Distinguish a discrete breast mass from nodularity.

Determine the appropriate diagnostic modality for the woman with a solid or cystic breast mass.

Evaluate and manage women with breast pain, nipple discharge, mastitis, and breast abscess.

Determine appropriate candidates for breast magnetic resonance imaging

Evaluate and counsel women at risk for breast cancer.

Management of Breast Conditions
Rebecca A. Jackson, MD, Associate Clinical Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences & Epidemiology and Biostatistics, University of California, San Francisco, School of Medicine; Medical Director, Women’s Health Clinic, San Francisco General Hospital

General considerations: 5 to 10 women undergo breast biopsy for every 1 woman diagnosed with breast cancer; 15 million breast-related visits annually; 5% of deaths attributable to breast cancer (perceived as leading cause of death); failure to diagnose breast cancer leading cause of malpractice claims; prememopausal woman with self-identified breast mass and normal mammography result and no further evaluation who subsequently develops breast cancer most common claim

Differential diagnosis: fibroadenoma (adolescents); fibrocystic change (reproductive-aged women); cyst (40- to 50-yr- old women); ductal carcinoma in situ (DCIS) and cancer increase with age; discrete mass—stands out from adjoining breast tissue; definable borders; measurable; nodularity—poorly defined, vague sense of thick breast tissue; usually bilateral, fluctuates with menstrual cycle; ≈10% of all palpable discrete breast masses cancerous; 8% of abnormal masses detected on mammography cancerous; increases with age (37% of discrete masses in older women cancerous)

Clinical breast examination (CBE): neither sensitive nor specific; cannot distinguish cyst from solid mass or benign from malignant; important in determining whether mass discrete or thickening; adjunct to mammography; required for follow-up; perform with patient in sitting and lying positions, using methodical technique (eg, spirals, vertical strips); mark mass when referring patient for core needle biopsy or fine-needle aspiration (FNA)

Palpable breast mass: first step to determine whether mass cystic or solid; simple cyst—benign cyst does not require reevaluation; common, especially in perimenopausal women; ultrasonography (US)—classifies mass as cystic or solid; provides guidance for cyst aspiration; adjunct to mammography (reflective US often done to distinguish between cystic and solid mass); can be first (often only) work-up if cyst confirmed; 98% to 100% accuracy in diagnosing simple cyst; reevaluation required if results show anything other than simple cyst

Biopsy: cyst aspiration—simple office procedure; 20-gauge needle and syringe; US guidance not required; fluid indicates cyst; if no fluid, indication that location missed or mass not a cyst (further work-up needed); relief of pain due to symptomatic cyst secondary benefit; criteria for no further follow-up—cyst collapses (no residual mass); fluid not brown or red (acceptable if cloudy or mucinous); does not reaccumulate on follow-up (repeat breast examination in 2-3 mo); additional work-up required if fluid bloody, blood suspected, or no fluid; FNA—should be done by experienced cytopathologist or breast surgeon; primarily used for diagnosis of solid mass; least invasive method; sensitivity operator- dependent (92%-98% for experienced personnel; average 75% for untrained personnel [can be as low as 65%]); experienced cytopathologist necessary for interpretation; cannot be used to diagnose carcinoma in situ (no basement membrane to examine), atypical hyperplasia, or infiltrating carcinoma; nondiagnostic result in setting of discrete mass requires further work-up (possible sampling error)

Diagnostic mammography: poor sensitivity in young women because of increased breast density; 15% to 20% of mammographies normal in women with palpable mass; primary use is to screen entire breast for nonpalpable abnormalities and to screen other breast; secondary use is to classify mass; palpable discrete breast mass requires further work- up, even if mammography normal (regardless of patient’s age)

More on biopsy: core needle biopsy—removes sample of breast tissue; can differentiate DCIS from invasive cancer; interpretation easier, does not require cytopathologist; primarily used for diagnosis of solid masses and follow-up of nondiagnostic FNA; FNA slightly more sensitive than core needle biopsy; requires expertise to prevent sampling errors; excisional biopsy—used when other tests discordant or diagnosis unclear; personal or family history—work-up same whether patient’s risk low or high

Determining first step: depends on availability and expertise of services; FNA—therapeutic, diagnostic, and cost-effictive; US similar in cost to FNA; FNA more cost-effective because 80% of masses not cystic on US and require FNA for further evaluation; if FNA not available—doing US first eliminates need for core biopsy in 20% of patients with breast cysts; mammography—cannot distinguish benign from malignant mass; should not be first step (usually part of complete evaluation); criteria for follow-up of cyst in 1 to 2 mo—patient <40 yr of age and reliable about returning for reevaluation

Triple test: improves accuracy by combining physical examination, pathology (eg, FNA, biopsy), and radiographic imaging (eg, mammography, US); 99% accuracy when all 3 results concordant; continue work-up with next most aggressive type of biopsy if any component of test suspicious; accuracy of triple test—small portion (0.6%) of women have cancer even when mass benign on palpation and FNA and mammography benign; 2%, if mass feels suspicious on palpation; if anything suspicious, chance of cancer high; continue to reevaluate suspicious mass until reassured not cancer

