Breast ComplaintsBreast Complaints

You gotta know when to screen em,You gotta know when to screen em,

know when to street em,know when to street em,

know when to reassure,know when to reassure,

know when to referknow when to refer

Morbidity and MortalityMorbidity and Mortality

Second leading cause of cancer Second leading cause of cancer deathdeath

1 in every 8.2 diagnosed1 in every 8.2 diagnosed 1 in every 30 will die1 in every 30 will die more than 50% of cases occur in more than 50% of cases occur in

women WITHOUT known predictorswomen WITHOUT known predictors

What are the major What are the major predictorspredictors

what history do I need to know what history do I need to know

Personal history of Personal history of CACA

Personal history of Personal history of biopsy with atypiabiopsy with atypia

ageage age of menarche age of menarche

(before 12) (before 12) nulliparitynulliparity obesityobesity

First baby after First baby after age 30age 30

family history family history breast, ovarian, breast, ovarian, colon CA in first colon CA in first degree relativedegree relative

early onset CA in early onset CA in 1degree relative1degree relative

known BRCA I/IIknown BRCA I/II

Should I know about the Should I know about the Gail risk profileGail risk profile

YesYes only useful in patients over 35only useful in patients over 35 in your palm, info retriever, in your palm, info retriever,

calculationscalculations also on the web also on the web

http://brca.NCI.nih.gov/brc/questions.hthttp://brca.NCI.nih.gov/brc/questions.htmm

CASE 1CASE 1

Pts age 35Pts age 35 age at menarche 15age at menarche 15 nullipnullip zero biopsieszero biopsies 1 first degree relative with CA1 first degree relative with CA 10 yr risk 2.1%10 yr risk 2.1% 30 yr risk 10%30 yr risk 10%

What about screeningWhat about screening

Depending on which data you believe you Depending on which data you believe you could justify many different screening could justify many different screening protocolsprotocols

probably best to be conservative probably best to be conservative (your insurance company agrees)(your insurance company agrees)

age 20-39 SBE monthly and clinical age 20-39 SBE monthly and clinical breast exam at least q3yrsbreast exam at least q3yrs

age >40 SBE monthly, CBE qyr, age >40 SBE monthly, CBE qyr, mammo yearly mammo yearly ACS & COPICACS & COPIC

I heard the SBE isn’t usefulI heard the SBE isn’t useful

You may be rightYou may be right Currently the USPSTF Currently the USPSTF (US preventive (US preventive

services task force) states services task force) states that there is that there is no good no good evidenceevidence to support the practice of SBE and to support the practice of SBE and this practice may lead to more invasive this practice may lead to more invasive procedures (unnecessary)procedures (unnecessary)

However… if you ask the patient if they However… if you ask the patient if they would rather have a benign problem would rather have a benign problem removed or miss a possible CA ?...removed or miss a possible CA ?...

SO...SO...

AAFP guidelines agree with USPSTF AAFP guidelines agree with USPSTF BUT BUT believe that it is OK to continue the practice believe that it is OK to continue the practice for nowfor now

ACOG says we don’t know but we’ve always ACOG says we don’t know but we’ve always done it so we will keep doing itdone it so we will keep doing it

IM says we practice only EBM, we won’t IM says we practice only EBM, we won’t recommend itrecommend it

Cochrane not only challenges SBE but also Cochrane not only challenges SBE but also screening mammography ?any change in screening mammography ?any change in mortalitymortality

What if the patient is high What if the patient is high risk?risk?

Screening should begin 5-10 years Screening should begin 5-10 years earlier than the age at cancer earlier than the age at cancer diagnosis of 1st degree relativediagnosis of 1st degree relative

BIG RED FLAGS=need a BIG RED FLAGS=need a definitive diagnosisdefinitive diagnosis

Palpable massPalpable mass = proceed even if the = proceed even if the mammo/ultrasound are negative or if the mammo/ultrasound are negative or if the mass is “benign” but solidmass is “benign” but solid

Non-palpable massNon-palpable mass=proceed even if =proceed even if “benign” if solid“benign” if solid

Abnormal but probably benign mammo Abnormal but probably benign mammo must correlate with exammust correlate with exam

ANY Breast Complaint brought to ANY Breast Complaint brought to you by the patient IS A problemyou by the patient IS A problem

More FlagsMore Flags

Breast discharge : unilateral, heme+ Breast discharge : unilateral, heme+ spontaneous, copious, focal OR clearspontaneous, copious, focal OR clear

Breast pain with no mass: if non-Breast pain with no mass: if non-cyclic, unilateral, focal or unresolving cyclic, unilateral, focal or unresolving you MUST work it up you MUST work it up even if <40even if <40

Cyst: must confirm simple cyst via Cyst: must confirm simple cyst via ultrasound or aspiration.ultrasound or aspiration.

