Breast Lumps and Abnormal Mammograms – Cancer Example

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"Breast Lumps and Abnormal Mammograms"  is an engrossing example of a paper on cancer. The patient is a 59-year old Caucasian female, gravida 3, para 2, presenting a mass in the right breast, which she discovered about 3 weeks ago. The patient is not sure if the mass increased in size since she first noticed it. In addition, the patient denies typical symptoms such as associated pain, bruising, erythema, skin changes or nipple discharge. The patient’ s history for risk factors such as breast lumps or biopsies, hormone replacement therapy, alcohol use, early menarche, first pregnancy after thirty years of age and any family history of breast, ovarian, or colon cancer were negative.

The patient is healthy otherwise and is not on any medication. The physical exam revealed that the mass was non-tender, firm-to-hard inconsistency, immobile, approximately 3 cm across and was located at the 10 o’ clock position in the right breast. Furthermore, there was no palpable, supraclavicular, infraclavicular, or axillary lymphadenopathy. Etiology, epidemiology, and characteristics of the problem Breast masses can be either benign or malignant. Generally, benign breast masses are caused by: fibrocystic disease; intraductal papilloma; abscesses;   In contrast, malignant breast masses are constituted of multiple histologic kinds which may include (but are not limited to): infiltrating ductal or lobular carcinoma; in situ ductal or lobular carcinoma; inflammatory carcinoma. The largest concern for women with breast masses is the chance of cancer development (Miller, Saraon, Hussain, & Silverberg, 2012). Breast cancer has a high prevalence rate of women diagnosed with cancer.

Its prevalence is eclipsed only by skin cancer and it is estimated that one in every four women diagnosed with cancer in the United States is suffering from breast cancer.

Chances of developing breast cancer tend to increase with age. Around 12.5% of invasive breast cancers are reported in women under the age of 45. In contrast, some 67% of invasive breast cancers are reported in women over the age of 55 (American Cancer Society, 2012). The etiology of discrete breast lumps according to prevalence by age reveals that some 85% of discrete breast masses in women older than 55 years of age are cancerous in nature. Hence, any postmenopausal women who report a breast mass should be dealt with as a cancerous growth unless evidence proves otherwise (American Congress of Obstetricians and Gynecologists, 2012) (Medscape, 2010). Figure 1 - Etiology of discrete breast lumps sourced from (Medscape, 2010)   The patient under review meets three of the major risk factor criteria for breast cancer that are gender, age, and residence in North America.

In addition, the physical examination of the mass reveals three worrisome findings that are firmness, immobility, and a size larger than 2 cm (Medline Plus, 2012). Given the circumstances, there is a need to be aggressive with the evaluation of the mass and for immediate referral for consultation. Management recommendation with a rationale to support your plans The next recommended diagnostic tools for evaluating this patient’ s breast mass are diagnostic bilateral mammography and ultrasonography.

The rationale for performing a diagnostic bilateral mammogram would be to search for other lesions that could be clinically occult. This would also aid in further evaluation of the mass in question. On the other hand, ultrasonography will help in determining whether the mass is a simple or a complex cyst or a solid tumor. Furthermore, ultrasonography is helpful for evaluating non-palpable masses that may be detected in the mammography (Parikh, 2007). Diagnostic mammography is limited in that it misses 10% to 20% of clinically palpable breast cancers and cannot determine whether a lump is benign.

Similarly, ultrasonography may also fail to visualize a palpable abnormality. If a lesion is isodense with surrounding tissue then it is not imaged by ultrasound and provides a false-negative reading. Therefore, any palpable abnormality warrants further evaluation even with normal ultrasound and no visible lesions on the mammogram. Given these conditions, this patient has to be referred to a breast surgeon for biopsy regardless of the radiological findings. The only exception is if the radiological findings show the mass as a simple uncomplicated cyst (less than 3% likely) (Tea, Grimm, Heinz-Peer, Delancey, & Singer, 2011).

Alternatively, if the primary care practitioner has adequate training and feels confident then a fine needle aspiration could be performed in the office. This is a fast, inexpensive and accurate method to differentiate between solid and cystic masses. An uncomplicated cyst provides clear fluid aspirate and the caregiver would continue to watch and evaluate the mass through follow up visits and later screening tests.

However, if there is bloody aspirate or residual mass then the specimen is sent for pathological analysis and the patient is referred to a breast surgeon (Institute for Clinical Systems Improvement, 2012). In the case of a biopsy, the breast surgeon will perform a fine needle biopsy and/or a core-needle biopsy to evaluate the mass further. The "gold standard" test is the histologic examination of the excised lump (although rare false-positive results can occur even with open biopsies).

