Module 6 Practice Questions

Question 1

Which of these screening tools help prevent breast cancer deaths? (check ALL that apply)
self breast exam
clinical breast exam
mammography

Answer 1

Mammography

Question 2

Which of these are CONCERNING features for a breast lump? (check ALL that apply)
-large (>4 cm) size
-rubbery texture
-irregular contours
-gritty texture
-fixed position

Answer 2

-irregular contours
-gritty texture
-fixed position

Like all cancers, breast cancer tends to be a disorderly growth. Round, smooth lumps are reassuring…but lumps that are not rounds and smooth, are not.

A hard texture like a stone or pebble is more likely to be cancerous than rubbery or soft-textured masses.

A lump that is immobile may be fixed to underlying structures, and is more likely to be cancerous.

Question 3

T/F: Pain is a common sign of breast cancer.

Answer 3

False

Only about 10% of breast cancers present with pain; most are painless.

Question 4

T/F: Breast discharge is always a worrisome sign in those who are not lactating.

Answer 4

False

Some discharges, especially those that are clear or bloody, are definitely a cause for concern! Those that are milky or pasty are often caused by a non-malignant condition.

Question 5

When is the earliest a person of normal risk should start having cervical cancer screening done?

Answer 5

Age 21

Unless a person has active HIV disease, DES exposure in utero or is severely immunocompromised, 21 is the earliest screening should begin…and the American Cancer Society recommends age 25.

Question 6

T/F: The purpose of a Pap smear is to detect cervical cancer.

Answer 6

False

Paps will detect cervical cancer. But the real purpose is to detect cells that may BECOME cancerous if we don’t intervene in time. More about that in the module!

Question 7

Who should be vaccinated against human papillomavirus (HPV)?
-12-year old girls
-47 year old men
-pregnant women
-11 year olds who have already received 2 doses of Gardisil-9.

Answer 7

12-year old girls

This is a great age to vaccinate against HPV. New recommendations from CDC say that 2 doses, either 6 or 12 months apart, are enough for girls and boys aged 9 through 14. This is because their immune systems respond better, and build more immunity to less vaccine, than do older adolescents’

Question 8

Which characteristic/s is/are typically found when a patient has a breast cyst?
-tenderness
-soft mass
-mobile mass
-fixed mass
-rubbery mass
-gritty mass

Answer 8

-tenderness
-mobile mass

Question 9

Which clinical characteristics would lead you to suspect a fibroadenoma of the breast?
-fixed mass
-smooth mass
-soft mass
-gritty mass
-tenderness
-not tender
-mobile mass

Answer 9

-smooth mass
-not tender
-mobile mass

Question 10

Which clinical caracteristics typically are found with a malignant breast lump?
-soft mass
-tenderness
-fixed mass
-gritty mass
-non-tender
-rubbery mass

Answer 10

-fixed mass
-gritty mass
-non-tender

Question 11

Which clinical characteristic/s is/are typically found with a lipoma of the breast?
-soft mass
-discrete mass
-tenderness
-nontender

Answer 11

-soft mass
-discrete mass
-nontender

Question 12

The clinician collects a Pap from a 45 year-old. The Pap result is: Atypical Glandular Cells (AGC) with atypical endometrial cells present. What is the appropriate next step?

Answer 12

Refer for- or perform endometrial and endocervical sampling.

Atypical GLANDULAR cells mean that the problematic tissues are located within the cervical canal, OR higher in the reproductive tract like the uterus, fallopian tubes or ovaries. Because of this, sampling is needed of endocervical and endometrial tissue, and referral is often indicated.

Question 13

A 42-year-old’s cervical cytology screening result is high-grade squamous intraepithelial lesions (HSIL). Her HPV test was negative. The screening was performed using a liquid-based method. What is the management plan?

Answer 13

Refer her to a clinician for colposcopy or loop electrosurgical excision (LEEP).

HSIL is analogous to CIN-3 and requires either tissue confirmation or presumptive treatment.

Question 14

A 27-year-old’s cervical cytology screening result is atypical squamous cells of undetermined significance (ASC-US). The screening was performed using a liquid-based method. What is the PREFERRED management plan?

Answer 14

Manage based on results of HPV DNA testing.

Because our patient is older than 24, it’s appropriate to determine whether high risk HPV is present and manage using that information. If our patient were 24 or younger, the likelihood of the immune system clearing a high-risk HPV is higher (a transient infection), so rescreening would be appropriate in a year. Remember that you can anticipate the possible need for this and order REFLEX HPV testing IF ASC-US. If you forget, the lab can still perform the HPV test–just call them and add it on.

