Breast Health and Breastfeeding

Kathy Koch, MEd, IBCLC
Great Mills MD USA
From: LEAVEN, Vol. 38 No. 6, December 2002 - January 2003, pp. 136-37.

As breast cancer awareness increases, women are reminded more frequently to be cognizant of their breast health. Unfortunately, many women believe that breast health guidelines and screening/diagnostic techniques do not apply to them if they are lactating. In most situations, a lactating woman can have mammograms, needle biopsies, and breast surgery while nursing her baby.

Diagnosis

The discovery of a breast lump often happens as a result of physical touch by the mother, her spouse, or her health care provider. Often, the health care provider will have an idea about the nature of the lump by its feel. Benign lumps usually feel round, smooth and move about in the breast tissue. Cancerous lumps can be irregular in shape, feel "gristly," and are more likely to be fixed in the breast tissue (Love 2000; Margolese et al 1998).

The next step is usually a mammogram to help determine the type of lump. Many doctors (and women) believe that a baby must be weaned before performing a mammogram. Lactation can make a mammogram harder to read and may make mammograms for routine screening purposes inappropriate. An experienced radiologist will be able to read a diagnostic mammogram on a lactating breast. This is especially true if the mother has had previous mammograms available for comparison, although this is unlikely for most women of childbearing age. The mother may feel more comfortable if she nurses her baby immediately preceding the mammogram. Ultrasound may also be used for determining the nature of a breast lump but may not be accurate for diagnosing areas of the breast that seem suspicious in a mammogram but contain no palpable lump (Margolese et al 1998; Robidoux et al 1998).

Sometimes a mammogram might be diagnostically inconclusive. In these cases, fine needle aspiration can help distinguish between a fluid-filled cyst and a solid mass. Aspiration of a cyst will cause it to collapse and assure that the lump is benign. Lactating women may have milk-filled cysts called galactoceles. These are harmless and can be aspirated or left alone. If the lump is solid, any cells obtained in a needle biopsy can be sent for pathological evaluation. (Love 2000; Margolese et al 1998).

If the lump is solid it needs additional evaluation. The health care provider might use a large-bore needle to remove part of the lump for analysis. This technique is also used when the area in question is not a palpable lump but a generalized area of concern seen by mammogram, such as calcifications. While calcifications are benign, some breast cancers look like calcifications on the mammogram so it is important to investigate further. The health care provider will use the large-bore needle to obtain tissue samples from several areas of the mass or suspicious area. If the pathology report shows benign changes in samples from several areas of the lump, the health care provider can be reasonably certain that the benign diagnosis is accurate. If no changes are seen in the tissue, the health care provider may not have obtained an accurate sample and further testing may be appropriate (Robidoux et al 1998).

In some cases, an open biopsy, or surgical removal, of the lump or questionable area is appropriate (Margolese et al 1998; Robidoux et al 1998). Lactation might make the surgery a bit trickier because milk may leak if ducts are cut, but does not preclude breast surgery. Some surgeons are not comfortable performing surgery on a lactating breast. They might insist that a mother wean her child before surgery so there is no milk present in the ducts. This is not practical because it can take several weeks to months for all milk to disappear completely and if a breast lump is suspicious the mother will not want to wait. Both mother and surgeon will want to be prepared for the presence of milk, both during the surgery and post-operatively. While this can be messy and may slow healing, it does not pose any danger to recovery. Some surgeons will leave the incision open to allow drainage of milk during healing. Others may insert a drain or wick to collect the extra milk. Still others will close the incision and allow it to heal as they would any other incision (Love 2000).

After surgery, the mother can nurse her baby as soon as she feels comfortable. If the incision is close to the baby’s mouth, she might want to pump that breast for a day or so. If she chooses to nurse on that side, she might feel more comfortable if she applies light pressure to the incision with her hand to support it as the baby nurses. She might see some blood or blood-tinged milk coming from her nipple. This is normal and will resolve as the breast heals. The blood will not hurt the baby but s/he might prefer not to nurse on that side. If this is the case, the mother can be encouraged to hand express or pump to maintain her milk supply and relieve discomfort (Love 2000).

In the majority of cases (80 percent) the pathology report will confirm that the lump is benign, usually a cyst, fibroadenoma (benign, fibrous tumor), scar tissue, or abscess (Love 2000). If the lump is found to be cancerous, and chemotherapy is the decided course of treatment, the mother will have to wean her baby during the chemotherapy treatments (Hale 2000). If radiation is used, she might be able to continue nursing on the unaffected side. If the cancer is removed by lumpectomy, breastfeeding can continue uninterrupted. Mastectomy obviously precludes breastfeeding on the side where the breast was removed, but the mother can nurse her baby with her remaining breast.

