Breast Lump

1. Given a well woman with concerns about breast disease, during a clinical encounter (annual or not):
   1. Identify high-risk patients by assessing modifiable and non-modifiable risk factors
   2. Advise regarding screening (mammography, breast self- examination) and its limitations.
   3. Advise concerning the woman’s role in preventing or detecting breast disease (breast self-examination, lifestyle changes).
2. Given a woman presenting with a breast lump (i.e., clinical features):
   1. Use the history, features of the lump, and the patient’s age to determine (interpret) if aggressive work-up or watchful waiting is indicated.
   2. Ensure adequate support throughout investigation of the breast lump by availability of a contact resource.
   3. Use diagnostic tools (e.g., needle aspiration, imaging, core biopsy , referral) in an appropriate manner (i.e., avoid over- or under-investigation, misuse) for managing the breast lump.
3. In a woman who presents with a malignant breast lump and knows the diagnosis:
   1. Recognize and manage immediate and long-term complications of breast cancer.
   2. Consider and diagnose metastatic disease in the follow- up care of a breast cancer patient by appropriate history and investigation.
   3. Appropriately direct (provide a link to) the patient to community resources able to provide adequate support (psychosocial support).

DDx

• Not a lump
  • Prominent rib
  • Costochondral junction
  • Firm margin at edge of breast
  • Defect secondary to previous biopsy
• Lump
  • Normal glandular tissue (upper/outer quadrant)
  • Fibrocystic changes (25%)
    • Nodular nondiscrete tender mass, changes with menses, cyclical or constant pain
  • Cancer (10%)
    • Infiltrating ductal (most common)
    • Infiltrating lobular and inflammatory breast cancer often present with no discrete mass
  • Gross Cyst
    • Galactocele - milk retention cyst in breasfeeding women
  • Fibroadenoma
  • Fat necrosis
    • Trauma, associated with ecchymosis

Risk for Malignancy

• Female
• Age >70 (RR 18)
• Prior hx of breast CA
• BRCA1/2 (RR 3-7)
• Prior hx of biopsy (RR 1.7-3.7)
• 1st degree relative with breast CA (RR 2.6)
• Unopposed estrogen
  • Bone density - High (RR 2.7-3.5)
  • Nulliparity/Age at first birth* >30 (RR 1.9-3.5)
  • Menarche<12 (RR 1.5)
  • Menopause >55yo (RR 2)
  • HRT* (RR 1.2)
  • OCP* (RR 1.07-1.2)
• Alcohol* (RR 1.4)
• Radiation (Mantle radiation in Hodgkin's)
• Benign breast disease

Protective factors

• Oophorectomy <35yo (RR 0.3)
• Postmenopause BMI* <22.9 (RR 0.63)
• Exercise* (RR 0.70)
• Parity* ≥5 (RR 0.71)
• Breastfeeding* ≥16mo (RR 0.73)
• Aspirin* ≥weekly for ≥6 mo (RR 0.79)

*Modifiable

History

• Change in breast mass (increase/decrease in size, change in symmetry)
  • Changes with menstrual cycle (benign if prominent premenstrual and regress during follicular phase)
• Skin changes
• Nipple discharge
• New (acquired) nipple inversion
  • Benign (ectasia)
    • Central, symmetric, transverse slit with normal areola
  • Malignant
    • Asymmetrical, areola changes, flattened nipple, varied nipple position

Screening

• Women 50-74yo routine mammography q2-3y (weak recommendation)
  • Benefits:
    • Reduces absolute risk of death from breast cancer by 0.13-0.22%
  • Risks:
    • False positive mammogram 20-25%
    • Unnecessary breast surgery 0.5%
• Clinical breast examination and Breast self-examination has not been shown to provide benefit (no reduction in mortality) and good evidence of harm (RR1.5 for benign biopsy)
• Consider genetics referral if risk factors present
  • Personal Hx Breast CA ≤ 40 or Ovarian CA at any age
  • Fam Hx Breast CA ≤ 50
• Consider Gail Model for Breast Cancer risk in women ≥ 35yo with risk factors