Questions and Answers

Q: I'm interested in enrolling in a clinical trial for breast cancer treatment. Can you explain to me how one works, what might be available and what I can hope to gain from it?

D. Lawrence Wickerham, MD

A: I am so glad to hear you're interested in clinical trials. Without clinical trials, the progress that has been made to better diagnose and treat breast cancer, and improve survival wouldn't have been possible. That's because new treatment approaches must undergo testing in people to prove their merit before they are approved and widely accepted by health care professionals. Clinical trials have resulted in a host of safe and effective therapeutic tools to help fight breast cancer (and many other diseases). They also have identified new medicines or combinations of therapies may cause more harm than good.

Patients decide to enroll in clinical trials for a variety of reasons. Some may decide to join a clinical trial to receive a new, investigational treatment because they are no longer responding to current therapies. Other patients want to contribute to medical research. Still others want access to new treatments that are otherwise unavailable, but which they hope will work better than the current standard. All too often people think that clinical trials are only for individuals who have failed all conventional therapy and ONLY clinical trials are left. While trials are available for such patients, newly diagnosed patients also are candidates for clinical trials and should carefully consider that option. Whichever is the case, patients' health is closely monitored throughout a clinical study and, sometimes, taking part in a study can mean access to state of the art medical care.

If you're interested in participating in a study, it's important to speak with your oncologist to learn more and find out whether there are any trials in your area for which you might be eligible. Many studies have inclusion criteria—a list of conditions you must meet to be considered for participation. These help researchers select a narrowly defined, comparable group of patients. For example, researchers may want to study a specific treatment in women who are postmenopausal, or in those who have undergone lumpectomy, or perhaps in women whose breast cancer has spread (metastasized) to other areas of the body.

Many community clinics and doctors' offices have started participating in clinical trials to allow participants to enter studies close to home, thus, avoiding the costs and burdens of travel to major cancer centers; however, this is not always the case Either way, it's important to do your homework. There are several online searchable databases that you can use to match your situation to trials currently enrolling patients. These include:

• National Cancer Institute, 1-800-4-CANCER, www.cancer.gov/clinicaltrials
• CenterWatch Clinical Trials Listing Service at www.centerwatch.com
• Coalition of Cancer Cooperative Groups, 1-877-520-4457, www.CancerTrialsHelp.org

Clinical trials are rigorously designed and are conducted in phases:

• Phase I trials are usually small studies to assess a drug's safety and to discover what, if any, side effects result.
• Phase II trials are larger than Phase I studies and, again, look at safety, but also gather data on efficacy.
• Phase III trials are the make-or-break tests of the treatment's efficacy, benefits and adverse effects in a specific patient population. Because Phase III trials are so much larger than other studies (several thousands of patients), they provide the best data on overall effectiveness and safety of the treatment in the general population. They are also available in many communities and allow patients to have greater support from family and friends.
• Phase IV trials are conducted after the FDA grants marketing approval.

There are some potential risks associated with clinical trials. The treatment may have side effects or produce adverse reactions. You may be assigned to the group receiving the standard of care, or you may receive the experimental treatment but not derive any benefit. In some cases, you may have some added inconveniences, such as frequent trips to the study site, hospital stays or difficult or uncomfortable procedures, depending on how the trial is designed. Participation in clinical trials isn't always free, so be sure to find out whether your health insurance will cover related costs.

Bottom line: Be sure to learn all you can and weigh your options before enrolling in a clinical trial.
Posted 4/21/2008

JoAnn V. Pinkerton, MD

A: This is a complicated and controversial issue, one that you should speak with your health care provider about if you are considering menopausal hormone therapy.

While we can't say that menopausal hormone therapy (HT) causes breast cancer, we do know that hormones can play an important role in cancer growth and may increase a woman's chances of having the disease. In 2002, the Women's Health Initiative (WHI) halted part of a large clinical study after finding that women taking estrogen plus progestin had an increased risk (a relative risk of 24 percent, but an absolute risk of 2 per 1,000 women) of developing breast cancer. While this increase may sound like a lot, it's still a small risk. For example, if your overall risk is 12 percent, taking combination estrogen-progestin only increases your risk by 2.9 percent.

It's also important to keep in mind that these results relate to this specific HT regimen (estrogen plus progestin); women who were taking estrogen only had no increased breast cancer risk, in fact there were fewer breast cancer seen after 6.7 years of estrogen only compared to placebo.

