BREAST CANCER   38A

A 53-year-old nulliparous woman presents to her primary care clinician for evaluation of a painless breast lump that she first noted a few months ago. She came for evaluation when she noticed bloody discharge from the ipsilateral nipple. She takes no medications, and her family history is remarkable for her mother and sister having breast cancer. On physical examination, there are a firm 2-cm mass with poorly defined margins in the left breast and firm left axillary lymph nodes.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Nulliparous woman; painless and firm breast lump; nipple discharge; family history of breast cancer in first-degree relatives; ipsilateral firm axillary lymphadenopathy

How to think through: Breast cancer is the second most common cause of cancer death in women and is a major source of morbidity. This woman’s presentation is highly concerning, and prompt evaluation is essential. This patient is nulliparous with a strong family history. What other factors increase a woman’s risk for breast cancer? (Total duration of menses, i.e., early menarche and late menopause; alcohol use, high dietary fat, and lack of exercise; high breast density on mammography.) If the physical examination is accurate, this patient’s presentation is concerning for invasive breast cancer, stage IIIa or greater, as defined by T2 (2-cm mass), N2 (ipsilateral matted axillary lymph nodes), with no comment on possible distant metastasis. Fortunately, fewer than 10% of women present with metastatic disease. How should she be evaluated? (Bilateral mammography and ultrasonography of breast and axilla; core needle biopsy of the mass [preferred over fine-needle biopsy].) What special studies should be conducted on the biopsy tissue? (Assays for hormone receptors and human epidermal growth factor receptor 2 [HER2] expression, both of which guide treatment and prognosis.) Computed tomography (CT), possibly with positron emission tomography (PET), is needed to detect metastases. Treatment will depend on histology, tumor markers, metastatic disease, and comorbidities but may include surgery, chemotherapy, radiation, and hormonal therapy. Should the patient or her family members undergo genetic testing for BRCA1 mutations? (A family history of breast cancer is common because of its prevalence. Although only 10% of breast cancers are associated with inherited genetic mutations, referral to genetic counseling is important in this case because two first-degree relatives had it.)

BREAST CANCER   38B

What are the essentials of diagnosis and general considerations regarding breast cancer?

Essentials of Diagnosis

Early findings include a single nontender, firm mass or a mammographic abnormality.

Later findings include skin or nipple retraction, axillary lymphadenopathy, breast enlargement, redness, edema, pain, and fixation of a mass to the skin or chest wall.

General Considerations

Second most common cancer and cause of death in women

Risk is higher with advancing age, positive family history, nulliparity or late first pregnancy (after age 30 years), early menarche (before age 12 years) or late natural menopause (after age 55 years), alcohol use, high dietary fat, lack of exercise, high breast density on mammogram, fibrocystic disease when accompanied by proliferative changes, papillomatosis, atypical epithelial hyperplasia on biopsy, history of uterine cancer

Estimated 85% lifetime risk in women with BRCA1 gene mutations

Stay updated, free articles. Join our Telegram channel

Join