A new breast lump (or breast change) should be investigated with the triple test.
The triple test refers to 3 diagnostic components.
Medical History and Clinical Breast Examination
Imaging
Biopsy
The triple test is more accurate at detecting breast cancer than the individual components alone. When performed appropriately, the triple test will detect over 99.6% of breast cancers. A triple test negative on all components means breast cancer can be ruled out with 99% accuracy. An abnormal result (indeterminate, suspicious, malignant) on any component of the triple test requires referral to a breast surgeon.
What is mastalgia?
Mastalgia literally means breast pain. It is a common breast symptom, affecting 7 out of 10 women at some point during their lives.
What are the causes of breast pain?
There are 3 types of breast pain.
Breast Pain Related to Menstrual Cycle
Breast pain related to the monthly menstrual cycle is referred to as 'cyclical'. Cyclical breast pain is most common in women in their 20s and 30s. It results from monthly fluctuations of the hormones oestrogen and progesterone. Oestrogen increases before a period, causing milk ducts and glands to swell and trap fluid in the breasts. The pain generally builds up from the middle of the menstrual cycle, peaks in the 3 to 7 days before each period and then improves when the period begins. The pain is often felt in the upper outer parts of both breasts and described as heavy, dragging, or aching. Cyclical breast pain may worsen during perimenopause (when hormones surge erratically) and continue into menopause (especially in women taking hormone replacement therapy).
Breast Pain Not Related to Menstrual Cycle
Breast pain that does not vary with the menstrual cycle is referred to as 'non-cyclical'. Non-cyclical breast pain is more common in women in their 40s or older. The pain can be constant or intermittent. The pain is usually restricted to a small area of one breast (typically in the inner part of the breast or under the nipple) and described as burning, stabbing, or throbbing. Non-cyclical breast pain can be due to benign breast conditions (e.g. cysts, fibroadenomas), medications (e.g. antidepressants, antipsychotics, diuretics, digoxin) or trauma. Often no specific cause is found.
Extramammary Breast Pain
Pain that is felt in the breast can also arise from conditions outside the breast, including
Pectoralis muscle strain from activities such as raking, shovelling and lifting.
Costochondritis: inflammation of the cartilage that joins the ribs to the breastbone.
Referred pain from heart disease, gastro-oesophageal reflux disease or gallstones.
Normal Variation
It is common for one breast to be different in shape and size from the other.
The breasts may also show normal changes during different stages of a woman’s life. Changes in breast shape and size can occur with hormonal changes during the menstrual cycle, pregnancy, breastfeeding and ageing.
Breast Cancer
Sudden changes in breast shape or size, that is unrelated to your menstrual cycle, always require investigation with the triple test, as it could be a sign of breast cancer.
What skin changes can be caused by breast cancer?
Redness or "Rash"
Redness in the breast is usually due to an infection or a skin condition, but it can also be a sign of 2 uncommon types of breast cancer.
Inflammatory breast cancer is a rare and aggressive form of breast cancer in which cancer cells block the lymph vessels in the skin of the breast. This causes the breast to become swollen, red, and tender (similar to an infection). The skin on the breast can also appear dimpled, like an orange peel.
Paget's disease of the nipple is an uncommon type of breast cancer in which cancer cells grow in the nipple-areolar complex. The causes nipple skin to become red, painful, scaly, and sometimes ulcerated, and it may be associated with blood-stained or clear nipple discharge.
Thickened Area
A thickened area in the breast, which feels different from the rest of the breast, can be caused by cancer cells blocking circulation in the breast (via blood or lymph vessels) or a tumour growing the near the surface of the skin.
Dimple
Breast cancer can pull the skin inwards causing it to ident. The lump may not be palpable. Dimpling can be more easily seen when lifting your arms above your head to see if the whole breast moves with you as your raise and lower your arms.
Skin Sores
Breast cancer can sometimes grow to the point that it breaks down the skin of the breast to form an open wound, which may be associated with a discharge. This is usually accompanied by an obvious hard lump. Skin sores are a late sign of breast cancer.
Nipple Inversion and Retraction
Inverted nipples are nipples that pointed inward, rather than pointing out. There are many causes of nipple inversion.
Normal Variation
Inverted nipples can be normal variation of a nipple type. Some people are born with inverted nipples. Nipple inversion can also occur slowly and gradually with age. Inverted nipples that are not caused by a medical condition do not require treatment. Surgery can be performed to correct an inverted nipple for aesthetic reasons.
Duct Ectasia
Duct ectasia is a benign condition in which there is enlargement and inflammation of the ducts under the nipple. It usually occurs in women after menopause. Duct ectasia can also cause nipple discharge. In most cases, no treatment is required. If the discharge is a nuisance, the ducts behind the nipple can be removed surgically.
Paget's Disease of the Nipple
Paget's disease of the nipple is an uncommon type of breast cancer in which cancer cells grow in the nipple-areolar complex. Paget's disease causes the nipple skin to become red, painful, scaly, and sometimes ulcerated, and it may be associated with blood-stained or clear nipple discharge.
Breast Cancer
Nipple inversion that occurs suddenly always requires investigation with the triple test, as it could be a sign of breast cancer forming underneath and pulling the nipple inwards. Around 8% of women with breast cancer present with nipple changes.
Skin Changes of the Nipple
There are many causes of skin changes of the nipple.
Nipple Eczema
Eczema or dematitis affecting the skin of the nipple, particularly if it becomes infected, can cause a weeping discharge associated with crusting of the nipple. Punch biopsies of the affecting skin may be required to rule out Paget's disease. Treatment is with steroid based creams, the same as for eczema elsewhere in the body.
Paget's Disease of the Nipple
Paget's disease of the nipple is an uncommon type of breast cancer in which cancer cells grow in the nipple-areolar complex. Paget's disease causes the nipple skin to become red, painful, scaly, and sometimes ulcerated, and it may be associated with blood-stained or clear nipple discharge.
What is nipple discharge?
