Unseen and hard-to-detect breast cancers

Prof Carol-Ann Benn likens unseen and hard-to-detect breast cancers to a good murder mystery story where the baddie is finally revealed.

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You’ve all heard the story: my cancer wasn’t seen on the mammogram. I go every year and they didn’t see it. A bit like those spy movies or a good Agatha Christie story, did you see Murder on the Orient Express and Death on the Nile? You don’t know who the baddie was or where they were until the last chapter.

Who is our Hercule Poirot of finding the breast baddie? Well it can be anyone from your GP to the radiologist to the breast specialist. All it requires is using the little grey cells. In other words, an intuitive approach to when the clinical, radiology and pathology don’t quite fit. 


I call this breast CPR: clinical, pathology and radiology resuscitation. Can you ensure that we have a successful cancer resuscitation and diagnose the breast cancer before we have a problem? We can’t if we don’t practice CPR.

So, what are the features of cancers that are often missed. Clearly a good disguise isn’t just about how the creature is trying to hide but also about the people trying to see past the disguise, uncovering the cancers.

Good disguises

A good disguise is about not looking like cancer, for example: hiding in plain site; being in a place that you don’t expect or the place in which they are hiding is so good that you can’t see them. Disguises are complex, a bit like a yin yang of now you see me, now you don’t.

Maybe people don’t see things because the cancer is blending in so well thus making it more difficult to detect cancers and maybe as people we should learn that not all is what it seems. Back to that Agatha Christie analogy.

Using little grey cells

Using little grey cells when we might suspect a cancer. People factors that make detecting difficult: anyone who is woke (learnt the word in theatre from the younger generation, it means understanding what is happening in the world); this means understanding that breast cancer may happen to anyone regardless of age, race or sex. Therefore, we shouldn’t be judgy judgy at all as to who gets cancer.


Ages we don’t expect to see cancer in: this is such an important concept because anyone can get a cancer. In young women, cancers may be missed because we don’t think that cancers can occur in young peeps.

Firstly, being a youngster, you don’t expect a cancer, so this may be the first disguise. Next, it’s not uncommon for young women to have non-cancerous lumps (fibroadenomas). Spoiler alert: these lumps can’t become breast cancers. However, there is a cancer that mimics a fibroadenoma (what a spectacular disguise looking innocent but behaving like a psychopath). The way these cancers create mayhem is that they are usually rapidly growing (have a high Ki index (running shoes)); aren’t hormonally sensitive; and can fool a non-expert radiologist and a few experts as well. Sometimes you go for an ultrasound and a radiographer with possibly less experience tells you to come back in six months when really the safest detection rule is to be alert. If you have a breast mass detected for the first time, what you should be told is a three-month follow-up ultrasound or a core needle biopsy to confirm the diagnosis.

Please ask for the costs of the core, both from a radiology and pathology point of view. These palpable masses don’t require a vacuum biopsy (VAB) but an ultrasound-guided biopsy which can be less expensive than a VAB. And they most definitely don’t require a trip to your friendly surgeon to cut out the mass to find out what it is. Don’t and I repeat don’t be pushed into a surgical biopsy to find out what this fibroadenoma is doing. This is just playing into the hands of this psychopath. Cutting it out prior to diagnosis means that the oncology treatment is blind, and this is one sure way to jeopardies potential successful treatment.


What about men? Many men have moobs and while we get this, sometimes if there is a small mass we assume that it’s related to the increased male breast tissue, and thus we miss breast cancers in men.

Why? Partly because we don’t suspect breast cancer in men; men don’t check their breasts and we don’t inform men that if they have a family history of breast cancer and other cancers they are at-risk.

There are some studies on transgender peeps who are on hormonal manipulation that they may have a slight increase in breast cancer; so back to that old adage it can happen to anyone.

Other disguises

How about much older women, who go for their routine mammograms and are on hormone replacement therapy (HRT)? I’m not anti HRT but many years on hormonal therapy provides for a wonderful fertiliser for breast tissue, resulting in dense tissue; and it’s extremely hard to find the predators when they are hiding in a jungle.

