Breast Health. Learning Objectives. Breast Anatomy. Poll Question. Breast Anatomy

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1 Learning Objectives Describe breast anatomy to a patient Breast Health Answer questions about causes of breast pain and masses Explain breast cancer screening/diagnostic modalities Appropriately triage women presenting with breast issues Provide patient education on breast health Poll Question What health care position best describes you? A. Nursing personnel B. Provider C. Administrative/Other Breast Anatomy Most tissue is adipose Lobules produce milk Ducts bring milk to surface though openings on nipple Breast Anatomy Lymph system removes fluids from tissues A B D E F Lymph node areas Pectoralis major muscle Axillary lymph nodes Supraclavicular lymph nodes Internal mammary lymph nodes Poll Question How many years have you worked in women s health (both non VA and VA experience)? A. Less than 1 year B. 1 3 years C years D. More than 10 years 1

2 Causes of Breast Masses Normal structures Biopsy and scar tissue Cysts Fibroadenomas Fibrocystic changes Carcinomas Ribs Costochondral junction Inframammary fold Fat lobules Fibroglandular tissue Benign Soft, firm, or cystic Regular Mobile Cancerous Solitary Hard Immobile Irregular 2 cm in size Breast Mass Characteristics Case 1 A 42 year old woman telephones your clinic with a complaint of breast pain and possibly a lump. How would you respond? What clarifying questions would you ask? What issues need to be considered for someone in her situation? Nursing Role in Breast Health Clarify/Triage Rule out emergency conditions: mastitis, inflammatory breast cancer, non breast conditions Ask questions to identify problem Identify needed follow-up Individual facilities will have different protocols Provide support and education Resources: websites for individual review Education: pamphlets Support: physical, emotional, psychosocial Clarifying Questions Rule out emergency issues (e.g, mastitis, inflammatory breast cancer, non breast conditions) Symptoms: mass, discharge, skin changes, pain, one or both breasts involved? LMP/pregnancy status? Implants? Risk factors: personal biopsy hx, family hx? Trauma hx? Contraception? New medications? Breast screening hx? Triage and Follow up Consider infection Presence of mass? Protocol available? Facility guidelines? Know provider s preferences Ensure careful documentation 2

3 Education and Support Educate Breast changes Modifiable risk factors Managing benign pain Support Know guidelines and protocols Facilitate screening/testing Explain tests, provide instructions, consider transportation issues Provide emotional support Address fear of pain, address fear of cancer Benign Breast Disorders Premenstrual Breast Pain Fibrocystic Breast Changes Bilateral and diffuse Cyclical, peaking prior to menses and improving during or immediately after Associated with normal menses, hormonal meds (e.g., OCPs) Treat symptoms OTC acetaminophen or NSAID Low fat diet, avoid salt 1 2 weeks before menses, limiting caffeine helps some women Supportive bra; ill fitting underwires may be source of pain Fibrocystic Breast Changes Normal finding Women 20 40, especially with family hx ~60% of premenopausal women Changes vary over menstrual cycle; subside with menopause in 20% of women Symmetric thickening in upper outer breast quadrants Rubbery, diffuse, painful lumps Treatment Soft supportive bra, NSAIDs, acetaminophen, limit caffeine, small studies show slight effectiveness for Vitamin E or evening primrose oil taken orally Fibroadenomas Most common solid benign tumor Stimulated by hormonal changes (OCPs, HRT, lactation, pregnancy) Common in young and African American women Firm, rubbery, well circumscribed, mobile, non tender Usually diagnosed by biopsy; remove if symptomatic 3

