include those with:

• Dense breast tissue
• Large, palpable (able to be felt) abnormalities that cannot be imaged well with mammography or ultrasound
• Breast implants
• When multiple tumors are suspected (see below)
• A lump at the surgical site after mastectomy (breast removal) since scar tissue may be difficult to distinguish from other tumors with other breast imaging exams
• To check the axillary (underarm) lymph nodes to determine whether they contain cancer cells (sentinel lymph node biopsy)

How useful is scintimammography in the diagnosis of breast cancer?

Like magnetic resonance imaging (MRI) of the breast, scintimammography may also be helpful to determine if multiple breast tumors are present. For instance, a mammogram or ultrasound (sonogram) of the breast may reveal breast cancer in one area. However, a nuclear medicine breast imaging test may show that the cancer is in fact multi-focal; tumors are present in several areas of the breast.

Determining the extent of breast cancer with nuclear medicine can help indicate treatment: breast conserving surgery (lumpectomy) or breast removal (mastectomy). Mastectomy is indicated if there are multiple tumors.

Studies show that scintimammography is only 40% to 60% accurate in imaging small breast abnormalities but more than 90% accurate in detecting abnormalities over one centimeter. However, mammography and physical exams are often very useful for detecting large abnormalities. It is the small abnormalities that tend to need additional imaging. Therefore, in this respect, scintimammography is often of limited value.

Inflammatory breast cancer

Inflammatory breast cancer (IBC) is a rare cancer that gets its name from the swollen and red or “inflamed” appearance of the breast. Although quite rare, IBC is a very aggressive type of breast cancer in which the cancer cells block the lymph vessels in the skin of the breast. In the US, IBC accounts for up to 5 percent of all breast cancer cases.

Typically diagnosed in younger women than other forms of breast cancer, IBC is more likely to spread (metastasize) and its patients have a very low survival rate. About 70 percent of all women with the disease do not live five years beyond their diagnosis.

Causes

Despite its name, IBC isn't caused by an inflammation or infection. It occurs when cancer cells clog the lymphatic vessels in the skin overlying the breast. The blockage in the lymphatic vessels causes the red, swollen and dimpled skin that's a classic sign of IBC.

Signs and symptoms

Inflammatory breast cancer grows rapidly — changes can become apparent in a matter of days to weeks. And unlike other types of breast cancer, IBC probably won't develop a distinct lump. It' is also easy to confuse the signs and symptoms of IBC with those of a breast infection (mastitis). In some cases, redness, warmth and swelling of the breast are caused by a previous operation or radiation therapy that involved the outer breast or underarm, and not IBC.

Signs and symptoms of IBC include:

• A breast that appears red, purple, pink or bruised
• A tender, firm and swollen breast
• A warm feeling in the breast
• Itching of the breast
• Pain, heaviness, burning and aching
• Ridged or dimpled skin texture, similar to an orange peel
• Thickened areas of skin
• Enlarged lymph nodes under the arm, above the collarbone or below the collarbone
• Flattening or retraction of the nipple
• Swollen or crusted skin on the nipple
• Change in color of the skin around the nipple (areola)

How is IBC diagnosed?

Diagnosis of IBC is usually based on the results of a doctor’s clinical examination. Biopsy, mammogram an breast ultrasound are also used to confirm the diagnosis. IBC is classified as either stage IIIB or IV breast cancer.

How is IBC treated?

Treatment consists of chemotherapy, targeted therapy, surgery, radiation therapy and hormonal therapy. Chemotherapy is generally the first treatment for patients with IBC. After chemotherapy, patients with IBC may undergo surgery and radiation therapy. Additional systemic treatments such as chemotherapy, hormonal therapy, targeted therapy or all three may also be given to reduce the risk of recurrence.

What is the outcome for patients with IBC?

IBC is more likely to have spread to other areas of the body at the time of diagnosis and as a result, the 5-year survival rate of IBC patients is only between 25 and 50 percent, which is significantly lower than the survival rate for patients with non-IBC breast cancer.

Paget’s disease

Paget’s disease of the nipple, also called Paget’s disease of the breast, is an uncommon type of cancer that forms in or around the nipple. It is an eczema-like change in the skin of the nipple, and 9 out of 10 women who have this have an underlying breast cancer.

Paget’s disease occurs in about 1–2 out of every 100 women with breast cancer. It usually occurs in women in their 50s, but can occur at an earlier or later age. It can affect men but this is extremely rare.

Signs and symptoms

• Redness, inflammation and mild scaling or flaking of the nipple skin that won’t go away and may become sore.
• There may also be crusting, slight bleeding and ulceration around the area.
• In the more advanced stages of the disease, symptoms may include tingling, itching, increased sensitivity, burning, pain and discharge from the nipple.
• Around half of the women who have Paget’s disease will have a breast lump that can be felt at the time it is diagnosed.

Causes

The cause of Paget's disease is unknown, but two major theories have been suggested for how it develops.

One theory proposes that cancer cells, called Paget cells, break off from a tumor inside the breast and move through the milk ducts to the surface of the nipple, resulting in Paget’s disease of the nipple. This theory is supported by the fact that more than 97 percent of patients with Paget’s disease also have underlying invasive breast cancer or ductal carcinoma in situ (DCIS), a condition in which abnormal cells are present only in the lining of the milk ducts in the breast, and have not invaded surrounding tissue or spread to the lymph nodes.