Cystic mass: aspirate if symptomatic; diagnosed by US and aspiration not performed—follow up in 1 yr; if aspirated and fluid not bloody—follow up in 1 to 3 mo to ensure no residual mass and no reaccumulation; patient >35 yr of age—screen other breast (some suggest waiting after aspiration)

Solid mass on FNA or core needle biopsy: mammography recommended to further characterize mass and screen other breast; reevaluate in 3 to 6 mo if both negative; refer patient to breast surgeon for further evaluation if results equivocal or not concordant

Algorithm for dominant breast mass: US or FNA; simple cyst—no further work-up; routine follow-up; solid or complex cyst—FNA or core needle biopsy; perform next most aggressive biopsy if mass atypical or suspicious; benign with negative mammography—repeat CBE in 3 to 6 mo; benign with positive mammography—more imaging or next most aggressive biopsy; nondiagnostic—repeat biopsy or perform next most aggressive biopsy; patient vs provider discrepancies—patient dissatisfaction and risk for malpractice suit; refer patient for second opinion if patient not satisfied with examination

Breast pain: >50% of all office visits for breast complaints; etiology unknown; not shown to be associated with prolactin, estrogen, or progesterone levels; chronic and relapsing; severe breast pain (rare) interferes with quality of life (QOL); cyclic—more common; dull, bilateral pain changes with menses (usually better with menses, worse preceding menses); usually not improved by oral contraceptives (OCs); noncyclic—continuous sharp, burning pain; not associated with menses; can be associated with fibroadenoma or cyst; treatment—risk factor evaluation and screening mammography; treatment driven by impact on QOL; spontaneous resolution in 60% to 80% of cases; reassure patient that condition not cancer; medications—topical and nonsteroidal anti-inflammatory drugs (NSAIDS); evening primrose oil (moderately effective; bid to tid daily for 2 to 3 mo for effects); progesterone vaginal cream; bromocriptine, danazol and tamoxifen (most effective, but associated with side effects; reserve for patient with severe pain disrupting QOL); well- fitting bra, bra while sleeping; trigger point injections for localized pain; OCs effective for some patients

Nipple discharge: usually benign; intraductal papilloma most common cause of unilateral discharge; cancer more likely if associated with mass; physiologic—multiple ducts, usually bilateral; due to galactorrhea or nipple stimulation; clear, yellow, or white; no mass; work-up not warranted if milk secretion stops after breast stimulation discontinued; obtain prolactin and thyrotropin (TSH) level if discharge continues; can occur in runners; psychotropic drugs can cause galactorrhea; pathologic—spontaneous, single duct; associated with papilloma or cancer; isolate affected duct; hemoccult to confirm blood; cytology not useful; mammography with retroalveolar views; galactography controversial; referral to surgeon recommended

Mastitis: secondary mastitis—cellulitis, folliculitis; lactational mastitis—usually wedge-shaped; consider culturing breast milk for community-acquired methicillin-resistant Staphylococcus aureus (MRSA); trimethoprim-sulfamethoxazole (TMP-SMZ; eg, Septra) or clindamycin if MRSA suspected; cephalexin (Keflex) or doxycycline; intravenous (IV) antibiotics if no improvement; nonlactational mastitis—central pain and nipple retraction; often associated with discharge; more difficult to treat than simple lactation mastitis; need coverage for gram-negative organisms and anaerobes; clindamycin, metronidazole (eg, Flagyl) plus cefazolin (eg, Ancef) or nafcillin; obtain biopsy if mastitis recurrent or does not resolve; peripheral mastitis—usually seen in older women with underlying disease (eg, diabetes); anaerobes and gram-negative organisms; breast abscess—US useful for diagnosis; better cosmetic result with aspiration than with incision and drainage

Selected Topics in Breast Health
Steven Mestitz, MD, Adjunct Assistant Professor, Department of Family Practice/Community Health, University of Minnesota Medical School, and General Surgeon, HealthPartners Parkway and West Clinics, Minneapolis, MN

Screening mammography: controversial when to start and when to stop; screening recommendations of National Cancer Institute—start when patient 40 yr of age and perform every 1 to 2 yr; every 1 to 2 yr for women 50 yr of age; women with higher than average risk should seek medical advice about earlier start and frequency (speaker recommends starting 10 yr before index case in first-degree relative); screening recommended as long as patient in reasonably good health and candidate for treatment if cancer detected

