Women's Health: Breast Conditions - Lecture Notes PDF

Women’s Health (MW326) Lecture 3: Breast Conditions Prepared by: Dr. Sarah Al-Ja’freh Second Semester 2023/2024 1  Introduction ▪ Culturally, the female breast is often intertwined with the concept of womanhood. Even thou...

Women’s Health (MW326) Lecture 3: Breast Conditions Prepared by: Dr. Sarah Al-Ja’freh Second Semester 2023/2024 1  Introduction ▪ Culturally, the female breast is often intertwined with the concept of womanhood. Even though the primary function of breasts is lactation, breasts are frequently considered to be erotic and the size and shape subject to sexual description. ▪ Conditions of the breast encompass a broad range of pathology, from benign disorders such as fibroadenomas to life-threatening malignancies such as breast cancer. Injury or loss of a breast can be emotionally devastating for a woman. ▪ This chapter reviews normal development of the breast, current recommendations for breast examination, common benign breast disorders, and an overview of breast cancer.  Breast Development ▪ Often the first sign of puberty is thelarche, or the onset of breast development. ▪ On average, breast development is initiated at 10 years of age. ▪ Both estrogen and progesterone influence the development of the breast, with estrogen stimulating the ductal portion of the glandular system and progesterone stimulating the alveolar or milk-producing components of the system. ▪ These two hormones are not sufficient to achieve optimal growth and development; instead, stimulation of insulin, cortisol, thyroxine, prolactin, and insulin-like growth factor is also required.  Breast Development ▪ Breast tissue changes with aging. The adolescent breast has increased density relative to the older breast, as the former consists predominantly of glandular tissue. ▪ The breast also undergoes cyclic changes in non pregnant women due to the influence of estrogen and progesterone. These cyclic changes include increased size of breasts, fluid secretion, and premenstrual tenderness. ▪ In women who breastfeed, glandular tissue regresses and some tissue remodeling occurs once lactation ceases. ▪ As women age, breasts become less dense and most women progressively acquire more fat and fibrous connection tissues that gradually replace the glandular tissue  Evaluation of Breast Symptoms ▪ History The history of presenting symptoms should include the items noted in Table (1). The healthcare professional should document these components in the record of the woman’s visit as positive or negative as appropriate.  Evaluation of Breast Symptoms ▪ When evaluating a woman with breast symptoms, factors that increase or decrease her risk for breast cancer should be identified and documented in her health record. ▪ Table (2) lists the common risk factors for breast cancer to be reviewed when taking a history. ▪ Factors that are known to be protective against breast cancer include breastfeeding & physical activity.  Evaluation of Breast Symptoms Physical Examination ▪ Formal breast self-examination is no longer recommended, but rather has been replaced by “breast awareness” as a way to encourage women to recognize abnormal changes between clinical evaluations. ▪ The American College of Obstetricians and Gynecologists continues to recommend offering clinical breast examinations to women at average risk for breast cancer every 1 to 3 years for women aged 25 to 39 years and annually starting at age 40 years. Procedure for Breast Examination 1. Wash hands prior to beginning the examination. 2. The woman should be seated on the examining table so that she is facing the examiner. Her chest area should be entirely exposed. Throughout the examination, use the drape or gown to cover any parts of the woman’s body not being examined. 3. Have the woman sit erect, facing the examiner. Look at the breasts with her arms loose at her sides, raised overhead, and then with her hands on her hips so that her elbows are extended 90 degrees from the plane of her abdomen. Ask her to lean forward to check that the breasts hang freely. a. With her arms raised, the pectoral fascia is elevated. If there is a carcinoma that has attached to the fascia, the breast may show an indentation in the contour or skin retraction. When her hands are pressed against her hips, the pectoral muscles contract and if there is a carcinoma that is fixed to the underlying fascia, the breast may elevate more than expected or skin dimpling or nipple deviation may occur. Similarly, when leaning over, the breasts will normally fall freely away from the chest but may exhibit asymmetry or retraction if the fibrosis of a breast lesion is present. b. Note any visible scars. 4. Palpate the lymph nodes above and below the clavicle on both sides. 