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How to help women understand benign breast conditions

Jackie Harris
RGN MSc
CNS Breast Health
Breast Cancer Care
London

During the reproductive years, women's breasts are constantly going through change, from the time of development, through pregnancy and the menopause. This is a result of normal responses to the aging process along with fluctuations in hormone levels, namely follicle-stimulating hormone (FSH), luteinising hormone (LH) and oestradiol. So it's not surprising to learn that benign breast conditions are very common. In fact they are as twice as common as breast cancer - for every 10 women referred by their GP to their local breast unit, nine will be shown to have a benign breast condition.(1)
However, every time a woman has a new symptom, such as a change in breast shape, breast lump, breast pain or nipple discharge, she experiences great levels of anxiety and fear that it may be cancer, until a diagnosis is made.(2)
Until recently it was difficult to get a consistent diagnosis for a breast problem, as the term "benign breast condition" covered a range of conditions, such as: 

  • Fibrocystic disease.
  • Fibrocystic change.
  • Cystic disease.

In 1987, a classification system called Aberrations of Normal Development and Involution (ANDI) was published in an attempt to clear up the confusion over the different terms and clarify whether having a specific benign condition increased a person's risk of developing breast cancer.(3) This has since been accepted and used as a valuable tool when assessing breast changes.
The ANDI classification provides an overall framework for benign breast conditions. It groups the reproductive life of the breast into three phases: development, cyclical activity and involution.(1) ANDI describes a spectrum of changes that can occur to the breast during development through to involution, placing them under the headings normal, aberration and disease (see Table 1).

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Diagnosing and treating all benign breast conditions is not achievable at the GP surgery, and referral to a local breast clinic is usually recommended.(4) Here an investigation known as the "triple assessment" will take place, which consists of:

  • Clinical examination.
  • Imaging (ultrasound and/or mammography).
  • Biopsy.

Treatment may be needed at any stage to improve quality of life, but benign breast conditions are not cancer, and they do not increase the risk of breast cancer developing in the future (with the exception of atypical hyperplasia, gross cysts and papilloma). Primary care nurses can play a pivotal role in reducing anxiety in women with a breast concern. By having a better understanding yourself of the ANDI framework and the referral guidelines and process, you will be more equipped to inform and support those who are concerned about their breast changes.

Development and involution of the breast
The breasts start to grow from around nine to  10 years of age. Each breast develops independently, so it is not unusual for one breast to grow bigger than the other. The breasts reach full development at around 17 years of age.
Once menstruation has started, the changing hormone levels are responsible for the tenderness, discomfort and lumpiness that can be experienced just before a period starts.
During pregnancy the secretion of the hormone progesterone is responsible for the changes that occur in the breast - the breasts become tender and then enlarge, the nipples become more sensitive and the pigmentation of the areola becomes darker. Following pregnancy and breastfeeding the breasts gradually settle back to how they were before pregnancy, although it is not unusual for the breasts to be a different size and softer in texture.
From the age of 35 to the menopause, the stroma (fibrous tissue) is gradually replaced by fat, and as the woman reaches the menopause very few lobules and ducts remain. This results in a softer and often pendulous breast. It is during this time that many women notice breast changes, such as lumps, pain and nipple discharge. Such changes can often be explained when you consider that at this time in her life, a woman will be experiencing many hormonal changes, including rising FSH levels, while LH and oestradiol levels remain fairly constant.
Further changes are seen after the menopause when oestrogen levels fall and periods cease. The breasts lose their firmness, become smaller and droop as the major ducts behind the nipple become shorter and wider. For those who are taking hormone replacement therapy, these changes may be less noticeable.

What are the aberrations that commonly occur in the three different phases of the reproductive life?
Developmental phase (15-25 years)
During development it is not unusual for lumps to appear, due to the changing hormone levels. These lumps are usually fibroadenomas (a collection of fibrous tissue), which develop within the lobules and usually present as a solid mobile lump. A lump of this kind is often termed a "breast mouse", as it moves away from the finger when pressure is applied. Fibroadenomas are divided into three types: common (1-3cm); giant (5cm or more); and juvenile.
In 1981 the World Health Organization (WHO) classified fibroadenomas as being benign and stated that having one does not increase that person's risk of developing breast cancer.(5) So once a diagnosis has been made, fibroadenomas can be left. However, if they are large and cause discomfort they may need to be surgically removed.
Juvenile hypertrophy (breast enlargement) is another common aberration during breast development. Having large breasts at such a young age can cause both psychological embarrassment and physical shoulder or neck pain. Surgery to reduce the size of the breasts (reduction mammoplasty) may help improve a young girl's quality of life. However, there is a risk of loss of nipple sensation and potential problems with future breastfeeding.
As the breasts are developing it is not uncommon for the nipples to either stay flat or become inverted. This is because the major ducts that lay behind the nipple fail to develop. Cosmetic surgery can help, but it is rarely carried out because there is a risk of breast abscess and lactation difficulties in the future.(1)

Cyclical phase (25-45 years)
Mastalgia (breast pain) is very common during the cyclical phase. In fact, two out of three premenopausal women will be affected by mastalgia sometime in their life.(6) Generally no medical treatment is needed, but it is important that when a woman goes to see her GP about her mastalgia a full detailed assessment is carried out. Research has shown that when a full assessment has been done 75-85% of women will need only reassurance.(7) However, for some women mastalgia can be severe and prolonged and is regarded as an aberration. For these a number of treatment options may need to be explored.
There are two main types of mastalgia:

  • Cyclical (related to the menstrual cycle).
  • Noncyclical:
    • True pain
    • Referred pain (Teitze's syndrome or lateral         chest wall discomfort).

