There are many causes for lumps in the breast. These range from normal physiologic changes to abnormal breast disease. Some lumps are age dependent. Both male and female newborn infants have lumps of enlarged breast tissue beneath the nipple, which have been stimulated by maternal hormones. These disappear within a few months of birth.

Beginning as early as age 8, girls may develop tender lumps beneath one or both nipples (frequently only one). These lumps are breast buds and are one of the earlier signs of the beginning of puberty.

Boys at mid-puberty (usually around age 14 or 15) may develop tender lumps beneath one or both nipples, also in response to the hormonal changes of puberty. These tend to disappear over a period of 6 months to 1 year.

It is also important to remember that hormonal changes just prior to menstruation may cause a lumpy or granular feeling to the breast tissue.

The discovery of a lump in the breast usually brings the thought of cancer immediately to mind. However, it is important to remember that 80% to 85% of all breast lumps are benign, especially in women less than age 40 to 50. Benign causes include fibrocystic breast changes, fibroadenoma, fat necrosis (damage to some of the fat tissue within the breast), and breast abscess.

FIBROCYSTIC BREAST DISEASE
The term "condition" is preferred to "disease" by many providers since it occurs so frequently in the normal population. The cause is not completely understood but is believed to be associated with ovarian hormones, since the condition usually subsides with menopause and varies with the menstrual cycle.

The incidence is estimated at over 60% of all women. It is common in women aged 30 to 50 and is rare in postmenopausal women. The incidence is lower in women taking birth control pills. Risk factors may include heredity and diet (excessive dietary fat, caffeine intake).

FIBROADENOMA
While the cause is not known, some research suggests that increased fat consumption may play a role. The highest incidence is in women from their teen years into their 20s. Fibroadenomas rarely develop after age 30. Single or multiple fibroadenomas may develop in one or both breasts.

FAT NECROSIS
Trauma is presumed to be the cause. Bruising is occasionally noted near the lump and the area may or may not be tender. The mass may be associated with skin or nipple retraction as time progresses. A fat necrosis mass cannot be distinguished from breast cancer without biopsy.

BREAST ABSCESS
In breast-feeding women, a local breast infection introduced through the nipple may wall off into an abscess. Young to middle-aged women who are not breast-feeding rarely develop subareolar abscesses (located beneath the areola, which is the darker area around the nipple).

Potential abscesses in breast tissue other than the subareolar area are excessively rare in women who are not breast-feeding, and such abscesses should be surgically removed and biopsied.

BREAST CANCER
Breast cancer may occur in men and women, but it is much more common in women. While the cause is unknown, a number of predisposing factors have been identified.

Recent statistics say that 1 in 8 or 9 American women will develop breast cancer at some point in her life. Risk increases exponentially after age 30. The average age of women diagnosed with breast cancer is 60. In general, the rate of breast cancer is lower in underdeveloped countries and higher in more affluent countries (with the exception of Japan, where the rate is quite low).

In the United States, whites (especially those of northern European descent) have a higher incidence compared to other racial groups. However, the incidence in blacks is increasing, particularly in women less than age 60.

Other risk factors include: family history of breast cancer, particularly in mother or siblings; past medical history of breast, ovarian, uterine, or colon cancer; menstrual history consistent with early menarche (start of menstruation before age 12) or late menopause (after age 50); no pregnancies or first pregnancy after the age 40; and radiation exposure.

Postmenopausal estrogen therapy and oral contraceptive use are considered possible risk factors, but the majority of recent studies do not indicate such risk.

Although the majority of breast cancers occur in postmenopausal women, it can also occur in women who are in their 30s or 40s. This is rare. In these cases, the cancers may have a strong genetic link.

A potentially malignant breast lump (cancer) may show a number of these symptoms:

• breast mass noted upon self-examination
• spontaneous nipple discharge
• nipple changes
• breast asymmetry aside from the previous norm
• skin changes
• bone pain
• weight loss
• armpit lump
• swelling of the arm

Note: Benign fibrocystic changes may range from mild to severe during the menstrual cycle. Symptoms typically peak just before each menstrual period and improve immediately after the menstrual period. The breast tissue has a dense, "cobblestone" consistency, usually more marked in the outer quadrants. An intermittent or persistent sense of breast "fullness" with dull, heavy pain and tenderness is experienced.

