Module 7: Breast Problems

Question 1

Mastalgia (Benign)

Answer 1

Breast pain
* Most common breast-related complaint
* Cyclic mastalgia coincides with menstrual cycle
and is related to hormonal sensitivity
* Noncyclic mastalgia can be constant or intermittent
 May be due to trauma, fat necrosis, duct
ectasia, costochondritis, or arthritic pain
 Reassure that it is not a usual sign of breast cancer

Question 2

Lactational Mastitis (Benign)

Answer 2

Lactational mastitis
 Inflammatory breast condition that occurs most often
in lactating women
* Localized area that is red, painful, and tender to
palpation
* Fever is often present
* Pathogens gain access through cracked nipple
* Can be cured with antibiotics in early stages
 Periductal mastitis occurs most often in smokers
* Woman not lactating
* Treatment is the same

Lactational breast abscess
 From persistent lactational mastitis
* Palpable mass with red, edematous skin over involved
breast; possibly fever
* Drainage of abscess is necessary
 Ultrasound-guided needle or surgical incision and
drainage
 Cultured and treated with appropriately sensitive
antibiotics
 Breastfeeding can usually continue

Question 3

Fibrocystic Changes (Benign)

Answer 3

Fibrocystic changes
 Benign condition with changes in breast tissue
* Development of excess fibrous tissue
* Hyperplasia of the epithelial lining of mammary ducts
* Proliferation of mammary ducts
* Cysts
 Occur most commonly between ages 30 and 50
 Women with premenstrual abnormalities, nulliparity,
history of spontaneous abortion, nonusers of oral
contraceptives
Possibly due to exaggerated responsiveness to
hormones
* Estrogen and progesterone
 Not linked to increased breast cancer risk
* Pone or more palpable round, well-delineated, freely
movable lumps
* Discomfort ranging from tenderness to pain
* Lump usually increases in size and tenderness before
menstruation
* Nipple discharge often green or dark brown

Question 4

Fibroadenoma (Benign)

Answer 4

Fibroadenoma
 Common cause of discrete benign breast lumps in
young women
 Painless, round, solid, firm, and rubbery
 Growth is slow and ceases at 2 to 3 cm
 Most often in blacks than whites
 May be due to ↑ estrogen sensitivity
Easily detected by physical assessment
 Definitive diagnose by FNA, core, or excisional biopsy
 Treatment
* Observation with regular monitoring after ruling out
cancer
* Surgical removal if increases in size and/or
symptomatic
* All new lesions should be evaluated by breast
ultrasound and possible biopsy

Question 5

Galactorrhea (Benign)

Answer 5

Galactorrhea
 Milky secretion due to inappropriate lactation
 May result from
* Certain medications
* Endocrine or neurologic problems
* No known cause

Clear, serous, bloody, or brown to green secretions
 Cytology slide to determine cause and recommended
treatment
* Benign breast conditions
 Fibrocystic changes
 Intraductal papilloma
 Ductal ectasia
* Usually not caused by cancer
 However spontaneous, unilateral discharge needs further evaluation

Question 6

Intraductal Papilloma

Answer 6

Benign, soft or hard, wart-like growth
 In mammary ducts
 Usually unilateral
 Bloody discharge from nipple
 Difficult to palpate- usually beneath areola
 Usually occur in 35- to 55-year-old women
 Associated with a slightly ↑ risk for developing breast
cancer
* Core biopsy recommended
* If there are abnormal cells surgical excision is done

Question 7

Ductal Ectasia (benign)

Answer 7

Duct dilation
 Benign breast disease of perimenopausal and
postmenopausal women
 Involves several bilateral ducts in subareolar area
* Multicolored, sticky nipple discharge- main symptom
* Progresses to burning, itching, pain around nipple
* May see inflammation and nipple retraction
* Not associated with cancer
 If abscess develops, warm compresses, antibiotics
 Surgical excision of involved ducts may be done

Question 8

Male Gynecomastia (Benign)

