of these women are also encouraged to consider risk assessment counseling, and in some cases, genetic testing (see chapter eighteen).
OTHER SYMPTOMS in this age group, such as nipple discharge, are managed in much the same manner as with younger women.
WHAT I’D TELL MY DAUGHTER
• The vast majority of breast problems in this age group (birth to forty) will be associated with non-cancerous conditions.
• Still, breast changes merit attention. Persistent or progressive changes need a timely answer.
• When in doubt, get an opinion from a breast care specialist.
THERE IS OBVIOUS OVERLAP when treating breast symptoms in the various age groups. For example, the care of symptomatic women in their thirties is nearly identical to what is offered for patients in their forties. To avoid repetition, we have simply summarized basic treatment in this and the previous chapter. A more detailed discussion of common breast problems is provided in Section II.
However, women in their forties should be aware of these concerns in particular:
Breast Lumps
Any new breast lump in a woman over forty merits concern. The older she is, the higher the probability of cancer. In menstruating women, breast lumpiness is common, but any nodule that persists after completion of a menstrual period requires medical attention. An ultrasound is often the only test needed to determine the nature of the lump. However, if doubt remains, a diagnostic mammogram is the next step. When findings on the mammogram or ultrasound are worrisome, a core needle biopsy (see page 48) will establish an accurate diagnosis.
If all diagnostic studies are negative, a further, two-month re-evaluation is still important, both to reassure the patient and to guard against a possible missed diagnosis of malignancy.
Abnormal Mammograms
The second most common breast problem in this age group is an abnormal screening mammogram. In most cases, additional imaging will eliminate concerns and the woman can return to routine yearly screening.
In the event of a positive finding, a core needle biopsy (see page 47) will provide an accurate diagnosis. If the biopsy is benign, the patient returns to regular screening. However, if the biopsy proves positive, the patient is referred to a breast surgeon.
Nipple Discharge
Nipple discharge is common in over-forty age groups, and squeezing the nipples is the primary cause. It is normal for breast ducts to contain fluid, and it is common for the breast, when squeezed, to produce a drop or more of yellow, green, or white fluid from the nipple. Although this discharge is not worrisome, women are advised not to squeeze their nipples.
However, discharge that occurs spontaneously requires medical attention—though in most cases the event is not related to a hidden breast cancer. Still, we are concerned when the fluid is either clear or bloody. If the discharge is suspicious enough to warrant a biopsy, it usually turns out to be benign, or associated with small, potentially curable breast cancers. For a more detailed discussion, see chapter nine.
Breast Pain
Breast pain is one of the most common symptoms that send women to a breast care center. While it is unusual for a breast cancer to cause pain, it can be the first indicator of an underlying malignancy. Pain that is centered in one specific area and becomes more intense in a matter of weeks merits the attention of a specialist. For further details, see chapter six.
Breast Infections
Breast infections are relatively common in nursing women, an issue covered in chapter four.
In non-lactating females such infections are rare but require immediate medical attention. With most patients, the inflammatory process responds to standard antibiotics. After treatment, an attempt should be made to determine the root cause. Infections that don’t respond to antibiotics, or episodes that recur, should be referred to a breast care specialist.
MAMMOGRAMS
One of the biggest breakthroughs in the history of women’s health care was the development of screening mammography. Initial studies in the United States and Sweden demonstrated a 30 percent or greater reduction in breast cancer mortality for women undergoing screening mammography. With improvements in technology and a better understanding of who is at risk, there is now an incredible opportunity for making even more dramatic improvement in the rate of survival of this number-one cancer killer of young women.
That said, age is one of the critical factors that increases a woman’s chance of developing breast cancer. The older she gets, the greater her peril. By forty, vulnerability has reached the point where it’s appropriate to start routine annual mammographic screening—and as always, the goal is to detect small cancers before they cause symptoms or even before they grow large enough to be felt.
Despite the well-established benefits of mammographic screening, we’re seeing an increasingly strident disagreement over several issues: the best age to start, how often women should be tested, and the proper age to quit. This controversy will be explored in more detail in chapters fifteen and sixteen. It is first necessary to understand the basics of mammographic screening.
Screening vs. Diagnostic Mammogram
One of the first issues that needs clarification is the difference between a screening and a diagnostic mammogram. The screening mammogram is for women who are symptom free. They have no suspected breast lumps, no new patterns of breast pain, no nipple discharge, and basically no newly revealed breast symptoms. Diagnostic mammograms, on the other hand, are for women who have breast symptoms.
Women who are about to undergo their yearly screening exam should make certain they alert the technician or support staff about any recently discovered breast problems. Such symptoms will be reported to the radiologist (mammographer), who will then determine what additional procedures might be helpful to evaluate the new issues.
When to Start Screening
Despite all this recent controversy, there is a general consensus that starting mammographic screening at age forty saves lives. A government funded task force is now recommending