Interestingly, after increasing for decades, the rate of new breast cancer cases started to decline between 2001 and 2004, which many researchers believe may partly reflect the reduced use of HT by millions of women after the results of the WHI study were widely reported. Because estrogen fuels most breast cancers, researchers suspect this sudden withdrawal may be slowing the growth of miniscule tumors too small to be seen on mammogram, at least in the short term. Breast cancer may also be found at a more advanced stage in women on certain HT treatments.

As with most medication therapy, HT has benefits and risks. Although there are risks to hormone therapy, including an increased risk of breast cancer, heart disease, stroke and blood clots, most health care professionals agree that hormone therapy is still appropriate for perimenopausal and recently menopausal women with moderate to severe symptoms (for example, hot flashes, sleep disturbances, night sweats and vaginal changes). HT has also been used for years to prevent osteoporosis (a thinning and weakening of the bones) for women at high risk of the condition.

To make informed decisions about HT, it's important that you know your individual risk of breast cancer, taking into account your age, race, age of menarche, age at first pregnancy, family history and previous breast biopsies. Be sure to talk openly with your health care provider about your personal risk for breast cancer, especially if you have a strong family history, specific peri- and postmenopausal symptoms you are experiencing and any concerns you have about HT. There are more than 20 varieties of hormone therapy on the market, so you have plenty of options. Some regimens are more effective in treating certain symptoms. Discuss the risks and benefits of different types of therapy with your health professional.

If you decide to take hormone therapy, you may want to start at the lowest dose for the shortest amount of time needed to gain relief. However, if you need to, you can use hormone therapy for an extended length of time.

Bottom line: Only you and your health care provider can decide if hormone therapy is right for you, which type is best and for how long you should use it.
Posted 4/21/2008

Ari Brooks, MD

A: The only way your doctor can determine whether a suspicious lump is cancerous or not is to perform a breast biopsy. That involves removing a sample of breast tissue to examine it under a microscope for signs of cancer. Rest assured, having a biopsy does not mean you have breast cancer. In fact, most biopsy results (four out of five) are not cancer, according to the American Cancer Society. Still, it's the only way to be sure.

A breast biopsy is either done using a needle or with surgery. The type of biopsy will depend on a number of factors, including how large the lump is, where it's located, your preference, as well as other medical problems. Be sure to tell your doctor about any allergies you have or if you are taking blood-thinning medications (anticoagulants) or aspirin.

Many biopsies can be done in your doctor's office or in the radiology suite under local anesthesia. The sample of breast tissue is then sent to the laboratory where it is examined by a pathologist (a doctor who has special training to examine cells under a microscope and identify diseases).

There are several types of breast biopsies, including:

• Fine needle aspiration biopsy (FNAB): A very thin needle is attached to a syringe to drain (aspirate) cells from the suspicious area. This is a fast and easy way for your doctor to collect a small sample of tissue from a tumor the doctor can feel or see with ultrasound. There are no stitches or scarring. However, because it's such a small sample, the rate of false negatives or misdiagnosis can be high, and additional studies (such as checking for estrogen or progesterone receptors) may be difficult to perform.

  If there is something visible only on your mammogram or MRI, your doctor will probably use a different method to be able to collect more tissue.

• Core needle biopsy: This procedure uses a slightly larger, hollow needle to remove several tissue samples often with ultrasound guidance. This type of biopsy is usually done in a doctor's office or radiology suite with local anesthesia to numb the breast. Because more tissue is collected, it can result in a more accurate diagnosis. Stitches are not needed, and while there may be bruising, there is no associated scarring. You may be advised to apply an ice pack and take a nonaspirin pain reliever with acetaminophen (Tylenol) to reduce any swelling or discomfort.

• Vacuum-assisted core biopsy (VACB): A single, small incision (about one-quarter inch) is made, and a probe is inserted, which sucks a larger piece of tissue out through the opening. The area is numbed beforehand, no stitches are needed and there is minimal scarring. This machine is usually used with ultrasound, mammogram or MRI guidance.

• Surgical biopsy: This procedure removes part (incisional biopsy) or all of the lump (excisional biopsy or lumpectomy). It is usually done in a hospital, with sedation and a local anesthetic. You will have stitches and some scarring where the incision was made. You should avoiding strenuous activities for a day or so and follow post-operative care instructions.

