MAJOR HEALTH CONCERNS IN WOMEN
| BREAST LUMPS —Armando E. Giuliano, MD, Chief of Surgical Oncology, John Wayne Cancer Institute, St. John’s
Hospital and Health Center, Santa Monica, CA, and Clinical Professor of Surgery, David Geffen School of Medicine at the
University of California, Los Angeles
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| Risk factors associated with malignancy: genetic mutations (eg, BRCA-1, BRCA-2; 5% of breast cancers); family
history (treat as if patient had genetic mutation); previous breast cancer (1%-2% chance per year of developing contralateral
breast cancer); proliferative breast disease (ie, atypical ductal or lobular hyperplasia); hormone replacement therapy
(HRT; 1 in 1000 patients on HRT get breast cancer); age at menarche/ menopause (increased risk associated with longer
reproductive window); age at first live birth
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| Clinical assessment: history—duration and change of breast lump; ask patient about pain and whether pain changes
with menses (fibrocystic breasts often painful before menstrual period); evaluate patient for risk factors (eg, family history,
HRT); physical examination—inspect breasts for symmetry, movement of muscle, skin changes, and retraction of
nipple; look for dimpling, edema, or redness of skin; palpation—after inspecting breast, begin palpation
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| Presentation: premammography—breast cancer presents as discrete lump in ≈80% of patients; patient may present
with complaint of breast lump or describe swelling or thickening or asymmetry of breasts; complaints of pain probably
not related to breast cancer, but to other factors (ie, concomitant fibrocystic disease), unless cancer invading skin or underlying
muscle fascia; cancer may present as bleeding or changes in nipple, but this almost always results from intraductal
benign tumors; sometimes breast cancer presents as skin puckering or as lump in axilla; mammographic era—at
least 50% of patients present with mammographic abnormality
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| Breast examination: most cancers present in upper outer quadrant; fewer cancers occur in lower or inner hemisphere;
some cancers occur under nipple (physical examination more difficult); patients with fibrocystic disease have pain in
upper outer quadrants; patient seated for examination; have patient place arms over shoulder, then on hips and squeeze
(motions change pectoralis major and pull on Cooper’s ligaments); examine lymph nodes (supraclavicular and axillary),
then breast, with patient seated; then have patient lie down; palpate breast carefully and wholly; use method of
palpation that works best for each patient
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 | Parenchymal characteristics: most examinations normal, despite nodularity; document normal breast examination in chart as
area of increased nodularity, no dominant mass (writing mass or lump in chart requires physician to refer patient down
different pathway); postmenopausal women not on HRT—have breasts with predominantly fatty tissue and minimal or
no nodularity; area that feels different should trigger work-up; premenopausal or postmenopausal women on HRT—
breasts have diffuse nodularity, especially in upper outer quadrants; areas of increased nodularity common and symmetric
or asymmetric; some breasts have subareolar nodularity or dense plate-like appearance; look for dominant mass
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| Breast masses: normal structures—some can feel like mass; eg, normal nodularity, prominent fat lobule, prominent
rib, intramammary lymph node, edge of biopsy site in patient who had excisional biopsy, or accessory breast; non-neoplastic
masses—fibrocystic disease (variant of normal breast tissue); galactocele (milk-filled cyst) can occur during
pregnancy or lactation; looks solid on ultrasonography (US); stromal fibrosis; inflammatory problems, eg, mastitis, abscess;
fat necrosis (indistinguishable from carcinoma on physical examination or imaging studies); granuloma; Mondor’s
disease (superficial thrombophlebitis of breast; commonly caused by seat belts); skin mass, eg, sebaceous cyst or dermatofibroma;
benign neoplastic masses—primarily fibroadenoma in young women, papilloma (intraductal tumors), lipoma,
and granular cell myoblastoma (rare); intermediate neoplastic masses—cystosarcoma phyllodes; most benign;
tend to recur locally; some phyllodes tumors have sarcomatous features that metastasize; malignant masses—
