Learning Objectives
By the end of this section, you will be able to:
- Explain the signs and symptoms, diagnosis and management, and nursing care of fibrocystic changes in the breast
- Explain the signs and symptoms, diagnosis and management, and nursing care of fibroadenomas in the breast
- Explain the signs and symptoms, diagnosis and management, and nursing care of nonlactating mastitis
- Explain the signs and symptoms, diagnosis and management, and nursing care of intraductal papilloma
A common fear of people experiencing a change in their breasts is that they have cancer, especially because some of those changes mimic symptoms of breast cancer. While it is always advisable for a person with breast abnormalities to be examined, many benign diseases also cause the same symptoms. In fact, these benign conditions are more common than breast cancer (Breastcancer.org, 2022a). One study estimates that 50 percent of women over age 30 have breast pain, or mastalgia, and fibrocystic changes (Stachs et al., 2019).
The term benign breast changes encompasses several different breast conditions. It describes noncancerous conditions, including trauma, breast pain, infection, skin changes, nipple discharge, and tumors. These changes are often associated with fluctuations in estrogen, which may explain why they are more common in people of childbearing age. In most cases, benign breast changes resolve on their own or are easily treated, but a few may increase the future risk of breast cancer.
Fibrocystic Breast Changes
Changes in either or both breasts that can cause lumpiness, or nodularity, or pain in the affected breast(s) are called fibrocystic breast changes (Figure 8.2). They represent the most common benign breast disease in persons assigned female at birth between 20 and 50 years of age (Chen et al., 2018; Gopalani et al., 2020).
Several hypotheses exist to explain the development of these changes, but they are most commonly a result of cyclic hormonal changes associated with a person’s menstrual cycle. Other proposed etiologies include:
- other hormonal imbalances, such as:
- “progesterone deficiency in luteal phase,
- estrogen excess,
- change in estrogen/progesterone ratio,
- differences in sensitivity and expression of estrogen and progesterone receptors,
- alterations in follicle-stimulating hormone (FSH) and luteinizing hormone (LH) secretion, and
- androgen deficiency.” (Yadav et al., 2020, p. 31)
- excess consumption of or withdrawal from caffeine and nicotine
- increased dietary fat intake (Yadav et al., 2020)
Other symptoms that may accompany these changes include:
- fullness or heaviness in the breast
- tenderness, usually in the upper, outer quadrant
- the presence of palpable, well-differentiated, and movable cysts
- nipple discharge
These symptoms tend to come and go, typically getting worse the week before a menstrual period and getting better about a week after the period.
Diagnosis and Management
Fibrocystic breast changes are diagnosed after a careful history and clinical breast exam. Some providers will also order a mammogram or sonogram to determine if fibrocystic changes are present. The health-care provider will palpate the breast tissue to feel evidence of thickening of the glandular tissue, called fibrosis, which will feel like firm or ropy tissue underneath the skin. The provider will also note any round and fluid-filled sacs (cysts) that can be felt in the breast tissue. If a cyst or mass is palpated, a diagnostic mammogram, ultrasound, and/or biopsy will be performed as needed. If the cyst is found to contain fluid, the fluid will be aspirated and sent for pathologic examination. If the cyst is solid, a fine needle aspiration will be performed, and the cells sent for pathologic examination. Core biopsy may be needed if a larger sample is required for analysis.
Fibrocystic breast changes usually require only conservative management, and the provider will recommend a “watch and wait” approach after diagnosis is confirmed. The patient will be instructed to return to the office for routine examinations to ensure that the lump or cyst has not grown or changed. In some cases, oral contraceptives can improve fibrocystic breast changes, but some people report a worsening of symptoms. Rarely, the provider may recommend surgical removal of the cyst or lump, usually only in cases where it is causing significant discomfort or distress to the patient or if there are multiple lumps or nodules.
Nursing Care
Nursing care centers on providing education about fibrocystic breast changes to the patient, as well as offering reassurance and support if the patient is expressing anxiety. The nurse can also suggest strategies to reduce discomfort:
- Use nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin).
- Reduce caffeine consumption.
- Reduce nicotine and alcohol usage.
- Wear a supportive bra.
- Use heating pads.
- Apply topical vitamin E oil.
The nurse should reinforce that it may take trying a few different strategies before finding what works for the patient.
Fibroadenomas
A painless, solid, noncancerous tumor found in the breast tissue is called a fibroadenoma. They are most common solid tumors of the breast. They can occur in people of all ages but are most common in those between 14 and 35 years old (Ajmal et al., 2022). Fibroadenomas are less common in postmenopausal people, perhaps because of decreased estrogen stimulation (Ajmal et al., 2022). Just as the etiology of fibrocystic changes is not certain, researchers are not clear on what causes fibroadenomas to develop, but it is hypothesized that they may be related to hormonal receptivity in the breast tissue. However, a key difference between fibrocystic cysts and fibroadenomas is that fibroadenomas do not change in size during the menstrual cycle. Instead, they tend to stay constant in size or grow slowly with time. However, fibroadenomas may enlarge with pregnancy and decrease in size after menopause.
