Transcript Breast Health - Linda Baier Files

Breast Health
Learning Objectives
Describe breast anatomy to a patient
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
VETERANS HEALTH ADMINISTRATION
Poll Question
What health care position best describes you?
A. Nursing personnel
B. Provider
C. Administrative/Other
VETERANS HEALTH ADMINISTRATION
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
Lymph node areas
A
Pectoralis major muscle
B-D Axillary lymph nodes
E
Supraclavicular lymph
nodes
F
Internal mammary
lymph nodes
Poll Question
How many years have you worked in women’s
health (both non-VA and VA experience)?
A.
B.
C.
D.
Less than 1 year
1-3 years
3-10 years
More than 10 years
VETERANS HEALTH ADMINISTRATION
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
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Solitary
Hard
Immobile
Irregular
≥ 2 cm in size
VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
Clarifying Questions
Rule out emergency issues (e.g, mastitis, inflammatory
breast cancer, non-breast conditions)
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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?
VETERANS HEALTH ADMINISTRATION
Triage and Follow-up
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Consider infection
Presence of mass?
Protocol available?
Facility guidelines?
Know provider‘s preferences
Ensure careful documentation
VETERANS HEALTH ADMINISTRATION
Education and Support
Educate
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Breast changes
Modifiable risk factors
Managing benign pain
Support
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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
VETERANS HEALTH ADMINISTRATION
Benign Breast
Disorders
Premenstrual Breast Pain
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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
VETERANS HEALTH ADMINISTRATION
Fibrocystic Breast Changes
VETERANS HEALTH ADMINISTRATION
Fibrocystic Breast Changes
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Normal finding
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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
VETERANS HEALTH ADMINISTRATION
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
Mastitis
(Inflammation of breast tissue)
Mastitis
•
Lactational mastitis is most common (2-10% of
breastfeeding women)
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Hard, red, tender, swollen area of one breast
Fever >101◦, patients typically look sick
Ibuprofen, cold compresses, continued breastfeeding,
antibiotics
− No improvement in 48 - 72 hours, may need ultrasound to
rule out abscess
•
Needs urgent provider evaluation
VETERANS HEALTH ADMINISTRATION
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?
Know protocol at your facility
VETERANS HEALTH ADMINISTRATION
Methods to
Evaluate the Breast
VHA Policy on Breast Evaluation Techniques
Recommendation
VHA
Teach breast self-exam
Against
Clinical exam for screening
beyond mammography for
women 40+
USPSTF Grade
D: Harms outweigh
benefits
Neither for nor I: Insufficient evidence
against
on benefits vs. harms
Biennial screening mammo- Recommended B: Moderate net
graphy women for 50-74
benefit
Biennial screening
mammography for average
risk women <50
Mammography screening
for women 75+
Individual
decision
C: Small net benefit;
may support providing
for individual patients
Neither for nor I: Insufficient evidence
against
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
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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
VETERANS HEALTH ADMINISTRATION
Breast Exam Documentation
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Locate mass on clock face
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Note mass characteristics
Report distance from nipple in
centimeters
Example:
Right breast mass is located at 12
o’clock, 5 cm from nipple, mobile,
rubbery, smooth, tender
VETERANS HEALTH ADMINISTRATION
Mammography
Options
Screening
vs.
Diagnosis
1.
2.
3.
4.
Screen asymptomatic women: 2 views per breast
Screen women with breast implants: 4 views per breast
Diagnose women with abnormality/symptoms: 4 views per breast
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 50-74 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
VETERANS HEALTH ADMINISTRATION
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
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Rates breast
density, masses,
calcifications, and
architectural
distortions
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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
VETERANS HEALTH ADMINISTRATION
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 3090 minutes
VETERANS HEALTH ADMINISTRATION
Fine needle aspiration
Core needle biopsy
Technique to
biopsy a breast
mass depends
on:
• Whether mass
is palpable
• Its location
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
VETERANS HEALTH ADMINISTRATION
Breast Cell Changes
Term
Definition
Hyperplasia
Overgrowth of cells lining ducts or lobules
Atypical hyperplasia
Accumulation of abnormal cells in duct of
lobule; marker for cancer
Non-invasive cancer
Carcinoma in situ (cancer confined to duct
or lobule where it developed)
Invasive cancer
Cancer has spread (progression described
as stages I-IV)
VETERANS HEALTH ADMINISTRATION
Breast Cancer Today
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200,000 diagnoses yearly
Survival rates climbing
5-year survival 98-100% 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.
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
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VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
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
VETERANS HEALTH ADMINISTRATION
• 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.
VETERANS HEALTH ADMINISTRATION
Local
guidelines &
policies?
System
resources for
follow-up?
Abnormal
results
tracking?
Know
Your
System
Testing
locations &
required
preps?
Results
reporting to
providers &
patients?
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
VETERANS HEALTH ADMINISTRATION
Ask the Presenter…