The Dilemma of Pre-Cancerous Breast Abnormalities―What to Do?

While there is a great deal of information about breast cancer in the lay press, there is less written about the problem of precancerous abnormalities of the breast.

What do we mean by a precancerous breast condition? It is simply an abnormality of the cells in the breast that, over time, can become an actual breast cancer. In other words, these abnormal cells may become cancer cells over a period of time if left untreated.

It would seem pretty obvious that if such cells have been identified, “doing something” to eliminate them makes great sense. This is true, but let’s look a little closer. A very close family member (let’s call her Claire) has just gone through this issue. A routine mammogram showed the faintest of abnormalities (so called small microcalcifications, which show up as small white specks on a mammogram). This led to further studies, including a breast ultrasound and breast MRI. It was recommended that Claire undergo a breast biopsy of these specks, which she did, and the specks were removed.

The diagnosis of the biopsy was neither normal nor cancer—it was somewhere in between. She was diagnosed with something called atypical lobular hyperplasia (ALH). Her doctors then recommended that she have another biopsy, where she would have an even larger portion of breast tissue removed to make sure all of the atypical cells had been taken out and to ensure that there was no actual cancer in that breast.

Fortunately, this second biopsy procedure did not show any residual abnormalities. But, now there are real dilemmas confronting Claire. Both Claire’s breast surgeon and oncologist are recommending that she undergo treatment—called breast cancer chemoprevention (i.e. preventing breast cancer with a chemical substance)—with a drug called tamoxifen. This drug is known as an anti-estrogen, which counteracts the effects of estrogen. That can be helpful for pre-cancerous cells in the breast because estrogen can promote the transformation of precancerous cells to cancerous cells. 

The recommendation is to take the medicine for five years; we are told that in women who take the medication, the reduction of developing subsequent breast cancer is about 50% (going from a 6% risk down to a 3% risk) compared with women who do not take this medicine. Other specialists have recommended the use of a drug called raloxifene, which is similar to tamoxifen. 

The problem is that tamoxifen has side effects, some of which are serious. Among its potential side effects are an increased tendency to form blood clots, a higher risk of stroke, and an increased risk of uterine cancer. Although each of these is rare, of course Claire was frightened about them, as are most patients. Less serious side effects include weight gain, headaches, and hot flashes.

This situation emphasizes the real dilemmas that both physicians and patients with precancerous breast changes face—do you take a medicine to prevent a disease you do not have and risk having some side effects, or do you forgo this treatment and take your chances that you may develop the dreaded diagnosis of breast cancer? No easy answers, to be sure. 

Because Claire’s mother also was diagnosed with breast cancer, she is leaning toward taking the preventive medication, tamoxifen. Her thinking is that if she experiences any signs of side effects from the medicine, she may quickly go off of it and say that she gave it her best shot. 

In future issues of this blog, I will update you on Claire’s progress.

Has a mammogram or breast ultrasound raised any concerns about breast cancer or precancerous conditions in you?  What would you do if you were in Claire’s shoes?

Marc Garnick, M.D., is an internationally renowned expert in medical oncology and urologic cancer, with a special emphasis on prostate cancer. He is a Clinical Professor of Medicine at Harvard Medical School and maintains an active oncology practice at Beth Israel Deaconess Medical Center. Dr. Garnick serves as Editor in Chief of Perspectives on Prostate Diseases, a quarterly report from Harvard Health Publications.

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