Magnetic resonance imaging (MRI): sensitive, but often not specific; specialized team required for needle-directed MRI biopsy; radio waves emit frequency which is detected and translated into picture; gadolinium contrast enhances malignant tissue (but also enhances benign tissue); indications (according to American Society of Breast Surgeons)—to determine size of tumor and evidence of axillary metastasis or contralateral disease; monitoring of hormonal or chemotherapy; part of screening for high-risk patients, especially suspected or proven BRCA 1/2 carriers; further evaluation of suspicious clinical findings or imaging results; indications (American Cancer Society [ACS])—individual who has BRCA mutation or is first-degree relative of BRCA carrier or who has lifetime risk of 20% to 25%; radiation to chest wall; history of other genetic syndromes; insufficient evidence to recommend for woman with average risk; strong evidence supporting MRI screening for women at increased risk based on family history; data show reoperation for positive margins lower than normal; multicentricity identified by MRI alone, 7.7%; contralateral disease found by MRI, ≈4%; 11.4% probability major discovery will occur preoperatively; sensitivity of MRI better than that of other modalities, but specificity lacking; concerns that MRI may overstage and steer women toward mastectomy, when breast conservation sufficient; counterbalancing argument that strong negative predictive value reassurance breast conservation safe

Risks: age (for woman 40 yr of age, risk 0.5%; 10% for women 80-85 yr of age); family history; presence of high-risk lesions (from previous breast biopsy); early menarche; late menopause; nulliparity or first birth at >30 yr of age; radiation exposure; hormone replacement therapy (HRT); Gail model—provides 5-yr and lifetime risk; overestimates risk in women not screened regularly; not applicable for women with family history of disease; mainly used by oncologists in deciding who would benefit from chemoprevention; Claus model—better for assessing patient with strong family history or who is BRCA 1/2 carrier; findings suggestive of hereditary breast cancer—multiple generations with breast, colon or ovarian cancer; multiple first-degree relatives; premenopausal breast cancer; bilateral breast cancer; ovarian cancer in family; multiple other cancers in family; genetic counseling and testing—goal to define groups of high-risk patients who might benefit from more intensive surveillance at earlier age; BRCA 1/2 carriers make up large portion of population with breast and ovarian cancer; estimated lifetime cancer risks in BRCA mutation carriers—contralateral breast cancer, 64%; average cumulative cancer risk with BRCA-1 mutation, 10% to 56% over lifetime (general population, 12.5%); 85% with BRCA-2 mutation; 15% to 60% for ovarian cancer with BRCA-1 mutation, and 15% to 30% with BRCA-2 mutation (general population, 1.4%); benefits of genetic testing—helps to define risk of developing breast cancer; enhances early detection and prevention of cancer; helps to determine if relatives at increased risk of developing cancer

Chemoprevention: Breast Cancer Prevention Trial (National Surgical Breast and Bowel Project-1[NSABP P-1]) showed tamoxifen decreases risk for breast cancer by 50% in high-risk women, 85% in women who had typical hyperplasia; tamoxifen did not change risk for estrogen receptor-negative breast cancer; increased risk for endometrial cancer, stroke, pulmonary embolism, and deep venous thrombosis; data show 50% reduction of invasive breast cancer with raloxifene in high-risk women; less reduction of noninvasive events; 30% fewer thrombotic complications; 36% fewer uterine cancers; prophylactic mastectomy—90% reduction in breast cancer risk in BRCA carriers; 90% to 94% decrease in breast cancer

Lifestyle interventions: dietary fat—meta-analysis showed increased risk as dietary fat increased by 100 g per day; magnitude of association compatible with biases due to recall; pooled cohort studies and Nurses’ Health Study showed no overall association; some prospective cohort studies show inverse association with monosaturated fats in European countries that use olive oil as primary fat (needs further investigation); findings in Nurses’ Health Study II showed higher intake of animal fat associated with significantly greater risk for breast cancer, but no association seen with intake of nonanimal fat; suggests that factors in foods containing animal fats (rather than fat, per se) may account for findings; fruits and vegetables—data show no association with decreased risk for breast cancer; fiber—data show no association between intake of fiber and breast cancer; red meat—increases risk for colon cancer; studies show no overall association observed with breast cancer; as shown in Nurses’ Health Study II, for premenopausal women, the risk for estrogen- and progesterone-positive breast cancer doubled when red meat consumption 1.5 servings per day vs 3 to 4 servings per week; vitamin D—data support decrease in risk for colon, breast, prostate, and pancreatic cancers; alcohol—dose-dependent carcinogen; physical activity and obesity—lack of physical activity increases risk for postmenopausal and less so for premenopausal women; household activity beneficial; obesity established risk factor for postmenopausal women; overall recommendations—counsel patient to maintain healthy body weight and regular physical activity; vitamin D recommended; limit or avoid red meat and alcohol; increase fruits and vegetables to reduce risk for cardiovascular disease; consume whole grains and avoid refined carbohydrates to lower risk for CV disease and diabetes

Surveillance guidelines for patients at high risk: monthly breast self-examination, beginning at 18 yr of age; CBE every 6 to 12 mo, beginning at 25 yr of age; mammography at 40 yr of age or 10 yr before index cancer; consider annual MRI screening, prophylactic mastectomy, or chemoprevention; assess history and discuss genetic testing; counseling issues—diagnosis not emergency; more important to do right thing than to do something; numerous options; most people survive