carcinoma; cystosarcoma phyllodes; lymphoma; sarcoma; metastases from another site
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| Other considerations: “orange skin”—usually considered sign of locally advanced cancer that obstructs lymphatic
system, causing edema of skin; however, feature commonly seen in patients who have had lumpectomy and radiation;
Paget’s disease—invasion of nipple from underlying cancer, usually close to nipple; usually early-stage cancer and curable;
skin rashes—raise index of suspicion if rash does not resolve in 1 to 2 wk; mastitis—usually occurs in lactating
women; treat with dicloxacillin; if patient not lactating and infection suspected, give 1- to 2-wk course of antibiotic; biopsy
required if condition does not resolve; freely movable mass as benign—most cancers freely movable and not fixed to
chest wall; not helpful in determining whether cancer benign or malignant
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| Mammography: indicated for screening or as diagnostic tool to evaluate mass or change in breast; in patient with palpable
mass, consider placing “X” on mass to communicate location to radiologist who performs diagnostic mammography
and US; in patient with palpable or nonpalpable mass who had mammography <3 mo ago, ignore, but repeat
mammography if >3 mo ago; American Cancer Society Guidelines for Breast Cancer Screening 2006—in average-risk
patients, recommend annual mammography starting at 40 yr of age; in patients with family history of breast
cancer, start screening 10 yr earlier than age of affected family member at diagnosis; in patients who have BRCA gene,
recommend annual mammography and magnetic resonance imaging (MRI) at 6-mo intervals after annual mammography
(MRI sensitive in detecting breast cancer, but high sensitivity can lead to unnecessary biopsy; recommend MRI
only in extraordinarily high-risk patients); survival rate—mammographic screening decreases mortality rate; survival
dependent on stage at diagnosis; improved survival rate associated with mammographically detected tumor
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| Evaluation of mass on mammography: benign mass—round and smooth; breast does not appear distorted; may see benign
coarse calcifications; often symmetric, do not grow; malignant mass—irregular, “crab-like”, spiculated, and distort normal
architecture of breast; microcalcifications present, often asymmetric, that exhibit growth; malignant findings associated
with mass include skin involvement, skin thickening or nipple retraction, edema of breast, architectural distortion and
asymmetry of breast, and increased density; calcifications—most women >40 yr of age have calcifications; benign calcifications
solitary or scattered throughout breast, often large and round and consistent in appearance; malignant calcifications
multiple and clustered in single area; small size and branching results from clustering inside ducts; polymorphic
appearance occurs during development of each calcification; breast implants—hardened capsule can hide cancer
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| Work-up of breast lump: needle aspiration—eg, in young patient with smooth nonfixed mass, consider taking needle
syringe and aspirating mass; if mass disappears and fluid nonbloody, reexamine patient in 2 to 4 wk; patient cured
if mass does not reappear; fluid cytology not helpful; test fluid for blood using Hemoccult; if mass does not disappear
after needle aspiration, reexamine patient in 2 wk, then send patient to mammography; biopsy—consider fine needle
aspiration (FNA) biopsy or core needle biopsy; prefer core needle biopsy because it obtains piece of tissue (can use to
check for tumor markers, eg, estrogen receptor (ER), progesterone receptor (PR), HER2); surgical biopsy almost never
performed; excisional biopsy indicated if mass too close to chest wall for stereotactic core machine or if US-guided biopsy
failed to produce unequivocal results; MRI—very sensitive with low specificity; expensive; indicated for screening
in high-risk patients, to look for implant rupture, in patient with abnormal mammography who had previous
lumpectomy and now has scar that appears worse, and to look for extracapsular implant leaks
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| Postmenopausal patient not on HRT: recommend mammography, US, needle biopsy, and preoperative counseling if
mass appears malignant (any new lump in breast probably malignant)
