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Breast Health Learning Objectives Describe breast anatomy to a patient Answer questions about causes of breast pain and masses Explain breast cancer screening/diagnostic modalities Appropriately triage women presenting with breast issues Provide patient education on breast health VETERANS HEALTH ADMINISTRATION Breast Anatomy Most tissue is adipose Lobules produce milk Ducts bring milk to surface though openings on nipple Breast Anatomy Lymph system removes fluids from tissues Lymph node areas A Pectoralis major muscle B-D Axillary lymph nodes E Supraclavicular lymph nodes F Internal mammary lymph nodes Causes of Breast Masses Normal structures Biopsy and scar tissue Cysts Fibroadenomas Fibrocystic changes Carcinomas • Ribs • Costochondral junction • Inframammary fold • Fat lobules • Fibroglandular tissue Benign • Soft, firm, or cystic • Regular • Mobile Cancerous • • • • • Solitary Hard Immobile Irregular ≥ 2 cm in size VETERANS HEALTH ADMINISTRATION Breast Mass Characteristics Case 1 A 42-year-old woman telephones your clinic with a complaint of breast pain and possibly a lump. How would you respond? What clarifying questions would you ask? What issues need to be considered for someone in her situation? Nursing Role in Breast Health Clarify/Triage • Rule out issues that require urgent follow-up: mastitis, inflammatory breast cancer • Ask questions to identify problem Identify needed follow-up • Individual facilities will have different protocols Provide support and education • Resources: websites for individual review • Education: pamphlets • Support: physical, emotional, psychosocial VETERANS HEALTH ADMINISTRATION Clarifying Questions • • • • • • • • Symptoms: mass, discharge, skin changes, pain, one or both breasts involved? LMP/pregnancy status? Implants? Risk factors: personal biopsy hx, family hx? Trauma hx? Contraception? New medications? Breast screening hx? VETERANS HEALTH ADMINISTRATION Triage and Follow-up • • • • • • Consider infection Presence of mass? Protocol available? Facility guidelines? Know provider‘s preferences Ensure careful documentation VETERANS HEALTH ADMINISTRATION Education and Support Educate • • • Breast changes Modifiable risk factors Managing benign pain Support • • • Know guidelines and protocols Facilitate screening/testing ─ Explain tests, provide instructions, consider transportation issues Provide emotional support ─ Address fear of pain, address fear of cancer VETERANS HEALTH ADMINISTRATION Benign Breast Disorders Premenstrual Breast Pain • • • • Bilateral and diffuse Cyclical, peaking prior to menses and improving during or immediately after menses Associated with normal menses, hormonal meds (e.g., OCPs) Treat symptoms ─ OTC acetaminophen or NSAID ─ Low-fat diet, avoid salt 1-2 weeks before menses, limiting ─ caffeine helps some women Supportive bra; ill-fitting underwires may be source of pain VETERANS HEALTH ADMINISTRATION Fibrocystic Breast Changes VETERANS HEALTH ADMINISTRATION Fibrocystic Breast Changes • Common findings ─ ─ ─ • • • Women 20-40, especially with family hx ~60% of premenopausal women Changes vary over menstrual cycle; subside with menopause in 20% of women Symmetric thickening in upper outer breast quadrants Rubbery, diffuse, painful lumps Treatment − Soft supportive bra, NSAIDs, acetaminophen, limit caffeine, small studies show slight effectiveness for Vitamin E or evening primrose oil taken orally VETERANS HEALTH ADMINISTRATION Fibroadenomas Most common solid benign tumor Stimulated by hormonal changes (OCPs, HRT, lactation, pregnancy) Common in young and African-American women Firm, rubbery, well-circumscribed, mobile, non-tender Usually diagnosed by biopsy; remove if symptomatic Mastitis (Inflammation of breast tissue) Mastitis • Lactational mastitis is most common (2-10% of breastfeeding women) • • • Hard, red, tender, swollen area of one breast Fever >101◦, patients typically look sick Ibuprofen, cold compresses, continued breastfeeding, antibiotics − No improvement in 48 - 72 hours, may need ultrasound to rule out abscess • Needs urgent provider evaluation VETERANS HEALTH ADMINISTRATION Cysts Common in perimenopause Vary with menstrual cycle Smooth, firm, mobile, round, well-circumscribed, fluid-filled sacs that are tender Ultrasound for women < 30 or pregnant Ultrasound + mammogram for women > 30 Simple cyst = fluid only Complex cyst = fluid and solids Refer to breast or surgical clinic; simple cysts may resolve with aspiration Case 2 Becky calls your office… “I just turned 40. I think I need a mammogram.” How would you respond? What