Clinical Correlate 12 Breast problemsThe purpose of this correlate is to encourage trainees at different levels to familiarize themselves with some basic issues of breast disease. The poem from Unit 2, though not about breast disease per se, should serve as a reference point for understanding a woman’s emotional relationship to her breasts.Study questions
A. Breast complaints . See the abstract and link below for an article on common breast complaints. An additional reference/abstract from the Mayo Clinical Proceedings is also given. 1. The Evaluation of Common Breast Problems. Monica Morrow MD Northwestern University Medical School, Chicago, Illinois The most common breast problems for which women consult a physician are breast pain, nipple discharge and a palpable mass. Most women with these complaints have benign breast disease. Breast pain alone is rarely a presenting symptom of cancer, and imaging studies should be reserved for use in women who fall within usual screening guidelines. A nipple discharge can be characterized as physiologic or pathologic based on the findings of the history and physical examination. A pathologic discharge is an indication for terminal duct excision. A dominant breast mass requires histologic diagnosis. A breast cyst can be diagnosed and treated by aspiration. The management of a solid mass depends on the degree of clinical suspicion and the patient’s age. (Am Fam Physician 2000;61:2371-8,2385.) http://www.aafp.org/afp/20000415/2371.html
2. Abstract: Detection and evaluation of a palpable breast mass. Pruthi S. Division of General Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA. Mayo Clin Proc. 2001 Jun;76(6):641-7; quiz 647-8. The discovery of a breast mass, either self-detected or identified by a clinician, is a common, often distressing occurrence for many women. Although most detected breast masses are benign, every woman presenting with a breast mass should be evaluated to exclude or establish a diagnosis of cancer. This article provides a succinct overview of normal breast anatomy and reviews common causes of breast masses. The role of the clinical breast examination is discussed, and an algorithm is provided for optimal utilization of available tools in the diagnostic evaluation of a breast mass. The evaluation should be performed expeditiously and the results communicated promptly to the patient. Regardless of the age of the woman, a clinically suspicious mass must be evaluated even if findings on a mammogram are normal. B. Breast cancer risk factors : see link below for ACS fact sheet http://www.cancer.org/docroot/PRO/content/PRO_1_1x_Breast_Cancer.pdf.asp?sitearea=PRO C. Breast Cancer Guidelines : Summary of guidelines for breast cancer screeing by the ACS and the USPSTF are given below1. American Cancer Society▪ Yearly mammograms starting at age 40 and continuing for as long as a woman is in good health.
▪ Clinical breast exams (CBE) 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 over.
▪ Women should report any breast change promptly to their health care providers. Breast self-exam (BSE) 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 (e.g., breast ultrasound or MRI), or having more frequent exams.
2. US Preventive Services Task Force http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm Summary of RecommendationsThe U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.
Rating: B recommendation .Rationale: The USPSTF found fair evidence that mammography screening every 12-33 months significantly reduces mortality from breast cancer. Evidence is strongest for women aged 50-69, the age group generally included in screening trials. For women aged 40-49, the evidence that screening mammography reduces mortality from breast cancer is weaker, and the absolute benefit of mammography is smaller, than it is for older women. Most, but not all, studies indicate a mortality benefit for women undergoing mammography at ages 40-49, but the delay in observed benefit in women younger than 50 makes it difficult to determine the incremental benefit of beginning screening at age 40 rather than at age 50. The absolute benefit is smaller because the incidence of breast cancer is lower among women in their 40s than it is among older women. The USPSTF concluded that the evidence is also generalizable to women aged 70 and older (who face a higher absolute risk for breast cancer) if their life expectancy is not compromised by comorbid disease. The absolute probability of benefits of regular mammography increase along a continuum with age, whereas the likelihood of harms from screening (false-positive results and unnecessary anxiety, biopsies, and cost) diminish from ages 40-70. The balance of benefits and potential harms, therefore, grows more favorable as women age. The precise age at which the potential benefits of mammography justify the possible harms is a subjective choice. The USPSTF did not find sufficient evidence to specify the optimal screening interval for women aged 40-49 The USPSTF concludes that the evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer.