5. Ask the woman to lie supine on the table, and have her raise one arm and fold it behind her head or across her forehead. If she has expressed concern about a possible mass or lesion, the opposite breast should be examined first. 6. Gently palpate the axillary lymph nodes. The palpating hand should be moved within the axilla to press anteriorly for the pectoral nodes, posteriorly for the subscapular nodes, along the upper arm for the lateral brachial nodes, and deep in the middle for the central axillary nodes (Figure 1). Small isolated lymph nodes that are palpable may reflect irritation from shaving or a localized infection. They should be reevaluated within 1 month. 7. Inspect the appearance of the nipples and areolae. a. Nipples may be erect, flat, or inverted. The appearance changes with reproductive maturity, pregnancy, breastfeeding, and aging. b. Spontaneous discharge, cracking, lesions, and bleeding are abnormal. c. Do not squeeze the nipple in an attempt to elicit discharge. 8. Inspect the appearance of the breasts. a. Skin texture and appearance change over time. b. Edema, redness, retracted or collapsed areas, visible sores, and masses are all abnormal observations. 9. The most effective pattern for clinical breast examination works up and down the breast, beginning under the axilla and working toward the sternum, and from the clavicle to below the inframammary ridge (Figure 2). 10. Palpate each breast for texture and masses. Using the flat surface of the fingers, gently palpate each area being assessed, as illustrated in Figure 3. A circular motion is used each time the fingers are placed on the breast. This should not be confused with an older method of breast examination in which the direction of palpation was circular— that method is no longer recommended. 11. The full depth of the breast to the underlying rib cage is examined (Figure 4). a. Breast tissue has texture. Some young women will have very smooth tissue, while an older woman who has breastfed may have an all-over nodular texture. The texture of the breast should be consistent. b. Prior to the menses, coarse nodularity or firmness may be more noticeable. c. Palpable masses of any kind need to be evaluated further (Figure 5). 12. While performing the breast evaluation, the examiner describes what is being felt and explains how a woman can recognize breast changes. If the woman wishes to learn self examination, this is the appropriate time to illustrate the procedure.  Evaluation of Breast Symptoms ▪ Breast findings characteristic of nonmalignant breast disorders include painful or even tender, firm, mobile, well-defined masses that may fluctuate in size and tenderness with menstrual cycle changes. ▪ The classic sign of a breast lesion suspicious for breast cancer is a hard, rocky, immobile mass with irregular or ill-defined borders.  Evaluation of Breast Symptoms ▪ Breast masses are to be described as dominant or nondominant and measured in centimeters when possible when noted in the woman’s health record. ▪ The location, consistency, symmetry, tenderness, and mobility are noted, as are any skin changes. The location may be recorded as distance in centimeters from the areola and by comparing the breast to a clock so that the “o’clock” location can be noted (e.g., a 2 × 3 cm firm, discrete, smooth, mobile, non-tender mass 3 cm from the areola at the 4 o’clock position).  Breast Assessment Modalities ▪ Several algorithms have been developed for evaluation of dominant breast masses. Some recommend a fine-needle biopsy as the first step, whereas others recommend ultrasound or mammography first. ▪ Variations depend on local radiology, pathology, and surgical resources; the woman’s age; and her preferences. ▪ Ultrasound is generally recommended for women younger than 30 years and diagnostic mammography for women older than 30 years, because the increased density of breast tissue in younger women tends to obscure abnormal findings from mammography. Table (3) lists components that could be included in a note for consultation or transfer of care to a specialist in the area. In this example, the woman has a breast mass.  Benign Breast Disorders ▪ Benign breast disorders encompass all nonmalignant conditions of the breast, including breast pain (i.e., mastalgia), nipple discharge, and benign breast tumors. ▪ Benign breast disorders often are classified as nonproliferative, proliferative without atypia, or atypical hyperplasia's. ▪ The risk of malignancy is related to the classification. Nonproliferative disorders, which include fibrocystic changes and breast cysts, are not associated with a risk of malignancy. Proliferative without atypia disorders, which include intraductal papillomas, are associated with a modest increase in risk for malignancy. Atypical ductal hyperplasia and atypical lobular hyperplasia are associated with a significant increased risk for malignancy.  