Breast Cancer Flashcards
Trends in the Picture
African American women tend to have more aggressive form of breast CA and not responsive to treatment
Issue of self-exam: done same time each month at end of period (when hormones are most neutral)
Breast feeding is protective for breast cancer
Obectives
- Review normal breast anatomy
- Discuss Breast Cancer Screening Guidelines for Average Risk Women (ACOG, ACS, USPSTF, NCCN)
- Review Breast Health History for risk assessment
- Describe Clinical Breast Exam (CBE) competencies and mass documentation
- Understand the BIRADS reporting system for mammograms and sonograms
- Review assessment, diagnosis, management and follow up of common breast conditions: Breast Masses and Nipple Discharge
Breast Cancer Incidence
___ leading cause of Cancer deaths
___ leading cause of Cancer Sites
2nd
1st
Breast Cancer Incidence vs. Mortality Rate
Overall what is the takeaway?
Although incidence is higher in white women, mortality rate is higher in AA women
Breast Anatomy
- Marks the upper boundary of the breast tissue
- (breastbone) can be felt beneath the skin
- Is a dark circle of skin that surrounds nipple
- Is the outlet for milk during breastfeeding
- Tissue that supports breasts, making them feel firm
- Helps move your arm
- Can be felt beneath skin (bones)
- Makes up the Axillary Lymph nodes
- Tissue that fills spaces around the ducts and lobules
- Mamary glands that produce milk during pregnancy and breastfeeding
- Carry milk from lobules during breastfeeding
- Clavicle
- Sternum
- Areola
- Nipple
- Fibrous Tissue
- Chest muscles
- Ribs
- Tail of Spence
- Fatty tissue
- Lobules
- Ducts
Normal Nipples
- ____ Range of what’s normal
- Nipple ____ vs ____
- Areola is ____ vs. ____
- ____ follicles
- Wide
- inverted, exverted
- wide, narrow
- Hair
Montgomery Glands
=
Glands that provide lubrication during lactation, immunoglobulin, and scent attracts infant to breast
More Variations of Normal
Left and Middle Pic =
Right Pic =
Scar for breast implants
Breast reduction scar
Breast Anatomy Cont.
Coopers Ligaments =
Inframmamary Ridge =
holds the breast up (weaker as we age)
Feels a little thick on palpation
Breast Physiology
- Follicular Phase: (2): proliferation of _____ tissue
- Luteal Phase: (1): duct ____, s____, interlobular _____
- Menstrual Phase: _______ of follicular/luteal changes
- Pregnancy/Lactation: Increase in (3): proliferation of d____, l____, al____; (1) -> contraction/milk ejection
- Menopause: _____ in E and P -> (1) < (1)
- FSH, E: glandular
- P: duct dilation, secretion, edema
- Regression
- E, P, Prolactin: ducts, lobes, alveoli/ Oxytocin
- Decrease -> connective/glandular tissue < fatty tissue
Breast Physiology Notes
- Natural aging process -> less what overtime? which is why we choose to do a ___ to look for abnormalities in younger women
- Mammography is better for women age?
- Screening technique is better with what type of breasts?
- less glandular/connective tissue overtime -> US for younger women
- Mammography 30 and older
- Less dense breasts (why we start >40)
Average Lifetime Risk of Being Dx’d with Breast Cancer
If you DO NOT have (3)
Personal History of breast, ovarian, tubal, or peritoneal cancer
Radiotherapy to chest 10-30y
BRCA1/2 Known carrier of pathogenic mutation for hereditary breast and ovarian CA
Average Lifetime Risk of Being Dx’d with Breast Cancer
If you do not have
- Mammographic breast _____
- Previous breast biopsy indicating ___-risk _____ (atypical hyperplasia)
- _____ history of breast, ovarian, tubual, or peritoneal CA
- _____ (1) associated with BRCA1 or 2 mutations
- density
- high risk lesion
- Fam hx
- Ancestry (Ashkenazi Jewish)
Breast Ca Risk Reduction Tools
- Calculate Lifetime or __-__yr risk for Breast Ca
- Multiple Tools: ____ Model https://bcrisktool.cancer.gov/Others: BCRAT, IBIS
- Variables include?
- Lifetime risk: average %? moderate %?