In most cases, fibroadenomas do not increase a person’s risk for breast cancer. However, one type of fibroadenoma, called a complex fibroadenoma, may slightly increase breast cancer risk (El-Essawy et al., 2020). Patients should be advised on ongoing follow-up and be aware of any changes to the lump or their breasts.
The primary symptom of a fibroadenoma is a small painless lump in the breast tissue, usually less than 2.5 cm in diameter (Breastcancer.org, 2022b). They are usually solitary lumps, meaning they are found one at a time; however, some people do develop multiple fibroadenomas or fibroadenomas in both breasts. These tumors are typically well defined, round, and rubbery in consistency (Figure 8.3). They are usually easy to move in the tissue. While the tumors don’t cause pain, some people do experience tenderness at certain points in their menstrual cycle.
Life-Stage Context
Breast Changes after Menopause
The hormonal changes associated with perimenopause and menopause affect not only the menstrual cycle but the breast tissue as well. The decline in estrogen causes connective tissue in the breasts to lose elasticity and hydration, causing the breasts to shrink and lose shape, and contributing to a sagging appearance. In addition, there is a decline in glandular tissue and an increase in fatty tissue of the breasts (North American Menopause Society, 2023). However, a person who is taking hormonal therapy may not experience these changes due to the supplementation of estrogen and progesterone.
Diagnosis and Management
Fibroadenomas are diagnosed based on the clinical exam and possibly a biopsy. A detailed medical history and family history are important because risk factors for fibroadenoma and breast cancer are very similar: person’s age and family history of breast cancer; negative risk factors are also similar: later age at menarche and multiparity (Li et al., 2018). Additional testing will usually be ordered to confirm the diagnosis. The most common types of testing for the breasts are mammograms, ultrasound exams, and biopsies:
- Mammography: Fibroadenomas appear as distinct growths with smooth, round borders.
- Ultrasonography: Ultrasound imaging of the breast helps to distinguish fluid-filled cysts from solid structures, like fibroadenomas. Fibroadenomas appear as round, well-defined masses that are hypoechogenic (decreased response to the ultrasound waves, producing a dark gray image).
- Biopsy: Biopsy is often performed in people over 30 years of age to definitively confirm the diagnosis. A small sample of the tumor is taken either by fine needle aspiration (FNA) or by core biopsy using ultrasound guidance.
People under the age of 30 years may just need “watchful waiting” to monitor for signs that the tumor is getting larger or changing. Ongoing visits with the provider may also be needed.
In most cases, fibroadenomas do not need any further treatment and will disappear over time. However, fibroadenomas can increase the risk of developing breast cancer by 74 percent (Li et al., 2018). The health-care provider may recommend removal through lumpectomy or excisional biopsy. Cryoablation, using a cryoprobe inserted into the tumor to freeze and destroy the tumor cells, is an alternative to surgery.
Nursing Care
Nursing care for the patient with a fibroadenoma will depend on the patient and their clinical situation but centers on education and support. Reassurance may be especially crucial for a patient who is anxious or nervous that they have breast cancer. The nurse should also stress the need to comply with instructions for follow-up care. The nurse may also review strategies and techniques such as self-breast exam to increase the patient’s awareness of their own breast tissue and potential changes.
If a patient is to have surgical removal of the fibroadenoma, nursing care occurs preoperatively, intraoperatively, and postoperatively. Table 8.1 describes nursing care during all phases of a surgical lumpectomy.
| Stage | Nursing Care |
|---|---|
| Preoperative care |
|
| Intraoperative care |
|
| Postoperative care |
|
Nonlactation Mastitis
Inflammation of the breast tissue in a non–breast-feeding person, which may or may not occur with an infection, is called nonlactation mastitis. Mastitis most commonly occurs during breast-feeding; however, it is possible for patients to develop this infection even while not lactating, known as nonlactational infectious mastitis (NLIM). This infection can be caused by several organisms, though most are caused by species of staphylococci (Costa Morais Oliveira et al., 2021). The two forms of NLIM predominantly affect younger people:
- Periductal mastitis (PDM): PDM, or mammary ductal ectasia, is a chronic inflammation of the breast tissue that also causes dilated mammary ducts with thickened walls; plasma cell infiltration; leakage of fluid into the surrounding tissue, leading to inflammation and fat necrosis; and sometimes the formation of an abscess (Figure 8.4). PDM is associated with obesity, smoking, and diabetes mellitus (Bajaj, 2020). PDM presents as pain or redness in the skin of the breast, nipple inversion, greenish nipple discharge, and a possible fever (Bajaj, 2020).
