Question:
A woman has contacted me because she has what appears to be a plugged duct or mastitis during her pregnancy. This is her second pregnancy. She is not nursing an older child. She is 34 weeks along and has had a red, hard spot below her nipple for 6 weeks.
She has seen her OB and a breast specialist. The breast specialist is saying that this is a normal change during pregnancy. The breast specialist did try to aspirate fluid from the lump, but there was no fluid. The woman has taken two courses of antibiotics. She is returning to her OB and the breast specialist. I suggested she also contact an LC. I also passed along information on treating plugged ducts and mastitis. At this point it does not appear to be mastitis because she does not have a fever.
What she is really interested in knowing is whether this is at all common. She had supply issues with her first baby and is worried that this situation will negatively impact nursing her second baby.
Robin Barnes, LLL Leader, Austin, Tx
Answer:
Barbara & Kay Respond (with guest commentary from Sandy Kugleman, a mother whose breast cancer was diagnosed when she was breastfeeding.)
It is possible for both men and women to experience mastitis unrelated to pregnancy or lactation, and it is possible to have mastitis without fever (Amir 1999). In the case you describe, it is certainly possible for the lump to be related to pre-natal mastitis, but it is critical to recognize that breast cancer can present as a persistent inflamed, solid lump without fever.
The fact that there was no available fluid to aspirate suggests it is a solid (rather than a cystic) mass. In the strongest possible terms we would suggest this woman get a second opinion and obtain an ultrasound visualization of the breast. She should inquire about whether she requires a breast biopsy. Biopsy this close to delivery may predispose her to difficulties with that breast healing in time for lactation, but biopsy is the standard of care for ruling out breast cancer.
Twenty-five percent of women are diagnosed with breast cancer during their child-bearing years (Camune 2007). The pregnant and lactating breast may often be lumpy, but typically the lumps move around. A discrete mass that persists may be a sign of cancer (Lind 2004). Lactation consultants and others assisting breastfeeding mothers must be alert when a woman relates suspicious findings (Petok 1995).
Warning Signs Include:
- Skin color changes on the breast, especially in the absence of fever (Cristofanilli 2003)
- Skin texture changes (wrinkling, puckering)
- Masses, lumps, especially fixed (non-movable), irregular shaped
- Spontaneous nipple discharge, typically only on one side
- Mastitis that recurs in the same area and does not respond with standard treatment
This is a challenging counseling situation. Neither LLL Leaders nor LCs can diagnose, and we want to assist women without alarming them. Hopefully this is not a cancerous tumor, but one of the leading causes of malpractice law suits reported in the medico-legal literature with regard to mid-diagnosis of breast cancer is “physician distraction.” Often, a woman’s pregnant or lactating status distracts providers and they fail to do the usual diagnostic tests to rule out carcinomas. Delays in diagnosis can have very tragic results for these women and their families. In terms of the counseling approach, the following wording is helpful:
“Clearly you are worried that there has been no change and that the diagnoses you have received seem inconclusive. Because you will just worry until you know what this lump is, I would suggest going back to the doctor or seeing a different doctor and stating that you are concerned about the persistence of the mass and would like it visualized to rule out breast cancer.”
We suspect this woman is lying awake at night imagining the worst, so it may be a relief for her to receive honest feedback. Misinformed reassurance, without sufficient assessment to legitimize it does her no favors. She deserves an answer and early diagnosis and treatment if this is a tumor. If it is not, a thorough assessment will provide real reassurance and she can get on with her life.
Because this post was originally on another discussion group, it was also responded to by Sandy Kugleman, whose diagnosis of breast cancer was made during lactation. The Leader who originally posted, Sandy, and the mother involved, have all given permission to share this information in the interests of preventing over-looked cases. Here is what Sandy has to say:
“Thanks for your reply to this, Barbara. Just another .02 cents from the breast cancer side: I have met a few women who were brushed away by their doctors because they were pregnant and so it was assumed that the lump in their breast was related to pregnancy. There is one woman in my cancer support group right now in fact, with Stage IV. I’ve even heard the “you’re too young to have breast cancer” line. I’m glad this woman is going to a breast specialist, who I’m guessing is a surgeon. In that case, she should be taken seriously. Bottom line: All unexplained lumps or masses that do not resolve should be checked out. Always. In fact, I would like the breastfeeding support organizations to take a more proactive stand on this issue!”
Best,
Sandy Kugleman
References:
Amir LH, Harris H, Andriske L: An audit of mastitis in the emergency department. J Hum Lact. 1999; 15(3):221-4.
Camune B, Gabzdyl E. Breastfeeding after breast cancer in childbearing women. J Perinatal and Neonatal Nurs 2007; 21(3):225-233.
Cristofanilli M, Buzdar A, Hortobagyi G. Update on the management of inflammatory breast cancer. The Oncologist 2003; 8(2):141-148.
Dahlbeck S, Donnelly J, Theriault Rd. Differentiating inflammatory breast cancer from acute mastitus. Am Fam Phys 1995; 52(3):929-934.
Lind DS, Smith BL, Souba WW. 5 Breast Complains. in Souba WW, Fink MP, Jurkovich GJ, et al. ACS Surgery Online. New York: WebMD Inc. 2004.
Petok E. Breast cancer and breastfeeding: five cases. J Hum Lact 1995; 11(3):205-209.