Answer 8

Transient, noninflammatory enlargement of one or
both breasts
 Most common breast problem in men
 Usually a temporary, benign condition
 Not a risk factor for breast cancer
* Can occur in puberty
* May also be a manifestation of other problems
 Testicular tumors, adrenal cancer, pituitary adenoma,
hyperthyroidism, liver disease
 Side effect of drug therapy
 Marijuana may cause

Question 9

Senescent Gynecomastia (benign)

Answer 9

Occurs in many older men
 Likely cause is high plasma estrogen levels
 Tender, firm, centrally located enlargement
 Discrete circumcised mass with gynecomastia
* Biopsy to rule out rare breast cancer
 Usually regresses in 6 to 12 months with no treatment

Question 10

Gerontologic Considerations

Answer 10

Pendulous breasts
 Loss of subcutaneous fat
 Loss of structural support
 Atrophy of mammary glands
 Decreased glandular tissue density
 Makes breast masses easier to palpate
 Increased incidence of breast cancer
 Encourage annual mammogram and CBE

Question 11

Breast Cancer

Answer 11

Many new cases each year in U.S. women
 2nd most common cancer
 2nd only to lung cancer as leading cause of death in
women
 Incidence is slowly decreasing due to
* Decreased use of hormone therapy after menopause
* Early detection and treatment advances
 Breast cancer survivors are largest group of any
cancer survivors

Question 12

Breast Cancer Etiology and Risk Factors

Answer 12

Etiology and risk factors for women
 Cumulative and interacting
* Female gender and age are strongest risk factors
* Family history
* Environmental factors
* Genetic link
 Most who develop breast cancer have no identifiable
risk factors

Hormonal regulation is related to breast cancer
development
 Mechanisms are poorly understood
 Combined hormone therapy
* Increased risk of breast cancer
* Increased tumor size at diagnosis
* Increased tumor stage at diagnosis
 Estrogen alone may increase risk after 15 years

Modifiable risk factors
 Excess weight gain during adulthood
 Sedentary lifestyle
 Smoking
 Fat intake
 Obesity
 Nightshift work
 Alcohol use
 Environmental factors
* Radiation exposure, using hair dyes and straighteners

Up to 10% are hereditary
 Genetic link stronger if involved family member
 Most related to mutations of 2 genes
* BRCA 1 and BRCA 2
* BRCA= BReast Cancer
 Also mutations of genes that suppress tumor growth
 Had a history of ovarian cancer
 Was premenopausal
 Had bilateral breast cancer
 Is a first-degree relative
* Breast cancer risk doubles

Question 13

Breast Cancer Risk Factors for Men

Answer 13

Risk factors for men
 Estrogen use
 Hyperestrogenism
 Family history of breast cancer
 Radiation exposure
 BRCA-positive families
* Consider genetic testing
* Teach self-assessment
* CBE every year starting at age 35

Question 14

Breast Cancer Screening Guidelines

Answer 14

Yearly mammograms for average-risk women
 Starting at age 45
 Yearly ages 45 to 54
 Every 2 years ages 55 and older
 Continue screening mammograms as long as overall
health is good

Clinical breast exams (CBE)
 ACS does not recommend CBE among average-risk
women at any age

Women at increased risk
 Earlier 3D mammography screening
 Breast MRI
 More frequent CBEs

Consistent BSE may facilitate breast self-awareness
 Normal look and feel of breasts
 Review technique regularly through return
demonstration

Question 15

Breast Cancer Diagnostic Studies

Answer 15

Radiologic studies
 Mammography
* Digital mammography
 More accurate in younger women
* 3-D mammography (tomosynthesis)
 Ultrasonography
 MRI
* For women at high risk

Biopsy
 Fine-needle aspiration (FNA)
 Core needle biopsy
 Vacuum-assisted biopsy
 Excisional biopsy