The causes of mastalgia are not fully understood. It is thought to be related to low levels of an essential fatty acid called gamolenic acid (GLA). For many years evening primrose oil has been used to treat cyclical mastalgia as it contains GLA. A study carried out in 2002 found no evidence to support this, but it has been suggested that it may have a placebo effect.(8) For this reason many GPs continue to advocate taking evening primrose oil.
Treating cyclical mastalgia can include simple measures, such as wearing a supportive bra day and night, and reducing intake of caffeine, red wine and chocolate, which are thought to overstimulate breast tissue. Other treatment options include prescribed hormonal drugs, such as danazol and bromocriptine. Women who are being treated at a breast unit for their cyclical mastalgia may have been given either tamoxifen or goserelin (Zoladex; AstraZeneca). Neither of these medicines are licenced for this use, but they may be effective. The hospital will want to follow them up regularly to monitor their effect and any side-effects.
Treating noncyclical mastalgia can be more difficult to achieve. However, recent evidence suggests that oral and topical nonsteroidal anti-inflammatory drugs (NSAIDs) may be beneficial.(9)

Involution phase (35-55)
During this stage, if the stroma disappears too early breast cysts (fluid-filled sacs) will form. They are very common - one in 10 women has symptomatic breast cysts during their reproductive years and many more women have impalpable, asymptomatic breast cysts. Breast cysts are benign and generally do not increase a person's risk of developing breast cancer.(4,10) However, some studies have suggested that women with multiple, persistent palpable cysts are at increased risk of developing breast cancer, although this increased risk is very small.
Treating symptomatic breast cyst/s is done in the clinic time by aspiration, either freely or by ultrasound assistance.
During this phase it is normal for the ducts behind the nipple to shorten and dilate (duct ectasia). However, usually when a person is diagnosed with duct ectasia it is because they have been experiencing one or more of the following symptoms:

  • Fluid collecting and pooling within the ducts, resulting in nipple discharge.
  • The walls of the duct have become ulcerated and the nipple discharge is bloodstained.
  • Scarring has developed and this has pulled the nipple inwards (inverted).
  • Sometimes a lump can be felt behind the nipple.

For many women with duct ectasia no specific treatment is needed. However, for those who experience a persistent copious discharge, treatment may involve surgery to remove all the major ducts behind the nipple.

Educating and supporting women with benign breast conditions
As nurses we are expected to be able to disseminate up-to-date information on the latest investigative techniques, the different treatment options, as well as provide the appropriate support. Within primary care there are plenty of opportunities for you to discuss breast health with your clients/patients.
Generally, GPs and practice and community nurses are the first point of contact for women with breast changes and therefore you play an important role in educating and reassuring individuals. It is vital that you know the present guidelines on the referral of patients with breast problems (urgent and nonurgent), and/or where to find the answer to the relevant concern. This will enable you to inform and support the women under your care.(11)
However, it is not always possible to know every specific guideline for referral or even know in detail about every specific condition. Networking with other organisations, such as Breast Cancer Care (BCC), can assist you in your professional development on all aspects of breast health, so that you can provide up-to-date information and feel confident in the support you give. BCC has produced a series of leaflets on breast awareness, referral to a breast clinic and benign breast conditions that may be used to inform women about breast development and involution. It also provides training days for all health professional with an interest in breast health and breast cancer (see Resources).

References

  1. Hughes LE, Mansel RE, Webster DJT. Benign disorders of the breast, concepts & clinical management. 2nd ed. WB Saunders; 2000.
  2. Woodward V, Webb C. Women's anxieties surrounding breast disorders: a systematic review of the literature. J Adv Nurs 2001;33:29-41.
  3. Hughes LE, Mansel RE, Webster DJT. ANDI - a new perspective on benign breast disorders. Lancet 1987;2:1316-9.
  4. Austoker J, Mansel R. Guidelines for referral of patients with breast problems. 2nd ed. London: NHS Cancer Screening Programme; 2003
  5. World Health Organization. Histological typing of breast tumours. 2nd ed. Geneva: WHO; 1981.
  6. Mansel RE. Breast pain. BMJ 1984;304:866-8.
  7. Harris J. Breast pain. Practice Nurse J 2005;11 February:36-40.
  8. Bloomers J, delange-de Kirk E, Kuik D, et al. Evening primrose oil for severe chronic mastalgia: a randomized double-blinded controlled trial. Am J Obstet Gynecol 2002;187:1389-94.
  9. Smith R, Pruthi M, Fitzpatrick M. Evaluation and management of breast pain. Mayo Clin Proc 2004;79:353-42.
  10. Dixon M. ABC of breast disease. 3rd ed. London: BMJ Books; 2006.
  11. NICE. Referral guidelines for suspected cancer. London: NICE; 2005. Available from: www.nice.org.uk

Resource
Breast Cancer Care
BCC has been working for over 30 years to make a difference to the lives of people affected by breast cancer. It provides accurate, easy to understand information as well as practical and emotional support. Every year BCC receives almost two million requests for support and information through their helpline, website, publications, person-to-person support and health promoting activities, all of which are offered free. BCC is committed to campaigning for better treatment and support for people with breast cancer and their families helpline: 0808 800 6000 W: www.breastcancercare.org.uk