In very young women, masses and nipple discharges are generally assessed clinically and often advised to check again after your next cycle. We don’t have eyes on our fingers, so cancers are unseen by not following any presentation through with the correct radiology investigations and in young peeps, this is an ultrasound.

Sometimes we think people are too old to be screened for breast cancer; remember that we’re more likely to pick up cancers as we get older as our cells have more potential to undergo weird changes.

How about suspicious environments?

Breast density now has to be reported on screening mammograms because if the breast tissue is dense it’s difficult to see the baddies. This makes for an environment in which finding cancers is more difficult.

Disguised environments such as lots of benign calcifications. Calcifications are like cell skeletons and some breasts have many; if there are many it’s difficult to spot the suspicious ones without routine mammograms.

Pregnant breast

Hard to feel changes because they are tender, swollen and growing, and thus when lumps and changes arrive, no one suspects a breast cancer, even though breast cancer is the commonest cancer seen in pregnant women.

Red, hot breast

Often assumed to be an inflamed breast or a breast infection, when it could be an inflammatory breast cancer. And in this scenario, if you want to uncover the baddie and have laid the traps of a trial of antibiotics, checked the mammogram and ultrasound, and all you see is thickening in the tissue, look for suspicious glands on ultrasound and biopsy glands and the breast. Don’t operate.

The suspects

Nipple discharge

The spontaneous nipple discharge that continues to leak on its own. Remember don’t squeeze the nipple (discharges will occur if the nipple is squeezed). Worry about a blood-stained discharge even in the presence of a normal mammogram and ultrasound; the rare time when surgery is needed for a diagnosis: a microdochectomy (procedure to remove one or more of the milk ducts from your breast).

Remember nipple discharges and spontaneous nipple discharges, in my opinion, require mammograms looking for micro-calcs, not a ductogram (imaging test used to identify the cause of nipple discharge).

Changes on the nipple

Paget’s disease of the nipple presents as a small ulceration on the top of the nipple and can be very subtle (remember changes on areolar are not the same).

Suspect masses require ultrasounds and don’t be fooled by an unusual type of breast cyst (a cyst with blood-stained fluid and a growth on the wall (looks a bit like a cauliflower)); this can be an encysted papillary neoplasm and can vary from being an early cancer to a rare cyst carcinoma.

Hard lymph node

Another suspect is when you have a hard lymph node (gland) in the axilla (armpit). Again, a tender, hard gland gets a six-week follow-up ultrasound and if the cortex is thick and the gland is bigger then an ultrasound-guided biopsy of the gland (not surgical removal) is needed. 

The red herring

Don’t forget the red herring in the detective novel: the biopsy that is benign. The phone call that says: your pathology report shows no cancer. This may be so but don’t be fooled; make sure that if the biopsy is for calcification that there is calcification in the specimen and report and if the biopsy is for a mass, that there is a diagnosis that says fibroepithelial lesion.  

The lobular cancer

Be aware of the lobular cancer; due to the nature of its cells they are hard to see and often because the cells are lazy they are hard to see on mammograms, so insist the radiologist does an ultrasound and if you have a doughy breast mass and your mammogram is normal, see a breast specialist as you may need an ultrasound-guided core biopsy.

A team-approach solves the mystery

The most important part of using the little grey cells to detect the hard-to-detect breast cancers is to always remember the secret code: CPR. 

A team-approach ensures a successful resus in trauma and when detecting breast cancers as well; because we need to have your assessment done by a good clinician; have your radiology reviewed (that is why you should keep your disc and reports) and ensure you take time before you have your biopsy (ensure not a surgical biopsy; and get all costs first).

I know with all the suspects and twist and turns of what is and what isn’t a breast cancer in this mystery; the resultant anxiety for all of us is great. 

Beware of Google mystery solving; choose your Hercules Poirot and team with care and participate in solving all your small health mysteries.

Prof Carol-Ann Benn heads up an internationally accredited, multi-disciplinary breast cancer centre at Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.Prof Carol-Ann Benn heads up an internationally accredited, multi-disciplinary breast cancer centre at Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.

MEET THE EXPERT – Prof Carol-Ann Benn

Prof Carol-Ann Benn heads up an internationally accredited, multi-disciplinary breast cancer centre at Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.

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