Rating: I recommendation .Rationale: No screening trial has examined the benefits of CBE alone (without accompanying mammography) compared to no screening, and design characteristics limit the generalizability of studies that have examined CBE. The USPSTF could not determine the benefits of CBE alone or the incremental benefit of adding CBE to mammography. The USPSTF therefore could not determine whether potential benefits of routine CBE outweigh the potential harms. The USPSTF concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (BSE).
Rating: I recommendation .Rationale: The USPSTF found poor evidence to determine whether BSE reduces breast cancer mortality. The USPSTF found fair evidence that BSE is associated with an increased risk for false-positive results and biopsies. Due to design limitations of published and ongoing studies of BSE, the USPSTF could not determine the balance of benefits and potential harms of BSE D. Breast Cancer follow-up: The following abstract and link refer to an article on caring for cancer survivorsCare of Cancer SurvivorsAnnette Y. Sunga, M.D., M.P.H., and Margaret M. Eberl, M.D., State University of New York, Buffalo, New York Kevin C. Oeffinger, M.D., University of Texas Southwestern Medical Center, Dallas, Texas Melissa M. Hudson, M.D., St. Jude Children’s Research Hospital, Memphis, Tennessee Martin C. Mahoney, M.D., Ph.D., State University of New York, Buffalo, New York Cancer survivors are at increased risk for recurrence of their original malignancy; development of second primary malignancies; and medical, developmental, and psychologic problems resulting from cancer therapy, genetic predisposition to cancer, and other risk factors. Surveillance following curative cancer treatment generally includes interval history and physical examinations every six months for five years. Thereafter, histories and examinations are recommended annually for breast cancer; every three months for two years, then every six months for three to five years for colorectal cancer; and every six months for five years, then annually for prostate cancer. Recommended laboratory tests and ancillary procedures include annual mammography of preserved breast tissue in breast cancer survivors, carcinoembryonic antigen level monitoring in conjunction with annual colonoscopy in colorectal cancer patients, and prostate-specific antigen measurements every six months for five years and then annually in prostate cancer survivors. In addition, family physicians should be attentive to concerns about altered body image or sexuality issues following curative surgical procedures. Continued emphasis on preventive health practices is encouraged. Physicians should remain alert to nonspecific symptoms or physical findings (e.g., mass, adenopathy) that can indicate cancer recurrence. In childhood cancer survivors, periodic evaluation that includes a plan for surveillance and prevention, incorporating risks based on previous cancer, therapy, genetic predispositions, personal behaviors, and comorbid health conditions, is recommended. (Am Fam Physician 2005;71:699-706,713-4. Copyright© 2005 American Academy of Family Physicians.) http://www.aafp.org/afp/20050215/699.html E. Breast Cancer Treatment decisions: The following refer to two articles which deal with different aspects of communication and bias in treating women for breast cancer. 1. Effect of a Decision Aid on Knowledge and Treatment Decision Making for Breast Cancer SurgeryA Randomized TrialTimothy Whelan, BM, BCh; Mark Levine, MD; Andrew Willan, PhD; Amiram Gafni, PhD; Ken Sanders, MD; Doug Mirsky, MD; Shelley Chambers, MA; Mary Ann O’Brien, MSc; Susan Reid, MD; Sacha Dubois, BA JAMA. 2004;292:435-441. ABSTRACT Context The long-term results of randomized trials have demonstrated equivalent survival rates for mastectomy and breast-conserving therapy for the treatment of early stage breast cancer. Consequently, the choice of treatment should be based on a patient’s preferences. Objective To evaluate the impact of a decision aid regarding the different surgical treatment options on patient decision making. Design and Setting A cluster randomized trial for which general surgeons in the communities of central-west, and eastern Ontario, Canada, were randomly assigned to use the decision aid or not in the surgical consultation. Patients received the decision aid or not based on the surgeon seen. Participants Twenty surgeons participated in the study. Of the 208 eligible women with newly