A 44 year old womanwith breast pain………
March 10, 2004
Primary Care Conference
Shobhina Chheda MD MPH
(no financial disclosures)
History of Present Illness
SS is a 44 year old woman presents withconcerns about pain in her right breast
started several days ago after her sonjumped on the bed
4/10 in severity, constant, lateral location,non-radiating
History of Present Illness(continued)
Denies any bruising, redness, mass,
Not breastfeeding currently
Denies history of breast problems
Learning Objectives
Recognize frequency of breast pain ascomplaint
Review differential diagnosis of breastpain
Discuss the concern of breast cancer inpatients with breast pain
Breast symptoms
Barton et al. (1999) study of 2400women ages 40-69 enrolled in HMO for10 years (1983-1993)
16% presented with breast symptom
Women < 50 presented twice as oftenas women>50
Women with positive FHx more likely topresent
CC: Breast pain vs. other breast symptoms
Barton et al. 1999
Thinking about breast pain…
Cyclic breast pain
Noncyclic breast pain
Extramammary pain
Smith et al. 2004
Cyclic Breast Pain
–Pain severity > 4/10
–Pain duration > 7 days/month
–Starts in luteal phase and dissipates withmenses
–11% premenopausal women
Cyclic Breast Pain (continued)
–Diffuse, bilateral
•Upper, outer breast can radiate to axilla
–Onset age 30-40’s
–14% spontaneous resolution, 42%resolution with menopause
–Unclear etiology
Extramammary pain DDX
Musculoskeletal
–Costochondritis
–Chest wall pain
–Fibromyalgia
–Cervical radiculopathy
–Shoulder pain
–Herpes zoster
Extramammary pain DDX(continued)
Coronary artery disease
Pulmonary embolism
Pleurisy
Gastroesophageal reflux
Peptic ulcer disease
Psychologic
Noncyclic breast pain
Unilateral, localized to one quadrant
Onset age 40-50’s
Noncyclic breast pain DDx
Trauma
Thrombophlebitis
Mastitis
Medications
Benign tumors
Cancer
Many women seek medical attention forbreast pain because of concern aboutcancer
How concerned should we be…..
Breast cancer diagnosis according tocombination of symptoms
Barton et al 1999
Back to SS….
G2P2 (age 20 at first birth)
Menarche age 13
No family history of breast cancer
Tobacco use 2.5ppd quit age 20
Mammogram 18 months ago normal
Hodgkin lymphoma age 24
–Treated with full mantle radiation
Learning objectives (continued)
Review use of Gail/NCI model
Recognize Hodgkin disease treatmentas risk factor for breast cancer
Discuss challenges of providinggeneralist care to patients with history ofprior cancer
History: Risk factors for breastcancer in Gail Model
Age
Age at menarche
Number of biopsies
Pregnancy history
Number 1st degree relatives with breastcancer
Atypical hyperplasia
Breast Cancer Risk
5-YEAR RISK:
.6%
.9%
7.1%
12.0%
5 year risk:
Patient (age 44): 0.6%
Woman age 44 same race andaverage risk factors: 0.9%
•http://brca.nci.nih.gov/brc.
Risk of breast cancer in premenopausalwomen based on smoking initiation
SmokingInitiation
Cases
Controls
OR
P value
Yrs. from onset ofmenarche
< 5
104
83
1.69
(1.13-2.51)
0.01
> 5
58
70
1.05
(0.67-1.65)
0.83
Relation to 1stpregnancy
Before
146
131
1.47
(1.02-2.10)
0.04
After
11
18
0.83
(0.37-1.85)
0.64
Band et al 2002
What about history of HodgkinDisease (HD) ?
Second cancer is the leading cause ofdeath
Breast cancer most frequent solid tumorin women
Breast cancer risk inversely related toage at treatment
How does treatment impact risk?
Matched case control study of breastcancer within a cohort of 3817survivors of HD
Matched 105 patients with HD andbreast cancer with 266 patients withHD and no breast cancer
Travis et al 2003
Risk of breast cancer among young womendiagnosed with Hodgkin Disease, by Treatment
Travis et al2003
Back to SS……..
Breast exam revealed a tender 2 cmmass laterally at 11:00. Hard, mobileand irregular borders.
Mammogram : Spiculated mass withirregular calcifications (BI-RADS-5)
Infiltrating ductal carcinoma
A word on imaging with normalexam and low risk ..…
Unnecessary for cyclic breast pain
Noncyclic breast pain
– Studies suggest no difference inmammogram findings and frequency ofmalignancy between women with pain andthose presenting for routine screening
–Some consider ultrasound for persistentpain
Challenges for us ….
Eliciting an accurate history
–70% of children with cancer are long-termsurvivors
Understanding increasing data
–Latencies between treatment and 2ndcancers
•Alkylating agents- 1st decade out
•Radiation- 2 and more decades out
–Interactions between treatments
Challenges for us ….
Understanding increasing data (continued)
–Interactions of treatments and geneticcharacteristics
–Childhood Cancer Survivor Study
Understanding implications for screening andprevention
Educating our patients
–Discussion of “increases in risk”
Challenges for us ….
Understanding implications forscreening and prevention
Educating our patients
–Discussion of “increases in risk”
Summary
Recognize frequency of breast pain ascomplaint
Review differential diagnosis of breastpain
Discuss the concern of breast cancer inpatients with breast pain
Summary (continued)
Review use of Gail/NCI model to assessbreast cancer risk
Recognize Hodgkin disease andtreatment as risk factor for breastcancer
Discuss challenges of providinggeneralist care to patients with history ofprior cancer
References
Barton et al. Ann Intern Med,130(8).1999 651-657
Robinson BMJ 1996 312: 861-862
Travis et al. JAMA 290(4).2003 465-475
Hull et al. JAMA 290(21) 2003 2831-2837
Smith et al. Mayo Clin Proc. 200479:353-372
References (continued)
Rhodes D. Mayo Clin Proc. 200277:355-361
NCI site: http://brca.nci.nih.gov/brc.
Shirley R. Up to date(11.3) Breast pain
Yahalom J. JAMA 290(4) 2003 529-531
Childhood cancer survivor study site:http://www.cancer.umn.edu/ltfu