Fibrocystic Breast Disease
Factors Affecting Increased Risk of Breast Cancer
When a woman finds a breast nodule, the first concern is that it might be cancerous. Most of the time, breast nodules are not cancerous (benign). According to Hurley (1997), there are three basic, agreed-upon classifications of benign breast disease: nonproliferative, proliferative without atypia, and atypical hyperplasia. However, there can be an association with benign changes in the breast in young women and an increased risk of breast cancer with age, particularly later in life. Therefore, pathologists sometimes add comments to the pathology report indicating whether or not benign changes are relevant to an increased risk of cancer. One study followed 644 women with breast nodules between 1976 and 1982. The researchers found a relationship between subsequent cancer in women with multiple cysts and in 15 of the women whose cysts had been aspirated. The authors concluded that women with multiple breast cysts that have been aspirated have an increased risk of breast cancer. These women should perform more breast self-examinations and have follow-ups accordingly (Bundred 1991).
Benign breast conditions are more often found in premenopausal women (Ernster 1981; Bodian 1993a). Breast cancer occurs more often in postmenopausal women (75% of cases) (NBCC 1999). Estimating the risk for future breast cancer from a benign condition is difficult: the extent of mammography screening differs in the population and often, significant time passes between diagnosis of benign disease in a younger woman and the increased risk for breast cancer development in older women. Because benign breast disease is difficult to distinguish from malignant disease, diagnostic biopsy is required for a definitive diagnosis (NBCC 1999).
Women diagnosed with benign disease do appear to have an overall modest increase in risk for subsequent development of breast cancer, particularly for more hyperplastic or epithelial (the covering or lining) proliferative forms. However, the evidence regarding the risk of breast cancer for non-proliferative conditions is conflicting. Some research found that the risk of breast cancer for women with non-proliferative disease is about double that of women without benign disease (Bodian 1993b), while others find that lesions with no proliferative changes were not associated with an increased risk (Oza 1993; Henderson 1996; NBCC 1999). According to Hurley (1997), atypical hyperplasia is a risk factor, but is not with certainty followed by breast cancer; risk applies to both breasts, with greater risk on the affected side. There is no means to predict which women will go on to develop breast cancer and the effectiveness of current screening and management methods is unknown. Further complicating a physician's ability to predict a woman's risk for breast cancer is that most women do not have a history of biopsy for a benign lesion (Bodian 1993c; NBCC 1999).
Hormone Replacement and Breast Cancer
In the July 17, 2002 edition of the Journal of the American Medical Association, after decades of accumulated observational evidence, the Women's Health Initiative Investigators group raised concerns about the balance of risks and benefits for hormone use in healthy postmenopausal women. The concerns resulted from a randomized controlled primary prevention trial. The trial recruited 16,608 postmenopausal women (50-79 years of age) with an intact uterus at age 40 to United States clinical centers from 1993-1998. The study was designed to last 8.5 years. Participants in the study received placebo (8,102 subjects) or conjugated equine estrogen (0.625 mg daily) plus medroxyprogesterone acetate (2.5 mg daily) in a single tablet (8,506 subjects), commonly known as Prempro. The study monitored coronary heart disease, invasive breast cancer, stroke, pulmonary embolism, endometrial cancer, colorectal cancer, hip fracture, and death due to other causes.
After 5.2 years, the data and safety monitoring board recommended stopping the trial because one statistic (for invasive breast cancer) had exceeded the stopping boundary for an adverse effect and the global index statistic supported risks exceeding benefits. Although the absolute risk was still low, investigators stopped the estrogen plus progestin part of the study. They concluded: "Overall health risks exceeded benefits from use of combined estrogen plus progestin for an average 5.2-year follow-up among healthy postmenopausal U.S. women." Women in the other groups in the study (women taking estrogen alone, on a low-fat diet, taking calcium and vitamin D supplements, and women in the observation-only group) were advised to continue with their assigned treatment regime. However, prescribing the combination of estrogen and progestin was not recommended for long-term use or for prevention of chronic diseases (Women's Health Initiative Investigators 2002). Theories abound about why there appear to be complications with combination HRT, with one being that the progestin part of the therapy may have an antagonistic action on the estrogen part. Other co-factors include obesity, diabetes, and influence of family health history.
