Reproductive and Sexual Health Handbook

Breast tissue begins to develop in both men and women at the time of fetal development. For women, increased circulating oestrogen, working together with growth hormone⁽¹⁾ at the onset of puberty, heralds the onset of sexually dimorphic breast development.

The adult woman’s breast (Figure 5.1) is composed of a mixture of adipose and glandular tissue. The glandular component includes lobules (responsible for milk production after pregnancy) and ducts which carry the milk to the nipple during lactation. Hormonal fluctuations influence the amount of glandular tissue present. This is most pronounced during pregnancy and lactation. As women approach menopause, glandular tissue shrinks and is replaced by fat. The cyclical nature of women’s hormonal stimulation of the breast brings with it cyclical changes in the size and texture of the breast. It is usually during the menstrual cycle that most women will complain of breast symptoms, the nature of which will be highly variable.

Figure 5.1 The Breast

This figure is reproduced with permission of © The StayWell Company, LLC

Most breast symptoms are due to benign breast disease which commonly presents as breast lumpiness, lumps and/or pain. The primary challenge for the clinician is to exclude breast cancer.

Initial evaluation of a breast symptom involves a detailed clinical history and thorough breast examination. This should be performed first and accurately documented. The assessment will determine if further investigations are necessary and which ones are appropriate.

The information presented in this section is reproduced using information produced by Cancer Australia’s ‘The investigation of a new breast symptom: a guide for general practitioners.’⁽²⁾ Refer to their flow diagrams, ‘The investigation of a new breast symptom’, and ‘The investigation of a new nipple discharge’.

The most common benign causes of palpable breast lumps are:

lumpy fibroglandular tissue cysts fibroadenomas

Benign nipple changes include:

slit-like retraction inversion that can be easily everted

Clinically abnormal or suspicious nipple changes include:

colour and skin texture change fixed whole nipple inversion ulceration⁽²⁾

Benign nipple discharge is common and typically seen from multiple ducts, and is milky or greenish in colour. When investigating nipple discharge you should note its appearance and determine if the discharge occurs only with expression or spontaneously, and whether it is bilateral or unilateral and from a single or multiple ducts. Unilateral, spontaneous, bloody or serous discharge from a single duct raises the possibility of cancer, especially if it occurs in women over 60 years.

Cytology of the discharge can be performed:

A positive discharge cytology result is indicative of cancer (highly specific). A negative discharge result cannot be used to rule out cancer (low sensitivity).

Imaging should include mammography and ultrasound.

Mammary duct ectasia (a benign condition) is associated with dilatation and inflammation of the ducts under the nipple and usually causes a bilateral yellow, green, or brown discharge from multiple ducts.⁽¹²⁾

Hyperprolactinaemia (high prolactin levels) may cause galactorrhoea. Aetiology includes endocrine causes, e.g. pituitary and thyroid disease; and drug causes, e.g. oral contraceptives, hormone therapy, antiemetics, antipsychotics, cocaine, and stimulants.⁽¹²⁾

Mastalgia or breast pain is a common normal finding which may cause significant discomfort and anxiety. Up to 70 per cent of women experience this symptom in their lifetime.^{(14, 15)} 

Breast pain is not a common presenting symptom of breast cancer. It is important to differentiate between true breast pain and pain that is referred to the breast, such as from the chest wall or intra-thoracic structures, as management of these conditions is different. It is less important to differentiate cyclical mastalgia (pain that occurs only in the luteal phase of the menstrual cycle) from non-cyclical mastalgia, as management of these conditions is similar.⁽¹⁵⁾

The most common type of mastalgia is pain referred from the chest wall. The nerve supply to the breast is derived from branches of the intercostal nerves from T3 to T5 which if irritated, can lead to pain that is felt in the breast or nipple. In particular, irritation of a branch of T4 can result in the shooting pain up to the nipple that some women describe. Referred pain to the breast can also be caused by costochondritis, or tender costochondral junctions sometimes associated with swelling (Tietze’s syndrome).⁽¹⁶⁾

Features suggesting that breast pain is referred

Mastitis is an inflammatory condition of the breast. The most common type is lactational mastitis. This usually presents in the first few weeks of breastfeeding, with breast pain, swelling, lump or lumps, and redness of the skin overlying the breast infection/ abscess.

Lactational mastitis is a bacterial infection usually caused by Staphylococcus aureus. Poor positioning and poor attachment of the infant during feeding, along with milk stasis, contribute to the establishment of infection.

