Breast lumps

Finding something new in your breast is frightening, and the first thought that crosses most people's minds is the same one. So let us start with the main point: the great majority of breast lumps are benign. Cysts, fibroadenomas and the ordinary changes the tissue goes through before a period are what turns up most often. But that good news has a second half, and it matters just as much: nobody can tell a harmless lump from a dangerous one by touch, doctors included. Hence a simple rule that asks for no courage at all — every new lump gets shown to a doctor, and usually that is where the story ends.

What the lump usually turns out to be

• A cyst, a fluid-filled pocket. It appears mostly from the mid-thirties onwards, tends to be round, smooth and mobile, is sometimes tender and may change in size across the cycle. Small ones are left alone; large or uncomfortable ones can be drained with a needle in the clinic.
• A fibroadenoma, a benign overgrowth of glandular and connective tissue and the commonest finding in younger women. It is firm, smooth and well defined, and slips away under the fingers when you press it. Often it is simply kept under review.
• Cyclical change. In the week before a period many women's breasts become denser, lumpier and more tender, and settle again once menstruation starts. This is not a disease and not something that needs treating.
• A lipoma, a soft fatty lump, and an area of firmness after a knock, which gradually settles.
• Inflammation. A painful, hot, reddened lump in a woman who is breastfeeding is usually milk stasis or mastitis; sometimes an abscess forms and has to be drained.
• A widened duct or an intraductal papilloma, benign causes of a lump near the nipple, often with some discharge.

Why touch is not enough

It is easy to find descriptions online along the lines of "benign lumps move and hurt, cancerous ones are hard and painless". Broadly that is true, but it cannot be used as a test: there are far too many exceptions. Breast cancer can feel soft, can move and can be tender; a cyst can feel hard and fixed. Size settles nothing either — a small lump is no safer than a large one.

That is why assessment is built differently: the doctor examines the breast, adds an ultrasound scan or a mammogram, and if doubt remains takes a sample of tissue with a needle. Three sources instead of a pair of fingers. It is also why there is nothing to gain from watching a lump at home for weeks in the hope it will "go away on its own": watching clarifies nothing and spends time.

The rule worth keeping: a new lump that has not gone after your next period is shown to a doctor. After the menopause there is nothing to wait for — you go straight away. This is neither panic nor over-caution, it is the ordinary way of doing things.

Signs that should not wait

Everything below is a reason to arrange an appointment within days rather than in a month's time. None of these signs is a verdict on its own: several of them occur with benign conditions too. But they get checked promptly.

• a hard lump with irregular edges, tethered to the surrounding tissue and not moving under the fingers, usually painless;
• the skin over the lump has pulled in and a dimple or crease has appeared that was not there before; sometimes it only shows when you raise your arms;
• the nipple has turned inwards or changed direction, having been normal before;
• the skin has taken on an orange-peel look, thickened and with the pores standing out;
• discharge from the nipple without squeezing, particularly bloodstained or clear, from one breast and from a single opening;
• a persistent rash, scaling or a weeping crust on and around the nipple that creams do not clear;
• the shape or size of the breast has changed and one is now noticeably different from the other;
• a lump or swelling in the armpit or above the collarbone.

One picture deserves separate mention, because it is easily taken for an infection. The whole breast, or a large part of it, becomes red, swollen, hot and heavy, the skin thickens and takes on that orange-peel appearance, the nipple draws in — and all of it develops over a matter of weeks. That is how inflammatory breast cancer presents. It is rare and it is fast, often with no lump to feel at all, and it is frequently treated as mastitis. If you are not breastfeeding and the picture looks like mastitis, or if a prescribed antibiotic has produced no improvement in a week, what is needed is not a second antibiotic but assessment of the breast.

Breast pain is almost never cancer

This is the most widespread fear and at the same time the commonest misunderstanding. Breast pain is an extremely common complaint, and breast cancer most often does not hurt at all. Far more usually the pain comes from hormonal swings: it arrives before a period, affects both breasts, is worst at the sides and in the upper part, radiates towards the armpit and eases once menstruation begins.

There is also non-cyclical pain, sitting in one spot with no relation to the days of the cycle. Often the gland is not the source at all: a strained muscle, inflammation of a rib cartilage, pain from the upper spine, or simply a poorly fitting bra. Simple things help: a well-fitted supportive bra, including for sleeping and for exercise, painkillers in short courses and, where cyclical pain is marked, a conversation with your doctor.

But this reassurance has a limit. Pain that stays in one place, does not go for months and, above all, comes with any of the signs listed above is assessed exactly like a lump.

Knowing your own breasts

The old self-examination schemes — a set day of the cycle, fingers moving in a spiral, an obligatory monthly ritual — are no longer recommended: they do not save lives, while they reliably produce anxiety and unnecessary appointments. What has replaced them is simpler and more useful: knowing what your breasts are normally like.

No timetable is needed for that. It is enough to look in the mirror from time to time and pay attention to your breasts while washing or dressing: how they look, how they feel, what is normal for them at different points in the cycle. Then anything new registers by itself, with no technique involved. The one thing worth remembering is that most people's breast tissue feels uneven, and "lumpy" tissue that has always been that way and shifts with the cycle is your normal, not a finding.

A word about screening. Every country we work in runs a mammography programme aimed at women without symptoms; the starting age and the interval between scans differ from country to country, so check how it works where you live. Two things hold everywhere: an invitation to screening is worth accepting, and a lump that has just appeared is not left until the next scheduled scan — a symptom means seeing a doctor now.

Breast lumps in men

Men rarely think about their breasts, and they should. The commonest finding in men is gynaecomastia, an overgrowth of glandular tissue beneath the nipple on one or both sides. It occurs in adolescence and from the fifties onwards, and it turns up with liver and thyroid disease, with certain medicines and with excess weight. It is benign, but the cause is worth identifying.

Male breast cancer, on the other hand, does exist, even if it accounts for a small share of all cases. The worrying signs are exactly the same as in women: a firm fixed lump on one side, usually under or beside the nipple, an indrawn nipple, discharge, an ulcer on the skin, a lump in the armpit. Men come forward later than women because they do not expect such a diagnosis in themselves, and that is the only reason this needs saying out loud.

What happens at the appointment

The sequence is much the same everywhere. The doctor asks when you noticed the change and whether it relates to your cycle, then examines both breasts and the armpits. If the picture leaves no doubt — typical cyclical change, for instance — that may be the end of it.

If any doubt remains you will be referred to a breast clinic, where the assessment is usually done in a single visit:

• examination by a specialist;
• imaging — ultrasound in younger women, whose breast tissue is denser, and mammography at older ages; frequently both;
• biopsy — cells or a core of tissue taken with a needle under local anaesthetic, where the lump needs pinning down.

The results of the examination and the imaging are usually given the same day; the biopsy result takes about a week. The waiting is the hardest part, and you will be told so honestly. It is worth holding on to the fact that the great majority of these assessments end with "this is not cancer", and that treatment follows the finding: a cyst is drained, a fibroadenoma is usually just monitored, inflammation is treated, and only in a minority does anything larger come into it — and found early, that too is treated well.

Online consultation

Breasts cannot be examined online, and a consultation cannot replace being seen in person. What it can do is answer the questions that keep people awake: whether what you describe sounds like a cyst or a cyclical change, which of your signs calls for urgency, which specialist to see and with what, which test makes sense at your age, and what the results and reports you already hold actually mean. The doctor will help you prepare for the appointment and put your questions in order, and if there is even one worrying feature in your account they will say so plainly and send you for a face-to-face examination without delay.

This material is for information only and does not replace medical advice.