Mastalgia ▪ Mastalgia (breast pain) can be either cyclic or noncyclic. ▪ Cyclic breast pain generally occurs bilaterally during the luteal phase of the menstrual cycle and resolves after the onset of menses. It is often described as sharp, shooting, or deep aching and throbbing pain. ▪ Noncyclic breast pain may be caused by mastitis, cysts, tumors, history of breast surgery, or medications, or it may be idiopathic. Noncyclic mastalgia tends to be localized, sub-areolar, or medial, and is characterized as tender, burning, stabbing, pulling, or pinching. Approximately 15% of women with mastalgia require some pain-relieving therapy. Well fitting bras may relieve some degree of cyclical and noncyclical mastalgia.  Nipple Discharge ▪ Nipple discharge is common in reproductive-age women and generally benign. ▪ Benign discharge is generally bilateral, multiductal, and milky or green in color, and occurs with breast manipulation. ▪ Discharge that is unilateral, clear, serous, or bloody, and occurs spontaneously is more likely to be associated with cancer, especially when it occurs in conjunction with a breast mass and in women who are older than 40 years.  Galactorrhea ▪ Galactorrhea is defined as bilateral discharge that occurs in women who have not been pregnant or lactating within the last 12 months and is not caused by breast disease. ▪ Most often galactorrhea is idiopathic, but it can be associated with prolactin-secreting pituitary adenomas, medications that inhibit dopamine (e.g., COCs), hypothyroidism, breast stimulation, trauma, and herpes zoster. ▪ Uniductal, bloody discharge may be associated with intraductal papilloma “a benign tumor of the lactiferous ducts that is generally managed with surgical excision”. ▪ With unilateral, uniductal, spontaneous, and clear, serous, or bloody discharge, a diagnostic mammogram and ultrasound are indicated and care is usually provided by an expert in the area.  Fibrocystic Changes ▪ Fibrocystic changes are common and are associated with hormonal stimulation. Thus, fibrocystic changes are rare in postmenopausal women. ▪ These changes may be asymptomatic or associated with pain, tenderness, and bumpy areas throughout the breast tissue that fluctuate with the menstrual cycle. ▪ Clinical findings include symmetrical nodularity, with nodularity being more prominent in the upper outer region of the breast, and consistency described as like a “bag of beans” ▪ Management options include expectant watchful waiting, aspiration of large or painful cysts, and prescription of combined oral contraceptives to decrease the risk of additional fibrocystic breast changes. ▪ Minimal evidence exists to suggest that change in dietary practices, the use of vitamins (e.g., vitamin E) or herbal preparations (e.g., evening primrose), or avoidance of methylxanthines decreases the symptomology associated with fibrocystic changes.  Breast Cysts Breast cysts are smooth, round or oval, mobile, fluid-filled masses with well-described borders that develop from terminal breast lobules. Breast cysts may be single masses or present as a cluster of multiple small cysts. They may be painful, tender, or painless. These cysts are hormonally influenced and typically appear during menstrual changes in premenopausal or perimenopausal women. Breast cysts are classified as simple, complex, or complicated based on ultrasonographic evidence of the thickness of the cyst wall and presence of echogenic material within the cyst.  Fibroadenomas ▪ Fibroadenomas are breast masses that most frequently occur in adolescent and young women, although they may be found among women of any age until menopause. ▪ On examination, the tumors are non-tender, with a firm or rubbery consistency, mobile, and well circumscribed. ▪ Mammogram or ultrasound can determine whether the mass is solid or fluid filled (cystic), with the diagnosis then being confirmed through either core needle or open biopsy. If the biopsy indicates that the tumor is a fibroadenoma, it does not need to be removed. The tumor can be followed clinically and removed only if it becomes enlarged or visibly distorts the breast. If the pathology is unclear, the tumor should be surgically excised. ▪ Fibroadenomas can increase rapidly during pregnancy or estrogen therapy and may regress after menopause. ▪ They are not associated with an increased risk of breast cancer.  Atypical Hyperplasia and Lobular Carcinoma In Situ ▪ Atypical hyperplasia includes atypical ductal hyperplasia and atypical lobular hyperplasia. ▪ Both are often incidental findings from a core-needle biopsy that is performed as part of the evaluation of another breast mass. ▪ Atypical hyperplasia is a pathologic diagnosis that describes abnormal cells of the breast that are associated with an increased risk of breast cancer. This condition is generally treated with surgery (e.g., wide-excision biopsy or lumpectomy) to remove all the affected tissue.  