The Breast



The Breast






If a woman who is not with child, nor has brought forth, has milk, her menses are obstructed.

—APHORISMS, HIPPOCRATIC WRITINGS


The examination of the breasts is an extremely important part of the physical examination in women, largely because of concerns about breast cancer, the most commonly diagnosed cancer and the second leading cause of cancer death among women in the US. The annual incidence of breast cancer increased by 52% during 1950 to 1990, while the death rate from breast cancer increased by 4% during the same period (CDC, 1994). The increase in incidence was about 40% between 1973 and 1998 (Howe et al., 2001; Kufe et al., 2003). Moreover, the disease occurs in younger women, who are likely to have more aggressive tumors (Sundquist et al., 2002). The interpretation of trends is complicated by the fact that in 2003 ductal carcinoma in situ (DCIS) was removed from the overall incidence (A. Lanfranchi, personal communication, 2009). DCIS had increased more than threefold, from 3.8 per 100,000 to 12.1 in 100,000 in women under age 50 between 1975 and 2005 (National Cancer Institute).

Lumps are not uncommon. As many as 89% of postmenopausal women have evidence of benign breast disease at autopsy (Grady et al., 1988).

The examination should also not be neglected in men, although cancer of the male breast is rare.


History: Risk Factors for Breast Cancer

Various historic factors influence the prior probability of breast cancer. Certain risk factors that have received a great deal of publicity (hormone use, alcohol consumption, obesity, and nulliparity) present a fairly modest relative risk (RR) for breast cancer (RR < 2). A history of breast cancer in a first-degree relative confers an RR of 2.1 or more, and a positive test for a breast cancer susceptibility gene (BRCA), an RR greater than 4. Women with BRCA1 mutations are estimated to have a 65% risk of developing breast cancer by age 70 (American Cancer Society, 2008). Patients with goiters owing to iodine deficiency have a three times greater incidence of breast cancer. For this and other reasons, “subclinical” iodine deficiency manifested by a urinary iodine concentration less than 50 µg per L is thought by some to be a risk factor both for breast cancer and fibrocystic disease (Miller, 2006).

The effect of ionizing radiation depends upon the dose. High doses are harmful, but low doses appear to be beneficial through nonspecific stimulation of biologic repair mechanisms (hormesis). In the Canadian fluoroscopy study, the RR of breast cancer at 10 to 19 cGy (1 cGy = 1 rad) cumulative exposure was 0.66 compared with controls; the RR was 0.85 at 20 to 29 cGy, and it was not significantly higher at 30 to 69 cGy. Beginning between 1930 and 1952 and being followed for up to 50 years, this study involved 31,710 Canadian women examined and treated for tuberculosis with X-ray doses to the chest (Miller et al., 1989). Mammography routines in the 1990s were claimed to deliver as little as 0.2 cGy, apparently for each pair of views of each breast, totaling 0.4 cGy per total examination. Thus, if a woman of 50 began in 1990 to have annual mammograms until age 75, the cumulative dose would be 10 cGy, which is within the optimum hormetic dose range. Therefore, avoiding mammography because of the radiation is not justified (Kauffman, 2003).

Early childbearing has a protective effect. One study estimated that “women having their first child when aged under 18 years have only about one third the breast cancer risk of those whose first birth is delayed until the age of 35 years or more” (MacMahon et al., 1970).

Breast cancer is known to be hormonally sensitive, yet the role of various risk factors involving estrogens—hormonal contraceptives and estrogen-replacement therapy—has been intensely controversial. Evaluation of these factors is confounded by the undisputed enhanced risk of early menarche and late menopause and the likely prolonged use of hormonal contraceptives before the first full-term pregnancy (Fentiman, 2002). In one major textbook, the RRs are listed in the text, but not in a table, as being 1.24 for oral contraceptives and 1.26 for hormone replacement therapy (Bland and Copeland, 2004).

Oral contraceptives have been classified as a class I carcinogen (Cogliano et al., 2005), but conflicting information has been published on the National Cancer Institute’s website (Lanfranchi, 2008).

It is noteworthy that breast cancer incidence (i.e., the incidence of cancers that had grown large enough to be detectable) diminished by 3.5% per year between 2001 and 2004, particularly in women aged 50 to 69; this has been attributed to the rapid decrease in the
use of hormone replacement therapy beginning in 2002 (American Cancer Society, 2008).

