You Have a Breast Lump: Do You Need to See a Surgeon?

I receive countless emails and phone calls every day here at the Johns Hopkins Breast Center from women around the country who feel panicked after finding a lump during either a breast self-exam or a clinical examination.

For many decades, women with a breast lump were referred to a surgeon, who would cut out the lump to determine if it was malignant. About 80 percent of the time it was not, posing no health problem. Though new technology is now available to better evaluate and determine the nature of breast lumps, I continue to get phone calls saying, "I need a surgeon right away. I have a lump."

As a breast cancer survivor myself for more than 13 years now -- I was diagnosed at the age of 38 -- I understand and am empathetic to the panic and urgency that comes with finding a lump in your breast. It's time, however, to educate ourselves about alternative strategies to rushing off to a surgeon when we discover a lump.

Step 1 should be a complete diagnostic evaluation. If you haven't had a mammogram for six months or more, getting one should be the first action step in deciphering what this lump might be. The type of mammogram done in this case is a called a diagnostic mammogram and includes two views: One is a "spot film" that enlarges the view of the area in question, and the other is a sonogram to visualize the abnormality. These tests can help detect whether the lump is liquid (usually a cyst) or solid (benign or malignant mass), and what its features are. This is important because it can help determine if the mass might be suspicious for malignancy or not.

The patient's age, family history for breast cancer, personal medical history, and other medical information also can help determine what this breast abnormality might be. It's also important for your health care professionals to know if you perform monthly breast self-exams and if this lump is truly a new finding. Perhaps this lump is caused by changes in your hormones, in which case it may well disappear with your next menstrual cycle.

Step 2 is to eliminate the lump, if that's what is best medically. If it is a cyst, you most often will return to the office where you had your mammogram and the lump will be aspirated, which is just a fancy word for using a needle to withdraw fluid or tissue from the body.

Ninety percent of biopsies also can now be performed at these imaging centers using minimally invasive breast biopsy instruments. Additional radiology studies, like an MRI of the breast, also may be done.

If a biopsy is recommended, there are advantages to having it performed as a closed (core) biopsy procedure, rather than an open surgical procedure.

  • First, the amount of scarring in the breast is minimal. This is helpful when comparing future mammograms to previous imaging, because open surgical breast biopsies cause scarring that will appear as an abnormality on future mammograms.
  • Second, the procedure can be done using local anesthetic, doesn't require general anesthesia or other sedation, and can be performed in less time.
  • Third, results are usually back faster, allowing the patient to learn the results without losing many more nights? sleep.
  • Fourth, the radiologist performing the procedure is being guided with the help of a computer when necessary, allowing him or her to be more precise than the naked eye in an operating room setting.
  • Fifth, there is no external scar and thus no cosmetic defect on the breast.
  • Finally, healing time is fast.

The key is not to feel pressured into having an open surgical procedure before you know your options and the facts. Even though a lump may have become apparent to you very suddenly, if there's something serious inside the breast, it didn't begin growing overnight. You have time to make smart decisions about how it will be investigated.

I want to share with you two frustrating scenarios. The first is one that I hear too often from women: They found a lump, saw their gynecologist, were referred to a surgeon, waited some unacceptable length of time to be seen by the surgeon, and only then were told to go to a breast imaging facility for diagnostic evaluation. These women faced another delay in learning whether or not their lumps were cancer. In the meantime, a woman in this situation is ready to learn how to perform surgery herself and operate on her own breast, just to relieve her own anxiety and end her long wait.

My second frustration comes from the stories of women who saw a surgeon -- either on their own or at their gynecologist's direction -- who skipped the diagnostic evaluation and leapt directly to an open surgical procedure. In some cases the surgeon, not realizing the patient's tumor is cancerous, cut into the tumor, which can cause treatment complications for the patient. Women with a benign mass may be left with an unnecessary scar that will interfere with accurate readings of future mammograms. Efforts are under way to educate primary care doctors and gynecologists -- and, for that matter, general surgeons -- about the advantages of having a proper diagnostic evaluation before proceeding with an open breast biopsy.

So if you or someone you care about has a breast lump, try not to panic. Remember that 85 percent of women diagnosed today with breast cancer are long-term survivors. Like me.

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