Risk of breast cancer in women with breast cysts.

OBJECTIVE: To study the occurrence of breast cancer in women with breast cysts. DESIGN: Prospective follow-up study. SETTING: Office surgical practice. PATIENTS: All 742 women referred to the practice with breast cysts diagnosed by means of aspiration or, occasionally, biopsy between 1969 and 1985. MAIN OUTCOME MEASURES: The incidence of breast cancer and the number of years between diagnosis of breast cyst and diagnosis of cancer. The observed number of cases of breast cancer was compared with the expected number, calculated from Ontario rates of breast cancer. RESULTS: Fifteen of the women died but did not have breast cancer. No follow-up information was available for five women. Another 38 were lost to follow-up; they did not have breast cancer at the last contact, after 2 to 17 years of follow-up. These patients were withdrawn from the study in the year in which they died or were last observed. By 1990, 34 (5%) of the women had breast cancer. The overall ratio of observed:expected cases of cancer was 3.04 (95% confidence interval 2.09 to 4.28). Breast cancer developed after 7.5 years, but the average length of follow-up was only 10.1 years. Only 3.8% of 374 women after 10 years and 5.4% of 141 women after 15 years had breast cancer. CONCLUSION: Women who have a gross breast cyst are at moderately increased risk of breast cancer, which usually develops only after many years.

False alarms of breast cancer.

To assess the morbidity associated with false alarms of breast cancer, 2923 consecutive consultations for a breast disorder were reviewed. 391 women had breast cancer, which was found by accidental discovery in 57%, by breast self-examination in 15%, by routine physical examination in 24%, and by screening mammography in 4%. 20% of women in whom cancers were found by physician screening had had a previous breast cancer. The pathological stages of tumours found by accident were little different from those found by intervention. 87% (2532/2923) of signs/symptoms of breast cancer were false alarms--ie, 86% (565/659) of those found by routine physical examination, 88% (406/462) breast self-examination, 93% (220/237) screening mammography, and 86% (1341/1565) accidental discovery. Spontaneous breast pain was responsible for 575 false alarms and nipple discharge for 126. 534 (20%) of the false alarms could have been avoided if routine physical examinations before the age of 45, breast self-examination before the age of 35, and screening mammography before the age of 60 had been discouraged. Another 30% of false alarms would have been avoided if the patient had realised that breast pain and nipple discharge are not usually symptoms of breast cancer.

Benign breast disease in the postmenopausal woman.

Breast symptoms are surprisingly common in the postmenopausal period, especially (but not only) when taking hormonal therapy. All of the common conditions of the premenopausal period may be seen. Clinical examination is usually easier and more precise in the postmenopausal woman. The importance of accurate clinical observation is stressed, as a diagnosis can usually be made in this way, supplemented by mammography and aspiration cytology where reliable services exist.

Association of breast cysts and breast cancer.

A review of 915 consecutive patients with breast cancer and 812 with breast cysts showed that an association between the two is uncommon--5% of breast cancers were associated with cysts and 4% of cysts were associated with breast cancer. Four types of association were identified: (a) cystic cancers--easily diagnosed because of the characteristic features of the aspirate, failure of the mass to disappear and early recurrence in a patient whose age and menstrual status were not usually associated with cysts; (b) cancers occurring simultaneously with breast cysts--recognized because they did not contain cyst fluid; (c) cysts occurring after breast cancer--diagnosed by aspiration of the mass in premenopausal women; (d) cancers in patients who have had breast cysts--usually occurring many years after the cyst aspiration when menses had ceased. These associations were not sufficiently frequent to justify specific follow-up, but all suspected cysts should be successfully aspirated to confirm the clinical diagnosis.

Benign disorders of the breast in older women.

Five hundred and eighty-one women over the age of 55 years with a benign disorder of the breast have been studied out of a total of 4,379 consecutive consultations for a perceived mammary problem. The relative age specific incidence of benign disorders of the breast dropped dramatically after menopause. Eighty per cent of older patients seen with these phenomena were between 55 and 69 years of age. Older women with benign disorders of the breast were more likely to have had a previous benign finding at biopsy or aspiration than younger patients. The use of hormonal supplements in these women was no different than that believed to occur in the regular population, except in the patients with cysts of the breast. The most common complaint was nodularity with or without pain. Cysts and fibroadenomas were proportionately much less common than in younger women and one-half of the patients who had cysts were taking hormonal supplements. In women more than 55 years of age, papillomas of the duct are responsible for approximately one-third of the nipple discharges, although the most common cause is ectasia of the duct. The postmenopausal involution makes the breast much easier to examine, both clinically and roentgenographically so that diagnosis of benign disorders can be made with reasonable confidence. Cysts can be safely aspirated because cystic carcinomas which do occur in this age group can be fairly easily recognized by gross clinical features.

Management of nipple discharge by clinical findings.