Atypical Hyperplasia and Lobular Carcinoma In Situ ▪ Lobular carcinoma in situ (LCIS) is an area of abnormal cell growth. LCIS is a histologic diagnosis and the disorder is associated with an increased risk for breast cancer, both in the affected breast and the contralateral breast. ▪ There are no breast masses associated with LCIS. ▪ Because LCIS is not a precursor lesion for breast cancer, complete excision is not indicated. ▪ Increased surveillance for breast cancer and risk-reduction medication should be strongly recommended when a woman is diagnosed with LCIS.  Breast Cancer Cancer may develop in any of the tissues present in the breast including epithelial, muscle, connective tissue, or fat. The majority of breast cancers are carcinomas that appear in the epithelial cells that line other tissues. Breast carcinomas are categorized as invasive (infiltrating) or non- invasive (in situ). Worldwide, breast cancer is the most commonly diagnosed cancer and a leading cause of death among women age 40 to 55 years. Women have approximately a 1 in 8 chance of developing breast cancer over the course of their lifetime. The risk of developing breast cancer increases as one ages. Conversely, mortality rates have decreased.  Factors That Affect Breast Cancer Risk ▪ Several personal characteristics that increase or decrease one’s risk for breast cancer have been identified as noted in Table Previously. ▪ Other factors that may be associated with lowering the risk of breast cancer include breastfeeding, 3 to 5 hours of moderate to vigorous physical exercise per week, limiting alcohol intake, and maintaining a healthy body weight.  Breast Cancer Risk Assessment Tool: Online Calculator (The Gail Model) The Breast Cancer Risk Assessment Tool (BCRAT), also known as The Gail Model, allows health professionals to estimate a woman's risk of developing invasive breast cancer over the next five years and up to age 90 (lifetime risk). The tool uses 7 key risk factors for breast cancer: 1. Age 2. Age at first menstrual period 3. Age at the time of the birth of a first child (or has not given birth) 4. Family history of breast cancer (mother, sister or daughter) 5. Number of past breast biopsies 6. Number of breast biopsies showing atypical hyperplasia 7. Race/ethnicity  Screening for Women at Low or Average Risk for Breast Cancer Multiple low- and high-technological interventions have been used over the years for screening asymptomatic, low-risk women as well as for diagnostic purposes, especially when a breast mass is identified by a clinician. Breast Self-Examination (BSE) for Screening Traditionally, after menarche all women have been encouraged to perform monthly breast self examination (BSE) as an instrument for early diagnosis of cancerous tumors and, therefore, as a means to ensure early treatment and decrease the mortality associated with breast cancer.  Screening for Women at Low or Average Risk for Breast Cancer Currently, “breast awareness” is recommended in place of BSE. No standard definition exists for breast awareness, but the general consensus is “that women can be taught to be aware of the normal shape and consistency of their breasts. Any changes in how their breasts feel or look should be an impetus for a visit with a healthcare provider”.  Screening for Women at Low or Average Risk for Breast Cancer Clinical Breast Examination (CBE) Regular examination of the breasts by a healthcare professional also has been recommended as an important part of breast cancer screening. Several studies have noted that the CBE technique may influence the accuracy of the examination. A recent observational study noted that using a rubbing movement (defined as repetitive movements in a circular motion or pushing the fingers back and forth or right to left in a repetitive motion) was four times more likely to yield an accurate assessment compared to vertical movement (defined as pushing the fingertips or pads into and out of the breast tissue in a repetitive motion) or piano fingers (defined as the use of individual fingers, in series, to “march” across the breast tissue in a repetitive fashion). When firm pressure is used, breast masses are more likely to be identified.  