With any of the above, your surgeon or radiologist may use imaging studies, such as mammogram, MRI or ultrasound, to help guide the positioning of the needle or pinpoint the exact location of the lump during surgery.

It usually takes several days before the results come back. If the lump is benign (not cancer), no additional steps are needed, but it's important to stay on top of routine mammograms and monthly breast self-exams. If the biopsy is positive (shows signs of cancer), the results will help your health care provider determine recommendations for treatment.

Don't rush into any decisions. You may want to seek a second opinion before deciding which treatment is right for you. Remember, your input is important, so ask questions if you're unsure about anything, and get the support you need.
Posted 4/21/2008

Rebecca Sutphen, MD

A: I can understand your concern given your strong family history of the disease. To answer your question, it depends on several things.

The vast majority of breast cancer is not caused by hereditary factors. In fact, only five to 10 percent of cases are caused by the so-called "breast cancer gene." For women with a family history, the percentage is higher. The results of a genetic test—whether positive or negative—could have a big impact on your life, so you need to be informed and think things through before making a decision. As part of the decision process, your doctor will want you to speak with a genetic counselor, an expert who can assess your personal risk of developing cancer and help walk you through the pros and cons of getting tested, as well as the possible outcomes of the test and next steps.

The breast cancer gene (BRCA) test involves a simple blood test to examine your DNA and find out whether you have inherited specific changes (alterations or mutations) in the BRCA1 or BRCA2 genes—two genes related to breast and ovarian cancers. For women who have a mutation in either of these genes, the risk of breast or ovarian cancer is significantly higher than for women without the mutation. For example, women with an altered gene have a 36 to 85 percent chance of getting breast cancer (compared to 13 percent of women in the general population) and a 16 to 60 percent chance of ovarian cancer (compared to 1.7 percent in the general population). There is also some evidence that the risk of other cancers, including colon and pancreatic cancers, may be slightly increased in these women./p>

But remember, the test result is only one aspect of your risk. For example, if you test positive it doesn't mean that you will definitely get cancer and it doesn't tell you when. Not everyone who inherits changes to a BRCA gene will get cancer.

On the flip side, many health professionals are concerned that women who find out they don't carry the gene have a false sense of security and may not be as vigilant with lifestyle changes, breast self exams, mammograms and other recommended screenings. The fact remains that one in eight women (13 percent) will have breast cancer in their lifetime. Even if you don't have the gene, you should still take the same steps to help reduce your risk of breast and other cancers, such as getting regular physical activity, eating a healthy diet, not smoking and limiting alcohol consumption. You should also continue to take steps to help you detect cancer early, including performing periodic breast self-exams, getting yearly clinical breast exams and following your doctor's advice for screenings. Of course, if you have the gene, there are additional strategies you and your doctor will want to discuss. These include: screening with mammogram plus MRI; taking tamoxifen; and prophylactic removal of your ovaries or breasts.

It is also important to realize that if you are the first person tested in your family, the results won't be as helpful because you have never had cancer. It would be a good idea for your mom to consider genetic counseling and testing. If she doesn't have a mutation, you won't need to get tested. If she does, you'll know what mutation to be tested for. Many women also worry that a positive test result may make it difficult to get or keep health or life insurance down the road. These are all important issues that a genetic counselor can help you consider before getting tested, so you can map out a plan that's right for you.

Certain women have a higher chance of inheriting a BRCA mutation. The likelihood that breast and/or ovarian cancer is associated with BRCA1 or BRCA2 is greater in families with:

• a history of multiple cases of breast cancer, especially at a young age or in both breasts
• cases of both breast and ovarian cancer
• one or more family members with two primary/types of cancers
• An Ashkenazi (Eastern European) Jewish background

Arpana M. Naik, MD

A: Your doctor probably wanted you to have an ultrasound because the mammogram showed some suspicious spots. Ultrasound, or sonogram, uses sound waves to identify structures within muscle and fatty tissue. It provides a much more detailed view of any breast lumps.

Your lumps are likely fluid-filled simple cysts, which are nothing to worry about. If they were solid in nature, or even cysts with solid material floating within the liquid, your doctor would probably order a biopsy. During this outpatient procedure, a bit of the cyst or lump is removed and carefully examined under a microscope for any abnormal cells.

