Download Breast Cancer Risk Assessment

Benign Breast Conditions
Evaluation, Treatment
and when to Refer
Lisa B. McCabe MS,APRN
Nurse Practitioner
Surgical Oncology/Comprehensive Breast Program
Dartmouth Hitchcock/Lebanon, NH
DISCLOSURES
None of the planners or presenters of this
session have disclosed any conflict or
commercial interest
Objectives
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Review Breast Cancer Statistics
Discuss Current Methods for Determining Breast
Cancer Risk
Review Screening Recommendations
Describe Screening Options
Discuss Commonly see Benign Breast Conditions
Discuss: Evaluation, Treatment and Referral
Process for Benign Breast Conditions
Incidence of Breast Cancer
in the United States
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230,000 women diagnosed with invasive cancer in 2013
DCIS incidence: approx 65,000 in 2013
40,000 deaths estimated
#1 cancer in women/excluding non melanoma skin cancer
#2 cancer death in women/lung being number 1
Main cause of death in women ages 40-59
About 1% of all breast cancers are found in men (approx 2,200 new
cases diagnosed annually with approx 400 deaths)
Treatments aimed at cure, improving disease free survival and
prolonging life of women with breast cancer
Average Risk woman has a 12% Lifetime Risk
Breast Cancer Risk Factors
Age and Gender
Race and Ethnicity
Benign Breast Disease
Personal History of Breast Cancer
Lifestyle and Dietary Factors
Reproductive and Hormonal
Family History and Genetic Factors
Exposure to Ionizing Radiation
Breast Density
Age and Gender
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100 times more frequently in women vs. men
(200,000 vs. 2000 per year)
Sharpest increase in incidence 50 years/older
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Incidence flattens at around age 75
Race/Ethnicity
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Highest Incidence in Whites: 124 per 100,000
Lower Incidence in African Americans 113 per
100,000.
 Higher Mortality among African Americans/all
ages: higher incidence of diagnosis before age 40
 Asian, Hispanic and Native American
82-92 per 100,000
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Socioeconomic Status
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Two fold increase in incidence in women of
higher socioeconomic status
Likely related to several factors seen with this
population: parity, age at first birth, utilization of
screening mammography
Exposure to Ionizing Radiation
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Hodgkin’s Lymphoma/Mantle Radiation
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Environmental/Nuclear Exposure
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Most vulnerable years 10-14 up to age 30
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Consider screening mammogram at 40, MRI 10
years after treatment when risk increases
Personal History of Breast Cancer
Risk of contra lateral invasive breast cancer
In Situ patients = 10 year risk is 5%
 Invasive patients = 1% per year for premenopausal
0.5% per year for post menopausal
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Breast Density
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Percent of opacity seen on mammogram
ACR requires density to be reported on
mammogram results
Extremely Dense: >75%
Heterogeneously Dense: 51-75%
Scattered Dense: 25-50%
Fatty Replacement: <25%
Breast Density
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Risk of developing breast cancer is 4-5 times
higher in extremely dense breast tissue
Mechanism not fully understood but likely
independent of estrogen mediated effects
Breast cancers associated with higher breast
density are equally ER positive/negative
HRT increases breast density
Tamoxifen decreases breast density
RMLO
LMLO
Benign Breast Disease as a Risk
Factor
Non-Proliferative Lesions (no risk)
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Simple or complex cysts
Proliferative Lesions without Atypia (slight risk)
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Simple fibroadenoma (no increase risk)
Usual Ductal Hyperplasia, intraductal papillomas (relative risk
of 1.6-1.9)
Complex fibroadenoma (slight risk if associated with adjacent
proliferative disease and or family history)
Radial Scar/Sclerosing lesion
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Pathologic diagnosis, needs to be excised if found on core, possible
pre malignant potential
Benign Breast Disease as a Risk
Factor
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Atypical Hyperplasia (moderate to high risk)
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Atypical Ductal Hyperplasia (ADH)
Atypical Lobular Carcinoma (ALH)
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Pathologic Diagnosis
Relative Risk is 3-6 fold, Multifocal lesions = 10 fold risk
Require surgical excision if diagnosed by core needle biopsy
DCIS found in up to 50% of cases
Clinical exams every 6 months/annual mammogram/?MRI
Benign Breast Disease as a Risk
Factor
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Lobular Carcinoma in Situ (LCIS)
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Significantly Increased Risk (7-18 x higher than general
population)
Typically diagnosed as an incidental finding
Not identified clinically or on mammogram
An index lesion for risk of bilateral invasive ductal or lobular
cancer
Needs to be re excised if found on core
Pleomorphic LCIS = DCIS
Lifetime Surveillance/Chemoprevention/MRI
Determination of Actual Risk
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Good History
GAIL MODEL
Claus Model
Referral to Familial Counseling for Discussion
about Genetic Testing
Know Your Risks !
