Symptoms and signs of breast cancer

What are the common signs?

The symptoms of a breast cancer can include:

• a breast lump

• change of shape of the breast including dimpling of the skin

• change in the skin overlying the breast such as ulceration or discharge

• in-drawing of the nipple, called nipple inversion or nipple retraction

• changes to the surface of the nipple including eczema or scaling

• discharge from the nipple

• breast pain

• swelling and inflammation of the breast

• swelling under the arm (armpit or axilla)

• breast lumpiness.

Most women with these symptoms do not have breast cancer.

Breast lumps

A breast lump is the most common reason for women to be referred to a breast clinic. Most breast lumps are not cancer and only about one in eight lumps is malignant (cancerous).

Although most areas of lumpiness are benign (non­cancerous) and related to changes that happen in relation to the regular menstrual cycle, very occasionally lumpiness is a symptom of breast cancer. For this reason

it is important that if you notice any change in the shape or feel of your breasts you get this checked by your doctor.

Cancerous lumps

Cancerous lumps tend to feel hard and tend not to be very mobile. They usually come up slowly and increase in size over time.

If the lump gets bigger, it can cause a change in the shape of the breast with puckering or dimpling of the overlying skin. If left untreated they can grow into the skin and cause ulceration or bleeding.

Benign lumps

Benign lumps tend to be smooth and mobile and move easily under the fingers. Benign lumps are also more likely to be tender whereas breast cancer tends to be painless. Common causes of benign lumps include fibroadenomas and cysts.

Fibroadenomas are benign solid lumps that are common in young women between the ages of 15 and 25. Although they are less common in older women, small fibroadenomas are often discovered in women over the age of 50 when they attend for breast screening.

Fibroadenomas tend to grow to a certain size and then stop – unlike cancers. This means that once a woman discovers a fibroadenoma it is rare for the woman to report that it continues to grow. Occasionally fibroadenomas are large and measure over five centimetres.

Provided that they are properly investigated by imaging and needle biopsy smaller fibroadenomas do not need to be removed. As large fibroadenomas cause a distortion and change in the shape of the breast, they are usually removed.

Fibroadenomas can get larger during pregnancy because they fill up with milk. A woman with a fibroadenoma is not significantly more likely to get breast cancer and cancer is not more likely to develop in a fibroadenoma than in any other part of the breast tissue.

Cysts

As the breast ages the leaves of the breast tree, the lobules, can fill up with fluid and these fluid-filled lumps are known as cysts. They are most common in women between the ages of 40 and 50 years.

Cysts usually feel very smooth and mobile but can sometimes be quite firm and hard. A woman who finds one cyst will often be shown to have more cysts when she is scanned using ultrasound.

Ultrasound can tell the difference between a cyst and a solid lump and, provided that the ultrasound shows that the lump is a simple cyst, the cyst does not need treatment unless it is causing pain or a change in the shape of the breast, when the fluid in the cyst can be drained using a needle. Cyst fluid ranges in colour from yellow to green to blue/black.

Cancers rarely develop in cysts. Ultrasound looks at the wall of the cyst so it can tell whether the cyst is innocent or if a cancer is present.

Benign localised lumpiness or nodularity

Many women’s breasts get lumpy and tender just before their periods. Most localised nodularity is caused by changes that occur in relation to the normal menstrual cycle. Very rarely an area of lumpiness is the first sign of a breast cancer.

It is for this reason that, if lumpiness is confirmed at the clinic, you will have an ultrasound to check the lumpy area. Ultrasound can see through the breast tissue and tell whether a lumpy area is simply normal breast tissue that has been affected by the menstrual cycle or whether it is more serious.

Changes in the skin of the breast

This includes dimpling, puckering and swelling of the skin of the breast (known as peau d’orange or orange-peel appearance). In-drawing or puckering of the skin, also known as dimpling, is the most common skin change seen in cancer.

Occasionally the skin over a breast cancer can ulcerate and bleed. A cancer that spreads can also produce one or more nodules in the skin.

Peau d’orange develops because cancer cells block the lymph channels draining the breast and stop the normal flow of fluid out of the breast. This results in a build-up of fluid in the skin of the breast. It is sometimes associated with redness and tenderness of the breast, characteristic of a particular type of cancer called inflammatory breast cancer.

Peau d’orange and redness can also happen as a result of infection or inflammation not related to cancer.

Nipple eczema or scaling

An itchy red rash of the nipple or the areola can sometimes be a sign of an underlying cancer. This change in the nipple is known as Paget’s disease and more details can be found on page 90. Most skin rashes around the nipple are not related to Paget’s disease but from eczema of the skin. The biggest difference between Paget’s disease and eczema is that Paget’s disease always affects the nipple first whereas eczema usually first affects the area around the nipple which is known as the areola.