You may also have lumpy breasts, also called fibrocystic breasts. It affects about one in three women in the United States, primarily those in their 30s and 40s, and is thought to result from hormonal changes throughout your menstrual cycle. It may also become progressively worse the closer you are to menopause.

Fibrocystic breasts can sometimes make breast cancers more difficult to detect on mammogram. If this is the case, your health care professional may prefer that you have ultrasounds performed in addition to your annual mammogram.
Posted 1/3/2006

Q: I'm 20 and have noticed that over the past few months my breasts seem like they are getting smaller. I have not lost or gained any weight and my diet hasn't changed. I would think that my clothes are just getting stretched out from being worn so much, but when I try on a new bra or shirt they don't fit the way they would have last year. Is this normal or should I be worried?

Lillie D. Shockney, RN, BS, MAS

A: There is nothing to be worried about. Your breasts will continue to change size or shape throughout your life. Just wait until you get pregnant! Although you say you haven't lost any weight, it's quite possible that the underlying muscle that supports your breast, called the pectoral muscle, may have gotten stronger, replacing some fat. This could change the size and appearance of your breasts.

I would suggest that you carefully measure your breasts (put the tape measure around your chest passing over the nipple area), write down the measurement, then remeasure in a couple of months to see if there really is any change.
Posted 12/19/2005

Q: I was wondering if you have a hysterectomy, is it possible to still produce breast milk?

Lillie D. Shockney, RN, BS, MAS

A: Definitely. You should have no problem nursing your baby even if you've had your uterus and/or ovaries removed, assuming the hysterectomy occurs after you've given birth (which, obviously, it would have to since you can't carry a baby to term without a uterus). The most important hormones in milk production are prolactin and oxytocin. Prolactin helps maintain your milk supply, while oxytocin controls the let-down response so the milk flows through the glands out the nipple to the baby. Neither of these hormones are related to the uterus or ovaries, so their production should continue after a hysterectomy.

If you have a hysterectomy while breastfeeding, make sure and ask your health care professional when you can resume breastfeeding. You probably want to make sure that all the anesthesia is out of your system before nursing your baby, since many drugs can pass through your breast milk to your baby. So it might be a good idea to express and freeze some breast milk before going into the hospital. If your health care professional wants you to take supplemental estrogen after your hysterectomy (likely if your ovaries were removed), let him or her know that you're breastfeeding, and ask for the lowest dose possible. Estrogen could reduce your milk supply.

Because you may have some postsurgical pain, you should talk to a lactation consultant about the best position for breastfeeding after surgery. Lying the baby on the pillow, or using the "football" hold, may help.

I really commend you for breastfeeding your baby. You probably already know this, but the health benefits of breastfeeding are almost too great to list. They range from a reduced risk of allergies and asthma to improved learning ability. Breastfed babies also get sick less often than babies who are bottle-fed, are less likely to develop diabetes and are less likely to be overweight.
Posted 11/29/2005

Q: I just had breast implants seven days ago and I feel like I can't breathe, it feels like someone is choking me...Is this a normal feeling?

Navin K. Singh, MD

A: If you are experiencing these symptoms, it is important to be evaluated by your surgeon, as this could signal a serious complication. There could be a number of reasons for feeling like you can't breathe, ranging from the physical -- infection or other problem with the breast implant -- to psychological anxiety. The first thing you need to do is contact your surgeon. Make a detailed list of any signs and symptoms you're having, no matter how minor they might seem. For instance, be sure to note if you've felt feverish, or unusually tired, or had any pain in the breast area. Do your breasts feel tender or warm to the touch? Does the problem with breathing occur all the time, or just occasionally? If the latter, when does it occur? When you're sitting quietly, or after exertion?

Breast implant surgeries are getting better and safer every year. But, like any operation, they can develop complications. These include: infection around the implant; leaking or rupture in the implant; contractures (in which scar tissue builds up around the implant, sometimes causing pain and distortion of the tissue); hematoma, in which blood or fluid pools around the implant causing pain and/or infection; movement of the implant; a blood clot that's lodged in the lung, or even injury to a rib or lung from the surgery or anesthesia.

Your doctor will likely do an exam, listen with a stethoscope, and perhaps recommend a chest x-ray. For now, however, please call your doctor and schedule an appointment as soon as possible. In a severe emergency, you should consider dialing 911.