The hormones of pregnancy have a far greater proliferative effect on the breast than exogenous hormone treatment. As the first pregnancy comes to term, however, the milk glands mature, accounting for the protective effect. If this process is interrupted before 32 weeks, by premature delivery or abortion, the woman is left with a large increase in the number of immature cells that are vulnerable to carcinogenic factors. Spontaneous abortion in the first trimester appears to have no significant effect on breast cancer incidence. Women often report that they “did not feel pregnant”; the pregnancy fails owing to inability of the fetal-placental unit to produce enough hormones to sustain the pregnancy or to stimulate growth in the mother’s breasts (Lanfranchi, 2008).

At least 38 epidemiologic studies exploring an independent link between induced abortion and breast cancer have been published, 29 of which report risk elevations. There have been two metaanalyses coming to conflicting conclusions (Brind et al., 1996; Collaborative Group on Hormonal Factors in Breast Cancer, 2004).

Brind et al. estimated that in 1996 an excess 5,000 cases of breast cancer were attributable to abortion and that the annual excess would increase by 500 cases each year. Reviewing a 2001 report, Brind stated that abortion could explain the entire rise in breast cancer since the mid-1980s and that the absolute numbers of increased cases fall within the range of the numbers predicted in the 1996 metaanalysis (Malec, 2003). The overall odds ratio was found in that analysis to be 1.3 (95% CI 1.2 to 1.4) for any induced abortion (Brind et al., 1996).

The increasing incidence of breast cancer in eight European countries since 1971 was found to correlate best with induced abortion, of the seven reproductive risk factors. Fertility was also a useful predictor. Using data up to 1997, the model gave accurate predictions through 2004 (Carroll, 2007).

Although an increased risk on the order of 30% is relatively modest in an epidemiologic sense, the absolute number of cases in the population would be large because breast cancer is so common. Moreover, the risk in certain subgroups appears to be quite significant. In one study, women without positive family histories who had obtained abortions before age 18 and gestation between 9 and 24 weeks had an RR of 9.0 (Daling et al., 1994). The study also included 12 cases with a family history of breast cancer in which the women obtained abortions before age 18. No controls free of breast cancer in the study had this history. All of the cases developed breast cancer before age 45. For this group, the study reported an RR of infinity.

Currently, many influential groups deny any possible connection between induced abortions and breast cancer. For some women, however, the existing evidence could influence their decisions, and some courts have ruled that the potential risk should be included in obtaining informed consent. Additionally, physicians at some point could be held liable if they are not sufficiently vigilant in monitoring patients who may be at risk or in advising patients of the risk. Aside from an independent effect of abortion on breast cancer risk, abortion in a nulliparous woman certainly increases the duration of the “susceptibility window”—the length of time between puberty and the first full-term pregnancy— during which the breasts are especially vulnerable to carcinogens.

In summary, the history of risk factors for breast cancer should include the use of hormones and a complete pregnancy history, including the patient’s age when she became pregnant and the outcome of each pregnancy, including the length of gestation.

The absence of risk factors is never decisive. Biopsies must be performed on all suspicious lesions. If the patient herself presents with a lump, ask how long it has been present, whether there is associated cyclic tenderness, and whether it waxes or wanes with the menstrual cycle. A nodule that has been unchanged for more than a year or one that shows cyclic changes is likely to be benign (Grady et al., 1988).


Draping the Female Patient

Adequate exposure, of course, is essential, but many women will be uncomfortable if their modesty is not protected. Gynecologists often have the patient wear a gown that opens in the front and then place a sheet on the patient’s lap. The gown can be opened to examine the breasts, then closed to cover them during the rest of the examination. The sheet can be used to cover the pubic area while the abdomen is inspected and then be raised to cover the abdomen when the genitalia are examined. From the viewpoint of the internist or general physician, it is inconvenient to have the gown open in the front for purposes of the general physical examination, especially the chest examination. (It cannot easily be raised because the patient will be sitting on it.) Therefore, some prefer to have the opening in the back. To examine the breasts and auscult the heart, the physician can either lower the gown from the shoulders (when the patient is sitting) or raise it (when the patient is supine), keeping the lower part of the body covered with a sheet. One solution is to use a short gown that opens in front, plus a sheet.

In these litigious days, it is advisable to have a female attendant present during the breast examination, especially if the physician is a man.