If the pathology results are positive for breast cancer, the patient is then referred to an oncologist for treatment (Total Women's Health, 2010). Surgical, pharmacologic, non-pharmacologic and alternative therapies If the pathology results are positive for breast cancer, the patient is then referred to an oncology specialist, such as a surgeon, medical oncologist and/or a radiation oncologist for the treatment of the disease. This often involves surgical removal of the mass, radiation, and chemotherapy. Hormone therapy such as Tamoxifen will also be indicated if the pathology reports indicate a receptor-positive type of cancer.

In addition, HER2/neu testing should also be done on all newly diagnosed breast cancers because HER2-positive cancers can be treated with drugs that target the HER2/neu protein (Lower, Glass, Blau, & Harman, 2009). As primary care practitioners, we can play a very important role during the patient’ s treatment by providing positive support and by educating and informing the patients on what to expect next during the treatment process.   Primary care providers also coordinate patient care and treatment possible side effects of cancer therapy but most importantly they closely monitor the general health status of the patient during cancer treatment. Many forms of alternative therapy such as meditation, positive guided imagery, music therapy, relaxation, can be helpful to reduce patient anxiety and increase a general feeling of well-being (Dunphy, Winland-Brown, Porter, & Thomas, 2011). For patients with a benign breast mass or those who have successfully completed cancer treatment, attention turns to reassuring the patient and treating symptoms like pain with NSAIDs or other analgesics.

Emphasizing the importance of follow up visits and timely future screenings are key factors for better long-term outcomes.

We must also collaborate with the patient through education and support to control modifiable risk factors such as HRT, obesity and alcohol use. Incorporation of cultural considerations It is very important to acknowledge the patient’ s feelings regarding their body and self-image after breast surgery. The patient’ s cultural background and religion may play a very important role in how one can cope with this feeling of disfigurement. All patients should be made aware of plastic surgery options and consultation with a plastic surgeon should be recommended unless there is a strongly personal, cultural or religious belief against it (Beckmann, Ling, Barzansky, Herbert, Laube, & Smith, 2010). Cultural beliefs also often shape women’ s willingness to do self-exams and get screenings.

Some women come from cultures that consider it inappropriate for women to touch or look at their own breasts. This is very important to consider before we rely on patient’ s self-examination for a follow-up or even screening measures.

References

American Cancer Society. (2012). Breast Cancer. Retrieved March 5, 2012, from Cancer.org: http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-risk-factors

American Congress of Obstetricians and Gynecologists. (2012). Search. Retrieved March 5, 2012, from American Congress of Obstetricians and Gynecologists: http://www.acog.org/Search?Keyword=breast+mass+in+post+menopausal+women

Beckmann, R. B., Ling, F. W., Barzansky, B. M., Herbert, W. N., Laube, D. W., & Smith, R. P. (2010). Obstetrics and gynecology, 6th Edition. Philadelphia: Lippincott Williams & Wilkins.

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary Care: The Art and Scienceof Advanced Practice Nursing, 3rd Edition. Philadelphia: F.A. Davis Company.

Institute for Clinical Systems Improvement. (2012). Health Care Guideline: Diagnosis of Breast Disease. Institute for Clinical Systems Improvement.

Lower, E. E., Glass, E., Blau, R., & Harman, S. (2009). HER-2/neu expression in primary and metastatic breast cancer . Breast Cancer Research and Treatment 113(2), 301-306.

Medline Plus. (2012). Breast Cancer. Retrieved March 5, 2012, from Medline Plus: http://www.nlm.nih.gov/medlineplus/breastcancer.html

Medscape. (2010). Breast Cancer. Retrieved March 5, 2012, from Medscape: http://www.medscape.com/viewarticle/443381_3

Miller, A. C., Saraon, T. S., Hussain, S., & Silverberg, M. A. (2012). Breast Abscess and Masses. Retrieved March 5, 2012, from E-Medicene: http://emedicine.medscape.com/article/781116-overview

Parikh, J. R. (2007). ACR Appropriateness Criteria on palpable breast masses. Journal of the American College of Radiology 4(5), 285-288.

Tea, M. K., Grimm, C., Heinz-Peer, G., Delancey, J., & Singer, C. (2011). The predictive value of suspicious sonographic characteristics in atypical cyst-like breast lesions. The Breast 20(20, 165-169.

Total Women's Health. (2010). Breast Lumps and Abnormal Mammograms. Baltimore: Total Women's Health.

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