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Family History
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First Degree Relatives with Breast and Ovarian Cancer or
premenopausal relatives
Male Breast Cancer
Genetic Testing Performed/Actual Mutation Carriers
Personal Risks
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History of Breast Biopsies/Pathology Reports
Breast Density
Difficult Exam
Mutation Carrier
GAIL MODEL
Gail Model http://brca.nci.nih.gov/brc/questions.htn
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Age
Age at time of first menstrual period
Age at time of first live birth
Number of first-degree relatives with breast cancer
Number of prior breast biopsies
Any biopsies with atypical hyperplasia
Race/ethnicity
GAIL MODEL
The Gail Model is used for a women >age 35 without a prior
history of breast cancer
The Risk Assessment tool will generate a five year and a
lifetime risk of developing breast cancer:
Five year risk of 1.66% is the threshold for considering
the use of tamoxifen as preventive therapy
Lifetime Risk of 20-25% is used by some/insurance for
consideration of adjuvant MRI but not designed for that
reason
Limitations of the GAIL Model
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Patients <age 35 not eligible
Ovarian Cancer not considered
Paternal History not considered
Younger non first degree relatives not
considered
Age at diagnosis not considered
Claus Model
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Probability of Breast Cancer Based on Family
History
First and Second Degree Relatives
Age at Diagnosis
Can be used on younger women (29-35)
Less validated than GAIL so less often used
Who is an Average Risk Patient ?
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12% Lifetime Risk or <1.7% 5 Year Risk
No family history/No mutation carriers
No personal risks
No biopsies
 Average/late menarche
 Live births before 30
 No Mantle radiation
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Screening Recommendations for
Average Risk Patients
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Self Breast Exam : optional
Clinical Breast Exam: every 3 years 20-39,annual
after 40
Mammography decisions should be
individualized
Screening Mammogram
Recommendations
Average Risk Patient
Annually Starting at 40
ACR (Am College Radiology)
ACOG (Am College Ob/Gyn)
ACoS (Am College of Surgeons)
American Cancer Society: 45 years
USPSTF: Every Two Years 50-74 years
Who is a High Risk Patient ?
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>3% 5 Year Risk
>20% Lifetime Risk
Family History
No live births before 30
Biopsies
Breast density
Early Menarche
Screening Recommendations for the
High Risk Patient
Clinical exams annually or semi annually
Imaging: Annual Mammogram, MRI for some
Low threshold for diagnostic work up/clinical
concern
Consider chemoprevention
Referral for possible genetic testing
Who is a Very High Risk Patient?
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BRCA 1 or 2 Mutation Carriers
History of Mantle Radiation before age 30
Personal History of Breast Cancer
Personal History of: ADH, ALH, LCIS
Personal History of Cowden’s, Li-Fraumeni,
Peutz-Jegher’s
Screening Recommendations for
Very High Risk Patients
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Annual 3D Mammogram
Annual Adjuvant MRI
Self Exam/optional
Clinical Breast exam every 6 months
Chemoprevention
Refer to Breast Center
Tomosynthesis/3D
Mammography
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Pre and Perimenopausal Women
Dense Breast Tissue
Additional Radiation (“two” mammograms)
Lower call back rate (20-30% fewer)
Detecting more cancers (30-40%)
Individualized in elders/post menopausal
Patient preference
Adjuvant MRI
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High False Positive Rate (more sensitive/less specific
than mammography for IDC)
Call Backs
Category 3 Status
Biopsies
Expense/Insurance Issues/Medicare Patients
Scheduling issues around cycle or off HRT x 3 months
Weight and Breast size Limitations
ACR Categories
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Category 0
Category 1
Category 2
Category 3
Category 4
Category 5
Category 6
“ Call Back”
Normal
Benign
“Probably” Benign
Suspicious/Biopsy Needed
Highly Suspicious/Malignant
Biopsy Proven Malignancy
Familial Cancer Counseling
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Patients can self refer
Encourage patients to discuss with family
members
Determines statistical risk of mutation carrier
status
Imaging
Chemoprevention
Risk reducing surgery
Who Should Have Genetic
Testing?
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Individuals should have a prior probability of
carrying a BRCA1 or BRCA2 mutation of at least 510%.
Known family members with the mutation
The information derived from testing should be
useful to the individual.
The individual should be tested only after he or she is
counseled about the possibilities of an indeterminate
or false negative result.
