I have a Breast Lump-I Think I Need a Surgeon?
an Editorial by Lillie Shockney, RN., BS., MAS

On a daily basis I receive countless emails and phone calls, here at the Johns Hopkins Breast Center, from women around the country, feeling a bit panicked, having performed a breast self exam or having had a health care professional do a clinical breast exam with the outcome being "a lump." For many decades the method of diagnosis was a referral to a surgeon who would surgically excise the lump and determine its origin, with 80% of the time, the cause being a benign finding that would do no harm. Though new technology is now available and better methods of evaluating and determining the nature of such lumps, I continue to receive these phone calls saying, "I need a surgeon right away. I have a lump."

As a breast cancer survivor, myself, of more than 9 years, diagnosed originally in 1992 at the age of 38, I understand and am empathetic to the panic and urgency finding such a lump can cause. It's time, however, to educate ourselves about what the best actions steps are to take, rather than embarking on the old method of diagnosis- meaning, calling for a surgical consult with the goal being to have an open surgical breast biopsy.

Step #1 should be a diagnostic evaluation. If the patient hasn't had a mammogram for 6 months or more, this should be the first action step in deciphering what this lump might be. The type of mammogram done in this case is a diagnostic mammogram, which would include 2 views, usually spot films to enlarge the area in question, and a sonogram to visualize the abnormality. These tests can help decipher if the lump is liquid (usually a cyst) or solid (benign or malignant mass), and the features of the mass which can help to 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 can further help to determine what this breast abnormality might be. Whether she performs monthly breast self exams and this lump truly IS a new finding is important to know too. This lump may be hormonally caused and may disappear with her next menstrual cycle.

Step #2 focuses on eliminating the lump, if medically warranted. Cysts are usually able to be aspirated in a breast imaging center (mammography facility) where the diagnostic evaluation is being performed. This involves inserting a needle into the cyst and removing the fluid that has collected in it; 90% of biopsies can also be performed now in such a setting using minimally invasive breast biopsy instrumentation. There also may be additional radiologic studies, such as an MRI of the breast, that are recommended for evaluating the cause of the breast abnormality.

If a biopsy is recommended, there are advantages to having it performed as a closed procedure rather than an open surgical procedure. 1) the amount of scarring in the breast is very minimal. This is helpful when comparing future mammograms to previous imaging because open surgical breast biopsies causes scarring which appears as an abnormality on future mammograms; 2) the procedure can be done with the use of local anesthetic and doesn't require general anesthesia/sedation and can be performed in a shorter length of time; 3) the results are usually back faster, allowing the patient to get results without losing many more night's sleep. (At Johns Hopkins, the turn around time is 24 hours); 4) radiologist's performing the procedure, being guided with the help of a computer when necessary, can be more precise than the naked eye is in an operating room setting; 5) there is no external scar on the breast thus no cosmetic defect; 6) the healing time is fast.

There certainly are circumstances when a minimally invasive breast biopsy cannot be performed, but this is the minority, not the majority. There are also situations in which the biopsy can be done, using hand held equipment, again, avoiding scarring of the breast, that enables the radiologist or a surgeon to remove a core of the mass, when such lumps are easy to feel and are located in an area relatively easy to access with such instrumentation. This method also doesn't require an incision or actual surgical procedure and can be done using local anesthetic.

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

I have two frustrations: 1) I too commonly hear from women that they found a lump, got an appointment with their gynecologist, was referred to a surgeon, waited some unacceptable length of time to be seen by a surgeon, was finally seen and then told to go to a breast imaging facility for diagnostic evaluation, thus resulting in another delay in learning if the lump is or is not cancer. In the meantime the woman is ready to learn how to perform surgery herself and operate on her own breast just to relieve her own anxiety and wait time. 2) I talk to women who sought out or were directed by their gynecologist to see a surgeon who skipped the diagnostic evaluation steps and leaped into an open surgical procedure. In some cases the doctor, not realizing the patient had a cancerous tumor, cuts into the tumor which can cause treatment complications for the patient; for those having a benign mass, they may be left with a scar than necessary, and now will experience problems with the reading of future mammograms caused by the scarring of the inside of the breast caused by the open surgical procedure being done without proper diagnosis known in advance..

Though efforts are underway to educate primary care doctors, gynecologists and for that matter general surgeons about the advantages of having a proper diagnostic evaluation performed before proceeding with an open breast biopsy without this information in hand, every day women are undergoing these procedures and may not necessarily have to be. So it is just as important to educate women, future patients, of these important facts. So if you or someone you care about has a breast lump, try not to panic, knowing that 80% of the time the news will be good. (For those who are diagnosed with breast cancer, the news also is promising with 85% of women diagnosed today being long term survivors like myself.) The more we know about breast health, breast cancer and its diagnosis and treatment, the better prepared we are in facing such a crisis and weathering the storm well. For more information about diagnostic evaluations of breast abnormalities, visit this section of our website: http://www.hopkinsbreastcenter.org/services/

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