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Breast Complaints

Breast Complaints. You gotta know when to screen em, know when to street em, know when to reassure, know when to refer. Morbidity and Mortality. Second leading cause of cancer death 1 in every 8.2 diagnosed 1 in every 30 will die

dahlia-klein
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Breast Complaints

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  1. Breast Complaints You gotta know when to screen em, know when to street em, know when to reassure, know when to refer

  2. Morbidity and Mortality • Second leading cause of cancer death • 1 in every 8.2 diagnosed • 1 in every 30 will die • more than 50% of cases occur in women WITHOUT known predictors

  3. Personal history of CA Personal history of biopsy with atypia age age of menarche (before 12) nulliparity obesity First baby after age 30 family history breast, ovarian, colon CA in first degree relative early onset CA in 1degree relative known BRCA I/II What are the major predictors what history do I need to know

  4. Should I know about the Gail risk profile • Yes • only useful in patients over 35 • in your palm, info retriever, calculations • also on the web http://brca.NCI.nih.gov/brc/questions.htm

  5. CASE 1 • Pts age 35 • age at menarche 15 • nullip • zero biopsies • 1 first degree relative with CA • 10 yr risk 2.1% • 30 yr risk 10%

  6. What about screening • Depending on which data you believe you could justify many different screening protocols • probably best to be conservative (your insurance company agrees) • age 20-39 SBE monthly and clinical breast exam at least q3yrs • age >40 SBE monthly, CBE qyr, mammo yearly ACS & COPIC

  7. I heard the SBE isn’t useful • You may be right • Currently the USPSTF (US preventive services task force) states that there is no good evidence to support the practice of SBE and this practice may lead to more invasive procedures (unnecessary) • However… if you ask the patient if they would rather have a benign problem removed or miss a possible CA ?...

  8. SO... • AAFP guidelines agree with USPSTF BUT believe that it is OK to continue the practice for now • ACOG says we don’t know but we’ve always done it so we will keep doing it • IM says we practice only EBM, we won’t recommend it • Cochrane not only challenges SBE but also screening mammography ?any change in mortality

  9. What if the patient is high risk? • Screening should begin 5-10 years earlier than the age at cancer diagnosis of 1st degree relative

  10. BIG RED FLAGS=need a definitive diagnosis • Palpable mass = proceed even if the mammo/ultrasound are negative or if the mass is “benign” but solid • Non-palpable mass=proceed even if “benign” if solid • Abnormal but probably benign mammo must correlate with exam • ANY Breast Complaint brought to you by the patient IS A problem

  11. More Flags • Breast discharge : unilateral, heme+ spontaneous, copious, focal OR clear • Breast pain with no mass: if non-cyclic, unilateral, focal or unresolving you MUST work it up even if <40 • Cyst: must confirm simple cyst via ultrasound or aspiration. • Bloody fluid or no fluid=further eval

  12. Pearls • If the patient is worried you are worried • low risk is still risk • negative mammography does NOT rule out cancer • dense breasts = 2 tests (at least) • If you can’t find it or resolve it, refer it • tender isn’t always benign • two opinions are better than one

  13. Case 2 • Pt is a 48 yo female who c/o breast pain. The pain is cyclic and has been going on for 3 months. She is healthy, perimenopausal and takes only herbal medicines. She performs SBEs monthly and has found nothing. You find nothing concerning on her exam.

  14. What to do? • Pain, >40yo, unresolving • Basically, if > 40 do the work-up and pursue until diagnosis made or pt referred • first test= DIAGNOSTIC mammogram • its only a screening test if there is NO complaint

  15. NEXT • 35 yo c/o discharge from her Left breast. Pt states the discharge is new, spontaneous and maybe bloody. She is a G0P0, does not do SBE and was adopted. You examine the patient and find NO mass or LAD. You do note a unilateral, spontaneousdischarge which for you is heme negative and clear.

  16. What do you do? • Is a diagnostic mammogram of one breast enough? • Is the heme test a good (reliable) test? • Does this patient need a definitive diagnosis? • What are the first tests to order and would you refer?

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

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

  19. What do you do? • Fine needle aspirate? • Screening mammogram? • Diagnostic mammogram of one breast? • Both breasts? • Ultrasound? • Do I need a diagnosis?

  20. Any solid mass = ASAP • Bilateral, diagnostic mammogram AND ultrasound with further testing to be determined by radiology based on results. Refer for tissue diagnosis via biopsy within 6 weeks.

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