Breast Cancer Genetics
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Current estimates are that 5-10% of breast
cancer cases are directly attributable to
inherited factors.
Women with a first degree relative with breast
cancer (male or female) have a higher risk of
developing breast cancer
Considerations if several pre menopausal
second degree relatives with breast or ovarian
cancer
Breast Cancer Genetics
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BRCA1 is located on Chromosome 17, and was the
first breast cancer susceptibility gene to be identified
Female carriers of a mutation in BRCA1 have a 5685% lifetime risk of developing breast cancer, and a
15-45% lifetime risk of developing ovarian cancer
Mutations in BRCA1 are generally silent in men,
although men can pass this mutation on to their
children
Breast Cancer Genetics
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BRCA2 was the second breast cancer susceptibility
gene to be identified, and it is located on
Chromosome 13
Female carriers of a mutation in BRCA2 have a 5685% lifetime risk of developing breast cancer, and a
10-20% lifetime risk of developing ovarian cancer
Mutations in BRCA2 are associated with prostate
cancer and male breast cancer
How is Genetic Testing Done?
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If possible, family member with cancer should
be tested first.
BART sequencing is the most recent
Consider re testing if initial results were
negative >10 years ago
Chemoprevention
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Tamoxifen/STAR Trial Data
Aromatase Inhibitors/AI’s are not approved for
chemoprevention
5 Year GAIL >/= 1.66%
LCIS
ADH/ALH
Risks of Tamoxifen
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Endometrial Cancer (elevated in elderly)
Stroke
DVT/PE
Unpleasant side effects for some
Hot flashes
 Weight Gain
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Strategies for Risk
Reduction/Prevention
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Used in Conjunction with Surveillance and
Screening
Lifestyle Modifications: exercise, low fat diet,
optimal post menopausal weight (reduce risk by
½)
Chemoprevention
Stop HRT
Risk Reducing Surgery: Mastectomy/BSO
Benign Breast Conditions
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Fibrocystic Breasts
Fibroadenoma
Duct Ectasia
Mastitis
Mastodynia
Nipple Discharge
Eczema
Fibrocystic Breast Disease
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Not a “disease”
Typically Cyclic in Nature
Microcystic and Macrocystic
Not a Risk Factor for Cancer
Fibrocystic Breast Disease
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Evaluation
Good Breast Exam
Consider Mammogram
Ultrasound
Management
Aspiration for symptomatic/large cysts
 Hormone Manipulation
 OTC products
 Patience! Better after menopause.
 Refer if imaging abnormal or not concordant/exam
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Ultrasound: Breast Cyst
Solid Breast Masses
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Fibroadenoma’s/benign
Phyllodes Tumors
Benign
 Borderline
 Malignant
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Breast Cancer
Angiosarcoma
Fibroadenoma
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More Common in younger women
May get larger during pregnancy
Asymptomatic/symptomatic
Some regress
Management
Imaging: Ultrasound, Mammogram if >30
 Observe/Interval imaging
 Biopsy to confirm
 Refer for consideration of surgical excision
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Fibroadenoma
Fibroadenoma of the breast
Breast Cancer on Ultrasound
Nipple Discharge
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Normal/Physiologic
 Spontaneous
 Non spontaneous
 Green, grey, tan, milky
 Unilateral/bilateral
 Small volume
Abnormal
 Bloody
 Watery
 Serous
 Large volume
Galactorrhea
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Thin, off-white, milky discharge, unrelated to
breastfeeding.
Physiologic – Usually bilateral, and due to
continued maternal expression or mechanical
stimulation.
Secondary – Increased levels of prolactin, as in
prolactinoma, or in use of various drugs.
Secondary Galactorrhea
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Drugs – Phenothiazines (chlorpromazine),
Haloperidol, Metoclopramide, Reserpine,
Methyldopa, Estrogen, Opiates
Tumors – Pituitary Adenoma or Microadenoma
Other – Ectopic prolactin secretion
(bronchogenic CA), Hypothyroidism, Chronic
Renal Failure
Underlying Pathology of Nipple
Discharge
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Solitary (discrete) Intraductal Papilloma
Multiple Duct Papillomas
Juvenile Papillomatosis
Duct Ectasia
Peri ductal mastitis
Cysts/’Fibrocystic Disease’
DCIS
Management of Normal/Physiologic
Nipple Discharge
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Clinical Breast Exam
Risk Assessment
Screening Imaging up to date
Diagnostic Imaging only if breast exam is
abnormal
Reassurance
No need to refer
Colored Discharge
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No increased cancer risk.
Expressed from one or
both breasts, and varies
widely in color and
consistency.
May be the result of duct
ectasia or a communication
of the duct with a cyst.
