Breast Cancer

Incidence: roughly 1 in 10 women will develop breast cancer in their lifetime.

Risk factors for breast cancer:

1. History of breast cancer (biggest risk factor)

2. Family history in first-degree relatives

3. Age (breast cancer is rare before age 30; the incidence increases with age). Greatest risk in women >75 years old,

4. Early menarche, late menopause, and late first pregnancy or nulliparity (more menstrual cycles more risk)

5. Atypical hyperplasia of the breast

6. Radiation exposure before age 30

7. Prolonged use of oral contraceptive pills (> 5 years) only if nulliparous or before first pregnancy (controversial)

Signs and symptoms that suggest a mass is breast cancer until proved otherwise: fixation of breast mass to the chest wall or overlying skin, satellite nodules or ulcers on the skin, lymphedema/peau d'orange, matted or fixed axillary lymph nodes, inflammatory skirt changes (red, hot skin with enlargement of the breast due to inflammatory cancer), prolonged unilateral scaling erosion of the nipple with or without discharge (may be Paget's disease of the nipple), microcalcifications on mammography, and any new breast mass in a postmenopausal woman.

The conservative approach is to biopsy every palpable breast mass in women over 35 when in doubt, especially if they have any risk factors. If the board question does not want you to biopsy the mass, it will give you clues that it is not cancer (e.g., bilateral, lumpy breasts that become symptomatic with every menses and have no dominant mass, age < 30).

important points:

1. In women under 30, breast cancer is extremely rare. With a discrete breast mass in this age group, think of fibroadenoma and observe the patient over a few menstrual cycles before considering biopsy. Fibroadenomas are usually roundish, rubbery-feeling, and freely movable.

2. The most common histologic ty pe of breast cancer is invasive ductal carcinoma.

3. In patients with a palpable breast mass, the decision to do a biopsy is a clinical one. A mammogram that looks benign should not deter you from doing a biopsy. On the other hand, a lesion that is detected on mammography and looks suspicious should be biopsied, even if not palpable (needle localization biopsy).

4. Do not do mammograms in women under 35 (breast tissue too dense to see cancer).

5. Tamoxifen (or other endocrine therapy) generally improves survival if the tumor is estrogen receptor-positive (ER+) and even more so if the tumor is also progesterone receptor-positive (PR-f).

6. Mastectomy and breast-conserving surgery plus radiation are considered equal in efficacy. In either case, do an axillary node dissection to determine spread to the nodes. If nodes are positive, give chemotherapy.

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