Fm 1 Flashcards
Familial breast cancer risk (as it relates to relatives)
A patient has an increased risk of breast cancer if a first-degree relative has had breast cancer. A first-degree relative is a parent or a sibling.
Breast Self-Exam and Clinical Breast Exam - Effectiveness and Recommendations
The USPSTF does not recommend breast self-exams (BSE’s).
Similarly, the USPSTF concludes there is insufficient evidence to assess the additional benefits and harms of clinical breast exam (CBE) beyond screening mammography in women 40 years or older, while ACS recommends that CBE should be part of a periodic health exam about every three years for women in their 20s and 30s and every year for women 40 and over.
Classification of Overweight and Obesity in Adults
BMI (kg per m2) Underweight < 18.5 Normal range 18.5 to 24.9 Overweight 25.0 to 29.9 Obese > 30.0 Class I 30.0 to 34.9 Class II 35.0 to 39.9 Class III -morbidly obese > 40.0
Obtaining Pap test
The sample is obtained using an extended tip spatula and then a cytobrush.
First, the spatula is rotated several times to obtain a sample from the ectocervix. The cytobrush is then inserted into the os and rotated 180 degrees.
Care is taken to make sure that the squamo-columnar junction (the area of the endocervix where there is rapid cell division and where dysplastic cells originate) is adequately sampled.
The sample is then placed into a liquid medium.
Using the liquid-based system over the conventional Pap smear technology allows for later testing of the sample for the presence of human papilloma virus (HPV) if the Pap comes back abnormal.
Currently two liquid-based systems are approved by the FDA. You should check with your lab to find out which system is preferred.
Ovarian cancer screening
Screening for ovarian cancer with a bimanual exam is not recommended
Cervical cancer screening
The guidelines recommend that:
At age 21: cervical cancer screening should begin.
Between ages 21 and 29: screening should be performed every three years.
Between ages 30 and 65: screening can be done every five years if co-tested for HPV (preferred) or every three years with cytology alone (acceptable).
However, they stipulate that certain risk groups need to have more frequent screening. They include women with compromised immunity, are HIV positive, have a history of cervical intraepithelial neoplasia grade 2, 3 or cancer, or have been exposed to diethylstilbestrol (DES) in utero (DES is a nonsteroidal estrogen that was given to pregnant women to prevent miscarriages. However, it was linked to clear cell adenocarcinoma of the vagina and was discontinued in 1971).
Women older than 65 years who have had adequate screening within the last ten years may choose to stop cervical cancer screening. Adequate screening is three consecutive normal pap tests with cytology alone or two normal pap tests if combined with HPV testing.
Women who have undergone a total hysterectomy for benign reasons do not require cervical cancer screening.
Cervical cancer RF ( main cause, 5 RF)
Virtually all cervical cancers are caused by infection with certain high-risk types of human papilloma virus (HPV).
HPV is transmitted via vaginal (or oral) intercourse. Transmission by nonpenetrative genital contact is rare. Therefore, squamous cell carcinoma of the cervix is a disease of sexually active women. Factors such as age, nutritional status, immune function, and possibly silent genetic polymorphisms modulate the incorporation of viral DNA into host cells.
Sexual behaviors associated with an increased cervical cancer risk include:
Early onset of intercourse
A greater number of lifetime sexual partners
Other risk factors include:
Diethylstilbestrol (DES) exposure in utero.
Cigarette smoking, which is strongly correlated with cervical dysplasia and cancer, independently increasing the risk by up to fourfold.
Immunosuppression, which also significantly increases the risk of developing cervical cancer.
Interpret Pap smear results (5)
The Pap test generally shows one of the following:
normal results
low-grade squamous epithelial cells (LSIL)
high-grade squamous epithelial cells (HSIL)
atypical glandular cells of undetermined significance (AGUS)
atypical squamous cells of undetermined significance (ASC-US)
Characteristics of good screening test (6)
- Accuracy (high sensitivity and specificity)
Sensitivity
Measures proportion of actual positives that are correctly identified as such (e.g., percentage of sick people identified as having the condition)
The more sensitive the test, the fewer false negative results.
Specificity
Measures the proportion of negatives that are correctly identified as such (e.g., percentage of well people identified as not having the condition)
The more specific the test, the fewer false positives. - Able to detect disease in an asymptomatic phase
- Minimal associated risk
- Reasonable cost
- Acceptable to patient
- Have an available treatment for the disease
Skin and lung cancer screening
Skin Cancer Screening Recommendations
While skin cancer is the most common type of cancer, the USPSTF is currently reviewing guidelines regarding screening. Presently, the draft statement states that current evidence is insufficient to assess if there is more harm or benefit to visual skin cancer screening in adults. The USPSTF is also currently evaluating if there is any benefit in providing behavioral counseling for skin cancer prevention.