Prophylactic oophorectomy and mastectomy in
women with BRCA1 or BRCA2 mutations can ↓ risk
of breast and ovarian cancers
 Ovaries are main source of estrogen in
premenopausal women
 Oophorectomy does not decrease breast cancer risk
in postmenopausal women

Question 16

Metastatic breast cancer

Answer 16

Most common sites are bone, liver, lungs, and brain
 Factors that affect prognosis
* Tumor size
* Axillary node involvement
* Tumor differentiation
* Estrogen and progesterone receptor status
* Human epidermal growth factor receptors

Metastatic breast cancer is breast cancer that
has spread to other organs
 Most common sites are bone, liver, lung, and brain

Question 17

Types of Breast Cancer based on tissue types

Answer 17

Ductal carcinoma (affects milk ducts)
 Medullary
 Tubular
 Colloid (mucinous)
 Lobular carcinoma (affects milk-producing glands)

Other
 Inflammatory
 Paget’s disease
 Phyllodes

Question 18

Breast Cancer Types - based on invasiveness

Answer 18

Noninvasive (in situ)- 20% of breast cancers
 Ductal carcinoma in situ (DCIS)
 Paget’s disease

Invasive (spreading to other locations)
 Invasive (infiltrating) ductal carcinoma (80%)
 Invasive lobular carcinoma (10-15%)

Question 19

Breast Cancer Types - based on hormone receptor status

Answer 19

Estrogen and progesterone receptor status
 Estrogen receptor positive
 Estrogen receptor negative
 Progesterone receptor positive
 Progesterone receptor negative

Question 20

Breast Cancer Types - based on genetic status

Answer 20

HER-2 genetic status
 HER-2 positive
 HER-2 negative

Question 21

Noninvasive breast cancer

Answer 21

Noninvasive breast cancer
 Comprises 20% of breast cancers
 Ductal carcinoma in situ (DCIS)
* Tends to be unilateral
* May progress to invasive if untreated
 Paget’s disease
 Lobular carcinoma in situ (LCIS)
* Reclassified as benign, but with a risk for developing
breast cancer

Question 22

Invasive ductal carcinoma

Answer 22

Invasive (infiltrating) ductal carcinoma
 Most common type of breast cancer
 Starts in milk ducts, then breaks through walls to
invade surrounding tissue
 Multiple subtypes

Question 23

Invasive Lobular Carcinoma

Answer 23

Begins in the milk-producing glands of the breast
(lobules)
 Accounts for 10-15% of invasive breast cancers
 Presents as a subtle thickening in the upper-outer
quadrant of the breast
 Often not detected by mammography

Question 24

Inflammatory Breast Cancer

Answer 24

Aggressive and fast growing
 High risk for metastasis
 Cancer cells block lymph channels in skin of breast
 Breast looks red, feels warm
 Breast skin has a thickened appearance, looks like an
orange peel (peau d’orange)

Question 25

Paget’s Disease

Answer 25

Rare breast cancer
 Different from Paget’s disease of the bone
 Starts in breast ducts and spreads to nipple and
areola
 Itching, burning, bloody nipple discharge,
ulceration
 Nipple changes often diagnosed as an infection
or dermatitis, which can lead to treatment delays

Question 26

Phyllodes Tumor

Answer 26

Very rare tumor
 Develops in connective tissue of the breast
 Tends to grow quickly
 Most are benign
 Treatment—Excision with wide margin

Question 27

Triple Negative Breast Cancer

Answer 27

Tests negative for all 3 receptors
 Estrogen, progesterone, HER-2
 Higher incidence
* Blacks
* Hispanics
* Premenopausal women
* BRCA1 mutation
 More aggressive tumors, poorer prognosis
 Does not respond to hormone therapy,
chemotherapy more successful

Question 28

Clinical Manifestations of
Breast Cancer

Answer 28

Detected as lump, thickening, or mammography
abnormality in breast
 Rate of lesion growth varies
 If palpable, hard, irregular, poorly delineated,
nonmobile, and nontender
 May be nipple discharge or retraction