The other theory suggests that skin cells of the nipple spontaneously become Paget cells. This theory is supported by the rare cases of Paget’s disease in which there is no underlying breast cancer, and the cases in which the underlying breast cancer is found to be a separate tumor from the Paget’s disease.

Diagnosis

Paget’s disease can be confused with other skin conditions such as eczema, dermatitis or psoriasis, as they can look very similar. This can make Paget’s disease difficult to diagnose.

Several tests may be carried out to diagnose Paget’s disease of the breast. They may include:

• Mammogram
• Ultrasound scan
• Biopsy
• Imprint or scrape cytology

Treatment

The treatment of Paget's disease of the breast will depend on:

• Whether or not there is an underlying breast cancer.
• Whether it is DCIS or an invasive tumor.
• How much of the breast is affected.

Surgery is the most common treatment for Paget's disease of the nipple. The specific treatment often depends on the characteristics of the underlying breast cancer. Removal of the breast (mastectomy) may be recommended, especially if the cancer is affecting a wide area (is extensive), is close to the nipple, or if there is DCIS in a number of areas in the breast (multi-focal). Some of the lymph nodes in the under-arm area may also be removed.

Alternatively, patients whose disease is confined to the nipple and the surrounding area may undergo a lumpectomy followed by radiation therapy. In most cases, radiation therapy is commonly used as an adjuvant therapy to help prevent recurrence (return of the cancer). For some people, no further treatment will be needed after surgery. Others may need to have radiotherapy, hormonal therapy or chemotherapy. These may be used separately or together.

Emerging areas of diagnosis

Research is continuing into ways in which faulty genes increase the risk of breast cancer in some women. There are also many studies going on into diet and lifestyle and how those factors can play a role in preventing breast cancer.

Early diagnosis is a crucial part in the fight against breast cancer. For this reason, plenty of research is currently focused on breast screening procedures, such as:

Intraductal screening

An innovative way of detecting breast cancer, intraductal screening includes tests that get samples of fluid from the milk duct. The fluid in the ducts is in direct contact with the cells lining the breast ducts and lobules. This lining is a common place for breast cancer to develop. The breast cells in these ducts always produce a certain amount of fluid, even when a woman is not producing milk. The 3 tests that are being looked at are nipple aspiration, intraductal lavage and duct endoscopy.

Researchers have yet determine the reliability of intraductal screening in picking up cancer, or whether it can help determine a woman's risk of developing breast cancer in the future. Clinical trials are still ongoing in the UK for intraductal screening.

Digital mammograms

This is a new way of recording mammograms. Instead of putting them on X-ray film, a computer is used to create and store the scans. X-rays are used to produce both digital and standard mammograms. As far as having the screening is concerned, there isn't much difference between the 2 tests. The breast still has to be pressed down before the X-ray is taken.

Digital mammography is being tested in the US to see if it is any better at picking up breast cancers than film mammography.

MRI scans

Magnetic resonance imaging (MRI) is one of the methods used for diagnosing cancer, but doctors are still unsure about how useful it is for breast cancer. An ongoing trial is comparing MRI with mammogram and breast ultrasound. One of the aims of this trial is to find out if MRI provides any extra information for doctors before surgery.

Breast lumps that are not cancerous are benign. Some cause discomfort or pain and require treatment, while others are of little concern and need no medical attention. Unfortunately, many breast diseases mimic the symptoms of cancer and so require tests and sometimes surgical biopsy to diagnose to prove they are not cancerous.

Most lumps turn out to be fibrocystic changes. The term "fibrocystic" refers to fibrosis and cysts. Fibrosis is the formation of fibrous (or scar-like) tissue, and cysts are fluid-filled sacs. Fibrocystic changes can cause breast swelling and pain. This often happens just before a period is about to begin. Your breasts may feel lumpy and sometimes you may notice a clear or slightly cloudy nipple discharge. Some of the more common benign breast diseases:

Hyperplasia

Is a term describing the excessive accumulation (proliferation) of cells. It is usually found on the inside of the lobules or ducts in the breast tissue. There are two main types of hyperplasia—usual and atypical. Both raise the risk of breast cancer, though atypical hyperplasia does so to a greater degree.

Cyst

Unlike cancerous tumors which are solid, cysts are fluid-filled masses in the breast and are almost always benign. Often they can be left alone, or if painful, they can be drained of the fluid (aspirated). They may also be drained if they are palpable and could potentially interfere with clinical exams. Up to a third of women between the ages of 35 and 50 have cysts in their breasts, though most cysts are too small to feel and can be detected only by examination with ultrasound.

If cysts are large enough, they may feel like lumps in the breast. In a small proportion of patients, the cysts will recur after being aspirated. If this happens repeatedly, patients may want to have them removed. Cysts are more common in women as they approach menopause, but they are not associated with an increased risk of cancer. After menopause, cysts occur much less frequently.

Ultrasound is the best way to tell a cyst from a cancer, because sound waves pass right through a liquid-filled cyst. Solid lumps, on the other hand, bounce the waves right back to the film.

Fibroadenomas

These are movable, solid, rounded lumps made up of normal breast cells. While not cancerous, these lumps may grow. And any solid lump that's getting bigger is usually removed to make sure that it's not a cancer. Fibroadenomas are the most common kind of breast mass, especially in young women. They are not generally associated with an increased risk of cancer.