Four Northern Virginia doctors discuss breast cancer signs and misconceptions.
Signs of Cancer
This year, the Susan G. Komen breast cancer organization estimates there will be just over 266,000 new cases of breast cancer diagnosed in women in the United States, which is 126.5 women out of 100,000. Nearly 41,000 women will also lose their lives to the disease this year—20.3 per 100,000 women.
Breast cancer in men is quite rare, with an estimated 2,550 cases in 2018—about 1.1 men for every 100,000. Just under 500 men will die from the disease—0.3 out of 100,000 men.
Women are told routinely from a young age to do monthly self-breast exams by taking the balls of their fingers and moving in a small circular motion from the nipple outward. Some do the exam in the shower while others lie down on their beds.
When speaking to patients, Virginia Hospital Center’s Reinsch Pierce Family Center for Breast Health’s Medical Director Dr. Molly Sebastian describes breast texture as similar to a bag of cooked oatmeal that has not been stirred very well. “There are dried out oats that are more lumpy and then there are really mushy oats in there,” she says. “The texture of breast tissue can be quite different depending on the age of the woman and genetics and some of these things we don’t have much influence over. We aren’t talking about the oatmeal. We are talking about a rock in the bowl of oatmeal. … Something as hard as your knuckle does not belong in your breast.”
Reston Breast Cancer Specialists’ Dr. Elizabeth Feldman is a big believer in self-examinations. “The fact of the matter is that you know your body the best and if something changes, you are the first person to notice it before any doctor is going to notice it,” she says. The self-breast exam is similar to noticing a mole on the skin change color or shape.
“I don’t like patients to feel like if they don’t do that exam exactly once a month that it is an awful thing,” Feldman notes. “Just having patients be aware of their own bodies and be cognizant and pay attention to changes, I think, is a huge aspect. … If people are paying attention to their bodies, they are less likely to miss a change.”
Consistency in the exams is key, according to Feldman. “It’s a matter of feeling and seeing if you notice a change in what is normal for you because patients come in all the time and say ‘I am lumpy,’” she says. “Everybody’s breasts are lumpy but it is a matter of: Are these lumps different for you? Is it a change in your own exam, the way you normally feel things? … If somebody’s lumps feel different then that is when you call your doctor and say ‘Hey, I noticed a change. Should I come in? What should I do?’”
Some of the common signs of breast cancer include finding a lump or noticing a change in the size and shape of the breast to include some dimpling and/or puckering. Uncommon signs include a bloody nipple discharge, a nipple retraction that does not correct itself or when skin gets very thick, similar to an orange peel, where tumors may also involve the skin.
“When breast cancer spreads, the first place it spreads is to the lymph nodes under the arm, so a rock in the underarm is another warning sign,” Sebastian says. Sometimes there will also be swelling over the clavicle.
Many focus on whether or not they have a history of breast cancer in their family tree, yet Feldman says the majority of patients who develop breast cancer don’t have a family history. “It’s actually a misnomer that they do have a family history,” she says. “Seventy percent of the patients that walk in my office with breast cancer have zero family history. That’s something people don’t know. … If you have a family history of any kind of cancer it is important to understand who had what and when because the risk of it being something that is likely to be inherited changes based on the age at which somebody develops something for some cancers.”
If your mom had breast cancer at 90, a doctor is not as concerned about that family history, yet if she was diagnosed at 45, there may be a genetic component to it.
Once a lump is detected, doctors may employ a number of ways to detect if it is cancerous, including a mammogram, ultrasound and/or a biopsy. Virginia is also one of the states that alerts women to their breast density after a mammogram. Virginia Hospital Center’s Dr. Sarah Mezban believes it is important for women to know their breast density because they may want to talk with their provider for additional screenings if a lump is detected and they have denser breasts. “Nothing replaces the mammogram … but (additional screenings) can add value to the mammogram when detecting breast cancer.”
Sentara’s Dr. Susan Boylan strongly encourages patients to ask questions of their healthcare providers because “breast cancer is unique. Just as every human being [is unique], everybody’s treatment is unique. The right treatment for a particular patient may not be the perfect treatment for the woman sitting next to her in the waiting room. I try to tell them to get your information from the people who know all the facts and figures about your tumor, that know the biology of your tumor, and that is your healthcare team. I’d rather them get that information than from a well-meaning neighbor or friend who’s treatment may not be appropriate for this particular patient.”
While the internet does have some good information, Boylan notes some websites can be quite overwhelming or misleading. “I know patients are going to go out there and search but I try to encourage them to at least go to websites from academic institutions and good research centers.”
If a patient ever gets the sense that they are not being taken seriously, the plan of evaluation is not as thorough as they think is appropriate or it is not explained well, Sebastian tells patients to get a second opinion. “No doctor should ever be offended by that because you are just trying to take care of yourself,” she says.
Sebastian saw a woman in her 30s for a second opinion after her first doctor told her not to worry about a nipple retraction. Sebastian found a 1-centimeter tumor behind the nipple. “I am a big believer in check and double check,” she says. “… There is a role for women and men to self-advocate.”
When teaching residents and medical students, Sebastian says one of the basic principles she tries to instill in them is any lump gets a definitive diagnosis. “Sometimes a formal imaging study is strong enough evidence but sometimes it is a combination of imaging and a biopsy. There is a role for following the lump if it is a vague thickening and it seems to track with the menstrual cycle.”
The average age of her breast cancer patients is 59 but her youngest patient is 26. “It is a vicious, fairly random disease,” she says.
When advocating for yourself, Boylan notes women do have time to gather all their information so that they can approach their treatment in a comfortable manner. “They can get all their options,” she says. “They can figure out which treatment is most appropriate for them. Obviously, we don’t want women out there for six to 12 months trying to figure out do they want to have a mastectomy or breast conservation therapy, but they certainly have time to investigate all their options and come up with a treatment plan along with their healthcare providers that they feel comfortable with. If breast cancer is caught early, it is usually a very treatable disease.”