14. Is Nipple Discharge Breast Cancer?
Don’t Panic. The Fluid Coming Out of Your Nipple is Most Likely Not Caused by Cancer
Nipple discharge is any fluid that comes out of the milk ducts through the nipple. This is a normal and expected occurrence during breastfeeding but may be alarming at any other time. Nipple discharge can vary widely in color, with the most common colors encountered being yellow, green, brown, white, clear, and red (or bloody). Nipple discharge can occur from one breast in multiple ducts or just one duct, or in both breasts. Finally, discharge may occur with or without nipple stimulation, including squeezing or repeated chafing from clothing. If the discharge occurs without nipple stimulation, this is referred to as spontaneous discharge. If the discharge occurs after stimulation, this is referred to as non-spontaneous discharge.
Most nipple discharge is physiologic discharge and is NOT related to cancer. Physiologic discharge is described as non-spontaneous or spontaneous, may occur from one or both breasts, and is colored green, yellow, brown, black, or white. However, a small subset of nipple discharge may be related to a non-cancerous mass in the milk duct called a papilloma, or less likely, breast cancer. This type of discharge is referred to as pathologic discharge. Pathologic discharge occurs spontaneously from a single duct in one breast, and is either completely clear and colorless, or bloody.
No matter the type, all patients with nipple discharge should discuss their symptoms with their primary care provider. It is always best to have your provider see and evaluate the discharge before any definitive decisions are made concerning additional tests and possible causes.
Imaging and Evaluation Protocols
Many patients will be sent for imaging of the breast to further evaluate nipple discharge. Imaging protocols will vary between facilities, so please understand this is only meant to serve as a general guide.
Patients Younger than 30 Years
For patients younger than 30 years, the patient will start with breast ultrasound where the technologist images right behind the nipple experiencing the discharge. Most women in this age group will only need a breast ultrasound; however, a mammogram may be performed in select cases depending on the ultrasound findings.
Women Between 30-39 Years
For women between 30-39 years, a diagnostic mammogram of both breasts will be performed, followed by an ultrasound behind the nipple experiencing the discharge.
Women Older than 40 Years
For women older than 40, a mammogram of both breasts is performed if it has been 12 or more months since their most recent screening mammogram. If it has been less than 12 months since their most recent screening mammogram, a mammogram only of the breast experiencing nipple discharge will be obtained. The ultrasound technologist then images the area behind the nipple experiencing discharge.
When to Pursue Additional Imaging
If the initial imaging workup does not reveal any suspicious findings, women with physiologic discharge do not need to obtain additional imaging. Although there are many causes of benign physiologic nipple discharge, one of the most common causes producing these symptoms is duct ectasia. Duct ectasia is a benign condition in which the milk ducts dilate or enlarge. Fluid may then collect within the dilated ducts. When enough fluid builds up within the duct, some of the fluid will be expressed through the nipple and is typically yellow, green, brown, or black in color. White nipple discharge often results from prior breastfeeding, even when it has been years since the woman last breastfed. If you squeeze your nipple hard enough, most women can express some fluid from the nipple. Just because you are able to force the liquid out does not mean that something is wrong. (We highly recommend that you DO NOT squeeze the nipple to check for discharge. This can cause irritation resulting in a small amount of bloody discharge which can confuse the picture.)
Pathologic nipple discharge may be caused by a benign mass in the milk duct referred to as a papilloma. If an intraductal mass is identified on diagnostic imaging, an image-guided biopsy will often be performed to make the diagnosis. Although a papilloma is not generally malignant, making this diagnosis is important, as surgical removal of a papilloma may be recommended based on the size of the mass and the pathology results.
For women who have pathologic discharge and a negative diagnostic mammogram and ultrasound, additional imaging evaluation with breast MRI will likely be recommended. MRI is a more sensitive exam than mammography and ultrasound and may identify subtle abnormalities behind the nipple that may represent a papilloma or breast cancer. If an abnormality is seen by MRI, an MRI guided biopsy may be performed in order to make the diagnosis.
Although it is important to go through these steps to ensure that the discharge is not caused by a benign mass or cancer, most often nipple discharge is not something to be overly concerned about. We encourage you to discuss any new or changing breast symptoms with your primary care provider so that all breast symptoms may be thoroughly evaluated.
Written by Danielle Carroll, M.D.
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