Lactational mastitis requires prompt treatment with antibiotics usually without investigation provided there is close clinical surveillance with investigation (usually breast ultrasound) if symptoms do not resolve in 24–48 hours. First line antibiotics include:

oral flucloxacillin or dicloxacillin 500 mg four times per day for 10 days, or cephalexin 500 mg four times per day for 10 days^{(12, 25)}

Non-lactational inflammatory breast symptoms should always be investigated as any other breast symptom. Lesions found to be benign on initial assessment should be followed to complete clinical and imaging resolution.⁽¹²⁾

Inflammatory breast cancer is a specific clinical presentation of breast cancer that should be considered in the differential diagnoses of every inflammatory breast condition. It represents 1 – 2 per cent of breast cancers per year ⁽²⁴⁾, and has a particularly poor prognosis.

The classic presentation is one of rapid onset of breast mass, pain, breast enlargement, and skin changes (red or purple, and ‘orange peel’ in appearance). Axillary lymph node involvement is almost universal.

Breast imaging may reveal subtle changes of increased skin thickness and increased tissue density rather than the classic features of breast cancer (such as a spiculated lesion with microcalcification).

All infective conditions should be followed to complete clinical and imaging resolution, and where an infective lesion does not resolve, or does not behave as expected, the diagnosis of inflammatory breast cancer should be considered. Inflammatory symptoms should be investigated as with other breast symptoms with imaging followed by fine needle biopsy or core biopsy of any abnormalities. Where there are significant skin changes such as erythema or an ‘orange peel’ appearance (peau d’orange), skin biopsy may confirm the diagnosis of inflammatory breast cancer.⁽¹²⁾

As of 2015, breast cancer was the second most commonly diagnosed cancer in Australia, and for women it is the most commonly diagnosed cancer. This trend has continued to date. It is estimated that 1 in 7 women are at risk of being diagnosed with breast cancer by the age of 85 years. A woman’s risk of breast cancer increases with age, peaking at the age group 70-74 years (Table 5.1).⁽²⁵⁾

Table 5.1 Age-specific incidence rate of breast cancer, by sex, 2015

This information is reproduced with permission of Cancer Australia.

The incidence of breast cancers is increasing and it is predicted that the rate of new cancer cases for women will reach 434 per 100,000 women in 2019. ⁽²⁶⁾ The development of new technologies such as MRI, the introduction of the BreastScreen Australia screening program and increased breast awareness may have contributed to the increased diagnosis of breast cancer.⁽²⁶⁾

While breast cancer incidence rates have been rising in the past two decades, the mortality rates have been falling. The age-standardised rate of death due to breast cancer among women has fallen from 30.8 deaths per 100,000 women in 1994 to 20.9 deaths per 100,000 women in 2014, and is

Australia has a national breast screening program to detect early breast cancer. Population-based screening using mammography is the best early detection method available for reducing deaths from breast cancer.⁽⁴¹⁾

Family Planning NSW fact sheets:

Breast awareness Breast pain: Mastalgia

Cancer Australia

Cancer Institute NSW fact sheet:

Breast screening

BreastScreen NSW

 

Javed A, Lteif A. Development of the Human Breast. Semin Plast Surg. 2013;27(1):5-12. The investigation of a new breast symptom: a guide for general practitioners [internet]. Cancer Australia: Australian Government; 2017. Available from: https://www.canceraustralia.gov.au/publications-and-resources/cancer-australia-publications/investigation-new-breast-symptom-guide-general-practitioners Cancer Australia. Triple Test guide for GPs maximises accuracy of breast cancer diagnosis. Cancer Council: Australian Government. 2017 Oct. Available from: https://canceraustralia.gov.au/about-us/news/triple-test-guide-gps-maximises-accuracy-breast-cancer-diagnosis. Cancer Australia. Early detection of breast cancer [internet]. Cancer Council: Australian Government; 2004 [updated 2015 Aug]. Available from: https://canceraustralia.gov.au/publications-and-resources/position-statements/early-detection-breast-cancer. BreastScreen Australia. Information for women with breast implants [internet]. CancerScreening: Department of Health; 2013 [updated 2015 Dec]. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/br-policy-mgmt2. Department of Health. MRI (Magnetic Resonance Imaging) breast services Q&A (questions and answers) [internet]. Health: Australian Government; 2013. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/mri-breast-services-q-and-a BreastScreen Australia. BreastScreen Australia Evaluation Final Report. Department of Health; 2014 Oct. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/programme-evaluation Breast pain, cyclical [Internet]. NHS; 2017 [updated 2017 June]. Available from: http://www.nhs.uk/conditions/breastpaincyclical/pages/treatment.aspx. Brennan M, Nehmat H, French J. Management of benign breast conditions (Part 2- breast lumps and lesions). Australian Family Physician 2005;34(4):253-5. Tohno E, Cosgrove DO, Sloane JP. Ultrasound diagnosis of breast diseases. London: Churchill Livingstone 1994. Brennan M, Nehmat H, French J. Management of benign breast