Conditions Expert Dr. Otis Brawley Chief Medical Officer,
American Cancer Society

Expert answer

You give me an opportunity to remind women about breast health. Women should always consult a physician if they feel an abnormality in the breast, and especially a breast mass.

There are a number of masses that occur within the female breast. Most masses are not cancer. I emphasize this, hoping to keep women from panicking if they do find a mass.

Among the benign masses, most are only an inconvenience and of no threat, but some are associated with increased long-term risk of breast cancer.

A fibroadenoma is a benign mass of fibrous and glandular tissue. Fibroadenomas are most commonly found in women aged 15 to 35. They increase in size with estrogen stimulation and regress after menopause.

These masses can often be felt in the breast, and can be seen on ultrasound, mammogram and magnetic resonance imaging. One out of every five women with a diagnosed fibroadenoma has more than one.

Fibroadenoma is one of a group of benign masses that are collectively called "proliferative lesions without atypia." Other tumors in this category include ductal hyperplasia, intraductal papillomas, sclerosing adenosis, and radial scars.

Some women will have a fibroadenoma mixed with other proliferative lesions. A pathologist generally makes the diagnosis of fibroadenoma after a piece of the mass has been removed through a needle biopsy or the entire mass has been removed through a small incision.

There are two types of fibroadenomas. They are called simple and complex. Simple fibroadenomas are not correlated with an increased risk of breast cancer and often the only treatment given is surgical removal of the mass and the routine follow-up that all normal risk women should undergo. It is actually not necessary to remove all of a proven simple fibroadenoma, although most women do want it removed.

A complex fibroadenoma is associated with a modest increase in long-term risk of breast cancer. When I say modest, a woman with this mass is 1.5 to 2 times more likely to develop breast cancer in her lifetime than women in general.

To give some perspective, some BRCA1 and BRCA2 genetic mutations increase risk of breast cancer by a factor of 7 to 11 times. The treatment of a complex fibroadenoma is complete surgical removal followed by enhanced surveillance or enhanced screening for breast cancer.

For routine surveillance, most encourage women at normal risk, under age 40, to practice breast awareness and get routine clinical breast examinations.

Breast awareness is the concept that women should know how their breasts normally look and feel and seek assessment of any breast change promptly from their health care provider.

Over the past two decades, most respected organizations that make recommendations have de-emphasized systematic monthly breast self-examination. Think of the newer recommendation as more of a daily, quick, less thorough examination as opposed to the intense once-a-month examination.

The movement away from monthly breast self-examination recognizes that most breast masses found by the patient are found while dressing or in the shower, even among those who did the intense monthly examination.

In addition to breast awareness, most respected recommendations also encourage women of normal risk under 40 to undergo a clinical breast examination by a health care provider who is specifically trained to do it. This clinical exam should be done on a regular basis (every one to three years).

Most recommend that normal-risk women age 40 and older get annual mammography and breast clinical examination. Enhanced surveillance for a woman at high risk needs to be planned by a trained health care provider taking into account the woman's specific risk factors, such as whether her pathology has more than just a complex fibroadenoma, her breast density, her age, her genetic risks and her family history.

There is no definite answer as to what the appropriate follow-up should be. A woman in her 20s and 30s whose breasts are not very dense might get annual mammography and once or even twice a year clinical breast examination. A woman of the same age with more dense breasts might be given regular ultrasound or magnetic resonance imaging with routine clinical breast examination.

Women who maintain an ideal body weight and exercise regularly do have a lower risk of a number of diseases to include breast cancer. Women over age 35 and at a very high risk for breast cancer might consider taking tamoxifen or raloxifene.

These are anti-estrogen drugs that are FDA approved for reducing breast cancer risk. These drugs do have a risk of side effects that must be considered in making a decision. Women at extremely high risk can also consider prophylactic mastectomy.

None of these preventive measures prevents 100% of all breast cancers. Even prophylactic mastectomy cannot remove all breast tissue, so some of these women still get breast cancer.

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