Risk Factors

As stated by Dr. Susan Love, there are two types of risk factors for breast cancer: genetic and external. The genetic factors that impact breast cancer risk include:

Age: The risk for breast cancer increases as a woman ages. Caucasian and African-American women have a 1:12-14 risk of developing breast cancer by the age of 75.
Menstrual history: Earlier menarche contributes to an increased risk of breast cancer. A study indicated that the number of ovulatory cycles was directly related to breast cancer risk.
Age at menopause: An earlier menopause reduces the number of ovulatory cycles and decreases risk.
Family history: Women with first-(mother and sisters) and second-degree (aunts and grandmothers) relatives with breast cancer are at an increased risk for developing breast cancer. The majority of women with a positive family history, however, do not develop breast cancer.
BRCA genes: Possessing the breast cancer genes (BRCA1 and BRCA2) will increase a woman’s chances of getting breast cancer but it is not a guarantee that she will develop the disease. A woman can still develop breast cancer that is not related to the gene (Love 2000).

There are also external risk factors for breast cancer:

Age of first pregnancy: A woman who has her first pregnancy before age 20 will dramatically reduce her breast cancer risk. Similarly, the older a woman is when she has her first child will increase her breast cancer risk.
Breastfeeding history: Breastfeeding reduces a woman’s breast cancer risk. This is due in part to lactational amenorrhea.
Diet: A diet that is low in fat and high in fiber may be beneficial in reducing breast cancer risk. Eating foods rich in vitamins A, C and E can be protective against breast cancer.
Alcohol consumption: Consumption of alcohol may increase breast cancer risk. Even moderate consumption of alcohol (three to nine drinks per week) can increase risk by one-third.

Prevention

There are many things we can do to decrease our personal risk of developing breast cancer in our lifetime (Love 2000).

Diet: A diet high in fiber, vitamins, fruits and vegetables and low in fat, as well as minimal consumption of alcohol, can increase overall health and possibly reduce breast cancer risk.
Breast Self-Exam: A 2001 review of trials evaluating the effects of breast self-exams on breast cancer outcomes indicated that routine breast self-examination does not improve mortality rates and may increase unnecessary biopsies and fear among women (Baxter 2001). Love (2000) is in agreement that breast self examination has limited value in saving lives from breast cancer. As breast self-exam does help find lumps at a slightly earlier stage than other means, lumpectomies might have better cosmetic outcomes (due to a smaller lump).
Exercise: Our understanding of the role of exercise and its relation to breast cancer prevention is preliminary. It appears to have a beneficial effect of breast cancer risk reduction (Love 2000), as well as contributing to overall health.
Medication: Hormones such as tamoxifen are used in women who have had breast cancer to prevent a recurrence. It is not yet clear whether tamoxifen is preventing cancer from developing or treating very small, and yet undetected, cancers that are already present in the breast (Love 2000). In any case, tamoxifen is not considered to be an appropriate medication for breastfeeding women as it may accumulate in the infant’s body with prolonged use and can reduce prolactin levels and inhibit lactation (Hale 2000).
Breastfeeding History: Breastfeeding reduces a woman’s breast cancer risk. According to a recent report (Lancet 2002), a woman’s risk of breast cancer decreases by 4.3 percent for every year she breastfeeds. This is due in part to lactational amenorrhea.

Many women fear developing breast cancer, but with a better understanding of diagnostic techniques, as well as risk and prevention factors, hopefully the fear can be replaced by empowerment and a proactive approach to preserving breast health.

References:

Baxter, N. Preventative health care, 2001 update: Should women be routinely taught breast self-examination to screen for breast cancer? Can Med Assoc J 2001; 164(13):1836-1846.

Hale, T. Medications and Mothers’ Milk. Amarillo, TX: Pharmasoft Publishing, 2000.

Love, S. M. Dr. Susan Love’s Breast Book, 3rd edition. Cambridge, MA: Perseus Publishing, 2000.

Margolese, R.G. et al. The palpable breast lump: information and recommendations to assist decision-making when a breast lump is detected. Can Med Assoc J 1998; 158(3):S3-S8.

Robidoux, A. et al. Investigation of lesions detected by mammography. Can Med Assoc J 1998; 158(3):S9-S14.

Kathy Koch, MEd, IBCLC was accredited as an LLL Leader in 1992. She currently serves as Area Professional Liaison (APL) for LLL of MD/DE/DC (Maryland / Delaware / District of Columbia), USA. Kathy lives in Maryland, USA with her children, Andrew (12), Abby (10), and Molly (7), and her husband, Paul. With a mother and grandmother with breast cancer, she has a special interest in promoting breast health education. Send ideas and articles for "Keeping Up-to-Date" to Contributing Editor, Norma Ritter at norma at stny.rr.com (email) or to: 58 Antler Road, Big Flats, NY 14814 USA.