Another much smaller study of 158 women (58 using HRT with Prempro [conjugated equine estrogen, 0.625 mg, plus medroxyprogesterone acetate, 5 mg]; 51 using low-dose oral estrogen alone [estriol], 2 mg daily; and 55 using transdermal estrogen via a patch with estradiol, 50 mcg each 24 hours) evaluated the impact of different HRT regimens on mammographic breast density. Independent radiologists were unaware of the HRT and analyzed coded mammography films. The research indicated that an increase in mammographic density was more common in women taking continuous combined HRT (40%) than in those using oral low-dose estrogen (6%) or transdermal (2%) treatment. The researchers reported that increased density was already apparent at the first visit after beginning HRT. During long-term follow-up, there was very little change in mammographic status, leading to the conclusion that there was an "urgent need to clarify the biological nature and significance of a change in mammographic density during treatment and, in particular, its relation to symptoms and breast cancer risk" (Lundstrom 2001).
Scientists, environmentalists, physicians, and governmental agencies have all produced reports in support of their particular stance on hormones: are they safe or not and should they be used or not? Therefore, in light of continuing concerns about the safety of using HRT, particularly HRT containing estrogen plus a progestin component, decisions concerning hormone use and modulation are personal ones related to each woman's particular risk factors and her reasons to consider using HRT. It is more important than ever to consult a physician for guidance concerning the decision to use any hormone therapy. (For more information, see Life Extension’s Female Hormone Restoration protocol)
Signs of Breast Cancer
Nodules that are hard, poorly delineated, and fixed to the skin or to underlying tissue are suggestive of breast cancer. Cancerous nodules can cause dimpling, nipple deviation, or nipple retraction. They usually occur singly and are often not painful. There may be nipple discharge that is clear or bloody. Bloody discharge is more suggestive of breast cancer. Ulceration may occur in later stages (Anon 2000). (Further discussion of breast cancer is beyond the scope of this protocol. See Life Extension’s Breast Cancer protocol for a discussion of additional information.)
Other Causes of Breast Nodules
Mastitis or postpartum mastitis is an infection in women who are breastfeeding in which a milk duct becomes blocked, causing milk to pool, permitting a bacterial infection, and resulting in inflammation (AMA 1989). The breast appears red, feels warm, and may be tender. Mastitis can be accompanied by chills, fever, and cracking of the nipple.
Mammary Duct Ectasia
Mammary duct ectasia causes ducts beneath the nipple to become clogged and inflamed, particularly in women nearing menopause or in postmenopausal women (National Cancer Institute 2001b). The condition can be itchy and tender, with transient pain, and may produce a thick, sticky multicolored discharge. The skin over the nodule may be a blue-green color. Nearby lymph nodes can also be inflamed.
Pseudolumps are normal lumpy areas of breast tissue. This type of lumpiness will often disappear or vary with cyclic hormonal levels. Pseudolumps also result from silicone injections (to enlarge the breasts) or as a consequence of breast surgery or radiation therapy.
Fat necrosis produces painless, round, firm lumps that form from damaged and disintegrating fatty tissue (National Cancer Institute 2001b). Fat necrosis is more likely to occur in obese women with large breasts. It may also develop in response to a bruise or blow to the breast. Sometimes the skin around these lumps looks red or bruised.
Mastalgia refers to breast pain that is severe enough to cause a woman to seek medical treatment. Mastalgia can occur at rest or during movement, intermittently, cyclically, or constantly and can be sharp or dull and radiate to the back, arms, or neck. Pain can be aggravated by palpation (such as during physical examination). However, mastalgia is an unreliable indicator of a serious condition such as cancer (Anon 2000). Although many women experience uncomfortable tenderness and swelling, pain characterized as severe occurs only about 15% of the time.
Breast pain not related to the menstrual cycle is called non-cyclical breast pain. Non-cyclical breast pain is rare and much more difficult to treat. Non-cyclical breast pain can be caused by old trauma to the breast (such as a blow to the breast, biopsy, or surgery), infection, or some other condition completely unrelated to the breast (Anon 2000). Arthritis is a possible cause of breast pain. Arthritis pain is usually felt in the breastbone, at the center of the chest. Women with arthritic breast pain also may experience increased discomfort when they breathe deeply.
An early study showed that there were significant abnormalities in pituitary function (via prolactin mechanisms) seen in severe cyclical mastalgia and nodular breast disease, but not in women with noncyclical mastalgia (Kumar 1984).