Most women who have fibrocystic disease, hormonally-induced lumps in the breast, are not likely to develop breast cancer, the College of American Pathologists announced last week.
The findings suggest that women with fibrocystic disease are sometimes unjustifiably considered a high risk for cancer by many insurance companies who either refuse to insure them or require them to pay higher premiums.
"In most people's minds, a breast lump equals breast cancer," said Dr. Kay Herrin Woodruff, spokeswoman for the College of American Pathologists. "There's always the nagging suspicion that a lump is going to turn into cancer or predispose a woman to developing cancer. That's just not correct."
Biopsy results show that 70 percent of women with fibrocystic disease are no more likely to develop breast cancer than women without this condition, according to Woodruff. Of the remaining 30 percent, only four percent have a significantly greater chance of developing breast cancer and the remainder has a slightly increased change of breast cancer.
Fibrocystic disease, which generally entails multiple lumps in the breast, afflicts 50 to 80 percent of all women. The ailment, in fact, is so common that Woodruff and other physicians recommend using the terms "condition" or "changes" rather than "disease."
"By age 30, practically all women have fibrocystic disease," said Dr. Edward Scanlon, chairman of the American Cancer Society's National Task Force on Breast Cancer Control. "It's a rare breast, indeed, in a woman over 30 that has no lumps."
A fibrocystic condition, usually afflicting women aged 30 to 50 years old, fluctuates with the menstrual cycle. Hormone levels change during ovulation and before menstruation, sometimes causing the breast ducts to retain fluid. When pregnancy does not occur, the fluid is usually reabsorbed by the breast tissues.
Fluid, however, sometimes becomes trapped and forms cysts which persist or disappear. The condition can be uncomfortable and worsen over years -- increasing from monthly soreness to constant pain -- until menopause.
Experts do not know what causes these cysts to develop, though some believe it is a normal aspect of the menstrual cycle. Theories implicating caffeine, cigarettes, chocolate and birth control pills have proven unfounded.
"Scientific evidence today is not as strong as we thought it was several years ago," said Scanlon, who is affiliated with Evanston Hospital and Northwestern University Medical School. The lack of certainty about the causes of fibrocystic changes has made it difficult for industry to decide to insure women with the condition. No industry standard exists.
Some insurance companies and physicians consider fibrocystic disease to be a precancerous condition, said Scanlon who suggested that women with fibrocystic conditions are treated unfairly by insurance companies.
Many people, said Scanlon, object to insurance companies' practice of grouping together women with fibrocystic conditions and "putting them all in the waste basket." He added, "Some women pay higher premiums or are excluded from coverage unjustifiably."
"It's an individual company's decision -- there's no real consensus," said Amy Biderman, media information manager for Health Insurance Association, an industry group. "Yes, there are going to be problems in getting insurance but it doesn't mean it's going to be an industry-wide problem."
Some companies discontinue insurance or like Prudential, raise the premiums for women who are diagnosed with the condition. Several companies, including Blue Cross and Blue Shield and Equitable Life Insurance, do insure these women. Others, including Mutual of Omaha Company and Pacific Mutual Insurance, do not cover expenses related to the condition. Still others such as Allstate Insurance do not cover expenses for any breast disorders.
"This is no different from any other disease," said Tondl. "We issue insurance based on risk and this would, in fact, add more risk. We're in business to determine how we can provide insurance as opposed to eliminate insurance."
According to Geno Effler, Pacific Mutual spokesman, the company decides on individual cases. "The company could very well decline to insure the person or to require restrictions," said Effler. "There are a lot of variables -- it seems like a big grey area."
One insurance agent for Prudential Insurance Company of America said many insurance salesmen would be reluctant to insure a woman with fibrocystic condition. "You can't insure a building that's on fire," he said. "A woman with fibrocystic disease has a pre-existing health condition that's an open invitation to claims."
It is not yet clear what impact the College of American Pathologists' announcement will have on insurance companies.
"Obviously you don't change underwriting practices every day," said Len Tondl, spokesman for Mutual of Omaha Company. "I can't answer what one study will do because we probably have actuarial information that disputes the study. But underwriting practices do change and certainly we are insuring risks today which we never did before."
For insurance companies and physicians, fibrocystic disease is a catch-all term for many breast conditions. Because of the ambiguity, it is also a term that scares many patients.
"If you throw in the fact that one in 11 women develop breast cancer," Woodruff said, "you have the ingredients for a real epidemic of fear."
To reduce fear and ambiguity, the College of American Pathologists has defined three categories of cancer risks for women with fibrocystic disease, appearing in the Archives of Pathology and Laboratory Medicine's March issue.
These categories are based on biopsy results, examinations under a microscope of surgically removed tissue, of 10,366 women originally reported in the New England Journal of Medicine last year. That study found that the majority -- or 70 percent of women -- face no increased risk of developing breast cancer.
The report in the Archives defines both the type of fibrocystic condition and the chances that it will develop into a cancer.
Twenty-five percent of women with fibrocystic breasts have twice the risk of other women for developing breast cancer. The cells within their fibrocystic lumps continue to grow.
Four percent of women with fibrocystic breasts are five times more likely than other women to develop breast cancer and are categorized as having a "moderately" increased risk. These lumps have both an increase in the number of actively growing cells and nonuniformity among those cells.
"This is an extremely small number of women with fibrocystic condition who do have a moderately increased chance of developing breast cancer but we can identify these women and we have a chance to cure them," said Woodruff. Women at the highest risk can be identified by biopsy.
Dr. Robert V.P. Hutter, chairman of the College of American Pathologists' Cancer Committee, hopes these categories will prompt physicians to be more specific in diagnosing fibrocystic conditions and so reduce anxiety among patients and insurance companies.
"We have provided a mechanism for greater specificity," said Hutter. "We can now separate risk categories in a way that's more meaningful to women and their physicians. Eventually and inevitably, these categories will also be meaningful to insurance companies."
Resources To get a brochure on "Is Fibrocystic Disease of the Breast Precancerous?" send a self-addressed stamped envelope to College of American Pathologists, P.O. Box 566, Skokie, IL 60077-0566. It will be available after April 1. Nora Zamichow is a free-lance writer living in New York City who regularly contributes to Health.