Chances are good that this is a solvable problem that your surgeon can help you resolve. Good luck!
Posted 11/22/2005

Q: I am a 51-year-old female perimenopausal woman. My mother got breast cancer when she was 40 (long before her menopause at 52). I have heard that premenopausal breast cancer is different from postmenopausal breast cancer. I am wondering if my inherited risk factor will decrease after menopause?

Lillie D. Shockney, RN, BS, MAS

A: Yes, you are right that breast cancer that strikes in younger, premenopausal women tends to be more aggressive than in postmenopausal women, likely due to higher levels of estrogen. Estrogen is a hormone that serves as fuel to many breast cancers. That's why widely used treatments such as tamoxifen and aromatase inhibitors work by reducing estrogen levels in the body.

The fact that your mother had breast cancer before she reached menopause does put you at an increased risk for breast cancer. About eight percent of all breast cancers are hereditary, and about half of those are related to mutations in two breast cancer susceptibility genes, BRCA1 and BRCA2. Hereditary breast cancer is more common in premenopausal women, and is more likely to affect both breasts than nonhereditary breast cancer.

Your risk of breast cancer doesn't change once you reach menopause, however. In fact, breast cancer is much more common in postmenopausal women, and the risk of cancer increases with age.

I hope that you have shared your mother's medical history with your health care professional, and that you are having regular mammograms and conducting regular breast self examinations. You might also consider going for genetic counseling. Genetic counselors help identify your risk of hereditary disorders, analyze patters of risk in your family, and review options with you. They will also provide supportive counseling and serve as an advocate. Based on the information you receive from the genetic counselor, you may decide to be tested for one of the genetic mutations related to breast cancer -- something that may be particularly important if you have a daughter yourself.
Posted 11/8/2005

Q: Are there any known cases of complications during a breast augmentation surgery with a patient that has aplastic anemia? I am scheduled for surgery and have had no luck finding anything specific that may help me make an informed decision other than the obvious risk of bleeding due to low platelets.

Caroline A. Glicksman, MD

A: You have a serious blood disorder in which your body doesn't produce enough white or red blood cells, or enough platelets, the component in blood that enables it to clot. Consequently, you're prone to unexplained bleeding, infections and fatigue. There are numerous causes of aplastic anemia, including cancer treatments (radiation or chemotherapy), exposure to toxic chemicals like those used in some insecticides, paint, and household cleaners, some drugs (like those that treat rheumatoid arthritis), autoimmune diseases like lupus, viral infections that affect bone marrow, or other bone marrow diseases. The treatment depends on how serious the anemia is. It can be treated with blood transfusions, medicines or may require a bone marrow transplant.

You don't say whether your anemia is mild, moderate or severe, but if you're considering elective surgery, I would guess it's mild. Nonetheless, I would caution you against a procedure like breast augmentation. Although it is considered an elective cosmetic procedure, it is still surgery, performed under anesthesia with a risk of bleeding and infection. Any surgery is dangerous for people with aplastic anemia -- but if your life is at stake, it might be worth the risk. Putting your life at stake for the sake of larger breasts, however, is a serious decision that you and your surgeon need to discuss.

Even if the initial surgery goes well, you should be aware of the post-surgical complications that may occur with breast augmentation with implants. These include excessive bleeding after the surgery, which is especially dangerous for you. If the bleeding continues, you may need another surgery to control it and remove any blood that's built up. Other possible complications include infection around the implant, the eventual leaking or rupture in the implant if not maintained or replaced, capsular contractures (in which scar tissue builds up around the implant, sometimes causing pain and distortion of the tissue). Most importantly, all implants, both silicone and saline, must be replaced at some point requiring additional surgery.

In summary then, I urge you to talk about this procedure not only with your plastic surgeon, but also with the physician who treats you for your aplastic anemia before making any decision.
Posted 10/25/2005

Q: I have detected a lump in my breast, which I can feel. It moves when pressed. Ultrasound guided core biopsy has revealed that it is benign. It is about 3 to 4 centimeters as per ultrasound as well as mammogram. I am 30 years old. Since it is non-cancerous, should I have this surgically removed? What are the side effects of surgery? What happens if there is no surgery at all? What is the best possible course of action?

