Breast Lumps
Breast lumps are still unusual for this age group, but any such lump should be reported to the pediatrician. Although breast cancers are rare in teenagers, they do occur, and diagnostic delays must be avoided. Again, ultrasound is the diagnostic procedure of choice and mammograms are rarely indicated. A needle biopsy is usually needed to make the final diagnosis. Surgical removal should be considered only after an accurate diagnosis.
Breast Infections
Though infections are unusual in this age group, they are now being seen with increasing frequency as a result of nipple piercings. These infections usually respond to antibiotics. However, we’ve had cases in which the infection did not go away, requiring removal of the nipple ring. In some cases, the infection can lead to a disfiguring scarring of the nipple. Any sign of redness, pain, or swelling should be reported immediately and treated aggressively with antibiotics.
Radiation Exposure
It is well established that the developing breast is very sensitive to radiation exposure. Studies of women who, when they were teens, were treated for scoliosis (curvature of the spine) and had frequent chest X-rays to evaluate the progression of their disease show them to be at increased risk of developing a future breast cancer. X-rays cause direct damage to the DNA in the cells of the developing breast, an onslaught that sets the stage for future development of an early-onset breast cancer.
Now every effort is made to avoid X-ray exposure to the breasts of young women. When such treatment is required, the breasts are shielded with lead drapes. The dangers of radiation slowly diminish with the years, and by age thirty the risk is reduced to the point that it is safe to do a diagnostic mammogram when cancer is strongly suspected.
Young women who have had chest radiation for other malignancies are also at risk for early-onset cancer. The most common incidents are in girls who, during their teens or early twenties, receive chest wall radiation for the treatment of Hodgkin’s disease.
Such women are often unaware of their risks and fail to follow early detection guidelines. Those who have been exposed to therapeutic radiation for Hodgkin’s disease or other malignancies should be followed by experienced physicians, preferably in clinics that manage patients who are at increased risk of tumors. In addition to twice-yearly exams by an experienced physician, yearly MRI screening should start as early as age twenty-five. Yearly screening mammography should start as early as age thirty.
Radiation associated with cell phone exposure is an issue of recent controversy. See chapter seventeen to learn more about this debate.
WOMEN TWENTY TO THIRTY
Breast Lumps
Breast cancer is unusual in this age group. It does occur, however, and because of its rarity, diagnostic delays are common. The breasts in young women tend to be lumpy and tender, anyway, and most such women are not confident in doing breast self-examination.
A diagnostic ultrasound—the extreme value of which is described at length in chapter fourteen—is particularly accurate in defining the nature of a breast lump at any age. It works with sound waves, which are completely safe, as compared to X-rays employed by mammograms. It is also painless and inexpensive.
In most cases of concern about a potential breast lump, a normal ultrasound along with a negative breast exam is all that is needed. However, if symptoms persist, the patient should be referred to a surgeon with experience in caring for young women with breast problems.
Nipple Discharge
As will be discussed in chapter nine, nipple discharge that occurs on its own, without squeezing, requires medical attention, as it could be an early sign of cancer, except in the case of pregnant women or women who have just given birth.
OTHER BREAST PROBLEMS, such as pain and infection, are treated much the same in all age groups.
The key point to remember is that any new breast change that persists after a woman has completed her menstrual cycle should be reported to her physician. If her doctor is unresponsive to her concerns, she should seek a second opinion, preferably from a breast surgeon.
WOMEN THIRTY TO FORTY
Breast Lumps
Though breast lumps are common in women in their thirties, the good news is most prove to be benign. However, differentiating between benign and malignant can be challenging—generally because breasts in this age group, as with younger women, tend to be lumpy under normal circumstances.
Here, the menstrual cycle plays a role, adding both lumpiness and tenderness just before the onset of menstruation. That said, the best time to do a breast exam or evaluate a lump is five to ten days after the onset of the period.
And the best way to evaluate the seriousness of a nodule is with an ultrasound. If the diagnosis still remains sketchy, a diagnostic mammogram can be both helpful and safe.
This focused mammogram, covering a specific worrisome area, can be distinguished from a screening mammogram, which is done on women forty and over who have not experienced symptoms.
Breast Pain
Though breast pain is common in this age group, it’s rarely associated with an underlying malignancy. Most such pain can be alleviated with over-the-counter anti-inflammatories, as well as caffeine restriction. Pain that is localized in one spot and increases in intensity over one or two menstrual cycles merits medical attention.
Breast Infections
Breast infections in this age group are typically associated with lactation, discussed in chapter four. Infections in non-lactating women usually respond well to antibiotics. Those that don’t, or that recur after initial treatment, should be seen by a breast care specialist.
SCREENING MAMMOGRAMS FOR WOMEN UNDER FORTY
Compared to younger age groups, women in their thirties do have a somewhat higher occurrence of breast cancers. Since their breasts still tend to be dense, small malignancies don’t show up well on mammograms.
For all these reasons, routine screening mammograms are not recommended, and a diagnostic ultrasound remains the first line of defense.
However, there are exceptions: Mammographic screening in this age group is restricted to women who have a first-degree relative (mother or sister) who was diagnosed with breast cancer under the age of fifty. Screening for those women should start ten years earlier than the age at which the relative was diagnosed. For example, if the mother was found to have a malignancy at age forty-five, the daughter would start yearly screening at age thirty-five.
In addition, very high-risk women, such as Angelina Jolie, who had multiple family members with breast and ovarian cancers and who tested positive for the BRCA gene mutation, require more aggressive screening. We follow these women twice yearly in our high-risk clinic, and we start yearly MRI screening at age twenty-five and yearly screening mammograms at age
