A 44 year old woman

with 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 with concerns about pain in her right breast

started several days ago after her son jumped 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 as complaint

Review differential diagnosis of breast pain

Discuss the concern of breast cancer in patients with breast pain

Breast symptoms

Barton et al. (1999) study of 2400 women ages 40-69 enrolled in HMO for 10 years (1983-1993)

16% presented with breast symptom Women < 50 presented twice as often

as women>50 Women with positive FHx more likely to

present

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 with menses

– 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 for breast pain because of concern about cancer

How concerned should we be…..

Breast cancer diagnosis according to combination 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 treatment

as risk factor for breast cancer Discuss challenges of providing

generalist care to patients with history of prior cancer

History: Risk factors for breast cancer in Gail Model Age Age at menarche Number of biopsies Pregnancy history Number 1st degree relatives with breast

cancer Atypical hyperplasia

  

Calculate Risk for New Patient

5 year risk:

Patient (age 44): 0.6%

Woman age 44 same race and average risk factors: 0.9%

•http://brca.nci.nih.gov/brc.

Risk of breast cancer in premenopausal women based on smoking initiation

Smoking Initiation

Cases Controls OR P value

Yrs. from onset of menarche

< 5 104 83 1.69

(1.13-2.51)

0.01

> 5 58 70 1.05

(0.67-1.65)

0.83

Relation to 1st pregnancy

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 Hodgkin Disease (HD) ? Second cancer is the leading cause of

death Breast cancer most frequent solid tumor

in women Breast cancer risk inversely related to

age at treatment

How does treatment impact risk?

Matched case control study of breast cancer within a cohort of 3817 survivors of HD

Matched 105 patients with HD and breast cancer with 266 patients with HD and no breast cancer

Travis et al 2003

Risk of breast cancer among young women diagnosed with Hodgkin Disease, by Treatment

Travis et al 2003

Back to SS……..

Breast exam revealed a tender 2 cm mass laterally at 11:00. Hard, mobile and irregular borders.

Mammogram : Spiculated mass with irregular calcifications (BI-RADS-5)

Infiltrating ductal carcinoma

A word on imaging with normal exam and low risk ..… Unnecessary for cyclic breast pain Noncyclic breast pain

– Studies suggest no difference in mammogram findings and frequency of malignancy between women with pain and those presenting for routine screening

– Some consider ultrasound for persistent pain

Challenges for us ….

Eliciting an accurate history– 70% of children with cancer are long-term

survivors Understanding increasing data

– Latencies between treatment and 2nd cancers

• 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 genetic

characteristics– Childhood Cancer Survivor Study

Understanding implications for screening and prevention

Educating our patients– Discussion of “increases in risk”

Challenges for us ….

Understanding implications for screening and prevention

Educating our patients– Discussion of “increases in risk”

Summary

Recognize frequency of breast pain as complaint

Review differential diagnosis of breast pain

Discuss the concern of breast cancer in patients with breast pain

Summary (continued)

Review use of Gail/NCI model to assess breast cancer risk

Recognize Hodgkin disease and treatment as risk factor for breast cancer

Discuss challenges of providing generalist care to patients with history of prior 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. 2004

79:353-372

References (continued)

Rhodes D. Mayo Clin Proc. 2002 77:355-361

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