- 5-10
- Gail
- Age, race, relatives w br ca, PMHx of br bx, breast density, age at menarche, age at first birth, abnl bx, chest irradiation, known BRCA 1 or 2 mutation
- <15%, _>_15-20% (>15% requires enhanced screening)
Refer for Genetic Counseling
__ positive response needs referral
- Did any of your ___-degree relatives have breast or ovarian ca?
- Did any of your relatives have _____ breast ca?
- Did any ___ in your family have breast ca?
- Did any _____ in your family have breast ca before age __?
- Do you have 2 or more relatives with breast and/or _____ ca?
- Do you have 2 or more relatives with breast and/or ____ ca?
1 (any positive response)
- First
- bilateral
- man
- woman, <50
- ovarian
- bowel
Breast Cancer Screening Guidelines for Ave Risk (Female sex at birth)
***Diagnostic CBE important part of assessment of women with breast _____ or _____***
Guidelines apply to those with _____ for benign reasons
Note: Overall different guidelines have different age ranges: all depends on?
We don’t really use CBE to screen but important to use when woman presents with _____, on the other hand ______ definitely decreases mortality its just a question of when to start
Complaints or Abnormalities
Implants
Diff conclusions dt variation in weighing risks and benefits - if you start earlier and do it more often your going to find more cancers AND non-cancers (false positives) -> unecessary intervetion
Professional Societies Breast Cancer Screening Recommendations
Just a diff look at screening guidelines
Mast majority about __-__ yo recommend ______ screening
55-70 - Biennial
Modifiable Behavioral Risks List
(4)
Postmenopausal weight gain
Alcohol consumption
Smoking
Physical Inactivity
Risk Based Screening
Folks at increased Risk
Don’t need to memorize just understand we approach screending differently in those at high risk: we screen ____ and more ____: sometimes even using other mechanisms like ____
Earlier, More often (Annually), MRI
Imaging Tests
(5)
What is the difference between Mammography and DBT?
DBT is best for? Significant of DBT?
- Mammogram
- Digital Breast Tomosynthesis (DBT)* 3D mammography
- Ultrasound
- MRI
- Thermography
DBT is a 3D mammogram (we get more info) - both are mammography but DBT is more detailed***
Best for detecting lesions in dense breasts, we’re moving towards that being the norm
Mammography V Tomosynthesis (DBT)
Which is which?
What Tests are these Pictures?
Mammogram (Left), Sonogram (Right)
BI-RADS mammographic assessment categories
Breast Imaging Rating and Data System
- Is a _____ classification from __-__
- Recommendations for further evaluation _____vs. _____
- Probability of _______
Generally a __ or __ = normal interval follow up
- numeric 0-6
- further eval biopsy v. surgery
- malignancy
1 or 2 = normal
Results of Screening Mammography
- BI-RADS 0 =
- BI-RADS 1, 2 =
- BI-RADS 3 =
- BI-RADS 4,5 =
- Additional Imaging required
- Routine Follow up
- CBE
- Negative CBE: follow recommended short interval follow up in radiology report
- Positive CBE: refer to outside specialist
- Refer to outside specialist
Breast Density
Another part of the mammography report (certain states require) to include Breast Density
Common Mammographyic Finding: Calcifications
-
Macrocalcifications**
- _____ distribution
- _____ after age 50 (>50%)
- _____ with cancer
- Require _____
-
Microcalcifications**
- _____ distribution
- _____ with cancer
- Require further ____
-
Macro
- random
- common >50
- unrelated
- consult
-
Micro
- Clustered
- Correlated
- eval
- Not from dietary calcium
- Calcifications: know the macrocalcifications are extremely common and normal >50yo
- MICROcalcifications we need to worry about
Breast Health: At each visit
-
Breast Health ___
-
Periodic Assessment of Breast Cancer ____
- ____ and ___ cancers
- _____? pain, nipple discharge, masses, skin changes, redness
- _____? Encourage Breast Self ______
-
Periodic Assessment of Breast Cancer ____
- Pt education regarding ______ risk factors
- Review ____ Based Breast Cancer Screening Recommendations for Average Risk Women or Enhances screening for higher risk
- Perform ___ prn
-
Hx
-
Risk
- Personal, Hx
- Symptoms
- Changes: Self Awareness
-
Risk
- Modifiable
- Age Screening Recommendations
- CBE
Pt Education: Breast Self Awareness
Symptoms of Breast Cancer
(6)
Lump
Pulled in Nipples
Dimpling
Dripping
Redness/Rash
Skin Changes
When is Nipple Discharge Concerning?
