Resident R id t A Ambulatory b l t Curriculum PGY 3 Dr Tracie Wilcox Dr. Assistant Professor of M di i Medicine Breast Disease Case 1: A 41 y o female presents to clinic for her annual exam. She has no medical problems and denies a family history of breast cancer. She has had routinely normal pap smears smears. She is asking you about breast cancer screening. screening She performs self breast exams diligently every month and has not noticed any changes changes. Screening for Breast Cancer How would you counsel her regarding screening for breast cancer in a low risk women of her age group? Clinical breast exam Self breast exam Mammogram MRI Self Breast Exams USPTF: recommends against teaching breast self – examination – updated 11/09 No change in breast cancer mortality American cancer society: “ women should be educated about benefits and limitations of monthly self breast exams” ACOG: recommends routine teaching of SBE Clinical Breast Exams American Cancer Society: Recommends every 3 years between age of 20 39 then annually 20-39 USPTF does not recommend clinical breast exam without mammogram Mammogram ACS/ACOG/AMA Recommend starting routine screening at age 40 with frequency of every 1-2 12 years ACP/ AFP Recommend routine screening at age 50 Recommend shared decision making model and individual risk assessment for women age 40-49 40 49 Screening Mammography for Women 40 to 49 Years of Age: A Clinical Practice Guideline from the American College of Physicians Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Katherine Sherif, MD et al., For the Clinical Efficacy Assessment Subcommittee of the American College of Physicians.3 April 2007 | Volume 146 Issue 7 | Pages 511-515 Mammogram New USPTF Guidelines – 11/09 Recommends against routine screening mammogram in women of the general population age 40-49 Recommends mammography screening every 2 years in women 50-74 50 74 Based on data showing: increased rate of false-positive mammograms for women in their 40’s leading to psychological harm and unnecessary tests/procedures Higher number needed to screen to save one life Mammogram ACS response to new USPTF Guidelines: “The ACS continues to recommend annual screening mammography and breast exam for all women beginning at age 40”. Recommendations based on data similar to that reviewed by USPTF + “additional additional data the USPTF did not consider” Based on data showing mortality benefit in women age 40-49 Mammogram Age g g 40-50 Summaryy What is the argument g against? g Breast cancers less common in younger women Mortality benefit for screening smaller than seen for women 50 and over NNTS 50-59 to save one life: 1339 NNTS 40-49 to save one life: 1904 Abnormal mammogram less likely to be malignant and leads to unnecessary stress and biopsies Increased rates of detection of DCIS Unclear how often DCIS would progress to further cancer if left untreated Mammogram Age 40-50 40 50 What is the argument for? Screening mammograms for women 40 to 49 years of age decrease the risk for breast cancer deaths compared with women who do not get screened A recent estimated ece t meta-analysis eta a a ys s est ated tthe e relative e at e reduction in the breast cancer mortality rate to be 15% after 14 years of follow-up Diagnose breast cancer at earlier stage Breast cancers in younger patients may be more aggressive (ER negative) Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:34760. Breast MRI American Cancer Society recommends annual MRI in the following high risk groups: Known BRCA mutation carriers First degree relatives of known BRCA mutation carriers Women with increased lifetime risk of over 20-25% based upon prediction models Case 2 KP is a 50 y o white female who presents with concerns about her personal risk of developing breast cancer. Her mother was diagnosed with breast cancer at age 62. She wants to know if she would be a p p y candidate for chemoprophylaxis. How could you determine this? Breast Cancer Risk Assessment Tool (Gail Model) Calculates a woman’s 5-year y and lifetime risk of developing breast cancer Includes: Current age Number of 1st-degree female relatives with a history of breast cancer Age at first live birth, or nulliparity