Screening for Women at Low or Average Risk for Breast Cancer Mammography ▪ Mammography, which uses X rays to image breast tissue, can be done as either a screening modality or a diagnostic test. ▪ A standard screening mammogram involves four images that are evaluated for changes suspicious of cancer, microcalcifications (a benign finding), distortions of the normal architecture of the breast, and nonpalpable lesions. ▪ Mammography can often detect early-stage breast cancers for which treatment may be more effective, with a subsequent increased likelihood of a cure. ▪ Numerous studies have shown that routine mammography may reduce breast cancer mortality by 30% overall and by 20% in women age 40 to 49 years. ▪ Mammography can detect an estimated 80% to 90% of breast cancers in asymptomatic women. Screening for Women at Low or Average Risk for Breast Cancer Initiation and Frequency of Mammography ▪ Studies have indicated that the sensitivity of mammography is highest among women 50 years and older, since they tend to have reduced breast density due to increased fatty tissue within the breast. ▪ The updated American Cancer Society screening guidelines recommend that women 40 to 44 years be given the choice of undergoing annual mammography; those 45 to 54 years have annual mammography; and those 55 years and older have biennial or annual mammography as long as their overall health is good and they have a life expectancy of 10 or more years.  Screening for Women at Low or Average Risk for Breast Cancer Digital Breast Tomosynthesis A new mammographic technique, known as digital breast tomosynthesis, provides a three dimensional picture of the breast using X rays. Magnetic Resonance Imaging Magnetic resonance imaging (MRI) is the most sensitive test for breast cancer. Nevertheless, due to its high expense, it is recommended only for screening of women who are at very high risk for breast cancer. Ultrasonography Ultrasonography is employed to screen the breast tissue of younger women at increased risk for breast cancer, diagnostically to differentiate between solid and cystic breast masses, and to guide fine-needle biopsies. The performance of this test is not affected by breast density.  Diagnosis of Breast Cancer ▪ The definitive diagnosis of breast cancer is generally made through tissue sampling. ▪ This can be accomplished through fine-needle aspiration, mammography- or ultrasound-guided core-needle biopsy, or excisional breast biopsy. ▪ The tissue sample obtained through the selected modality is then sent for histologic examination. If cancer is present, the histology report will state whether the tumor is ductal or lobular in origin. ▪ When the diagnosis of cancer has been made, it is also necessary to assess the lungs, abdomen, brain, and bone for metastasis.  Treatment of Breast Cancer ▪ Breast cancer treatment usually involves surgery, which may be followed with radiation therapy, chemotherapy, hormonal therapy, or immunotherapy. ▪ Most women with Stage I and Stage II breast cancers can be managed with breast conserving surgery (lumpectomy) and sentinel node dissection, which is generally followed by radiation therapy. ▪ Mastectomy involves removal of the breast tissue and the nipple/areolar complex, with conservation of the pectoralis muscle, as well as sentinel lymph node dissection.  Treatment of Breast Cancer ▪ Women need information about both the short-term (skin rashes and redness) and long-term side effects of radiation therapy (damage to the heart, lungs, or blood vessels in the chest; development of lung cancer; osteoradionecrosis). ▪ Breast reconstruction is an option for all women who undergo surgery. The reconstruction can be performed immediately post mastectomy or at a later time. Reconstructive surgery does not influence recurrence of the breast cancer or overall survival.  Treatment of Breast Cancer Follow-up ▪ During the first 2 years after breast cancer treatment is completed, follow-up appointments generally occur every 3 to 6 months and include physical examination and mammography. ▪ Ovarian dysfunction is common in women of reproductive age who are treated for breast cancer, and reflects their age, ovarian function at the time of treatment, and the specific chemotherapy agents used. One study observed that 83.1% of women between the ages of 18 and 34 years resumed menstruating, on average, 3.5 months following breast cancer treatment; therefore, a discussion regarding contraception is merited.  Contraception Following Breast Cancer ▪ Breast cancer is a hormonally sensitive tumor and therefore, hormonal contraception is contraindicated for women with current or past history of breast cancer. ▪ Copper-containing intrauterine devices, tubal ligation, and vasectomy are considered to be better contraceptive options for women with a history of breast cancer.  Conclusion The midwife may be the first healthcare provider a woman consults for breast-related concerns. Breast cancer is one of the most frequently diagnosed cancers in women throughout the world. Screening and early detection are essential components of primary care services provided by midwives. The midwife is also an important member of the multidisciplinary team caring for a woman with the diagnosis of breast cancer, and fulfills this role by providing accurate information and support as the woman is making decisions regarding breast cancer treatment, and management of symptoms