Beauty and the Breast: Evaluation of the Younger Woman

by Janet Hoagland, MD

As a young woman , have you ever been told that your breasts were "lumpy" or that you had "fibrocystic disease" making your clinical exam difficult? Evaluation of the younger breast may be sometimes difficult due to the fact that younger breasts have more dense glandular tissue. Glandular tissue may produce "cyclical" lumps, that is lobules of breast tissue which may be stimulated by higher levels of estrogen and progesterone at different times in the menstrual cycle. Sometimes these lumps are tender. We do know that the best time to examine your breasts is the week after your cycle ends, not the week before it starts. You want to check your breasts when they are the least tender and the least lumpy. Awareness about your own breasts and how they feel is one of the best guides for deciding what is normal for you.

Occasionally, you or your doctor may feel tissue that feels like a lump but really is normal glandular tissue. It could be a prominent breast lobule, or a fat lobule. We certainly have to rule out "real" lumps, like cysts, benign tumors (fibroadenomas,) and cancers. A cyst may feel compressible, that is it may flatten out or feel soft. A solid benign tumor, like a fibroadenomas, may be firmer and mobile. Cancer usually will be thick, immobile and/or hard, although not always. Cancer in a young woman sometimes grows quickly and has pushing margins, so it can feel like a fibroadenoma in shape, texture and movement.

Breast pain can be cyclical or noncyclical. Breast pain in both breasts is a common complaint and is usually related to the timing of the menstrual cycle. This is called cyclical breast pain. Occasionally the pain will be located only in one spot in one breast. This is called focal breast pain. In general, the remedy for most breast pain is to give up the coffee, soda, tea, including green tea and chocolate (oh no!) for 3 months. It could certainly be the fault of being large breasted or even the way your underwire bra fits. We always have to rule out the presence of a cyst (a fluid filled blind milk duct) as the reason for pain. If a cyst is large, inflamed and/or painful, a cyst aspiration with a skinny needle will drain the cyst so it collapses and the walls stick together so it doesn't come back! If the fluid is yellow or green, we just throw it away. If the wall of the cyst was irregular or there is blood in the fluid, we can send it to the lab for evaluation. Some fibroadenomas, benign tumors of young women, can also be painful. It is a myth that breast cancer doesn't hurt. Breast cancer in young women can be associated with tenderness or discomfort.

The tools are very limited when it comes to the evaluation of the younger woman's breasts. Mammography uses low energy radiation to evaluate breast architecture. Mammograms are extremely useful in the older post reproductive fatty replaced breast because the x-rays can easily penetrate the fatty tissues, exposing the outlines of any remaining glandular tissue or abnormal "lump" in the breast. However most, not all, young women have dense breasts. Mammography does not penetrate dense tissue well and the dense tissue may hide any lesions in the breast. Although radiation exposure is small , the equivalent of flying from NY to Los Angeles while sitting in the window seat of an airplane, it is felt that younger immature tissue is more susceptible to genetic injury from the radiation. We know that the breast tissue does not completely mature until a woman goes through a full term pregnancy. These reasons, in addition to the lower incidence of breast cancer in younger women, is why the American College of Radiology recommends Screening Mammography begin at age 40. If a young woman under the age of 40 requires a mammogram, it must be for a very good reason and then it is called a Diagnostic Mammogram. I personally feel that age recommendations are in general arbitrary, and that the need for mammographic evaluation should be decided on an individual basis, based on risk factors, reproductive or prior birth history, clinical breast exam and the specific nature of the problem (i.e. pain, nodularity, mass, etc).

Sonography or ultrasound is utilized to evaluate dense breast tissue in that it uses sound (sonar) to differentiate between different densities in the breast. For example: the fluid in a cyst has a different density than the wall of the cyst. This allows us to tell whether the wall is smooth or irregular. Some cystic fluid may have oil, or fat or debris or thick fluid floating within the cyst, and this will also show up as a different densities on ultrasound. Solid benign tumors, such as fibroadenomas, appear as dense solid masses, some with gentle lobulations. Cancer can look like a black thundercloud without margins because it is so dense it blocks all sound. Sometimes they can resemble benign tumors. Because
of certain characteristics on clinical breast exam, mammography, ultrasound, age greater than 30 years old or high risk factors, a biopsy might be recommended.

Sampling the mass may be the best way to be sure it is benign, if there is any question. I always say, like your hairdresser, only your pathologist knows for sure! Needle biopsies for solid masses are fairly benign procedures. A little local anesthetic in the skin and all around the lump might sting a bit, but make you perfectly comfortable for the needle biopsy. Results should be called or mailed to you and your doctor. Always get a copy of the report for your records! Any truly solid mass not biopsied, or any mass biopsied and found to be benign should be followed every 6 months for 2 years.
Finally, a few facts to raise your awareness:

Facts:
· Women of all ages are at risk for breast cancer. We are seeing an increasing number of women under 40 diagnosed with breast cancer. The incidence of breast cancer increases with age: 1 out of 2,212 by age 30, 1 out of 233 by age 40 and 1 out of 58 by age 50 (SEER 2007)
· Since the national guidelines for women starts at age 40, no standard services are available to younger women who may be at risk
· Risk may be increased by family history, young age at 1st menstruation, no full term pregnancies before the age of 30, history of a previous biopsy, or history of a previous biopsy demonstrating atypical cells
· A breast cancer can be missed or discovered later due to a lack of awareness about the prevalence of breast cancer in young women and the lack of awareness about a normal breast self exam
· Only a small number of breast cancers, between 5% and 10% are due to an abnormal breast cancer gene that may be inherited from the mother OR the father
· 80% of women diagnosed with breast cancer have absolutely no risk factors, other than being a woman
· Per American Cancer Society: 10,000 of the 182,460 new cases of breast cancer will be under the age of 40 and 23,000 under the age of 43
· Breast cancers in young women are in general more aggressive, exhibit faster growth and result in lower survival rates.
· Breast cancer in younger women may be biologically different than that in older women
· The younger dense breast is limited and more difficult to evaluate without a standard and effective screening tool
· Younger women are underrepresented in many research studies

Dr. Janet Hoagland-Sorensen has been associated with The Rose since 1998. She earned her Bachelor of Science degree from the University of New Mexico in Albuquerque. She attended Tulane University School of Medicine in New Orleans, Louisiana and was awarded her Doctor of Medicine degree in 1978.

Dr. Hoagland-Sorensen completed her five-year internship and residency in General Surgery at the University of Texas Health Science Center and Affiliated Hospitals in the Texas Medical Center in Houston, as well as an additional research year in Immunology of Tumor Suppressor Cells from 1982-1988. She was a Surgical Oncology Fellow at the University of Texas M.D. Anderson Cancer Center in Houston from 1998-1989. In 1989, she entered private practice specializing in surgical diseases of the breast at Memorial Southwest Hospital.

Dr. Hoagland-Sorensen is married to James Sorensen, C.P.A., and together they happily share 6 children, ages 16 to 28. She has a personal and family history of breast cancer and is a lung cancer survivor.