Breast Cancer - Not Always a Lump

Published: 09th February 2012
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Fifty-year-old Carolyn was an avid jogger and a very health conscious person. She always tried to eat properly ensuring she met the daily recommendations of fruits, vegetables and water. For cardiovascular health, she jogged at least two miles most days of the week. So when she noticed a rash on one of her breasts, she thought little of it. It was a little itchy and red and she recognized it as being some sort of rash. Making an appointment to see her general practice physician, she contemplated what could have caused this rash since she was always very careful when she visited the gym. Her physician, also aware of Carolyn’s health practices, spent less than three minutes examining the rash and determined it was an allergic reaction. She informed Carolyn that is was most likely caused by her sports bra and she should invest in one that contained moisture barrier technology. Armed with her doctor’s advice and a prescription for a topical steroid cream, she felt confident that the rash would soon be a thing of the past.
Rachelle, a 48 year old mother of three, noticed that one of her breasts was tender and slightly swollen. She also noted that was a little red and warm to the touch. She knew that mastitis, an infection of breast tissue, had been a problem for her when she was younger, but that had been years ago. As she examined her breast, she did not feel any lumps or notice any dimpling, only the tender swelling and a slight heaviness. Making an appointment with her gynecologist, she padded her bra for comfort and went to see her physician. Upon examination, her gynecologist assessed the tenderness, swelling and erythema (redness of the skin). She concluded that Rachelle had mastitis and ordered antibiotics. Rachelle completed a seven day regimen of medication, only to have her condition persist.
What do both these women have in common? The most obvious answer is that they both have something wrong with their breasts. What is not so obvious is that they have the same condition and this condition is deadly. These women both have inflammatory breast cancer also know as IBC. And like many other women, their physicians have initially misdiagnosed their condition.
There has been a lot of attention in the media promoting breast cancer awareness. Women are encouraged to perform monthly self-breast exams (SBE) and have yearly clinical breast exams performed by their doctors. However, not much attention has been given to the signs and symptoms of a rarer and much deadly form of breast cancer. Several years ago, I received a call from a lady who wanted me to write an article in our monthly bulletin about IBC. She told me that someone close to her had lost their life in the battle against this disease and she wanted to make others aware of it. I wrote the article back then and had not given any more thought until recently as we approach the Susan G. Komen Marathon for the Cure (ww5Komen.org). I felt obligated to make women aware that it is not always a lump than leads to breast cancer.
IBC present with erythema (redness or pink-purplish discoloring of the skin) on the breast. The area may be warm to touch and swollen which often leads to the misdiagnosis of mastitis (infection of the breast). The rash appears over a large area of the breast and the nipple may or may not be inverted (turned inward). The rash may have ridges or an orange peel appearance and can also be itchy. In Carolyn’s case, her rash was red and itchy, not painful. Her nipple was not inverted and she had no other signs and symptoms when she presented to her doctor. However, upon further examination a clinician would probably notice swollen lymph nodes under the arm and above the collar bone (clavicle). A patient does not always have a lump in the breast.
Inflammation is a change in the body’s tissue in response to injury, irritation or infection. If you have a spider bite for example, the body’s response would be to send WBC (white blood cells) to fight the invading pathogen (the spider’s venom). This increase of red blood cells to the site of insult causes swelling and warmth. This type of breast cancer presents with similar symptoms in addition there is the rash. However, it is not WBC’s causing the swelling, but cancer cells blocking the lymphatic system to the skin. Rachelle’s doctor treated her the most common way, with antibiotic. However, after seven to 10 days of unsuccessful treatment, other diagnostic tests should be ordered.
Signs and Symptoms:
• Breast warmth
• Redness over more than 1/3 of the breast
• Swelling of the skin
• Breast nipple may or may not turn inward
• The woman may feel a heaviness in the breast or chest
• A lump may not be detected
• The rash may be itchy or painful and have an orange peel texture
• Swollen axillary (under the arm) and clavicular (collar bone) lymph nodes

The American Cancer Society recommends that women follow the following guidelines:
• “Women age 40 and older should have a screening mammogram every year
• Women 20 – 30 years of age should have a clinical breast exam (CBE) as part of a periodic (regular) health exam by a health professional, preferably every 3 years. After age 40, women should have a breast exam by a health professional every year.
• Breast self-exam (BSE) monthly for women starting in their twenties. Women should report any breast changes to their health professional right away.
• Women at high risk (greater than 20% lifetime risk) should get a magnetic resonance imaging (MRI) scan with their mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%”.
IBC is rare, but recently has become more common accounting for about 1-5 percent of breast cancers diagnosed in the United States (American Cancer Society, 2012). It also occurs at a younger age when compared to other types of breast cancer. IBC is more aggressive and spreads more rapidly. It is always diagnosed at least in Stage IIIB (locally advanced).This is because the cancer cells have grown into the skin and had often already metastasized (spread through other parts of the body). IBC is also more common among African American women as compared to Caucasian and affects younger women more than other types of breast cancers.
Diagnosis can be made with a mammogram because of the thickening of the tissue. However, it is often missed this way or a definitive diagnosis cannot be made due to the tenderness and swelling of the breast. An ultrasound of the breast can detect enlarged lymph nodes under the arms and can be used in conjunction with a needle biopsy (this involves the insertion of a very thin needle into the questionable tissue to retrieve a sample for microscopic examination). MRI (magnetic resonance imaging), PET scans (positron emission tomography), and CT scans (computed tomography) are additional diagnostic tests that can be used and diagnosing IBC.
Once a diagnosis of cancer is made, the cancer is then classified by stages which reflect the extent or severity of the disease. IBC is classified as either Stage IIIB or Stage IV breast cancer when diagnosed with Stage IV meaning the cancer has spread to other organs in the body.
Treatment involves chemotherapy to shrink the tumor followed by surgical removal of the breast (mastectomy) and removal of lymph nodes (lymphectomy). This is often followed with radiation and another round of chemotherapy. The woman may also receive hormone therapy to interfere with the affects of estrogen (estrogen has been found to promote the growth of certain cancer cells).The five year survival rate for IBC is poor with the average woman living only about 18 months after diagnosis. This is can be attributed to the late stage in which IBC is first diagnosed. However, advances in medicine and continued research have improved the outcome of this disease.
References: Andic, F., Godette, K., O’Regan, R., Zelnak, A., Liu, T., Rizzo, M., Gabram, S. Torres, M. Treatment adherence and outcome in women with inflammatory breast cancer. Cancer, Dec 2011, 117(24), 5485 -5492; American Cancer Society. Retrieved from www.cancer.org; www.IBCresearch.org.


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