Evaluation of Breast Masses

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 D�Orange

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 Patient�s 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