Considered physiologic
Management of Abnormal Nipple
Discharge
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Clinical Breast Exam
Mammogram/US for some/? Breast MRI
Review Meds
TSH/Prolactin Levels
Brain MRI/Endocrine referral
Refer for Duct excision
No cytology or culture
Hematest
Watery/Serous Discharge
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Typically from one duct
Spontaneous and Non Spontaneous
May be hematest negative or positive
Etiology: Intraductal Papilloma or Cancer
Work up: Mammogram and Periareolar
ultrasound
Surgical referral for duct excision
Watery/Serous Discharge
Bloody Nipple Discharge
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Usually one duct
Spontaneous and non spontaneous
Good History: ?Breast trauma
May be an intraductal papilloma or cancer
Clinical Breast Exam
Mammogram and Periareolar US
MRI for some
Surgical Referral if persists
Bloody Nipple Drainage
Duct Ectasia
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Dilatation of large ducts near nipples
May result in pain,abscess,mastitis
May require duct excision
May become chronic
More frequent in smokers
Duct Ectasia
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The older the patient, the more
ducts involved.
Often seen in smokers
Typically a chronic condition with
frequent infections
Often requires surgical
management
Periductal Mastitis
PDM and Smoking
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Histological evidence of PDM is associated with
smoking.
Cigarette smokers have an increased association
with development of non-lactating abscesses,
recurrence after initial treatment, and
subsequent mammmary duct fistula formation.
Mastitis
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Inflammation or Infection of Breast
Very painful/systemic symptoms for some
Most Common in Lactating Women
Rare in Men
Initial Treatment with Antibiotics
Ultrasound to rule out Abscess
Skin Biopsy if no response
Need to Rule out Inflammatory Cancer!
Breastfeeding Mastitis
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Treated with antibiotics
OK to nurse
Pumping may help
US to rule out abscess
Assessment of Breastfeeding
Mastitis
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Need to rule out
inflammatory cancer if
mastitis doesn’t
resolve
Idiopathic Granulomatous
Mastitis
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Uncommon, Benign, Inflammatory Disease
Unknown Etiology/?Autoimmune
Clinical presentation: mass, infection, abscess
May be mistaken for Inflammatory Breast
Cancer
Imaging often suspicious
Diagnosis made with core/excisional biopsy
Management of IGM
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May take months to resolve
Antibiotics
Cephalexin, Dicloxicillin, Augmentin/Empiric
 Bactrim, Doxycycline/MRSA
 Metronidazole for anaerobes
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Drainage/Surgical Management if Abscess
Steroids Controversial
Short term follow up to resolution
Inflammatory Breast Cancer
Principles of Mastalgia
Treatment
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Thorough evaluation (exclude cancer)
Reassurance
History and pain chart
Cyclical pain: Evening Primrose Oil, Danazol, Kelp
Non-cyclical pain: Danazol, Bromocriptine
Musculoskeletal pain: Steroid injections
Surgery is the last resort.
Mastodynia
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Also called Mastalgia
Cyclic vs Non Cyclic
Unilateral vs Bilateral
Clinical Breast Exam, Imaging to Rule out Disease
Treatment
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Good Bra
NSAID’s
Primrose Oil
Hormones
Kelp/Iodine
Gynecomastia
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Benign
Often reversible
Identify Etiology
Hormone imbalance (puberty/”andropause”)
 Medications
 Narcotics, marijuana, ETOH
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Evaluation
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Mammogram/US
Rule out Cancer
Gynecomastia vs Male Breast
Cancer
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Gynecomastia
Some asymmetry
 Prominent/Rubbery mass/under areolar
 No distortion of nipple areolar complex
 Flame shaped appearance on mammogram
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Male Breast Cancer
Firm mass
 Distortion of Nipple Areolar Complex
 Nipple inversion
 Cat 4/5 mammogram
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Male Breast Cancer
Other Benign Breast Conditions
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Eczema
 Itchy, scaling, rash
 Often involves the nipple
 Bilateral/unilateral
 Triamcinolone Cream 0.1%
 Need to Rule out Paget’s
Mondor’s Disease
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Thrombophlebitis of the Breast
Exquisitely Painful
Treat with ASA
May need duplex/US
Eczema
Paget’s Disease
Mondors Disease (male)
Care needs to be individualized
based on personal risks and
patient preference.
Resources for Patients
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Familial Cancer Program/Dartmouth Hitchcock
National Breast Cancer Coalition
Susan G. Komen Foundation
Medically Underserved Women
Ladies First/NH
 Let No Woman Be Overlooked/Vt
 Avon Foundation Breast Care Fund
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