You've been told all your life to be on the alert for breast lumps, the primary sign of breast cancer. But a lump isn't always the first sign of malignancy, or it may not be the first change a woman notices, says Andrew Putnam, director of the Palliative Care Program at Lombardi Comprehensive Cancer Center and Georgetown University. "Sometimes a lump is deep in the breast tissue, or the tissue surrounding it is very dense, making it hard to feel," says Putnam. And inflammatory breast cancer causes another set of symptoms entirely. "So it's important to be on the alert for other red flags as well."
Any one of these five lesser-known symptoms of breast cancer is important enough to send you straight to the doctor for a checkup, followed by a mammogram or MRI if recommended.
1. Itchy, sore, or reddened breasts
Skin that feels rashy or hot to the touch is one of the telltale signs of inflammatory breast cancer, a rare form of the disease that's less well known than the more common breast tumors. Inflammatory breast cancer may cause breasts to become swollen and irritated or sore. The skin may be unusually red or scaly, or you may notice purplish areas that look like bruising. Dimpled or "orange peel" skin is characteristic in some cases of inflammatory breast cancer. "It looked like I suddenly had cellulite on my breasts," is how one woman described this sudden change in skin texture, which may be bumpy or indented.
At first, the achy feeling may mimic the soreness typical of PMS, or the redness and itchiness might suggest an allergic skin reaction. But you'll know that's not it if it doesn't go away after a few days.
Why it happens: In inflammatory breast cancer, which makes up just 3 percent of all breast cancer cases, fast-growing cancer cells block blood vessels that feed the skin. Because red, itchy, hot skin is typical of inflammatory breast cancer, it's often mistaken for mastitis or infection of the milk ducts around the nipple.
2. Upper back pain
Although it's not well known, spine specialists routinely look for the presence of tumors, because some women experience back pain before any other sign of breast cancer. The pain, which is typically in the upper back between the shoulder blades, is easily confused with sore muscles, a pulled tendon or ligament, or osteoarthritis of the spine.
Why it happens: Most breast tumors develop in the glandular tissue of the breast, which extends deep into the chest, close to the chest wall. If tumor growth pushes backward toward the ribs and spine, the resulting pain may be felt in the back rather than in the breast. Breast cancer also tends to metastasize or spread to the spine or ribs, becoming secondary bone cancer.
3. Nipple changes
One of the most common locations for a breast tumor is just underneath the nipple, which can cause changes in the appearance and feel of the nipple itself. And nipple changes are often the giveaway for men with breast cancer. You may notice that one of your nipples sticks up less than it used to. It may even appear uncharacteristically inverted or flattened. Many women also notice a decrease in sensitivity to touch, most likely to come to your attention -- or your partner's attention -- during sex. Another nipple change to take seriously is discharge when you're not breastfeeding, whether it's bloody, milky, or watery. The skin of the nipple may become crusty, scaly, or inflamed.
Why it happens: A tumor in the milk ducts, just behind the nipple or to one side, pushes the skin up around the nipple or pushes the nipple aside. As tumors grow, they may attach to -- and thus retract -- the skin or the nipple itself. The tumor may cause irritation and infection, leading to discharge.
4. A change in the shape or size of one breast
Contrary to popular belief, not all breast tumors cause a hard lump close enough to the surface to be noticeable. "Instead of feeling a lump, I noticed that one of my breasts was more oval than the other, hanging down lower and sort of sticking out to one side," says a California woman, who discovered she had breast cancer at the age of 42. The best way to spot these types of changes is to study the size and shape of your breasts in a mirror. Sit facing the mirror and look at both breasts dead-on, then raise your arms, turn sideways, and look from each side. Do both breasts look the same, or is there a difference in size or shape you haven't noticed before? Interestingly, some women spot this change when they notice that one side of their bra feels tighter. Or a partner may notice the difference during sex and bring it to your attention.
Why it happens: Tissue growth that's deeper in the breast or masked by dense breast tissue may push out the shape or size of the breast without causing a noticeable lump. If you've been told you have dense breast tissue, be particularly alert for this sign.
5. Pain, swelling, or a lump in your armpit
You know how the lymph nodes in your neck and throat can feel sore when you have the flu? The same thing happens to the lymph nodes in your armpit, because that's where breast cancer spreads first, by way of lymphatic fluid that drains from the breast. Affected lymph nodes may feel swollen or tender or develop a lump before a tumor is big enough to be felt in the breast itself. Any pain in the armpit area is a sign to check the area carefully with your fingers. A lump under the armpit is likely to be hard and attached to surrounding tissues, so it doesn't move when you touch it. Or tissue may feel thickened and dense compared with the armpit on the other side.
Why it happens: The lymph nodes in the armpit are the closest ones to the breast and can therefore be affected by lymphatic fluid that drains from the area. As breast cancer spreads, this is the first place it's like to metastasize, which is why breast cancer is staged according to whether it's lymph-node positive or negative.