Breast surgery and breastfeeding (Part 3)
Part 3, evaluation of a breast lump
This article is part 3 of 3 articles the first two of which discuss breast surgery done on the breast before the mother has a baby and breast surgery done on the breast at a time when the mother is breastfeeding.
When a breastfeeding mother or her physician finds a lump in the breast, the question of what to do arises. In breastfeeding mothers, the most common reasons for a lump in the breast would likely be the following:
- A blocked duct (which tends arise suddenly, is usually painful and then tends to resolve quickly and often without specific treatment)
- Mastitis (which also arises suddenly or over a few hours, is painful, and frequently resolves without specific treatment)
- Abscess (which often opens spontaneously to the skin and thus is often cured without specific treatment)
- Galactocele (which usually should be left alone once the diagnosis is made)
There are also several sorts of benign lumps not related to breastfeeding, which may include a fibroadenoma, benign cysts, papilloma, fat necrosis, hamartomas.
Unfortunately, it is also possible for a mother to develop breast cancer while breastfeeding.
The following story is as described by one mother is, unfortunately, not an uncommon situation:
“Two lumps were found in my breast during my pregnancy, and it was recommended I get them biopsied. I got the core biopsy done at ten days postpartum. I have had constant milk leakage from the incision site (6 days now). Yesterday I soaked through 4 hospital maxi pads. I went to the doctor today and was told that the lumps were benign fibroadenomas, and to wait 1 week to see if the leaking stops, and if it doesn’t, I’ll need to stop breastfeeding altogether. She said if I wait longer, I’m at high risk for infection & mastitis. I don’t want to stop breastfeeding, and I’m wondering how often milk duct fistulas heal on their own. Just want your opinion and what you recommend.”
The first question that arises is why it was necessary to go to biopsy before other diagnostic methods were not tried first. Imaging methods have improved and have continued to improve over the past few years. Their judicious use can avoid the need for biopsy in many, but not all, cases. An ultrasound done even during the pregnancy could have helped allay the mother’s worries, although it is unlikely one can get a definite diagnosis from an ultrasound. A CT scan or MRI scan could have given enough information to avoid the biopsy. Positron Emission Tomography (PET scan) can also be done to characterize a breast lump in certain circumstances, though it does not seem to be commonly used for characterizing breast lumps and since the tracer is radioactive, perhaps not a good idea to be used during pregnancy.
A mammogram is not ideal for a breastfeeding mother because of the compression of the breast while the procedure is done. Mammograms have been traditionally used for screening, but alone they do not really help in diagnosing a breast lump.
It is necessary to emphasize that neither CT scan, nor MRI require the mother to interrupt breastfeeding, not even for a minute. See the bulletins from the American College of Radiology and Society of Urogenital Radiology which have both issued statements in 2001 and 2004 respectively stating that a breastfeeding mother can continue breastfeeding after these tests without any interruption at all. My article discusses the same question. With PET scan, with the half-life of the isotope being less than 2 hours, it is recommended that close contact between mother and baby be avoided for 4 hours after the procedure.
I am not saying that biopsy is never required to characterize a breast lump. However, if appropriate, a fine needle biopsy is less likely to cause continued leaking (fistula) from the biopsy site than a core biopsy, which uses a larger needle, and core biopsy is less likely to cause a fistula than an open biopsy.
Ultimately, a decision of how to investigate a breast lump in a breastfeeding mother has to take into consideration which approach results in the best way of diagnosing the breast lump without interfering with the mother’s ability to continue breastfeeding. If the lump is unlikely to be cancerous, less aggressive methods should be tried first. If it is very likely to be cancerous, then a more aggressive approach would be necessary. However, in the case above, it is unlikely that the lump was considered very likely to be cancerous, or the mother would have been advised to have diagnosis made during the pregnancy several months before. Indeed, a core biopsy would have caused fewer problems during the pregnancy than a core biopsy during lactation.
Incorrect information described in the mother’s story
This mother was told that there was a risk of infection or mastitis if the leaking did not stop. This is not true. Why would this occur if the milk is free flowing out the biopsy site?
And it makes no sense to say that if after another week the leaking hadn’t stopped, the mother would have to stop breastfeeding completely. What’s wrong with this advice?
1. It sounds as if the mother was told not to breastfeed on the side of the biopsy, though this is not 100% clear from the email. Stopping on the affected side increases the risk of a fistula because if the milk doesn’t go out the nipple, it will go out where it can go out the area of least resistance, the incision.
2. The time line of 1 week (after 6 days after the biopsy) for the leaking to stop or the mother must stop breastfeeding is very short. Why 1 week? What if the leaking is decreasing but not stopped? We have seen leaking for 2 or 3 weeks after such procedures and the leaking does stop when the mother continues breastfeeding on the affected side.
3. Many surgeons do not seem to understand that it is possible to stop breastfeeding on one side while continuing on the other if that becomes truly necessary. This is the reason for the mother being told to stop breastfeeding completely. But if worse gets to worst, the mother could stop on just the affected side. Eventually, the leaking will stop.
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Copyright: Jack Newman, MD, FRCPC, Andrea Polokova, 2017, 2018, 2020