4 Mastitis (Inflammation of breast tissue) Mastitis Lactational mastitis is most common (2 10% of breastfeeding women) Hard, red, tender, swollen area of one breast Fever >101, patients typically look sick Ibuprofen, cold compresses, continued breastfeeding, antibiotics No improvement in hours, may need ultrasound to rule out abscess Needs urgent provider evaluation Cysts Common in perimenopause Vary with menstrual cycle Smooth, firm, mobile, round, well circumscribed, fluid filled sacs that are tender Ultrasound for women < 30 or pregnant Ultrasound + mammogram for women > 30 Simple cyst = fluid only Complicated cyst = fluid and solids Refer to breast or surgical clinic; simple cysts may resolve with aspiration Case 2 Becky calls your office I just turned 40. I think I need a mammogram. How would you respond? What clarifying questions would you ask? Clarifying Questions Increased risk due to family hx? Increased risk due to personal hx? Skin changes? Nipple discharge? Pain? Mass? Methods to Evaluate the Breast Know protocol at your facility 4

5 VHA Policy on Breast Evaluation Techniques Recommendation VHA USPSTF Grade Teach breast self exam Against D: Harms outweigh benefits Clinical exam for screening beyond mammography for women 40+ Biennial screening mammography women for Biennial screening mammography for average risk women <50 Mammography screening for women 75+ Neither for nor against I: Insufficient evidence on benefits vs. harms Recommended B: Moderate net benefit Individual decision Neither for nor against C: Small net benefit; may support providing for individual patients I: Insufficient evidence on benefits vs. harms Don t Teach Breast Self Examinations USPSTF recommends against TEACHING breast self exam Does not mean USPSTF opposes breast self exam Harms outweigh benefits Finding lumps that turn out to be normal (falsepositives) leads to increased anxiety and unnecessary visits, imaging, and biopsies Teach Breast Self Awareness Be familiar with breasts Promptly report changes to provider: Nipple discharge Nipple inversion (retraction) Skin puckering, dimpling Lump/mass in breast or lymph nodes Pain For premenopausal women, examine breasts 1 week after end of menses Clinical Breast Exam USPSTF The current evidence is insufficient to assess the additional benefits and harms of clinical breast examination for women 40 years or older Bottom line provider should discuss pros and cons of clinical breast exam with Veteran and include her in decision making process. Obtain a Complete Medical Hx Identify concerns, self detected abnormalities Personal/family hx of breast cancer Hx of breast procedures Other risk factors Timing of menses, age at first pregnancy, number of pregnancies, timing of menopause Alcohol use, obesity Breast density Hx of radiation therapy, long term menopausal hormone therapy, DES exposure Genetic alterations (BRCA1, BRCA2), Ashzenazi Jewish Heritage Breast Exam Documentation Locate mass on clock face Report distance from nipple in centimeters Note mass characteristics Example: Right breast mass is located at 12 o clock, 5 cm from nipple, mobile, rubbery, smooth, tender 5

6 Mammography Options Screening vs. Diagnosis 1. Screen asymptomatic women: 2 views per breast 2. Screen women with breast implants: 4 views per breast 3. Diagnose women with abnormality/symptoms: 4 views per breast 4. Diagnose with spot compression/magnification if screening mammo shows abnormality (better imaging of particular region) **Mammography misses 10 20% of clinically palpable cancers. Also less able to find abnormalities in women <40 due to denser breasts. Mammography Recommendations VHA follows USPSTF recommendations: Biennial screening mammography for women ages is recommended / Grade B: there is a moderate net benefit Biennial screening mammography for average risk women <50 is an individual decision / Grade C: there is a small net benefit; VHA may support providing for individual patients Mammography screening for women 75+ is neither recommended nor against / Grade I: there is insufficient evidence on benefits vs. harms Mammogram Reports: Red Flags Presence of a mass Architectural distortion ( spiculated, irregular ) Distribution of calcifications ( linear vs. cluster ) Ductal asymmetric density Breast Imaging Reporting and Data System (BI RADS) Category Diagnosis 0 Incomplete 1 Negative 2 Benign 3 Probably benign 4a 4b 4c Cancer 2 9% Cancer 10 49% Cancer 50 94% 5 Highly suggestive 6 Proven cancer Rates breast density, masses, calcifications, and architectural distortions Notes axillary adenopathy, skin or nipple retraction, and skin thickening Can be used in conjunction with a diagnostic mammo Determines if lesion is cyst vs. solid Not routinely used for screening Useful for women <30, pregnant, or lactating Guides core biopsies Photo courtesy of Royal Philips Electronics. All rights reserved. Breast Ultrasound Magnetic Resonance Imaging (MRI) Pros Screening high risk patients Evaluating new diagnosis Monitoring patients in chemo Evaluating metastatic cancer with unknown primary site Evaluating patients with breast implants Cons: More false positives Higher exam cost More limited availability 6