Bloody fluid or no fluid=further evalBloody fluid or no fluid=further eval

PearlsPearls

If the patient is worried you are worriedIf the patient is worried you are worried low risk is still risklow risk is still risk negative mammography does NOT rule negative mammography does NOT rule

out cancerout cancer dense breasts = 2 tests (at least)dense breasts = 2 tests (at least) If you can’t find it or resolve it, refer itIf you can’t find it or resolve it, refer it tender isn’t always benigntender isn’t always benign two opinions are better than onetwo opinions are better than one

Case 2Case 2

Pt is a Pt is a 4848 yo female who yo female who c/oc/o breast breast painpain. The pain is cyclic and . The pain is cyclic and has been going on for has been going on for 3 months3 months. . She is healthy, perimenopausal She is healthy, perimenopausal and takes only herbal medicines. and takes only herbal medicines. She performs SBEs monthly and She performs SBEs monthly and has found nothing. You find has found nothing. You find nothing concerning on her exam.nothing concerning on her exam.

What to do?What to do?

Pain, >40yo, unresolvingPain, >40yo, unresolving Basically, if > 40 do the work-up Basically, if > 40 do the work-up

and pursue until diagnosis made or and pursue until diagnosis made or pt referredpt referred

first test= DIAGNOSTIC first test= DIAGNOSTIC mammogrammammogram

its only a screening test if there is its only a screening test if there is NO complaintNO complaint

NEXTNEXT

35 35 yo c/oyo c/o discharge discharge from her from her Left Left breast. Pt states the discharge is breast. Pt states the discharge is newnew, , spontaneousspontaneous and maybe and maybe bloodybloody. . She is a G0P0, does not do SBE and She is a G0P0, does not do SBE and was adopted. You examine the was adopted. You examine the patient and find NO mass or LAD. You patient and find NO mass or LAD. You do note a do note a unilateralunilateral, , spontaneousspontaneous dischargedischarge which for you is which for you is heme heme negative and clearnegative and clear..

What do you do?What do you do?

Is a diagnostic mammogram of one Is a diagnostic mammogram of one breast enough?breast enough?

Is the heme test a good (reliable) Is the heme test a good (reliable) test?test?

Does this patient need a definitive Does this patient need a definitive diagnosis?diagnosis?

What are the first tests to order and What are the first tests to order and would you refer?would you refer?

ONE MOREONE MOREthis one is easythis one is easy

30 yo female presents with a “lump” 30 yo female presents with a “lump” found on SBE. She is Very concerned found on SBE. She is Very concerned b/c her sister who is only 38 was b/c her sister who is only 38 was recently diagnosed with breast CA. recently diagnosed with breast CA. Pt is a G0P0, menarche age 12, has Pt is a G0P0, menarche age 12, has never had a biopsy and tries to eat never had a biopsy and tries to eat right and exercise. The rest of the right and exercise. The rest of the history is benign.history is benign.

EXAMEXAM

Exam is difficult because pt has Exam is difficult because pt has dense breasts. You can feel a firm, dense breasts. You can feel a firm, rubbery, mobile and well rubbery, mobile and well demarcated mass in the upper demarcated mass in the upper outer quadrant of the left breast. outer quadrant of the left breast. No LAD or skin changes noted.No LAD or skin changes noted.

What do you do?What do you do?

Fine needle aspirate?Fine needle aspirate? Screening mammogram?Screening mammogram? Diagnostic mammogram of one Diagnostic mammogram of one

breast?breast? Both breasts?Both breasts? Ultrasound?Ultrasound? Do I need a diagnosis?Do I need a diagnosis?

Any solid mass = ASAPAny solid mass = ASAP

Bilateral, diagnostic mammogram Bilateral, diagnostic mammogram AND ultrasound with further AND ultrasound with further testing to be determined by testing to be determined by radiology based on results. radiology based on results. Refer Refer for tissue diagnosis via biopsy for tissue diagnosis via biopsy within 6 weeks.within 6 weeks.