clarifying questions would you ask? Clarifying Questions • Can you tell me why you think you need a mammogram? • Increased risk due to family hx? • Increased risk due to personal hx? • Skin changes? • Nipple discharge? • Pain? • Mass? Know the protocol at your facility VETERANS HEALTH ADMINISTRATION Methods to Evaluate the Breast VHA Policy on Breast Evaluation Techniques Recommendation VHA Teach breast self-exam Against Clinical exam for screening beyond mammography for women 40+ USPSTF Grade D: Harms outweigh benefits Neither for nor I: Insufficient evidence against on benefits vs. harms Biennial screening mammo- Recommended B: Moderate net graphy women for 50-74 benefit Biennial screening mammography for average risk women <50 Mammography screening for women 75+ Individual decision C: Small net benefit; may support providing for individual patients Neither for nor I: Insufficient evidence against on benefits vs. harms Don’t Teach Breast Self-Examinations • USPSTF recommends against TEACHING breast selfexam - Does not mean USPSTF opposes breast self-exam • Harms outweigh benefits - Finding lumps that turn out to be normal (falsepositives) leads to increased anxiety and unnecessary visits, imaging, and biopsies VETERANS HEALTH ADMINISTRATION Teach Breast Self-Awareness • Be familiar with breasts • Promptly report changes to provider: ─ Nipple discharge ─ Nipple inversion (retraction) ─ Skin puckering, dimpling ─ Lump/mass in breast or lymph nodes ─ Pain • For premenopausal women, examine breasts 1 week after end of menses Clinical Breast Exam USPSTF… The current evidence is insufficient to assess the additional benefits and harms of clinical breast examination for women 40 years or older Bottom line … provider should discuss the pros and cons of the clinical breast exam with the Veteran and include her in the decision-making process. VETERANS HEALTH ADMINISTRATION Obtain a Complete Medical Hx • • • • Identify concerns, self-detected abnormalities Personal/family hx of breast cancer Hx of breast procedures Other risk factors − Timing of menses, age at first pregnancy, number of pregnancies, timing of menopause − Alcohol use, obesity − Breast density − Hx of radiation therapy, long-term menopausal hormone therapy, DES exposure − Genetic alterations (BRCA1, BRCA2), Ashzenazi Jewish Heritage VETERANS HEALTH ADMINISTRATION Patient Mass Description Documentation • • Locate mass on clock face • Note mass characteristics Report distance from nipple in centimeters Example: Right breast mass is located at 12 o’clock, 5 cm from nipple, mobile, rubbery, smooth, tender VETERANS HEALTH ADMINISTRATION Mammography Options Screening vs. Diagnosis 1. 2. 3. 4. Screen asymptomatic women: 2 views per breast Screen women with breast implants: 4 views per breast Diagnose women with abnormality/symptoms: 4 views per breast Diagnose with spot compression/magnification if screening mammo shows abnormality (better imaging of particular region) **Mammography misses 10-20% of clinically palpable cancers. Also less able to find abnormalities in women <40 due to denser breasts. Mammography Recommendations • VHA follows USPSTF recommendations: ─ Biennial screening mammography for women ages 50-74 is recommended / Grade B: there is a moderate net benefit ─ Biennial screening mammography for average risk women <50 is an individual decision / Grade C: there is a small net benefit; VHA may support providing for individual patients ─ Mammography screening for women 75+ is neither recommended nor against / Grade I: there is insufficient evidence on benefits vs. harms VETERANS HEALTH ADMINISTRATION Mammogram Reports: Red Flags • Presence of a mass • Architectural distortion (“spiculated”, “irregular”) • Distribution of calcifications (“linear” vs. “cluster”) • Ductal asymmetric density Breast Imaging Reporting and Data System (BI-RADS) Category Diagnosis 0 Incomplete 1 Negative 2 Benign 3 Probably benign 4a 4b 4c Cancer 2-9% Cancer 10-49% Cancer 50-94% 5 Highly suggestive 6 Proven cancer • Rates breast density, masses, calcifications, and architectural distortions • Notes axillary adenopathy, skin or nipple retraction, and skin thickening • Can be used in conjunction with a diagnostic mammo • Determines if lesion is cyst vs. solid • Not routinely used for screening • Useful for women <30, pregnant, or lactating • Guides core biopsies Photo courtesy of Royal Philips Electronics. All rights reserved. Breast Ultrasound Magnetic Resonance Imaging (MRI) Pros • Screening high-risk patients • Evaluating new diagnosis • Monitoring patients in chemo • Evaluating metastatic cancer with unknown