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2007 Estimated US Cancer Deaths*. ONS=Other nervous system.Source: American Cancer Society, 2007.. Men 289,550. Women 270,100. . . 26%Lung
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1. Evaluation of Breast Masses Susan C. Brunsell, MD
Executive Health
National Naval Medical Center
2. 2007 Estimated US Cancer Deaths* Lung cancer is, by far, the most common fatal cancer in men (31%), followed by prostate (9%), and colon & rectum (9%). In women, lung (26%), breast (15%), and colon & rectum (10%) are the leading sites of cancer death. Lung cancer is, by far, the most common fatal cancer in men (31%), followed by prostate (9%), and colon & rectum (9%). In women, lung (26%), breast (15%), and colon & rectum (10%) are the leading sites of cancer death.
3. Cancer Death Rates*, for Women, US,1930-2003 Lung cancer is currently the most common cause of cancer death in women, with the death rate more than two times what it was 25 years ago. In comparison, breast cancer death rates were virtually unchanged between 1930 and 1990, but have since decreased by about 24%. The death rates for stomach and uterine cancers have decreased steadily since 1930; colorectal cancer death rates have been decreasing for over 50 years.
Lung cancer is currently the most common cause of cancer death in women, with the death rate more than two times what it was 25 years ago. In comparison, breast cancer death rates were virtually unchanged between 1930 and 1990, but have since decreased by about 24%. The death rates for stomach and uterine cancers have decreased steadily since 1930; colorectal cancer death rates have been decreasing for over 50 years.
4. Cancer Incidence Rates* for Women, 1975-2003 After increasing rapidly in the 1980s due to increased use of mammography, breast cancer incidence rates in women leveled off from 2001 to 2003 due to saturation of mammography and reduction in use of hormone replacement therapy. During the most recent time period (1998-2003), incidence rates of lung cancer have leveled off, while rates of colorectal cancer have decreased.
After increasing rapidly in the 1980s due to increased use of mammography, breast cancer incidence rates in women leveled off from 2001 to 2003 due to saturation of mammography and reduction in use of hormone replacement therapy. During the most recent time period (1998-2003), incidence rates of lung cancer have leveled off, while rates of colorectal cancer have decreased.
5. Lifetime Probability of Developing Cancer, by Site, Women, US Approximately one in three women in the United States will develop cancer over her lifetime. The leading sites are breast, lung, and colon and rectum. Approximately one in three women in the United States will develop cancer over her lifetime. The leading sites are breast, lung, and colon and rectum.
6. Mammogram Prevalence The prevalence of women reporting a mammogram within the past year increased from 50% in 1991 to 64% in 2000, and has since declined to 58% in 2004. During this time, mammogram utilization varied considerably by educational attainment. The prevalence of women with less than a high school education reporting a recent mammogram was approximately 9 percentage points lower than the prevalence for all women. Even more striking is that the prevalence for women with no health insurance is approximately 25 percentage points lower than the prevalence for all women. The prevalence of women reporting a mammogram within the past year increased from 50% in 1991 to 64% in 2000, and has since declined to 58% in 2004. During this time, mammogram utilization varied considerably by educational attainment. The prevalence of women with less than a high school education reporting a recent mammogram was approximately 9 percentage points lower than the prevalence for all women. Even more striking is that the prevalence for women with no health insurance is approximately 25 percentage points lower than the prevalence for all women.
7. Screening Guidelines for the Early Detection of Breast Cancer, American Cancer Society Yearly mammograms are recommended starting at age 40.
A clinical breast exam should be part of a periodic health exam, about every three years for women in their 20s and 30s, and every year for women 40 and older.
Women should know how their breasts normally feel and report any breast changes promptly to their health care providers. Breast self-exam is an option for women starting in their 20s.
Women at increased risk (e.g., family history, genetic tendency, past breast cancer) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (i.e., breast ultrasound and MRI), or having more frequent exams. The American Cancer Society states that women aged 40 and older should have an annual mammogram and clinical breast exam (CBE) as part of a periodic health exam. Women should know how their breasts normally feel and report any changes to their health care provider. A breast self-examination (BSE) is an option for women starting in their 20s. The American Cancer Society states that women aged 40 and older should have an annual mammogram and clinical breast exam (CBE) as part of a periodic health exam. Women should know how their breasts normally feel and report any changes to their health care provider. A breast self-examination (BSE) is an option for women starting in their 20s.