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| Premenopausal or postmenopausal patient on HRT: recommend mammography, US, and needle biopsy if mass feels malignant;
avoid “discordant needle biopsy”; recommend lumpectomy if mass felt cancerous, but test results benign; reexamine
patient in 2 to 4 wk if mass felt cancerous, but mammography and US results benign; recommend biopsy if clinical judgment
and imaging studies discordant (eg, judged mass as fibroadenoma, but mammography and US indicate malignancy);
consider needle biopsy or reexamining patient after next menstrual period if imaging studies show mass solid and benign;
biopsy mass if still apparent after patient’s next menstrual cycle; aspirate mass if clinical judgment indicates cystic mass;
avoid negating patient who comes in complaining about breast mass; affirm what patient feels and reassure her that clinical
judgment and studies show what she feels not mass but normal breast tissue; reexamine patient in 2 mo and repeat until
patient convinced what she feels not mass
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| CARDIOVASCULAR DISEASE IN WOMEN —Anne L. Taylor, MD, Professor of Medicine and Associate Dean, University
of Minnesota Medical School, Minneapolis
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| Clinical presentation: women with heart disease or myocardial infarction (MI) present more often with atypical symptoms;
women may present with less specific chest pain; women with typical angina may have small-vessel disease and
not epicardial coronary disease; study—survey of 500 women presenting with acute MI showed 95% identified symptoms
1 mo before; complaints of unusual fatigue 70%, sleep disturbances 48%, dyspnea 42%, and chest pain in only
29%; at time of MI, symptoms included dyspnea 58%, chest pain 57% (often in atypical locations, eg, shoulder pain, jaw
pain, arm pain, instead of substernal pain), weakness 55%, unusual fatigue 43%, cold sweats 39%, and dizziness 39%
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| Determinants of cardiovascular health: lifestyle, biologic factors, socioeconomic factors (risk for cardiovascular
disease increases with decreasing level of education; increased risk in people who feel they have less control over their
work environment), economic issues, physical environment (recommend 30 min of daily exercise; consider which factors
barriers to care in individual patients; assess potential barriers and address them to ensure appropriate care
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| Risk factors: include increasing age, family history and ethnicity, hypertension, hyperlipidemia, diabetes, sedentary lifestyle,
tobacco use, and obesity; menopausal status unique risk factor in women; endogenous estrogen may protect women
early in life from vascular disease; after menopause, sharp increase in risk for vascular disease may be due to loss of estrogen
and changes in risk factors (increase in blood pressure and less favorable lipid profile); postmenopausal HRT not associated
with cardiovascular risk reduction; prevention strategies—effective in reducing cardiovascular death and disability;
many poorly implemented in community; interventions still needed to raise awareness of women and health care professionals
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| Evidence-based guidelines for prevention of cardiovascular disease in women: risk groups based on
Framingham data; high-risk women those with calculated 10-yr risk for coronary artery disease (CAD) >20% and/or
established CAD, diabetes mellitus, chronic kidney disease, and other vascular disease; intermediate-risk women 10%
to 20% 10-yr risk for CAD, subclinical CAD, coronary calcification, metabolic syndrome, multiple risk factors, markedly
elevated levels of single risk factor, or first-degree relative with early onset of disease; low-risk women <10% 10-
yr risk and may have metabolic syndrome or other variable numbers of risk factors; optimal-risk women have desirable
levels of risk factors and heart-healthy lifestyle
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| Guidelines: recommend smoking cessation and avoiding environmental tobacco; recommended 30 min of daily physical
activity, cardiac rehabilitation, heart-healthy diet; maintain body mass index (BMI; weight (kg)/[height (m)]2 ) between
18.5 and 24.9; psychosocial factors, eg, depression, important; depression more prevalent in women than men; depressed
individuals have higher likelihood of developing cardiovascular disease, and depressed persons who have cardiovascular