primary site • Evaluating patients with breast implants Cons: • More false positives • Higher exam cost • More limited availability VETERANS HEALTH ADMINISTRATION MRI Patient Education • Lie face down on platform with openings for breasts • If contrast material will be used, IV is inserted into hand/arm • Pictures are produced over a period of time. Usually includes multiple sequences. • Session can last from 3090 minutes VETERANS HEALTH ADMINISTRATION Fine needle aspiration Core needle biopsy Technique to biopsy a breast mass depends on: • Whether mass is palpable • Its location Radiology-assisted biopsy Stereotactic biopsy Ultrasound-guided biopsy Wire-localized biopsy Excisional biopsy Post-Biopsy Discharge Instructions • Pain management: acetaminophen usually sufficient • Bleeding is rare but may occur; can produce hematoma • Monitor for infection: redness, fever, increasing pain or discharge • Use bra continuously for 1 wk to decrease complications • When/how to expect results • Who to call with a problem VETERANS HEALTH ADMINISTRATION Biopsy Results: Breast Cell Changes Term Definition Hyperplasia Overgrowth of cells lining ducts or lobules Atypical hyperplasia Accumulation of abnormal cells in duct of lobule; marker for cancer Non-invasive cancer Carcinoma in situ (cancer confined to duct or lobule where it developed) Invasive cancer Cancer has spread (progression described as stages I-IV) VETERANS HEALTH ADMINISTRATION Breast Cancer Today • • • • 200,000 diagnoses yearly Survival rates climbing 5-year survival 98-100% if localized >30% of women diagnosed after metastasized Where Breast Cancer Spreads • Lymph nodes help clear breast of excess fluid or infection • Also involved in how breast cancer spreads Considerations for Pregnant and Lactating Women Average age of women Veterans receiving care at VA is 47 years You will be caring for some women during peak reproductive years Causes of Breast Masses in Pregnant or Lactating Women • • • • • • • VETERANS HEALTH ADMINISTRATION Lactating adenoma (likely due to rising estrogen levels) Plugged ducts Milk retention cyst (galactocele) Mastitis Abscess Cancer (1/3000-1/10000 pregnant women) Other causes noted previously Evaluating Masses in Pregnant and Lactating Women • Ultrasound preferred • Biopsy complications − Fine needle aspiration not as accurate − Higher hematoma risk with pregnancy − More infection/milk fistula with lactation • Cessation may lower complications • Workup is not postponed for pregnancy if indicated − Mammo: lead apron to minimize ionizing radiation to fetus • Some leaking/expression of fluid during late pregnancy common; milky or yellowish color and bilateral occurrence is reassuring VETERANS HEALTH ADMINISTRATION Nursing Role in Breast Health • Clarify the issue • Provide education • Facilitate screening/diagnosis Educate Patients • Be aware of breast changes • Address modifiable risk factors − <1 alcoholic drink/day − Exercise − Weight control, low-fat diet VETERANS HEALTH ADMINISTRATION • Suggestions for benign pain − Supportive bra, avoid underwires − Nicotine and caffeine cessation may help − Warm compresses, ice packs, gentle massage − OTC acetaminophen or NSAID Facilitate Screening and Diagnosis • Explain the screening/diagnostic method • Suggestions to minimize pain with mammogram − Timing: 10 days after start of menses − Acetaminophen prior to test − Avoid caffeine week before − Talk to mammogram technician • Address her fear of cancer diagnosis − Explain early diagnosis = better prognosis and treatment success Although she may not agree to screening at this time, you are laying a foundation. She may change her mind during a future visit. VETERANS HEALTH ADMINISTRATION Local guidelines & policies? System resources for follow-up? Abnormal results tracking? Know Your System Testing locations & required preps? Results reporting to providers & patients? Summary • Any lump should be evaluated • Even if the mammogram is negative, mass still needs to be pursued • No physical exam can reliably distinguish between benign vs. malignant • Most common malpractice claim is failure to diagnose breast cancer • Nursing plays a key role in clarifying issues, providing education, and facilitating screening and diagnosis VETERANS HEALTH ADMINISTRATION Authors Ellen Yee, MD, MPH New Mexico VA Health Care System Rachel Bonnema, MD, MS VA Nebraska-Western Iowa Health Care System Linda Baier Manwell University of Wisconsin-Madison Division of General Internal Medicine Molly Carnes, MD, MS University of Wisconsin-Madison Center for Women’s Health Research VETERANS HEALTH ADMINISTRATION