Navin K. Singh, MD

A: It sounds like you have a fibroadenoma, a solid, smooth, benign lump in the breast that typically occurs in women in their late teens and twenties, but which can occur at any age, even in babies! It's very common, occurring in 10 to 25 percent of women.

There is some evidence that a history of fibroadenomas can slightly increase your risk of breast cancer, particularly if you have a history of breast cancer in your family, or have had hyperplasia, an abnormal increase in breast cells..Given that, it's important that regardless of what you decide to do about the lump, you make sure to continue having regular examinations, including mammogram or other breast-imaging procedure (like ultrasound or MRI) to evaluate your breasts for any abnormalities.

Lately, breast surgeons have been using a procedure called cryoblation to remove lumps. This is a minimally invasive, office-based procedure performed with just local anesthesia. It involves very little pain and leaves little to no scarring, and only takes about 15 minutes.

Basically, the surgeon creates an "iceball" around the lump using a special gas. The lump eventually shrinks away to nothing, although it may take up to a year or more to disappear entirely.

You should definitely talk to your health care professional about this procedure. Even knowing that a lump is benign can still be nerve wracking, and I can definitely understand your desire to have it removed.
Posted 10/12/2005

Q: I was recently reading a list of symptoms of breast cancer and came upon one I had never seen before. The list included an increase in the crustiness in the nipple area. Is this something to really be concerned about as it seems to ebb and flow as the years go by, but has increased somewhat in the past year? By the way, I am 54 years-old with no family history of breast cancer.

Arpana M. Naik, MD

A: While many women know that a lump or abnormal bump in their breast is cause for concern, few know that there are other, less obvious signs of a potential breast cancer. These include puckering, swelling, and retraction of the skin of the breast or the nipple, and, as you learned, nipple discharge. The crustiness you're referring to is likely related to the discharge from the nipple that has dried, forming a crusty scale.

In most cases, nipple discharge is nothing to worry about. It could be due to cysts in the breasts, non-cancerous tumors, or infection, among other conditions. Certain medications can lead to nipple discharge, as can consuming high amounts of caffeine, smoking and hormone therapy.

Generally, a discharge from both breasts, or one that is yellow, green, blue, or black is due to benign causes. But if you have a clear, colorless, or bloody discharge, particularly if it is only coming from one breast and spontaneous, you should be concerned.

In about 10 to 15 percent of cases, nipple discharge, particularly crusty nipples, may be a sign of breast cancer. In fact, one form of breast cancer called Paget's disease is marked by a crusty or scaly nipple sore or a discharge from the nipple.

This form of breast cancer does not usually show up on a mammogram and requires special procedures to identify. If you have crusty nipples (and you're not breastfeeding or pregnant), then you should see your health care professional.

He or she may want to refer you to a radiologist for testing. Breast imaging in addition to a mammogram may be required in order to identify specific problems causing the nipple discharge. The radiologist will likely perform a ductogram, also called ductography or galactography. The doctor gently inserts a small, hollow tube into the ductal opening of the nipple, then injects a small amount of a contrast dye into the tube and takes an x-ray. The dye helps the doctor see the duct on the tube and identify any problems.

The radiologist may also choose to perform an ultrasound or magnetic resonance imaging (MRI) to exam the breast, even if the results of other tests are negative.

Bottom line: If you have any discharge from your breast, and you are not pregnant, nursing, or have recently breastfed a baby, see your doctor for a complete evaluation.
Posted 9/15/2005

Q: My daughter is 17 years old. Her nipples are inverted and have not "popped" out. She's embarrassed and very self conscious about it. I don't know what to tell her, if it's normal or tricks to help the situation. I hope you have some suggestions for us! Thanks so much for considering our question.

Navin K. Singh, MD

A: First, I would tell you not to worry. Unless the inverted nipples occur suddenly, which could be a sign of breast cancer, they are in no way a health problem. However, they can become irritated and inflamed, and, as you already found, become a source of distress because of the way they look. Additionally, if your daughter wants to breastfeed, inverted nipples could cause difficulties.

The condition affects about two percent of women, or 18 women out of every 1,000, although some estimates put it much higher, at about 10 percent of women. It can involve one or both nipples. Nipple inversion usually occurs during fetal development because a small nipple base or constricted milk ducts develop, pulling the nipple inward. Sometimes, it can occur after childbirth if the milk ducts scar during breastfeeding.