Question 29

Complications of Breast Cancer

Answer 29

Recurrence and metastasis
 Local: skin
 Regional: lymph nodes
 Distant: bones, brain, lungs, liver
* Metastatic disease can be found at any distant site

Question 30

Diagnostic Studies

Answer 30

Some tests are used to predict risk of local or
systemic recurrence
 Axillary lymph node analysis

Tumor size
 Estrogen and progesterone receptor status
 Cell-proliferative indices
 Genetic/genomic assays

Axillary lymph node analysis
 An important prognostic factor
 The more lymph nodes involved, the greater the risk
of recurrence
* Sentinel lymph node biopsy (SLNB)
 Helps identify lymph nodes that drain first from the tumor site
 May indicate need for a complete axillary lymph node
dissection (ALND)

Question 31

Tumor Size

Answer 31

Tumor size
 Larger the tumor, poorer the prognosis
 More well differentiated the tumor, the less
aggressive
 Poorly differentiated tumors appear morphologically
disorganized and are more aggressive

Question 32

Estrogen/Progesterone Receptor Status

Answer 32

Estrogen and progesterone receptor status
 Receptor-positive tumors
* Often well-differentiated
* Lower chance for recurrence
* Diploid DNA content and low proliferative indices
* Frequently hormone dependent and responsive to
hormone therapy

Receptor-negative tumors
* Poorly differentiated
* Often recur
* High incidence of aneuploidy and higher proliferative
indices
* Unresponsive to hormonal therapy

Ploidy status
 Number of chromosomes in a cell
 Correlates with tumor aggressivenes

Question 33

Genomic Assay

Answer 33

Genomic assay
 HER-2 is a prognostic indicator associated with
* Unusually aggressive tumor growth
* Greater risk for recurrence
* Poorer prognosis
 Presence helps in selection and sequence of
drug therapy and predicts response

Question 34

Gene Expression Assay Test

Answer 34

Gene expression assay test
 Uses a sample of breast cancer tissue to analyze
activity of a group of genes that can affect how a
cancer is likely to behave and respond to treatment
* Oncotype DX—most often used
* MammaPrint, PAM50 (Prosigna), EndoPredict, Breast
Cancer Index

Cell-proliferative indices indirectly measure rate
of tumor cell proliferation
 Patients with cells that have high S-phase
fractions have higher risk for recurrence and
earlier cancer death

Question 35

Breast Cancer Staging

Answer 35

Staging of breast cancer
 TNM system
 Tumor size (T)
 Nodal involvement (N)
 Presence of metastasis (M)

Stage of breast cancer describes size and extent to
which it has spread

Question 36

Treatment Options

Answer 36

All options should be considered and discussed
 Surgical intervention
 Radiation therapy
 Drug therapy
 Hormone therapy
 Immunotherapy and targeted therapy

Question 37

Surgical Therapy

Answer 37

Most common surgical procedures for operable
breast cancer
 Breast conservation surgery
* Lumpectomy
* Segmental mastectomy
 Mastectomy, with or without reconstruction

Question 38

Surgical Therapy
Breast-Conserving Surgery

Answer 38

Lumpectomy
 Removing the entire tumor with a margin of normal
tissue
 Radiation therapy after surgery
 Delivered to entire breast, ending with a boost to
tumor bed
 Chemotherapy before radiation therapy

Question 39

Surgical Therapy
Breast-Conserving Surgery

Answer 39

Contraindications include
 Size of breast in relation to size of tumor
 Multifocal masses and calcifications
 Multicentric masses- in more than one quadrant
 Diffuse calcifications in more than one quadrant
 Prior radiation therapy

Question 40

Surgical Therapy
Mastectomy

Answer 40

Total or simple mastectomy
 Removes entire breast
Modified radical mastectomy
 Removes breast and axillary lymph nodes
 Preserves pectoralis major muscle
Nipple-sparing mastectomy
 Underlying tissue is removed

