Screening for breast cancer starts in women at the age of 40. In women under the age of 40 who are not screened routinely, there are symptoms which should prompt a visit to your doctor to determine if further testing is needed to exclude cancer and to initiate appropriate treatment. A breast lump is one of such symptom that should lead to a visit to your primary care doctor or your gynecologist. Management of breast cancer symptoms in those under 40 years varies based on the age group, i.e. in teenagers, those under 30 years of age and in women from 30-40 years of age.
Breast lump in women under the age of 20 years
Breast cancer is exceedingly rare in women under the age of 20. Nevertheless, a breast lump should be investigated with a breast ultrasound. Ultrasound does not involve radiation and is safe and accurate way to assess a breast lump.
• Mammography is almost never needed in this age group
• Ultrasound will help to determine the cause of the lump. A fluid filled cyst is left alone, if a solid tumor is discovered, ultrasound can determine if it requires biopsy for a definitive diagnosis
• Abnormal breast development, a fluid filled cyst and a solid tumor may cause a breast lump, an infection with development of an abscess can also cause a lump to develop in the breast
• Needle biopsy is generally avoided unless there is rapid enlargement of a tumor
• Most common cancerous tumor in the breast is a metastasis or a tumor that has spread through the blood stream
• The most common tumor that occurs primarily in the breast is a cancerous variety of Phyllodes tumor, which more commonly presents as a locally aggressive tumor. When a phyllodes tumor is diagnosed following a needle biopsy, surgical removal is a must.
• Irrespective of the type of tumor, progressive growth in the size of a breast tumor may require surgical removal (Figure 1)
Women between 20-30 years of age
• A breast lump should lead to prompt evaluation by your physician. The initial and often the only testing that is required is an ultrasound of the breast.
• Ultrasound very accurately identifies the cause of the breast lump. The lump may be a cyst filled with fluid, a solid tumor or fibrocystic change that causes a lump to be felt with no tumor or a cyst. When there is no ultrasound abnormality in the area of the breast lump a follow up clinical exam by your doctor in 3 months is recommended. In cases where a solid tumor is identified, based on the features of it on ultrasound, the breast imaging specialist will determine if the tumor can be serially followed usually at six to twelve-month intervals. An outpatient minimally invasive biopsy under local anesthesia may be recommended if the tumor is not clearly benign (non-cancerous)
• A diagnostic mammogram is when special views of the breast are performed tailored to assess specific breast symptoms and is directly supervised by the breast imaging specialist. In women under the age of 30, this test is performed only if deemed necessary based on an abnormal breast ultrasound.
• Less than 2% of breast cancers are diagnosed in women under the age of 30 years (Figure 2)
• Most of the solid tumors causing breast lumps are non-cancerous, most frequent being a fibroadenoma.
Women between 30-40 years of age
• In this age group a diagnostic mammogram and an ultrasound of the breast is ordered to determine the cause of the palpable lump.
• Less than 10% of breast cancers are diagnosed in this age group
• About 5% of the breast lumps in women under the age of 40 years are cancerous. It is important to have all breast lumps checked by your primary care doctor or gynecologist who will then order a diagnostic mammogram and an ultrasound
• A mammogram by itself is not adequate to assess a breast lump, many cancers that produce a breast lump may go undiscovered on a mammogram due to being obscured by dense glandular tissue. An ultrasound is always needed to assess a symptom of a breast lump
Figure 1. Enlarging breast lump in an 18-year-old. Ultrasound shows a solid tumor. This was surgically removed and was a fibroadenoma of the breast, a non-cancerous breast tumor
Figure 2. A breast lump in a 28-year-old woman showed a small tumor on ultrasound. Needle biopsy of this tumor revealed invasive ductal cancer