Doctors grade inverted nipples according to three levels:

• Grade I inverted nipples can "pop out" when exposed to cold or during arousal, or be manually popped out.

• Grade II nipples can be pulled out, but not as easily as grade I, and the nipple retracts quickly.

• Grade III nipples are severely inverted and it is very difficult to pull them out manually.

Treatment for inverted nipples depends on the severity. For instance, grade I nipples may be extracted using a plastic cup called a "nipple eversion device" that pulls the nipples forward. You can find these in breastfeeding sections of baby stores or online.

The majority of inverted nipples, however, are treated surgically. There are a variety of surgical techniques available, and the best one depends on your daughter's situation and the surgeon's skill. Make sure you ask the surgeon if the procedure will harm the milk ducts; it's a risk with this type of surgery, and could impact your daughter's ability to breastfeed in the future.

You should also be aware that, in rare instances, the nipple retraction may reoccur after surgery.
Posted 9/1/2005

Q: I had my yearly mammography yesterday. It was the first time I had used this facility since I recently moved out of my home state. I always experienced pain and just when I thought I could not stand any more the machine would release. This time there was only a slight pinch. I wonder if it was done properly. I even mentioned it to the tech. She didn't give me an explanation.

Arpana M. Naik, MD

A: First, let me congratulate you for getting regular mammograms. As you know, screening mammograms are one of the best ways to insure that any cancer is caught early enough to insure a good outcome. In fact, a woman whose breast cancer is detected through screening alone is, on average, 50 percent less likely to die from the disease.

Now, as for the pain you typically experienced. There is a lot of anecdotal discussion about pain during breast imaging. However, researchers find that few women feel actual pain. One study published in 1988 in the Archives of Internal Medicine surveyed 1,847 women at seven breast-imaging centers and found that 88 percent experienced either no discomfort or only mild discomfort, and no woman had pain severe enough to keep her from having another mammogram.

Any discomfort during a traditional mammogram (not an MRI or breast ultrasound) comes when the breast is compressed between the film paddle and a piece of plastic. This flattens out the breast, enabling the technician to film the maximum amount of tissue. But you're right, it can be uncomfortable.

The amount of discomfort you feel is likely related to several things, including the skill of the technician and the time of month in your menstrual cycle (if you're still menstruating). You'll likely have less discomfort if you schedule your mammogram a week after your period, when your breasts are least tender. You may also have discomfort if you have fibrocystic breast disease, or "lumpy" breasts. Make sure you tell the technician before the scan, so that can be taken into account. If you really do have pain, bad enough to make the experience very unpleasant, you might want to talk to your health care professional about other options, such as MRI or breast ultrasound.

However, it sounds like, for whatever reason, your problems may be solved. Maybe the imaging center where you had your most recent exam used Mammo-Pads. These soft foam pads create a cushion between your breast and the surfaces of the mammography device without interfering with the x-ray. Studies find that about 74 percent of women experienced a 50 percent decrease in discomfort when using the pads.

Bottom line: The fact that you felt minimal discomfort during your mammogram in no way reflects on the quality of the image. If there was a problem with the mammogram, your technician or radiologist would have retaken the image. Before you schedule a mammogram, be sure to ask if the mammogram facility is accredited by the U.S. Food and Drug Administration. This means that it meets high professional standards of safety and quality.
Posted 8/15/2005

Q: Can a postmenopausal woman have more density in one breast compared to the other breast? And just what causes breasts to be "dense" in the first place?

Lillie D. Shockney, RN, BS, MAS

A: Breast density actually refers to how well a mammogram can "see" any potential cancers or precancerous conditions within your breasts. Your breasts are made up of fat, through which x-rays penetrate fairly well, and fibrous tissue, which x-rays don't penetrate that well. This fibrous tissue, which doesn't just occur in one breast but occurs bilaterally in both breasts, is called "radiodense," and it appears on the mammogram as a white area. This makes it very difficult to identify any tumors, which also appear as white.

This is important because we know that early detection of breast cancer results in better outcomes. We also know from numerous studies that denser breasts are associated with an increased risk in breast cancer. One study, for instance, found that every 15 to 10 percent increase in breast density increased the risk of breast cancer, while another found a 43 percent increase in breast cancer for every level of increased density. Yet another found a fivefold increased risk of breast cancer for women with 75 percent or higher density compared to women with less than 1 percent density. This increase