Benign fibrocystic changes frequently are noted in both breasts. Benign lumps are usually rounded with smooth borders, either rubbery or slightly movable, and non-anchored. Associated nipple discharge occurs only after manipulation of the nipple, is milky looking, and may be expressed from both breasts.

For a potentially malignant breast lump (cancer), the health care provider confirms the breast changes noted by the patient by performing a physical exam. There may be spontaneous nipple discharge on one side from a single duct. Armpit (axillary) node enlargement/tenderness may be noted.

A mammography may delineate the breast mass. A needle aspiration does not yield fluid consistent with a cyst and the mass persists after aspiration. An ultrasound may be performed to differentiate between a solid and cystic mass. Cancer more commonly shows a solid mass.

Biopsies confirm or rule out suspected cancer in solid lumps:

• needle biopsy -- removal of cells for evaluation directly from the mass (can be done in conjunction with needle aspiration procedure)
• incisional biopsy -- surgical removal of a portion of the mass for evaluation
• excisional biopsy -- surgical removal of entire mass for evaluation

For known, diagnosed fibrocystic breast changes, a woman should examine her breasts monthly.

A well-fitting bra should be worn to provide good breast support. The effectiveness of vitamin E, vitamin B6, and herbal preparations (such as evening primrose oil) are somewhat controversial and should be discussed with your health care provider.

Self-care may also include restricting dietary fat to approximately 25% of the total daily calorie intake and eliminating caffeine intake and cigarette smoking to see if symptoms subside.

Oral contraceptives may be prescribed because they often decrease symptoms.

The choice of initial treatment for biopsy-confirmed breast cancer is based upon the extent and aggressiveness of the disease. Currently, breast cancer is viewed as a systemic disease that requires both local and systemic treatment.

Local treatment may include lumpectomy, mastectomy (partial, total, or radical with axillary dissection), and radiation therapy -- all directed at the breast and surrounding tissue.

Systemic treatment includes chemotherapy and hormonal therapy, which circulate throughout the entire body in an attempt to eliminate cancer cells that may be present in distant parts of the body.

Most women receive a combination therapy including surgery, radiation, chemotherapy, and hormonal therapy. Therapy will depend on the extent of the local disease, if there is cancer in local lymph nodes or in other parts of the body as well as the genetic findings after analyzing the cancer cells.

The prognosis depends on the type of problem. See the specific condition for detailed information regarding prognosis.

Because fibrocystic changes may make breast examination and mammography more difficult to interpret, early cancerous lesions may occasionally be overlooked.

Even with aggressive and appropriate treatments, breast cancer often spreads (metastasizes) to distant sites, such as the lungs, liver, and bones. The local recurrence rate is about 5% after total mastectomy and axillary dissection is performed when the nodes are found not to be involved. The local recurrence rate is 25% in those with similar treatment found to have nodal involvement.

Call your health care provider if new, unusual, changing, or "dominant" lumps are noted in breast tissue during breast self-examination.

Also call for an appointment if:

• you are a woman, aged 40 or older, who has not had a baseline mammogram
• you are a woman, aged 35 or older, with a mother or sister with breast cancer, or you have a past medical history of breast, uterine (endometrial), ovarian, or colon cancer
• you are a woman, aged 25 or older, and you are unfamiliar with how to perform breast self-examination

Avoiding excessive fat and caffeine in the diet may be helpful in avoiding fibrocystic changes in the breast tissue. Most of the associated risk factors for breast cancer cannot be controlled and this eliminates a means of primary prevention.

Secondary prevention, early detection, and appropriate treatment early in the disease process may be promoted through routine breast self-examinations and screening mammography after age.

Experimental studies are underway to determine if the drug tamoxifen can decrease the risk of breast cancer in women with a family history of breast cancer (mother, maternal aunts, and the affected individual's sisters).

Preliminary results showed that tamoxifen significantly decreased the incidence of breast cancer in women at high risk for the disease. In some women, the risk of breast cancer can be reduced by as much as 49% when drugs, such as tamoxifen, are taken regularly.

Tamoxifen use is also associated with the development of blood clots in the legs and with uterine cancer. See your health care provider to find out if you should take tamoxifen to prevent breast cancer.