Lung Cancer Screening Recommendations
As of 2013, the USPSTF recommends annual screening with a low-dose CT scan to screen for lung cancer in patients ages 55 to 80 who have smoked for 30-plus years.
To be considered, the patient should also be currently smoking or have quit within the prior 15 years.
Mammography screening (acs and uspstf)
Recommendations for Breast Cancer Screening Mammography
American Cancer Society
Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. The risks of screening as well as the potential benefits should be considered.
Women age 45 to 54 should get mammograms every year.
Women age 55 and older should switch to mammograms every two years, or have the choice to continue yearly screening.
US Preventive Services Task Force
Biennial screening mammography for women age 50 to 74 years
(Grade B recommendation)
Decision to start regular, biennial screening mammography before age 50 should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms
(Grade C recommendation)
Breast lump (dx test 3 and follow up if necessary)
Diagnostic tests:
If it feels cystic, aspiration can be attempted and the fluid sent for cytology. Fine needle aspiration is a procedure family physicians can do in the office.
If it feels solid, mammography is the next step.
Ultrasound can be helpful in distinguishing a solid mass from a cystic lesion.
Follow-up:
If the workup suggests that the lesion is benign (which the vast majority are), close follow-up with regular breast exams and mammography is indicated.
Evaluate nipple discharge (physiologic 2, pathological 6, follow up)
Reasons for nipple discharge may be physiologic or pathologic:
Physiologic:
Pregnancy
Excessive breast stimulation
Pathologic:
Prolactinoma
Breast cancer
> Intraductal papilloma
> Mammary duct ectasia- lactiferous duct becomes blocked or clogged. This is the most common cause of greenish discharge.
> Paget disease of the breast- unilateral nipple eczema + discharge
> Ductal carcinoma in situ
Hormone imbalance
Injury or trauma to breast
Breast abscess
Use of medications (e.g., antidepressants, antipsychotics, some antihypertensives and opiates)
A comprehensive history and breast exam are necessary to evaluate the discharge.
For example, it is important to know if the discharge appears milky, purulent or bloody. Palpate nipples and check for any discharge.
If a discharge is present, the patient needs further evaluation by imaging studies:
Mammogram
Ultrasound
Ductogram and/or
Biopsy
Consider hormonal testing to exclude endocrinological reasons. If discharge is milky, check the prolactin level.
Review and discontinue any medications that may be the cause.u
Breast cancer screening studies (3)
Mammography is a good screening test that can detect asymptomatic early stage disease, and there is good evidence that mammography decreases breast cancer mortality.
Risks
As with any other screening test, there is a potential for false positive results (leading to unnecessary procedures) or false negative results (giving patients a false sense of security). The sensitivity of mammography is between 60% and 90%. Low sensitivity means more false negative results. False negative results are more common in younger women since denser breast tissue makes it harder to find abnormalities on x-rays.
Mammography is a radiograph which involves some radiation exposure. However, modern mammography systems use extremely low levels of radiation, usually about 0.1 to 0.2 rad per x-ray, which is minimal and provides negligible risk.
Also, mammograms can be uncomfortable for patients.
Breast MRI
Not recommended for screening the general population of asymptomatic, average-risk women.
May be indicated in the surveillance of women with more than a 20% lifetime risk of breast cancer (for example, individuals with genetic predisposition to breast cancer by either gene testing or family pedigree, or individuals with a history of mantle radiation for Hodgkin’s disease).
May be used as a diagnostic tool to identify more completely the extent of disease in patients with a recent breast cancer diagnosis.
Contrast-enhanced breast MRI may be indicated in the evaluation of patients with breast augmentation in whom mammography is difficult.
Breast Ultrasound
Not recommended for screening purposes. This tool is used for evaluation of suspected abnormalities.
RF for breast cancer (modifiable and unmodifiable, decrease rf)
Non-modifiable risk factors include:
Family history of breast cancer in a first-degree relative (i.e., mother or sister)
Prolonged exposure to estrogen, including menarche before age 12 or menopause after age 45
Genetic predisposition (BRCA 1 or 2 mutation)
Advanced age (The incidence of breast cancer is significantly greater in postmenopausal women, and age is often the only known risk factor.)
Female sex
Increased breast density
Other hormonal risk factors include:
Advanced age at first pregnancy
Exposure to diethylstilbestrol
Hormone therapy
Environmental factors include:
Therapeutic radiation
Obesity
Excessive alcohol intake
Factors associated with decreased breast cancer rates include:
Pregnancy at an early age
Late menarche
Early menopause
High parity
Use of some medications, such as selective estrogen receptor modulators and, possibly, nonsteroidal anti-inflammatory agents and aspirin.
No convincing evidence supports the use of dietary interventions for the prevention of breast cancer, with the exception of limiting alcohol intake. And interestingly, most studies do not show that smoking increases the risk of breast cancer.