Question 15

The clinician collects a Pap and HPV from a 32 year-old and the results are: cytology negative, HPV positive. The clinician then reviews last year’s results which were: cytology negative, HPV positive. What is the next step now?

Answer 15

Refer for colposcopy.

So, what we have here is a persistent HPV infection in a 32-year-old: the patient’s body is not clearing the virus. Even if the Pap (which collects cells from the surface of the cervix and from some of the cervical canal) is negative x 2, that doesn’t mean that somewhere in or on the cervix there are no abnormal mutations taking place: it may be happening higher up in the cervical canal that the cytobrush has reached for these 2 negative Paps. The persistence of the virus is our primary concern, because HPV that sticks around and isn’t cleared by the immune system is what can, in some cases, lead to cancer, and we have evidence that this particular HPV infection is not clearing…. and our Paps may be falsely reassuring.

Question 16

A 34 year old’s cytology report is: negative with positive high risk HPV. The clinician immediately orders a follow up test to more specifically identify the high risk HPV strains and finds that HPV types 16 and 18 are negative. What is the appropriate management plan?

Answer 16

Recommend repeat HPV testing in 12 months.

Remember in the videos how I mention that types 16 & 18 are HIGH high-risk? They really are more likely to cause CIN 3 and cancer than the other oncogenic strains. The other ones can cause CIN 3 and eventual cancer, but they are not as likely to progress to CIN or progress as quickly. Thus, for the non-16/18 types, we can repeat HPV testing in a year and see if the HPV infection persists. If it does, off to colpo for the same reason as #4.

Question 17

What is the clinician’s next step when a Pap result is Atypical Squamous Cells: Cannot Exclude High-grade SIL (ASC-H)?

Answer 17

Refer for colposcopy.

Up to 5% of these Pap results indicate already-present cancer, so it’s critical to follow these cases closely to be sure your patient gets to colposcopy for a definitive tissue diagnosis.

Question 18

The clinician collects a Pap on a 34 year-old client. The result is unsatisfactory cytology with negative HPV. The clinician repeats the Pap 3 months later and the Pap is, again, unsatisfactory. What is the next management step?

Answer 18

Refer for- or perform colposcopy.

While it’s likely that this patient does not have cervical disease since the HPV test was negative, it’s not a good idea to assume they are fine and repeat at the regular interval (5 yeears for someone aged 30+). It may be useful to resolve any atrophic changes that are going on (e.g. prolonged breastfeeding could potentially cause this in a 30 year old), and to consult with the pathologist if your client is a transman on testosterone therapy since fewer cells from the surface of the cervix may be accessible via Pap. Here’s what ASCCP says about this situation:

Rationale: Literature was reviewed from 2012 to 2019, and no evidence was found to change recommendations.72–82 When cotesting is performed, a negative HPV test in the setting of an unsatisfactory cytology may reflect an inadequate sample. Although a negative HPV test (performed from the same vial as the cytology) may be adequate for testing even when the cytology cellularity is inadequate for diagnosis, interpreting the HPV result in the setting of insufficient cellularity has not been validated, which is of concern given that repeat testing is not recommended for up to 5 years after a negative HPV screen. Negative results on HPV tests that are not FDA approved for primary cervical cancer screening should not be considered valid in the absence of adequate cytology (Section F.3). In summary, a negative HPV result from a cotest with inadequate cellularity on cytology should not be interpreted as negative primary HPV test and should be repeated.

Question 19

The Pap result for a 24 year-old woman is: negative for intraepithelial lesion or malignancy (NILM) with an insufficient sampling of the transformation zone. The clinician should

Answer 19

Advise screening at the usual interval.

This client may not be negative for HPV. But it’s likely that they are, since the pathologist still decided they had enough information to say that the sample is negative for CIN or cancer. If she were 30+ we’d want to have HPV results to use to help guide management, but she is young and therefore even if HPV were present at the transformation zone, she’s likely to clear it on her own, which is why it’s acceptable to just try again when she’s due next time. I’m going to paste in the rationale for this approach from the 2020 guidelines just so you can see what ASCCP says about. this situation (quoted directly):

Rationale: Literature reviewed for the 2012 guidelines indicated a lower risk of CIN 3+ for patients with absent transformation zone/endocervical cells than those with cells present, leading to a recommendation to manage these results similarly.3 The HPV testing is preferred in women 30 years or older to facilitate subsequent risk-based management. A review of the literature from 2012 to 2019 on whether the absence of a transformation zone component (TZ/EC, i.e., endocervical cells or squamous metaplastic cells) on NILM cytology slides affected patients’ subsequent risks of histologic HSIL (CIN 2, CIN 3) diagnoses showed no evidence to change the 2012 recommendations.