Breast reconstruction can be done with the
mastectomy or it can be delayed
 Reconstruction is optional
 2 main types of procedures
 Implant reconstruction
 Tissue flap

Question 41

Radiation Therapy

Answer 41

Adjuvant therapy goals
 Prevent local cancer recurrences after breast-
conserving surgery
 Prevent local and lymph node recurrences after
mastectomy
 Relieve pain caused by local, regional, or distant
spread of cancer

External radiation
 Done after breast cancer surgery
 Decision based on chance that residual cancer cells
are present
* Includes radiating axilla and/or supraclavicular nodes
when indicated
* Does not prevent distant metastasis
 Fatigue, skin changes, breast edema may be
temporary side effects

Brachytherapy
 Internal radiation
 Minimally invasive
* Delivered directly into cavity left after lumpectomy
 Requires 5 treatments, 5-10 minutes eac

Question 42

Palliative Radiation Therapy

Answer 42

Decreases pain by reducing primary tumor mass
 Treatment option for symptomatic metastatic lesions
in
 Bone, soft tissue organs, brain, chest
 Often relieves pain, controls recurrent or metastatic
disease

Question 43

Drug Therapy

Answer 43

Systemic therapy including
 Chemotherapy
 Hormone therapy
 Immunotherapy
 Targeted therapy
 Patients at ↑ risk for recurrent or metastatic disease

Neoadjuvant therapy
 Given before surgery to shrink size of tumor
 Adjuvant therapy
 Given after therapy to decrease rate of recurrence
and increase length of survival

Question 44

Chemotherapy

Answer 44

Use of cytotoxic drugs to destroy cancer cells
 Combination drug therapy is usually superior to use of a single drug
 Usually given for 3 to 6 months
 With metastasis, may receive for the rest of their life

Combinations of drugs effective
 Different mechanisms of action
 Work during different parts of the cell cycle
 Common combination-therapy protocols used in
adjuvant and neoadjuvant setting
 CMF
 AC
 CEF or CAF

Side effects are related to
 Drug combination, schedule, dosage
 Involve rapidly dividing cells in
* GI tract (nausea, anorexia, weight loss)
* Bone marrow (anemia)
* Hair follicles (alopecia)
 “Chemobrain”

Question 45

Hormone Therapy

Answer 45

Blocks effect and source of estrogen, promoting
tumor regression
 Estrogen can promote growth of breast cancer cells if
cells are estrogen receptor (ER) positive
 Receptor assays have been developed for both
estrogen and progesterone
* Predict whether hormone therapy is a treatment option

Hormone therapy
 Block ERs
 Suppress estrogen synthesis
 Ovarian ablation
 Premenopausal women with ER-positive breast
cancer
 Accomplished surgically or with LHRH hormone
analogs

ER blockers
 Tamoxifen
* Agent of choice in ER-positive women with all stages of
breast cancer
* Drug alert
 Toremifene (Fareston)
 Fulvestrant (Faslodex)

Aromatase inhibitors
 Stops aromatase, an enzyme in fat tissue, from
changing other hormones into estrogen
 Anastrozole (Arimedex), letrozole (Femara),
exemestane (Aromasin)
 Used in treatment of breast cancer in
postmenopausal women
* Do not block ovarian estrogen production
* May be harmful in premenopausal women
* May cause osteoporosis in postmenopausal women

Estrogen receptor modulators
 In breast: estrogen-antagonistic effects
 In bone: estrogen-agonistic effects, for example:
* Raloxifene (Evista)
 Other drugs used to suppress hormone-dependent
breast tumors

Question 46

Targeted Therapy

Answer 46

Trastuzumab (Herceptin) is a HER-2 inhibitor
 Attaches to HER-2 receptors on surface of breast
cancer cells; blocks them from receiving signals to
proliferate
 Can be used alone or in combination with other
chemotherapies
 Drug alert
 Other drugs that target HER-2
 pertuzumab (Perjeta), ado-trastuzumab emtansine
(Kadcyla), lapatinib (Tykerb), nerotinib (Nerlynx)