7 MRI Patient Education Lie face down on platform with openings for breasts If contrast material will be used, IV is inserted into hand/arm Pictures are produced over a period of time. Usually includes multiple sequences. Session can last from minutes Technique to biopsy a breast mass depends on: Whether mass is palpable Its location Fine needle aspiration Core needle biopsy Radiology assisted biopsy Stereotactic biopsy Ultrasound guided biopsy Wire localized biopsy Excisional biopsy Post Biopsy Discharge Instructions Pain management: acetaminophen usually sufficient Bleeding is rare but may occur; can produce hematoma Monitor for infection: redness, fever, increasing pain or discharge Use bra continuously for 1 wk to decrease complications When/how to expect results Who to call with a problem Hyperplasia Term Atypical hyperplasia Non invasive cancer Invasive cancer Breast Cell Changes Definition Overgrowth of cells lining ducts or lobules Accumulation of abnormal cells in duct of lobule; marker for cancer Carcinoma in situ (cancer confined to duct or lobule where it developed) Cancer has spread (progression described as stages I IV) Breast Cancer Today 200,000 diagnoses yearly Survival rates climbing 5 year survival % if localized >30% of women diagnosed after metastasized Where Breast Cancer Spreads The lymph nodes play an important role in helping clear the breast of excess fluid or infection. They are also involved in how breast cancer spreads. 7

8 Considerations for Pregnant and Lactating Women The average woman Veteran receiving care in the VA is 47 years old. You will be caring for a number of women during their peak reproductive years. Causes of Breast Masses in Pregnant or Lactating Women Lactating adenoma (likely due to rising estrogen levels) Plugged ducts Milk retention cyst (galactocele) Mastitis Abscess Cancer (1/3000 1/10000 pregnant women) Other causes noted previously Evaluating Masses in Pregnant and Lactating Women Ultrasound preferred Biopsy complications Fine needle aspiration not as accurate Higher hematoma risk with pregnancy More infection/milk fistula with lactation Cessation may lower complications Do not postpone workup for pregnancy Mammo: lead apron will shield abdomen; minimal ionizing radiation to fetus Some leaking/expression of fluid during late pregnancy common; milky or yellowish color and bilateral occurrence is reassuring Nursing Role in Breast Health Clarify the issue Provide education Facilitate screening/diagnosis Educate Patients Be aware of breast changes Address modifiable risk factors <1 alcoholic drink/day Exercise Weight control, low fat diet Manage benign pain Supportive bra, avoid underwires Nicotine and caffeine cessation may help Warm compresses, ice packs, gentle massage OTC acetaminophen or NSAID Facilitate Screening and Diagnosis Explain the screening/diagnostic method Address her fear of mammogram pain Schedule 10 days after start of menses Acetaminophen prior to test Avoid caffeine week before Talk to mammogram technician Address her fear of cancer diagnosis Early diagnosis = better prognosis and treatment success Although she may not agree to screening at this time, you are laying a foundation. She may change her mind during a future visit. 8

9 System resources for follow up? Abnormal results tracking? Local guidelines & policies? Know Your System Results reporting to providers & patients? Testing locations & required preps? Summary Any lump should be evaluated Even if the mammogram is negative, mass still needs to be pursued No physical exam can reliably distinguish between benign vs. malignant Most common malpractice claim is failure to diagnose breast cancer Nursing plays a key role in clarifying issues, providing education, and facilitating screening and diagnosis Ask the Presenter 9