In a review of 249 office patients who complained of nipple discharge, breast nodularity and duct ectasia was the cause in three quarters. The clinical diagnosis was made by observing that more than one duct was involved and by the color of the discharge. On average, the patients were 10 years younger than those with cysts and 20 years younger than those with carcinoma. In half, the discharge could persist or recur for months or years. Nipple discharge was not commonly associated with carcinoma, and when it was, the carcinoma was almost always palpable. Nipple discharge, including bloody discharge, should be regarded as a sign of a benign breast disorder, not of breast cancer. Duct papillomas can be recognized by exploring the single profusely discharging duct, regardless of the color of the discharge. Other than patients with an obvious lump, the only patients who require surgical exploration are those with a single profusely discharging duct, not because cancer is a significant possibility but merely to rid the patient of the nuisance of the continuing discharge from a duct papilloma. Of 249 patients with nipple discharge, breast nodularity and duct ectasia was the cause in 75 percent. The median age of these patients was the mid 30s. The discharge was chronic or recurring in half. Only 4 percent of all the patients with nipple discharge had an associated breast cancer. When cancer was present, an obvious lump was usually palpable. Bloody discharge was much more likely to be associated with benign breast disorders than cancer. A single profusely discharging duct should be explored regardless of the discharge color because of the likelihood of finding a duct papilloma.

Screening for breast cancer: current status, problems, prospects.

The effect on breast cancer mortality of physical screening examinations and/or mammography will only be clear when current prospective studies are complete. The National Breast Screening Study will materially advance understanding of the value of current screening techniques. Until this information is available, however, physicians should consider practicing annual physical examinations of the breast in women over age 45, provided at least five minutes is spent in such examinations, which should consist of inspection as well as palpation of the breast in both the sitting and reclining position. If mammography of the caliber available to the American Breast Cancer Detection Project Centres is available, clinicians should consider periodic screening mammographic examinations.

The clinical recognition of cystic carcinoma of the breast.

Cystic malignant growths of the breast are uncommon, being only 1 per cent of all carcinomas of the breast. They can be easily diagnosed clinically by noting an unusual patient age, the nature of the fluid aspirated (bloody or peculiar) and recurrence or persistence of the "cyst." The results of cytologic examination of the aspirate has not been helpful in the diagnosis of these lesions.

How breast cancer presents.

A study of 501 new breast cancers in patients seen in a consulting surgical practice revealed that 87% were in patients 45 years of age or older. The patients had found 83% of the cancers. The distributions of size and stage were the same for the tumours found by the patients and those found by the referring physicians. Two thirds of the cancers had an associated visible clinical sign, demonstrating the importance of inspection in the examination of the breast. Dimpling, sometimes apparent only on manipulation of the tumour, was present with 264 of the cancers and was often associated with "minimal" lesions. Mammography was done for 63 of the breast cancers but it missed 27. Of the physician-found cancers 15 were in patients who had already had breast cancer, 4 were in patients presenting with symptomatic metastases and 14 were in women presenting with other disorders. Of the 52 cancers found by periodic examination 3 were locally advanced and 21 had axillary metastases, while among the 28 "early" cancers 12 were in women who were senile, mentally defective or psychotic. Only four of the cancers found by the physicians were in women under age 45; two were rapidly fatal, one had an axillary metastasis, and the fourth was in a woman who had had cancer of the opposite breast. The remaining 284 lesions found by periodic or routine examination in women under age 45 were benign. Thus, periodic or routine examination for unsuspected breast cancer in women under age 45 seems unjustified except in those who have already had breast cancer.

Clinical benign disorders of the breast and carcinoma of the breast.

Among 2,506 women with breast disorders seen in consecutive consultations, 345 had carcinoma. Clinical benign breast disorders occurred 6.3 times as frequently as carcinoma of the breast. The lifetime risk of clinical benign breast disorder was calculated to be more than 50 per cent. Clinical benign breast disorders occurred chiefly in young women and carcinoma occurred chiefly in older women. Thus, clinical benign breast disorders precede carcinoma because of the age at which the disorders occur. The incidence of a previous benign biopsy in women with carcinoma was 10.4 per cent and was estimated to be at least 8.2 per cent in the general population. Only a small number of women with carcinoma had previous benign biopsy. The likelihood of finding carcinoma in those women with a previous benign biopsy was 9.2 per cent and in those without 14.6 per cent. Thirty-one of the 36 patients with carcinoma of the breast with a previous benign biopsy were more than 50 years old and 18 were more than 60 years old. It is concluded that women with clinical benign breast disorders do not have an increased risk of having carcinoma of the breast develop.

Mammography: a surgeon's experience.

Most reports advocating mammography have been written by radiologists rather than by clinicians who are frequently confronted by women with breast complaints. The value of mammography in managing patients with breast problems was studied by reviewing its role in 1026 breast consultations; there were 129 patients with cancer. Mammography was performed in 95 patients. The procedure hastened the diagnosis of one comedocarcinoma, and in another patient was suspicious 3 years before she presented with a locally advanced lesion. It missed six cancers. In seven patients it recognized clinically obvious cancers, though in one of these it had given negative results 10 months before the patient presented with a lesion 15 cm in diameter. It also falsely suggested the possibility of cancer in 28 women. In the other 52 patients the clinical diagnosis of a benign condition was usually fairly evident. The morbidity caused by mammography does not seem to have been widely appreciated, no doubt because of the hope that clinically unrecognized cancers would be found by it. Most breast problems can be diagnosed without mammography.

Role of bilateral adrenalectomy (and oophorectomy) in the management of patients with metastatic breast cancer.

One hundred consecutive patients who underwent bilateral adrenalectomy for metastatic breast cancer with at least a 2 year "tumor-free" interval and with symptomatic bony, local-regional, pleural, or discrete pulmonary or mediastinal metastases had objective remission rates of 65 per cent at 6 months, 48 per cent at 12 months, 28 per cent at 18 months, and 16 per cent at 24 months.