- When discharge is _______
- _____ or blood stained
- When it is completely ____ and _____
- When there is ____ of discharge
- When it is associated with a ____ _____
- When it is from only ____ ____, ____ _____
- When it is ____
Note: after _____, some women will continue to have discharge for many ____
- spontaneous
- Bloody
- Clear and Colorless
- Alot
- Breast Lump
- One Duct, One Breast
- New
childbirth, discharge for many years
Clinical Breast Exam (CBE)
Includes assessment of ___
- Patient Standing with Arms ___
- Standing wiht Arms ____
- Pushing on ___ to ___ pectoralis Muscles
LN
- Down
- Elevated
- Hips, Tense
Palpation Technique
(3)
- Use _____ hand: pads of ____ fingers
- ____ sized circles
- _____ between palpations, without ____ fingers from breast
Superficial
Intermediate
Deep
- dominant, three
- dime
- Slide, without lifting
Breast Mass Documentation: Exam, Plan, F/U*
-
Location*
- ____ or ____ breast
- ____ face location
- _____ from ____ edge
- Sz: __ dimensions
- D______
- (1) Fixed, mobile
- (1) round, oval, smooth, lobulated
- (1) Soft, Firm, Rubbery
- (1) Pos or Neg
- (1) Pos or Neg
- Left or Right
- Clock
- Distance from areolar edge
- 2
- Drawing
- Mobility
- Shape/Margins
- Tenderness
- Consistency
- Lymphadenopathy
- Skin Changes
First 4 things to document is SUPER important -> allows you to know what/where to recheck/assess further
Diagnostic Algorithm for Palpable Breast Abnormalities in Women Less than 30 years of Age
Most important thing to take away is if you palpate something in the breast for someone <30 - first you order a diagnostic ___ -> determines what?
US -> determines if mass is cyst, fluid filled, or mass
Diagnostic Algorithm for palpable breast abnormabilites in women 30y and older
Key Takeaway =
>30 and postmenopausal start with diagnostic mammogram AND refer to breast specialist right away
Discordance: Self Breast Exam v. Clinical Breast Exam
- If SBE is positive but CBE is negative ->
After repeat
- SBE is still positive and CBE is still negative ->
- CBE is positive ->
- SBE Neg/CBE Neg ->
What can you always do per pt request?
- Repeat CBE in 2-3 months
- Refer or Age appropriate diagnostic imaging; specilaist/sampling prn
- Refer for Age appropriate diagnostic imaging; specialist/sampling prn
- Routine f/u
Can always appropriate imaging per pt request
Common Breast Conditions: Cysts/Fibrocystic Changes
=
- Discrete, m_____, “_____”
- Variable, c____ size/discomfort
- Tx (2)
Benign, Fluid Filled Masses
- mobile, “rubbery”
- cyclic
- Expectant or Aspiration
Common Breast Conditions: Fibroadenomas
=
- Etiology: ____, _____ effects
- Round with distinct _____
- M____, f___, r____
- Painful?
- Common in?
- Tx:
Benign, dense, epithelial and fibrous tissue
- unknown, estrogenic
- borders
- mobile, firm, rubbery
- Painless*
- Adolescents, young women
- <3cm expectant mngmt, f/u imaging
Best Practices for Breast Screening Cancer and Prevention
- Risk assessment _____ via hx
- Risk based ______ recommendations in accordance with guidelines; shared decision making
- Pt _____ re modifiable risk factors
- Referrals for ____ counseling prn
- Knowledge of _____ breast problems: assessment, dx, mngmt
- Follow established protocols for referring pts for ____/sampling/breast ____ rn
- Always refer to _____:______ women w/breast masses OR any _____ or confusing results
- Avoid ____ in Dx: follow up every breast mass or sx to conclusion and document exam, pt sx, referrals, results, pt education, and f/u
- annually
- screening
- education
- genetic
- common
- imaging, specialist
- specialist: menopausal or discordant results
- AVOID DELAYS