Kinase inhibitors prevent cells from dividing, slowing
growth
 For ER-positive, HER-2 negative cancer in
postmenopausal women
 palbociclib (Ibrance), ribociclib (Kisquali), and
abemaciclib (Verzenio)
 Drug that block mTOR, protein that promotes cell
growth- everolimus (Afinitor)

Question 47

Immunotherapy

Answer 47

Atezolizumab (Tecentriq), immune checkpoint
inhibitor, is 1st FDA-approved immunotherapy agent
 Used with chemotherapy to treat locally advanced
triple negative breast cancer with PD-L1 positive
biomarker

 Pembrolizumab- option with advanced breast cancer
that tests MSI-H (microsatellite instability-high) when
no other therapies are available

Question 48

Surgical Therapy
Postbreast Therapy Pain
Syndrome

Answer 48

Postbreast therapy pain syndrome (PBTPS)
 Nerve injury during surgery
* Intercostobrachial nerves
* Provide sensation to shoulder and upper arm
 Chemotherapy
 Radiation therapy

Symptoms range from mild to debilitating
 Chest and upper arm pain, tingling, aching, burning,
numbness, shooting or pricking pain, edema,
unbearable itching
 Treatment includes
 NSAIDS, low dose antidepressants, topical
anesthetics (EMLA), antiseizure drugs (gabapentin)
 Biofeedback, physical therapy, guided imagery

Question 49

Phantom Breast Pain

Answer 49

Feeling pain in breast after a mastectomy
 Occurs for same reasons phantom limb sensation
occurs after limb amputations
 Brain continues to send signals to nerves in breast
area that were cut during surgery

Question 50

Gerontologic Considerations for Breast Cancer

Answer 50

Major risk for breast cancer is increasing age
 More than half of all breast cancers occur in women
age 55 or older
 Older women are less likely to have mammograms
 Screening and treatment decisions are based on
health status, not age

Question 51

Mammoplasty

Answer 51

Surgical change in size or shape of the breast
 Elective surgery for cosmetic purposes
 Breast reconstruction after mastectomy
 Consider
* Body image
* Cultural values placed on the breast
* Outcomes and complications

Breast reconstruction
 Achieve symmetry
 Restore or preserve body image
* Timing is based on patient’s physical and psychologic
needs
 Immediate or delayed
* Can restore contour of the breast
* Cannot restore lactation, nipple sensation, or erectilit

Question 52

Breast Implants and Tissue
Expansion

Answer 52

Implants
 Silicone shell
* Silicone gel
* Saline
* Cohesive gel

Question 53

Tissue Flap Procedures

Answer 53

Use of autologous tissue to recreate a breast mound
 Abdomen
 Back
 Thighs
 Buttocks

TRAM flap
 2 types of TRAM: pedicle and free
 Extensive procedure with lengthy recovery period
 DIEP flap
 Version of the free flap that does not involve use of
muscle tissue
 SIEAP
 Another option using abdominal are, no muscle
 Latissimus dorsi flap
 Block of skin and muscle removed from patient’s back

Question 54

Nipple-Areolar Reconstruction

Answer 54

More natural-appearing breast
 Usually done several months after breast
reconstruction
 Tissue is taken from breast tissue to create a new
nipple
* Tattooing with permanent dye may be used
* Polyurethane removable nipples also available

Question 55

Breast Augmentation

Answer 55

Augmentation mammoplasty
 Procedure to enlarge the breasts
* Implant is placed in a surgically created pocket
between capsule of breast and pectoral fascia
* Ideally under pectoralis muscle

Question 56

Breast Reduction

Answer 56

Large breasts can be a source of discomfort
 Wedges of tissue are resected from the upper and
lower breast quadrants
* Excess skin is removed
* Areola and nipple are relocated
* Lactation usually can still occur
 Can have positive effect on psychologic and physical
health