Inspection


A Method

Patients should be examined both seated and supine. While the patient is seated, disrobed to the waist, the breasts should be inspected. Look for asymmetry (a certain amount is normal); a change in contour or a visible swelling; retraction, edema, erythema, or dimpling of the skin; or an increased prominence of the venous pattern. Skin retraction is usually a sign of carcinoma, although it can result from fat necrosis. If a tumor blocks the lymphatic drainage, an area of lymphedema, which often looks like an orange peel (peau d’orange, pronounced poe-der-awnj), may result. Local areas of redness indicate underlying inflammation; this can occur in inflammatory carcinoma or infection.

Changes induced by pregnancy are summarized in Table 22.2.

Traditionally, the inspection of the breasts has included the following maneuvers described by Haagensen: First, the patient’s arms should be in her lap so that the pectoral muscles are relaxed.
Second, she should be asked to press her hands firmly on her hips to contract the pectoral muscles. Third, she should raise her arms above her head. If the patient has pendulous breasts, it may also be helpful to have her stand and lean forward, supported by the back of a chair or the examiner’s hands.

These time-honored but time-consuming maneuvers seldom reveal changes suggesting a cancer in patients not having a palpable lump and are often deleted from a screening examination.


Nipples

Particular attention should be paid to the nipples. An inverted nipple, unless long-standing, suggests carcinoma. Normally, an inverted nipple can be everted to its correct anatomic position; inability to do so mandates a biopsy unless the patient recognizes the inversion as a congenital defect (Bland and Love, 1992). Scaling, crusting, or ulceration of the nipple suggests Paget disease of the breast, a malignant condition in which a lump may not be palpable. Paget disease of the breast does occur in men also. The differential diagnosis includes malignant melanoma and Bowen disease (intraepithelial squamous cell carcinoma) (Desai et al., 1996). Scaling of the areola only is probably eczema, but if scaling involving the nipple does not go away after using a corticosteroid cream for about 10 days, biopsy is needed (A. Lanfranchi, personal communication, 2009).


Supernumerary Nipples

Supernumerary nipples or breasts (polythelia and polymastia) are rather frequent minor errors in development, having an incidence varying from 0.22% to 2.5%. They are more common in men and in blacks. They are located in the milk line on the thorax and abdomen, most commonly just below the normal breast. They may be mistaken for a pigmented mole, but close inspection generally reveals a miniature nipple and areola.

Although supernumerary nipples have been considered clues to the diagnosis of congenital heart disease, they are of very low sensitivity and diagnosticity. Other associations have been suggested (Pellegrini and Wagner, 1983) but not proved. In fact, the only statistically significant associations are with duplicate renal arteries and renal adenocarcinomas (Goedert et al., 1981). However, black infants with supernumerary nipples do not need to be investigated for renal anomalies (Robertson et al., 1986).


Absent Nipples

Absence of a nipple on only one side with an absent pectoralis major on the same side, sometimes in association with brachydactyly, or a small hand, is known as Poland syndrome. In children, it has been associated with leukemia (Hicsonmez and Ozsoylu, 1982), but it is also seen in adults with prolapsed mitral valves and no other associated abnormality.

Bilateral absence of nipples is a completely different syndrome. Sometimes it is associated with other congenital abnormalities.


Adrenocortical Insufficiency

I only examine the nipples of men intentionally when I am trying to make the diagnosis of chronic primary adrenocortical insufficiency. Because adrenocorticotropic hormone and its precursors have the melanocyte-stimulating hormone peptide sequence, patients with primary adrenocortical insufficiency may eventually develop pigmentation of scars and nipples. However, the absence of pigmentation (light-pink nipples) is far more helpful in excluding the diagnosis than its presence is for establishing it. Just as the Indonesian connection altered the Dutch gene pool sufficiently to make pigmentation misleading (as Snapper and Kahn [1967] noted), the blue-eyed blond gene pool in the US is so mixed with DNA from Mediterranean and other swarthy people that pigmentation in any individual is worse than useless. Especially in black Americans, the “classic” skin signs of chronic primary adrenocortical insufficiency (including dark palms, dark elbows, and mucosal blue spots) are frequently encountered in those whose hypothalamic-pituitary-adrenocortical axes are paragons of adequate homeostasis.

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Aug 10, 2020 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on The Breast
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