Question 20

A 22 year-old ‘s Pap result is: low-grade squamous intraepithelial lesion (LSIL). The clinician should

Answer 20

Repeat cytology in 12 months.

A 22-year-old is highly likely to clear an HPV infection within a year, so rather than doing something invasive like endocervical curettage with colposcopy, it’s appropriate to rescreen in a year.

Question 21

A 33 year-old has a negative Pap with positive type 18 HPV. The clinician should

Answer 21

Refer for- or perform a colposcopy.

Type 18 HPV has truly high oncogenic potential—it’s High, high risk. Therefore, colposcopy to detect a possible CIN-3 is in order just to be sure abnormal tissue isn’t hiding where the Pap didn’t catch it.

Question 22

Which of the following is a concerning characteristic for nipple discharge?
A) Bilateral
B) elicited by squeezing
C) Clear
D) Green

Answer 22

C-Clear

Why? clear or bloody discharge can be pathologic

Question 23

In what age range do we typically see ectasia of the nipple?

Answer 23

50 and older

Question 24

What are the characteristics of intraductal papilloma?

Answer 24

Unilateral, bloody, caused by benign mass, 40-50y/o

Key: most commonly cysts

Question 25

When performing a CBE on a patient with symptoms. Which side should you begin the exam on?

Answer 25

The unaffected side

Question 26

What can increase prolactin?

Answer 26

Pregnancy, pituitary adenoma (tumor), medication (ex. birth control)

Question 27

What are symptoms of a pituitary adenoma?

Answer 27

Peripheral vision changes peripherally, headache

the mass is pushing on the optic nerve

Question 28

What lab imaging would we do on a patient over 30 years old with breast abnormalities on exam?

Answer 28

Mammogram and U/S

Question 29

What lab imaging would we do on a patient under 30 years old with breast abnormalities on exam?

Answer 29

U/S first

Question 30

What are the three key questions you should ask a patient presenting with mastalgia?

Answer 30

-When was your last period?
-Do you notice it happening with your cycle (is it cyclical?)
-Have you noticed any masses in your breast

Question 31

Which of the following is a concerning feature of breast pain?
A) Bilateral and generalized
B) Post-menopause occurrence
C) Recent discovery of frappucinos (yum!)
D) Resolves on cycle day 2

Answer 31

B) Post-menopause occurrence

Why? There are less hormones so there should not be breast pain

Note: Bilateral and generalized is likely not CA. Caffeine is associated with breast pain, D is associated with cyclic breast pain

Question 32

Which of the following interventions is NOT effective for mastalgia?
A) Supportive, well-fitting bra
B) Vitamin Supplements
C) Reassurance
D) Caffeine or fat reduction

Answer 32

B) Vitamin Supplements

Why? there are no known supplements to help

Note: some benefit from topical NSAIDs

Question 33

On a clinical breast exam. Which of the following is a NORMAL finding?
A) nipples that point in different directions
B) breasts that are different sizes
C) nipple retraction/flattening
D) palpable axillary lymph nodes

Answer 33

B) breasts that are of different sizes

Some people may have drastically different sizes

A/C) could signal a breast mass that is pulling the nipple
D) should be investigated

Question 34

What is the SOLE risk factor present in the vast majority people of breast Cancer?

Answer 34

Age

The older we get, the higher the rates of BCA

Question 35

Which HPV are responsible for most cervical CA?

Answer 35

16 and 18

Question 36

Which HPV are responsible for genital warts?

Answer 36

6 and 11

Question 37

What is the HPV vaccine and who is eligible? Who is it recommended for?

Answer 37

A 9-strain vaccine-Gardisil

For under age 45 y/o
Recommended for age 11 up to age 26, recommended to 9 year old if sexual assault

Question 38

Who should NOT be vaccinated against HPV?
A) 11 year old girls
B) 22 year old women who have already had sex and are not vaccinated
C) 47 year old women
D) 35 year old planning a pregnancy in a year

Answer 38

C) 47 year old women