Breast disease

Question 1

What is a woman’s lifetime risk of developing breast cancer?

Answer 1

12%

Question 2

What are the risks factors for breast cancer?

Answer 2

Main risk are = female sex and age
Female sex
advancing age
Early menarche
late menopause
Nullipiarty
Family history of breast cancer, ovarian cancer
Prior biopsy showing atypical ductal or lobular hyperplasia
Higher BMI
Smoking
Menopausal hormonal therapy with estrogen
Chest radiation between age 10-30
Dense breast

Question 3

What factors can decrease risk of hormone receptor positive breast cancer?

Answer 3

Parity
Breastfeeding

Question 4

What are risks/benefits of breast screening test?

Answer 4

Risks= false positive, cost, anxiety, over diagnosis, over treatment

Benefits= improves health outcomes

Question 5

What is ACOG recommendation for clinical breast exams?

Answer 5

May be OFFERED every 1-3 years from age 25-39, annually at age 40

Question 6

What is ACOG recommendation for mammogram screening?

Answer 6

OFFER starting at age 40
Can initiate between 40-49 after counseling if patient desires
Recommend by age 50

Question 7

What is ACOG recommendation for mammogram screening interval and discontinuation?

Answer 7

Annually or biennial
Stop at age 75
Beyond age 75 it should be a shared decision making process

Question 8

What is breast cancer risk assessment based on?

Answer 8

Patient history
Family history
Reproductive risk factors
prior biopsies
radiation exposure

Question 9

How do you determine breast cancer risk?

Answer 9

breast cancer risk assessment
Using risk assessment tool like GAIL or CLAUS

Question 10

Why is breast cancer risk assessment important?

Answer 10

To help determine proper surveillance, genetic testing, risk reduction

Question 11

Which women would GAIL model not be appropriate for?

Answer 11

1. Age <35
2. Family history of cancer in dad or distant relatives
3. Family history of germline mutations
4. Previous biopsy of lobular carcinoma in situ

Question 12

What is the recommendation regarding self breast exams?

Answer 12

Self breast exams are not recommended in average risk women due to risk of harm from false positives and no proven benefit

Women should instead be counseled about breast self awareness and come for evaluation if there is a change

Question 13

How do you counsel a patient regarding breast awareness?

Answer 13

Awareness of appearance and feel of her breast

Question 14

What are symptoms of potential breast cancer you should counsel patients about?

Answer 14

New onset pain
New mass
Nipple discharge
Redness of breast

Question 15

When is a clinical breast exam recommended?

Answer 15

High risk women for breast cancer
Symptomatic women

Question 16

What benign breast lesion has a significant risk of future breast cancer?

Answer 16

Lobular carcinoma in situ

Question 17

What is a fibroadenoma?

Answer 17

Benign proliferative mass composed of epithelial and stromal elements

Question 18

What is diagnosis of atypical hyperplasia associated with?

Answer 18

Future risk of invasive cancer of the same or contralateral breast

Question 19

How do you diagnose a tubular adenoma?

Answer 19

Tissue biopsy

Question 20

Single enlarging breast mass what should you think of?

Answer 20

Phyllodes tumor

Question 21

What other breast mass can phyllodes tumor present like?

Answer 21

Fibroadenoma

Question 22

How do you diagnose phyllodes tumor?

Answer 22

Excision biopsy

Question 23

What is the risk of developing invasive cancer after diagnoses of lobular carcinoma in situ?

Answer 23

1-20%

Question 24

What are characteristics of benign nipple discharge?

Answer 24

Green or milky in color
Bilateral
Only present when expressed

Question 25

What are causes of galactorrhea outside of pregnancy or postpartum period?

Answer 25

Chronic nipple stimulation Thyroid disease Prolactin secreting tumor Medications that inhibit dopamine

Question 26

Causes of mastitis?

Answer 26

Cyclical (hormonal) Noncyclical ( tumor, cancer, cyst mastitis, trauma, thrombophlebitis) Extramammary (costochondirits, rib fracture, medications)

Question 27

Treatment for mastitis?

Answer 27

Dicloxacillin 500mg QID for 7-10 days

Question 28

Alternative treatment for mastitis?

Answer 28

Cephalexin

Question 29

Ulcerated crusted scaling lesion on the nipple what should you think of?

Answer 29

Paget disease of the breast

Question 30

What is the initial evaluation for a women presenting with breast related problem?

Answer 30

History including characterization of symptoms and assessment of risk factors for breast cancer + clinical breast exam

Question 31

What are the BIRADS categories?

Answer 31

BIRAD 1= negative 0% chance of malignancy BIRAD 2= benign 0% chance of malignancy BIRAD 3= probably benign 0-2% chance of malignancy BIRAD 4= suspicious 3-94% chance of malignancy BIRAD 5= highly suggestive= >95% chance of malignancy BIRAD category 6= Known biopsy proven malignancy= excision biopsy

Question 32

What are next steps after a palpable mass at age <30?

Answer 32

1. Consider if low risk or high risk 2. If low risk consider observing over 1-2 menstrual cycles 3. If high risk offer ultrasound 4. Base further management on BIRAD score

Question 33

What are next steps after a palpable mass at age 30 or older?

Answer 33

1. Offer Diagnostic mammogram 2. Based on BIRAD score either do tissue biopsy or ultrasound 3. Based on ultrasound BIRAD score either do tissue biopsy or clinical exam with imaging yearly for 1-2 years. If BIRAD 1 or 2 consider clinical suspicious and either biopsy or observe

Question 34

What medication is FDA approved for mastalgia?

Answer 34

Danazol

Question 35

What is the next step after bilateral milky discharge is noted on clinical exam?

Answer 35

Pregnancy test If negative order galactorrhea workup

Question 36

What does a galactorrhea workup entail?

Answer 36

Review medications TSH level Prolactin level