event have higher mortality; impact of treatment (eg, antidepressants) unclear; recommend consumption of
omega-3 fatty acids and folic acid; major risk factor interventions include blood pressure (<120/80 mm Hg current optimal
BP; hypertension defined as ≥140/90 mm Hg); 120 to 140 considered prehypertensive); recommend tight control
of blood pressure in diabetic patients; recommend lowering cholesterol by dietary management and exercise, then by
pharmacotherapy; diabetic patient needs tight control of glucose to reduce risk for cardiovascular event; recommend
aspirin in all high-risk women and in intermediate-risk women if blood pressure controlled (women have more bleeding
complications than men); recommend β-blockers in women post-MI or who have CAD; recommend angiotension-
converting enzyme (ACE) inhibitors in high-risk women (eg, diabetics) or angiotension receptor blockers for high-risk
women intolerant of ACE inhibitors; warfarin still standard of care for patients with atrial fibrillation (best protection
against stroke); recommend warfarin in women with chronic or paroxysmal atrial fibrillation, unless risk for stroke
<1% per yr (eg, young person with structurally normal heart who has paroxysmal atrial fibrillation; treat this patient
with aspirin); recommend aspirin in women with atrial fibrillation with contraindications to warfarin; HRT not protective
for cardiovascular disease and may be harmful; role of HRT in perimenopausal period unknown; no role for antioxidant
supplements; diet rich in antioxidants cardioprotective; aspirin in low-risk women not beneficial
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| Approach to risk management in women: look at patient’s lipid profiles, blood glucose, hemoglobin (Hb)A1C ,
blood pressure, family history, C-reactive protein, and homocysteine; obtain risk profile of patient and stratify according
to risk level; lifestyle interventions recommended in all women; base other interventions on level of risk, strength of recommendation,
and level of evidence; avoid class III recommendations
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Educational Objectives
| The goal of this activity is to provide a greater understanding of the evaluation of breast lumps and of cardiovascular disease
in women. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Discuss the risk factors associated with breast cancer.
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| 2. Describe the physical examination of a patient who presents with a breast mass.
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| 3. Assess the most appropriate diagnostic tools to use for a patient with a breast mass.
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| 4. Describe the differences in the clinical presentation of women with heart disease, compared to men.
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| 5. List the risk factors for cardiovascular disease in women.
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Discussed on This Program
Aspirin (acetylsalicylic acid; ASA) [several trade names]
Dicloxacillin sodium
Suggested Reading
Brennan M et al: Management of benign breast conditions. Part 2--breast lumps and lesions. Aust Fam Physician.
34:253, 2005; Czubryt MP et al: The role of sex in cardiac function and disease. Can J Physiol Pharmacol. 84:93,
2006; Jacobson TA: Secondary prevention of coronary artery disease with omega-3 fatty acids. Am J Cardiol. 98:61i,
2006; Kerlikowske K et al: Evaluation of abnormal mammography results and palpable breast abnormalities. Ann Intern
Med. 139:274, 2003; Lucas JH et al: Breast cyst aspiration. Am Fam Physician. 68:1983, 2003; Morrow M:
The evaluation of common breast problems. Am Fam Physician. 61:2371, 2000; Pepine CJ et al: Estrogen and different
aspects of vascular disease in women and men. Circ Res. 99:459, 2006; Vargas HI et al: Outcomes of sonography-
based management of breast cysts. Am J Surg. 188:443, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue: Dr. Taylor
reports research support and consults for Nitromed, Inc.
Dr. Giuliano was recorded in Los Angeles, CA, June 5-9, 2006, at the 33rd Annual Family Practice Refresher Course,
sponsored by the David Geffen School of Medicine at University of California, Los Angeles. Dr. Taylor was recorded in
Minneapolis, MN, May 1-5, 2006, at the 32nd Annual Family Medicine Review Update, sponsored by the University of
Minnesota Medical School, Minneapolis. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation
in the production of this program.
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