8. Relevant History Breast lump characteristics
Changes over time
Duration
Pain/swelling/redness/discharge
Diet and medications
Hormone therapy
Family history
9. Relevant History Medical/Surgical history
Previous biopsies/surgery
Trauma
Radiation
Personal characteristics
Gs & Ps
Age of menarche/menopause
History of breastfeeding
Smoking/Alcohol
10. Risk Factors Age >50 years
Benign breast dz
Radiation exposure
First child after 20
Higher socioeconomic status
Hx of breast cancer
Family hx of breast ca
Hormone therapy
Nulliparity
Obesity
Alcohol consumption
Lack of breastfeeding
Menarche <12 yrs
Menopause >45 yrs
BRCA mutation
11. Physical Exam Inspection
Symmetry
Skin changes
Nipple discharge
Palpation
Sensitivity of CBE improved by
Longer duration (5-10 min.)
Using systematic pattern
12. Physical Exam Characteristics
Soft vs hard
Fixed vs mobile
Margins: well-defined vs poorly defined
Tenderness
Temperature
CBE alone not adequate for diagnosis of breast cancer or for ruling out the diagnosis
13. Peau DOrange
14. Ultrasonography Not considered screening test
Can distinguish cystic from solid masses
15. Diagnostic Mammography Evaluate specific lesion
Occult disease in surrounding tissue
Utilized spot compression and magnification views
Communicate with radiologist!
16. Magnetic Resonance Imaging Gadolinium enhances vascularity of malignant lesions
Highly sensitive, but lacks specificity
No cost benefit over biopsy
Potential roles
Silicone breast implants
High risk patients e.g. looking for cancer in contralateral breast, surveillance after breast-conserving surgery
17. Tissue is the Issue
18. Fine-Needle Aspiration 22- to 25- gauge needle used to aspirate lesion
If fluid is aspirated and lesion completely resolves, no further diagnostic tests required
Caveat: bleeding or disruption of cyst wall can make subsequent imaging problematic
Can be used for sampling solid lesions
19. Fine Needle Aspiration Cystic fluid analysis
no cytology is necessary if fluid is non-bloody
bloody fluid is probably from traumatic tap but should be sent for cytology anyway
If cyst does not resolve, or recurs after more than 1 tap should be evaluated with biopsy
20. Core-Needle Biopsy 14- to 18-gauge cutting needle with local anesthesia
2-6 cores of tissue for histology
Larger sample than FNA
Often used in conjunction with US or stereotactic imaging
Requires specific training
21. Stereotactic Needle Biopsy
22. Excisional Biopsy Gold standard
Removal of a portion of or the entire lesion
Needle localization may be used
23. Diagnostic Algorithm
Klein,S. Evaluation of palpable breast masses. American Family Physician. 2005;71:1736
24. Diagnostic Algorithm Patients age, risk factors and physician experience will determine first step
May want to get a diagnostic MMG with the ultrasound in postmenopausal woman
If CBE, and FNA +/- imaging all indicate benign disease can repeat exam in 1 mo
If lesion is solid refer for MMG and tissue
25. Legal Considerations Breast cancer common cause of litigation
Failure or Delay in diagnosis
Reason: excessive reliance on negative mammogram
A palpable breast lump must be taken to diagnosis
Tissue (or fluid) is the Issue
Re-evaluate after a SHORT interval
26. Adolescents Fibroadenomas---68%
Fibrocystic changes---19%
Malignancy---<1%
1/3 arose from breast tissue
2/3 non-breast or metastatic tumors (lymphoma, lymphosarcoma, angiosarcoma)
27. Adolescents Careful history and physical
Ultrasound is imaging modality of choice
Dense adolescent breast not conducive to MMG imaging
FNA if cystic
Caution with biopsy in early adolescence due to risk of harm to developing breast bud
28. Pregnancy Diagnosis difficult due to breast enlargement
Diagnosis often delayed 9-15 months after sx onset
average size:3.5 cm vs 2 cm non-pregnant
Best time for breast exam is 1st trimester
29. Pregnancy Most common symptoms of breast cancer: dominant mass and nipple discharge
Mammogram
Unreliable: density of pregnant breast
radiation is negligible
Ultrasound---procedure of choice
FNA if cystic
excision if solid
30. Fund the Fight. Find a Cure.
31. Manogram