Nipple Changes Your Doctor Should Not Have Brushed Off

Which nipple changes need a closer look?

Some nipple changes call for a workup, meaning tests to find the cause. These are the features that usually raise concern:

• Discharge from only one breast.
• Discharge from one opening in the nipple, not several.
• Discharge that happens on its own, without squeezing.
• Discharge that is bloody or clear, like water.
• A nipple that has newly turned inward or flattened.
• A scaly, crusted, or weeping rash on the nipple that does not heal.

The American College of Radiology is a national group of imaging doctors. Its 2022 guide on nipple discharge sets out a workup for this kind of discharge.  Although patient age determines the most appropriate workup, it typically starts with a diagnostic mammogram, which is aimed at the problem area, and an ultrasound, which uses sound waves to make a picture. If those are normal, an MRI may follow. An MRI is a scan that uses strong magnets.

Even discharge with these features is usually not cancer. A common cause is a papilloma, a small harmless growth inside a milk duct. But only testing can tell the difference.

On the other hand, some discharge is usually harmless. Milky discharge from both breasts usually is. So is discharge that comes only when the nipple is squeezed.

Is a nipple rash that won’t heal a sign of breast cancer?

Usually not, but it can be. A nipple rash that does not heal after a short course of treatment can be Paget disease of the breast. That is a rare cancer, and it calls for a biopsy.

Paget disease of the breast looks like eczema on the nipple. The skin may be red, scaly, flaky, itchy, or crusted. It may ooze or bleed. It often spreads to the darker skin around the nipple. It usually affects only one breast.

Paget disease is rare. The National Cancer Institute says it makes up a small share of breast cancers, roughly 1 to 4 percent. In most people with Paget disease, there is also a cancer deeper in the breast.

Careful care usually follows a set order. First, a doctor may try a cream for a short time. That is reasonable for a rash that looks like eczema. Second, the doctor sets a time to recheck it. Third, if the rash has not healed within a few weeks, the doctor arranges a skin biopsy. A skin biopsy removes a small round piece of skin for testing. Fourth, the doctor orders imaging of the breast, because Paget disease often comes with a cancer underneath.

A rash on one nipple only, in a woman with no history of eczema, deserves extra care.

Where does the chance to find it earlier get missed?

• A nipple rash was treated with creams for weeks or months without a biopsy. Each visit tried a new cream. No one stepped back to ask why none of them worked.
• Bloody or clear discharge from one breast was called normal. The doctor did not ask whether it came on its own or from one opening. No imaging was ordered.
• A newly turned in nipple was not noted as new. The doctor assumed it had always been that way. No one asked when it changed.
• A normal mammogram ended the workup. Paget disease and some causes of discharge may not show on a mammogram. A rash or discharge that continues still needs an answer.
• The patient was sent to a skin doctor, but the breast was never checked. The rash was treated as a skin problem only. No one ordered breast imaging.

What should I check in my own records?

You can answer most of these from memory, your patient portal, or your records.

• When did the nipple change start, and when did you first report it?
• Was the discharge from one breast or both? Was it bloody or clear?
• Did it come on its own, or only when squeezed?
• How many creams were you prescribed, and over how long?
• Was a skin biopsy or breast imaging ever ordered?
• Did any note describe the nipple as newly turned inward?
• How much time passed between your first report and your diagnosis?

Did the delayed diagnosis of breast cancer change the outcome?

A missed step alone is not enough for a claim. The question is whether earlier testing would likely have found the cancer at an earlier, more treatable stage.

That depends on the cancer. Breast cancers grow at different speeds. Some grow slowly over years. Others grow fast. A delay of a few months may matter a great deal for one woman and very little for another.

Medical malpractice lawyers and the experts they consult to review a case focus on a few things. They compare the size of any tumor at the missed chance to its size at diagnosis. They check whether the cancer had reached the lymph nodes, the small glands under the arm that filter fluid, or other organs. They look at the type of cancer and how fast that type tends to grow. And they measure the time between the missed chance and the diagnosis.

A delay can also change treatment. A woman who might have needed a small surgery may have needed a mastectomy, which removes the whole breast. Or she may have needed chemotherapy, strong cancer drugs, that might have been avoided.

In Pennsylvania, a family does not always have to prove that an earlier diagnosis would have saved her. It can be enough to show that the delay meaningfully raised the risk of harm. That added risk must also have played a real part in what happened.

When is a missed nipple change not medical malpractice?

Not every delay is malpractice. A bad outcome does not prove someone made a mistake.

• The discharge was the harmless kind. Milky discharge from both breasts, or discharge only when squeezed, usually does not need a cancer workup.
• A short trial of cream came first. Trying a cream for a few weeks, with a plan to recheck, is a reasonable first step for a rash that looks like eczema.
• The workup was done and read correctly. Some cancers do not show on a mammogram or ultrasound, even when the test is done and read well. A doctor who did the right workup is not at fault just because the cancer was found later.
• The delay likely made no difference in prognosis or treatment. The cancer may have already spread when the change was first reported.

What harms matter in these cases?

Our firm focuses on delays that led to death or catastrophic injury. In breast cancer cases, these are the harms that usually matter:

1. Cancer that spread to distant organs, such as the bones, liver, lungs, or brain, before it was found. It can still be treated, but it can no longer be cured.
2. Death from a breast cancer that, if found earlier, would likely have been curable.

What to expect when you contact our office

Before we take a case, we review the records and imaging with medical experts. Pennsylvania requires a medical professional’s written statement that a claim has merit before a case can go forward. That review also helps answer whether the delay changed the outcome. A doctor, a nurse practitioner, a practice group, or a hospital system may each have played a role.

Pennsylvania has filing deadlines. For a living patient, the deadline is generally two years from a key date. That is when she knew, or should have known, that she was harmed and that medical care may have caused it. In delayed diagnosis cases, that date is often near the cancer diagnosis. After a death, claims generally must be filed within two years of the date of death. Learn more about how long you have to file a medical malpractice in Pennsylvania. For additional information on breast cancer misdiagnosis, see our main article on delayed diagnosis of breast cancer.