Disorders of the Breast ppt

Breast Disorders - Primary Care Perspective

• Benign vs. Malignant Conditions: Primary care providers need to distinguish typically benign breast conditions from those potentially malignant.
• Imaging Needs: Determine which patients require imaging (mammogram, ultrasound) and what type, based on patient concerns and risk factors.
• Sampling Requirements: Identify patients needing breast tissue sampling (biopsy). Specify the type of biopsy needed.
• Referral Guidelines: Know when and to whom to refer patients for specialized breast care.
• Self-Care for Doctors: Understand how to manage patients undergoing breast cancer treatment and surveillance (post-treatment).
• PCP Limitations: Chemotherapy regimens and procedures (lab work) fall outside the scope of primary care. Don't interpret diagnostic imaging yourself; always defer to radiology.

Role of Physician Assistants (PAs) in Breast Care

• Risk Assessment & Education: Assess breast cancer risk factors and educate patients.
• Detailed Histories: Gather detailed patient histories.
• Thorough Physical Exams: Perform comprehensive physical breast exams.
• Appropriate Referrals: Recommend appropriate imaging and testing.
• Patient Education (Biopsy): Explain different biopsy procedures and patient expectations.
• Referral Network Knowledge: Know which specialists to refer patients to for proper care.
• Specialty-Specific Knowledge: Gain extra knowledge if working in specialties related to breast care, oncology, etc.

Breast Anatomy/Physiology

• Milk Production: Breast tissue produces milk for babies. Oxytocin and prolactin are crucial for lactation.
• Pregnancy Hormones: Prolactin levels rise during pregnancy and remain elevated until hormones drop post-pregnancy, triggering milk production.
• Milk Release: The suckling reflex (nipple stimulation) triggers prolactin elevation & milk release from ducts. Oxytocin facilitates milk "let-down"
• Anatomy: Lobes hold the milk; ducts carry milk to the nipple. The breast primarily comprises fat tissue. Lymphatic drainage is crucial.
• Supporting Structures: The pectoralis major/minor muscles and latissimus dorsi muscle provide support.
• Involution: Breast tissue naturally shrinks and becomes more fatty with age.

Preventative Medicine

• Clinical Breast Exams (CBE): Annually or with well-woman exams.
• Breast Self-Exams (BSE): Breast awareness, not necessarily monthly checks. (USPSTF guidelines).
• Screening Mammography: Bilateral, digital, and 3D are best. Key aspects in mammography include compression, proper positioning, and use of Eklund views (if applicable).

Bi-RADS Mammogram Reporting

• Categories: BI-RADS ratings help classify mammogram findings. Cat 0-6 classifications define the severity of abnormalities and need for further procedures.
• Benign/Suspicious/Malignant: Categories I-III are often benign; IV and V are suspicious for malignancy; VI indicates known malignancy.
• Referral Criteria: When suspicious findings (Cat. IV & V) or further imaging are needed, referral to a specialist is necessary.

Breast Cancer Risk Factors

• Age: Older age is a risk factor.
• Personal/Family History: Family history of breast cancer, particularly in first-degree relatives (mother, sister, daughter), significantly increases risk. Male breast cancer family history also raises concerns.
• Genetic Mutations: BRCA and PALB2 gene mutations are strong risk factors. If a relative has these mutations, genetic counseling and testing are recommended.
• Other Factors: Early onset of menstruation, late first pregnancy, benign breast disease, hormone replacement therapy, oral contraceptives, and obesity also increase risk.
• High Alert Risk Factors: Extreme concern for individuals with family history of breast cancer (close relatives), BRCA genetic variation, or prior chest radiation.

"High Alert" Risk Factors & Management

• High Risk Measures: Annual mammograms with CBE every 6-12 months, genetic counseling/testing if a relative has BRCA mutation, discuss alternating Breast MRIs with a specialist or local radiologist.
• Key Concerns: Ensure diligent breast exams & mammography, genetic screening for at-risk individuals, and specialist consultations.

Items Requiring Consideration

• Breast Self Exam Findings: Lumps, skin changes, nipple discharge, retraction, changes in breast shape, should prompt investigation.
• Physical Exam Findings: Palpable lumps, discharge, retraction, shape changes, skin changes, tenderness, or redness may indicate problems. Be especially wary of red, non-tender tissue.
• Abnormal Mammograms/Family History: Abnormal findings and substantial family history necessitate further evaluation.

Breast Imaging (Indications & Contraindications)

• Indications: Screening (mammograms, ultrasound) and breast problems; imaging should be performed in all patients.
• Contraindications: No absolute contraindications but pregnancy is a relative contraindication to mammography.

Screening Mammography

• Frequency: Yearly after age 40, every other year ages 40-49, annual starting at 50, and potentially later, based on individual risk factors.
• Imaging Views: Bilateral (both breasts) CC (craniocaudal) and MLO (mediolateral oblique) views are required.
• Implants: Mammograms with implants should include Eklund views to see around implant.

Breast Ultrasound

• Role in Diagnosis: Breast ultrasound differentiates cystic masses from solid ones, especially useful for younger women. Useful as initial imaging modality for palpable masses below age 30.

Diagnostic Imaging (Mammogram/Ultrasound)

• Diagnostic vs. Screening: In a patient with a significant finding or concern, perform a diagnostic mammogram/ultrasound, rather than a screening exam.
• One Side Only: If possible, only image the affected breast; however, always screen the unaffected breast to ensure no overlooked earlier issues.

Management of Breast Presentations

• General Rule: Image the breast, then sample if necessary for any breast related concern.