History and Number of breast biopsies History of atypical hyperplasia Age at menarche Race The Gail Model Based on data from the Breast Cancer Detection Demonstration Project involved white women undergoing annual screening examinations Estimates the probability that a woman will develop invasive or in situ breast cancer over a defined age interval Limitations of the Gail Model Not to be used in women alreadyy with history y of LCIS, DCIS, or invasive breast cancer. May underestimate the risk in women who have 2nd-degree degree relatives with breast cancer or who are known BRCA carriers May overestimate risk with women who are over age 50 with history of two or more breast biopsies or who were under age 20 at first live birth. Updated model validated in AA women in 2007 Not to be used in women age < 35 Constantino JP, Gail MH, Pee D, et al. J Natl Cancer Inst. 1999;91:1541-1548 . The CASH (Claus / Yale) Model Calculates a woman’s woman s risk of developing breast cancer over 10year intervals in women with family hx off breast b t cancer Includes: Number of 1st- or 2nd-degree relatives with a history of breast cancer (maternal and paternal) Age that 1st- and 2nd-degree relatives were diagnosed with breast cancer Limitations of the Claus M d l Model Woman must have at least one 1st- or 2nd-degree d relative l ti with ith b breastt cancer Does not take into account other risk factors associated with breast cancer Onlyy included 10% AA women in data collection studies Created prior to discovery of BRCA 1 and 2 genes Case 2 continued 45 yo white female Menarche at age 11 Nulliparous N lli Mother with breast cancer at age g 62; 2 healthy postmenopausal sisters 1 previous breast biopsy with benign pathology Using the Gail Model Model, this patient’s patient s risk for developing breast cancer is: 5-year risk = 2.8% Lifetime risk = 23.2% Chemoprevention Would you offer this patient chemoprevention? If so, what medication would you ff ? offer? Chemoprevention Average risk for 45 y o caucasian women is: 5 yr: 1% Lifetime: 11.9% Consider chemoprevention in patients age 35-59 if 5-year GAIL model risk > 1.66% Chemoprevention Options SERM: Tamoxifen Shown to decrease risk of ER positive invasive breast cancer and noninvasive breast cancer Highest benefit in younger women, women without uterus, and women with highest risk of breast cancer Taken for 5 years No study has shown survival benefit Raloxifen Reduces incidence of invasive breast cancer in high risk women Lower risk of DVT, PE, cataract Approved in US for prevention of breast cancer in postmenopausal women with osteoporosis and postmenopausal women at high risk of developing breast cancer A t iinhibitors hibit tl being b i studied t di d Aromatase – currently Case 3 35 y o female with significant family history for breast cancer tests positive for the BRCA mutation mutation. She opts against surgical prophylaxis. How would you screen her for breast cancer? Increased Surveillance in High Risk W ith BRCA mutations t ti Women with Annual mammogram starting age 25 Annual MRI starting age 25 Clinical breastt exam 2 2-4x/year Cli i l b 4 / starting age 20-25 Annual self breast exam p p Discuss chemoprevention options Case 4 A 45 yo AAF presents to your clinic for a routine physical. Two months prior to moving to Chicago she detected a lump on self breast examination. Follow-up mammogram and biopsy showed “fib ti changes”. h ” Sh t tto kknow “fibrocystic She wants whether this will increase her chances of breast cancer and has brought the report for you to evaluate: She has no family history of breast cancer cancer. Case 9 cont: Pathology: “Fibrocystic changes without atypia” Her breast cancer risk is: ) 1)Average 2)Increased 3)Decreased “Fibrocystic Changes” Fibrocystic Changes Non proliferative breast lesion Most common cause of breast nodularity g 20 to 50 and p pain in women age Increase in number of cysts and fibrous tissue Exam reveals rubbery non-discrete glandular tissue. May also appreciate cysts. May have associated nipple discharge: color can be pale green to brown Fibrocystic Disease Fibrocystic change of the breast in conjunction with severe pain (which is usually cyclical) cyclical), palpable mass