If the doctor decides that the condition is simple eczema, treatment is a short sharp course of steroids. Sometimes stronger steroids for a shorter duration are

more successful at controlling the eczema than a more dilute steroid over a longer period of time.

Nipple inversion or retraction

The nipple can be pulled in as a consequence of disease in the breast (benign conditions or cancer) or can happen as breast ducts shorten, which they do in some women as they get older. Inversion or pulling in of the nipple does not therefore mean that a cancer is present.

If the nipple appearance does change, you should see your doctor and be referred to hospital to have a mammogram and possibly an ultrasound scan. In some women the nipple can be pulled in at certain times and at other times the nipple comes out and looks normal; this is rarely associated with cancer.

In cancer the whole nipple tends to be pulled in and it is usually pulled in one particular direction which results in the two nipples being at different heights and not pointing in the same directions. Changes associated with cancer usually involve one breast rather than both breasts.

Nipple discharge

Discharge from the nipple is very common. Even in a woman who is not pregnant, the breast produces fluid that passes up the ducts towards the nipple. This discharge does not get out onto the surface of the nipple because the ducts of the nipple are normally plugged or blocked by keratin, which is produced by the skin.

If the ducts become unplugged which can occur either because the nipple is cleaned or the nipple is squeezed, it is common to get fluid appearing on the surface of the nipple. This fluid, which varies in colour from white to yellow to green to blue/black, is normal breast secretion. There is usually a very small amount of it and it dries up very quickly.

Abnormal nipple discharge is discharge that leaks out spontaneously. It usually stains clothes and occurs on a regular basis – more than twice a week.

Sometimes the discharge can be bloody in colour or bloodstained. Even bloodstained discharge is most commonly due to a benign (non-cancerous) cause and the most common cause of a bloody discharge is a wart in one of the ducts underneath the nipple. The proper name for this is an intraduct papilloma.

Occasionally women who are not pregnant produce milk from the breast. The main cause of this is one of a series of drugs that cause an increase in the hormone that results in milk formation, called prolactin. There are lots of drugs that can do this. Occasionally a tumour in the brain develops that produces increased amounts of prolactin, which then results in milk production.

Women who are not pregnant and produce a significant amount of milky discharge or women who have discharge that is spontaneous, persistent (more than twice per week) or at all troublesome should seek medical attention.

Breast pain

This is rarely a symptom of breast cancer. In one study about five per cent of women who had cancer had pain as their main symptom and only two per cent of women who presented with breast pain were found on investigations to have a breast cancer.

Most pain in the breast does not actually originate in the breast but arises from the underlying ribs and muscles. If you have what you think is pain in the breast, it is important to check that the pain is coming from the breast and not from the area under the breast.

This is best done by turning on your side, which lets the breast roll away from the chest wall. You should then check for any tender areas in the ribs and muscles underneath the breast.

Most breast pain requires no specific treatment. Measures that improve breast pain include wearing a soft supporting bra 24 hours a day and regular gentle stretching exercise such as swimming.

Chest wall pain is common in people who sit at computers all day. It is important not to sit for longer than an hour at a time and to take a rest and have a walk. If breast pain is severe try drugs such as paracetamol or ibuprofen. If the pain does not respond to these simple measures ask your doctor for a referral to a breast clinic.

Breast swelling/inflammation

If the breast swells and becomes tender and red this is usually a sign of infection. If you are concerned that you are getting a breast infection, particularly if you are breast-feeding, it is important that you see a doctor and start antibiotics as soon as possible to stop abscess formation.

Very rarely swelling and inflammation of the breast indicate a rare form of breast cancer called inflammatory breast cancer. Despite antibiotics, in inflammatory breast cancer the swelling and redness persist. The breast can also feel painful and is tender to touch in this condition.

What are the reasons why women attend breast clinics?

Prevalence (%) of various symptoms in patients attending a breast clinic

• Breast lump 36%

• Painful lump or lumpiness 33%

• Pain alone 17.5%

• Nipple discharge 5%

• Nipple retraction 3%

• Strong family history of breast cancer 3%

• Breast distortion 1%

• Swelling or inflammation 1%

• Scaling of nipple (eczema) 0.5%

KEY POINTS

• A lump in the breast is the most common symptom of breast cancer

• Pulling in of the nipple can be a symptom of breast cancer but most cases are due to benign disease

• A change in the shape of the breast or nipple, nipple discharge, redness and a lump in the armpit are sometimes found by women who have breast cancer

• Breast pain is rarely a sign of breast cancer

• Most women with symptoms in the breast (including lumps) do not have breast cancer