Figure 8.4 Periductal Mastitis Periductal mastitis causes an area of inflammation and redness in the breast tissue. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
- Idiopathic granulomatous mastitis (IGM): IGM is a rare chronic inflammatory condition of the breast tissue. It is noncancerous and most commonly affects women of childbearing age. However, the symptoms and presentation closely mimic those of breast cancer, which can complicate diagnosis and treatment. The exact cause of IGM is not known, but several possibilities are thought to increase the risk for this condition: reaction to oral contraceptives, infection, autoimmune or immunologic response, pregnancy, breast-feeding, hyperprolactinemia, galactorrhea, and alpha-1 antitrypsin deficiency (Sarkar et al., 2023). IGM presents as a well-defined, hard lump of the breast, along with nipple inversion, peau d’orange appearance of the skin (Figure 8.5), and ulceration and fistula of the breast tissue (Sarkar et al., 2023).
Figure 8.5 Peau d’Orange Appearance of the Breast Peau d’orange in the breast causes a characteristic “orange peel” appearance of the skin on the breast and can indicate several conditions, including inflammatory breast cancer or idiopathic granulomatous mastitis. (credit: “Clinical photo of IBC patient” by the Intramural Research Program of the Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services/National Library of Medicine, National Center for Biotechnology Information, CC BY 3.0)
Diagnosis and Management
Because nonlactational mastitis can mimic the signs and symptoms of breast cancer, careful evaluation and diagnosis are crucial. Diagnosis begins with assessing the clinical presentation, including a thorough history and physical exam. Further imaging may be ordered, such as ultrasound, mammography, or magnetic resonance imaging (MRI). However, mammography can be extremely painful in a patient with an abscess, and some types of lesions, particularly IGM, may be indistinguishable from breast cancer (Sarkar et al., 2023).
Fine needle aspiration is not usually indicated in routine cases of mastitis, but it may be indicated in patients with a complicated or atypical presentation or to confirm a suspected abscess. Any drainage from the nipple or aspirate should also be sent for pathologic study and culture and sensitivity tests to determine the presence of infection and guide antibiotic treatment. Other types of tissue biopsy, such as incisional or excisional biopsy and core needle biopsy, can be used to distinguish between granulomatous inflammation, infection, and cancer (Bajaj, 2020).
Once the diagnosis of NILM is confirmed, medical treatment may include:
- antibiotics based on the culture and sensitivity results
- pain medication if needed
- surgical incision and drainage of an abscess if present
- corticosteroids if IGM is diagnosed
- hospitalization, which is rarely necessary but may be indicated if signs of sepsis are present, if the infection does not respond to treatment and continues to progress, or if the patient is clinically unstable
Mastitis, if untreated, can lead to significant complications, including formation of large or extensive fistulas, bacteremia and sepsis, and recurrent infection or infections at extramammary sites. Rarely, mastitis and abscess can lead to death, particularly if the infection is poorly treated or not treated at all (Sakar et al., 2023).
Nursing Care
In addition to implementing medical management as ordered by the provider, the nurse can assist the patient by suggesting comfort measures to help alleviate pain and promote healing. These may include:
- applying heat or warm compresses to the affected area
- applying cold packs to the affected area
- having lymphatic drainage performed
- wearing a supportive bra
- sleeping on the unaffected side
- using breast pads to contain leakage or drainage
Patient education may also be needed about the importance of follow-up care, signs and symptoms to report to the provider, smoking cessation (if needed), and how to take any prescribed medications, including completing the entire course of antibiotics and reviewing side effects and drug interactions.
Link to Learning
Watch this video providing patient education for a fine needle biopsy of the breast to learn effective ways to prepare the patient for what to expect during a biopsy.
Intraductal Papilloma
A benign tumor that grows inside the milk ducts of the breasts is called an intraductal papilloma. These tumors are wart-like and made of fibrous tissue, gland tissue, and blood vessels (Figure 8.6). An individual, single tumor that grows close to the nipple in the larger milk ducts is called a solitary papilloma (American Cancer Society, 2022b). These solitary papillomas can cause an unusual bloody or clear nipple discharge. Patients may present to the office due to feeling a lump (sometimes painful) next to or behind the nipple. Papillomas found in the smaller milk ducts farther from the nipple are called multiple papillomas and do not produce nipple discharge.
Diagnosis and Management
When a patient has symptoms of nipple discharge, the health-care provider will order a thyroid and prolactin level to confirm the discharge is not due to another cause. A mammogram or ultrasound of the breast is also ordered for breast masses with nipple discharge. A ductogram can be performed to investigate nipple discharge. Dye is injected into the leaking duct, and an x-ray is taken to determine if a papilloma is present and causing the nipple discharge. A breast biopsy can be done to determine the actual diagnosis of papilloma. In larger, painful papillomas, surgery can be performed to remove the tumor.
Nursing Care
Nursing care of these patients consists of routine postsurgical care if a biopsy or papilloma removal is performed. The nurse instructs the patient to keep the dressing clean and dry. Nurses must also provide reassurance and support. These patients may have a great deal of anxiety and fear of having breast cancer. Nurses can provide reassurance that the tumor is benign and no cancer was found.