and occasionally nipple discharge Fibrocystic Breast and Cancer Ri k Risk Fibrocystic change denotes normal breast tissue without an appreciable increase in cancer risk Proliferative lesions with associated atypia increase risk Ex: Atypical hyperplasia – relative risk 36 fold Case # 5 A 36 y o female presents to your clinic with complaints of nipple discharge. What questions do you ask her and h d l t h ? how do you evaluate her? Historical Questions Is it unilateral or bilateral? Is it spontaneous or provoked by manipulation? What is the color and consistency of the fluid? How has it b been going H llong h i on? ? Any association with physical events such as trauma? Any new medications which might be associated? Associated amenorrhea or symptoms of hypogonadism (hot flashes flashes, vaginal dryness) Physical Exam Check for skin changes and asymmetry of breasts Determine the number of ducts involved Determine if discharge unilateral or bilateral Check for associated breast mass and LAD Check the color and consistency of the fluid? Straw colored: intraductal papilloma compressing venous/lymphatic system Grossly Bloody: 1/3 fibrocystic breast 1/3 intraductal i t d t l papilloma ill Intraductal carcinoma Test anyy discharge g for blood with hemoccult test Intraductal pathology, occasionally breast CA Case 5 Continued On further q questioning g she reports p unilateral discharge that is spontaneous and is straw colored. She denies any amenorrhea or hot flashes or vision changes. PE reveals no breast asymmetry asymmetry, no palpable mass, expressible unilateral discharge that is straw colored, from a single duct, i l d t and d guiac i negative. ti How would you evaluate her further? Diagnostic Testing Labs for multiductal discharge: TSH, prolactin, pregnancy test g Mammogram if >30 ((dedicated mammogram with magnified views of retroaerolar area) + peri-areolar u/s +/ductal studies Cytology – rarely helpful If negative does not rule out malignancy Surgical evaluation for breast lump, imaging abnormality abnormality, + guaiac test test, unilateral spontaneous from one duct Case 5 Continued Mammogram shows breast nodule and breast u/s + ductogram reveal intraductal papilloma Referred to surgeon and papilloma resected Characterization of Nipple Di h Discharge: Normal Discharge = Lactation Physiologic Discharge = galactorrhea g = nonpathologic d/c not related to pregnancy or nursing Discharge is usually seen only with compression of ducts (usually multiple ducts are involved) Discharge is usually bilateral Fluid color may be clear clear, yellow yellow, white or dark green Guiac negative g Causes of Galactorrhea Idiopathic Secondary Hyperprolactinemia – ex: pituitary adenoma Medications: TCA’s, antipsychotics,narcotics Menarche or Early Menopause Nipple Stimulation Trauma to anterior thoracic nerves Other: stress, mastitis Pathologic Causes = suspicous causes malignant or nonmalignant more likely to occur spontaneously spontaneously, be unilateral, and confined to one duct Fluid more often bloody Associated mass may be present Pathologic Nipple Discharge Ddx: Intraducal papilloma Most common cause ( 52-57%) Ductal ectasia Fibrocystic changes Malignancy - 5-15% Increases with increasing age DCIS most common False Nipple Discharge Fluid does NOT originate in breast secretory unit Eczema Cutaneous viral infections Nipple trauma eg eg. Joggers nipples Draining sebacous cyst Other off inflammations Oth skin ki infections i f ti i fl ti (e.g. moloscum contagiosum) Case 6 A 56 y o female presents with left sided nipple discharge associated with redness and skin irritation irritation. On PE there is no palpable lump in the breast but + erythema and skin thickening around the areola What kind Wh t is i your concern and d what h t ki d of work up should you order? Physical Exam Paget’s Paget s Disease Clinical symptoms: y p scaly, raw, vesicular, or ulcerated lesion that begins on the nipple and then spreads to the areola Pain, burning, pruritus yellow, clear, viscous or bloody discharge Associated with underlying breast cancer in 97% of cases Dx: breast exam,mammo,MRI, punch biopsy off th the skin bi ki Trx: mastectomy vs resection of nipple/areola complex + xrt