diagnosed clinical stage I or II breast cancer seen by study surgeons, 201 agreed to be evaluated: 94 were assigned to the decision board and 107 to usual practice. Patients were recruited from November 1999 to April 2002. Intervention The decision board is a decision aid designed to help physicians inform their patients about different treatment options and to enable patients to express a preference for treatment. Main Outcome Measures Patient knowledge about the surgical treatment of breast cancer; decisional conflict; satisfaction with decision making; and the treatment decision following the consultation. Results Patients in the decision board group had higher knowledge scores about their treatment options (66.9 vs 58.7; P<.001), had less decisional conflict (1.40 vs 1.62, P = .02), and were more satisfied with decision making (4.50 vs 4.32, P = .05) following the consultation. Patients who used the decision board were more likely to choose BCT (94% vs 76%, P = .03). Conclusions The decision board was helpful in improving communication and enabling women to make a choice regarding treatment. Such instruments should be considered by surgeons when communicating the different surgical options to women with breast cancer. 2. No age limit for adjuvant chemotherapy for breast cancer
Muss HB et al. Adjuvant chemotherapy in older and younger women with lymph-node positive breast cancer JAMA 2005: 293: 1073-81. March 2 Breast cancer incidence increases with age. Systemic adjuvant chemotherapy is used to treat early-stage breast cancer and has been shown to improve overall and relapse-free survival in women aged 50-69, but it is not known whether older women receive the same benefit. Because of tolerability issues, this adjuvant treatment may be underused in this older age group. This study reports the results of the Cancer and Leukemia Group B (CALGB) retrospective review of 4 trials comparing less aggressive with more aggressive chemotherapy regimens in order to determine the effects of dose-intensive regimens on older patients. The 4 CALGB trials compared various dosage regimens in patients with node-positive breast cancer. In the 7581 trial, cyclophosphamide, methotrexate and fluorouracil (CMF) plus vincristine and prednisone (VP)improved disease-free survival but not overall survival compared with CMF alone or CMF and methanol extraction residue of bacillus Calmette_Geurin (MER). In trial 8082, 2 types of CMF regimens were found to be equivalent, but when escalating doses of a doxorubicin-based regimen was added to one arm, this was associated with improved disease-free and overall survival. In the 8541 trial, three different dose-and duration ranges of cyclophosphamide, doxorubicin and fluorouracil (CAF) found that moderate and high-dose groups had longer disease-free survival and overall survival and a subset of patients in the high-dose groups benefited from addition to human epidermal growth factor 2. Finally, the 9344 trial found no differences among groups randomized to 3 doses of doxyrubicin combined with cyclophosphamide, but patients subsequently randomized to receive additional paclitaxil improved disease-free interval and survival. These 4 trials represent a span of 24 years with 6487 patients studied. Tumor sizes did not differ among age groups but number of positive nodes increased with age. Treatment-related mortality was 0.5% with chemotherapy-related mortality increasing linearly with age. Age was unrelated to disease-free survival or overall survival. Predictors of shortened survival included positive nodes, increased tumor size no tamoxifen use and estrogen receptor-negative tumors. More chemotherapy improved both disease-free and overall survival compared with less chemotherapy, regardless of age. Older patients receiving more chemotherapy did as well as younger patients, though their risk of recurrence was a priori higher given the greater number of positive lymph nodes in this group. The authors suggest that age bias may prevent physicians from treating older women with optimal chemotherapeutic regimens. In particular, only a small number of the women enrolled in the CALGB trials were older than 65, whereas the data show that these older women are as likely to benefit from trial regimens as younger women, in spite of a slightly higher chemotherapy related mortality. The authors caution that participation in new trials should be limited to women otherwise in good health.
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