Approach to the Patient with a Breast Lump

General

Early detection of a breast lump is critically important to a patient's prognosis. Most breast lumps are not diagnosed at the doctor's office, but rather are detected by women who give themselves breast self-examinations at home. Any breast lump that persists beyond a few days must be reported to a physician. In some cases, a needle aspiration of a breast lump may be performed. If the tissue obtained is clearly not cancerous (if blood wasn't seen on the aspirator, or if the lump disappears after aspiration and does not recur), the physician will often simply observe the patient. Otherwise, a breast lump is usually removed surgically to determine if cancer is present.

When evaluating a patient with a breast lump (regardless of whether it was noticed at home or incidentally on exam), the work-up is the same.  The assessment begins with an ordered inquiry of the symptoms and thorough medical history to assess the patients risk for breast cancer.  This is followed with a clinical exam and diagnostic evaluations (imaging and biopsy).  This approach lends itself to a gradually increasing degree of invasiveness, such that, when the diagnosis is made, the process can be halted with the least degree of invasion and discomfort to the patient.  The ultimate goal of this approach is to judge whether treatment is necessary, and if so, what the appropriate therapy is.

A review of breast anatomy follows, which is a primer to understanding the natural progression of breast cancer as well as important considerations when performing dissection.

Etiology

In America, 12% of women will be diagnosed with breast cancer in their lifetimes.  With the exception of skin cancer, it is the most common cause of cancer and 2nd leading cause of cancer death in women (second only to lung cancer).  More than 3% of women diagnosed with breast cancer will die from their disease, accounting for about 40,000 deaths per year.  The incidence continues to rise, and this may be due to improvement in screening, data collection, and treatment modalities.

Certain risk factors have been identified which increase the risk of invasive breast cancer, however 75% of women diagnosed with breast cancer, in fact, have no known risk factors.  They include female gender, age, estrogen exposure, previous breast cancer, family history, and genetics.

Controversial risk factors include exogenous hormone therapy, obesity, and radiation exposure.  Interestingly, cigarette smoking is not considered to increase the risk of disease (as defined by the Breast Cancer Detection Demonstration Project (BCDDP)), nor is modest alcohol use or long-term (>15 years) menopausal estrogen use.

Clinical Approach

A complete medical history, particularly including the elements above, should be obtained from any patient presenting with a lump or pain in their breast.  Although breast cancer can occur in younger women, a breast mass in a younger patient is (more often than not) likely to be a fibroadenoma or breast cyst (both benign conditions).  A breast mass in a woman older than 50 years, however, is breast cancer until proven otherwise.  In addition to questions which both assess the patients risk and narrow the diagnosis, the patient should be asked about nipple discharge, fever, pain, rate of growth and duration of mass, and changes with menses.

After a thorough history is obtained, a physical examination of the breasts is critical.  The exam should include inspection of the patient in both the upright and supine positions, assessing symmetry and changes in skin/nipples.  Size discrepancy, nipple inversion, skin changes and dimpling (peau d'orange) are suggestive findings.  Supraclavicular, infraclavicular, and axillary lymphadenopathy should be assessed. 

With the patient in the supine position with the ipsilateral arm extended over the head, the breast parenchyma can be compressed against the chest wall and each quadrant assessed for masses. Several techniques for palpating the breast have been described including beginning in the center with larger and larger outward circles, the "spokes of a wheel" approach, and the "strip method" (palpating vertically from lateral to medial).  Benign lesions are more frequently smaller, rubbery, well circumscribed, and mobile. Characteristics suggestive of malignancy include skin involvement, fixation to the chest wall, irregular border, firmness, and enlargement. Any masses noted should be described in location (i.e. 3 o'clock) and size.  Nipple discharge can be assessed, with the understanding that most unilateral discharge in younger women is normal. 

Diagnostic Evaluation

There are a number of different diagnostic modalities that can be utilized when assessing a breast lump.  They include mammography, ultrasound, and a number of biopsy techniques.  Below are links to a description of each of these procedures.

Breast Disease

Breast disease can be categorized into benign and malignant disease, the distinction of which is important in determining whether treatment is necessary and, if so, what modality will best deal with disease, with the minimum amount of side effects and complications.  The different types of diseases that commonly present themselves are discussed in the links below.

Treatment

Most women diagnosed with breast cancer will undergo some form of treatment for the disease. The grade and stage of the cancer, as well as the overall health of the patient, help guide the clinician to the form of therapy best appropriate for the patient.  Because the diagnosis, treatment, follow-up, and support of the patient can be very involved, the care of a breast cancer patient is often multifaceted.  The care of the patient is often managed by a team approach, involving surgeons (i.e. breast and plastic), medical and radiation oncologists, mammographers and sonographers, as well as pathologists, gynecologists, and (sometimes) psychiatrists.

A number of treatment modalities exist for combating breast cancer, and often times no one option is used alone.  Options include local treatment (surgery and radiation therapy) as well as adjuvant treatment (hormonal therapy and chemotherapy).  For the purposes of this tutorial, only the surgical aspects of disease treatment will be addressed, as they are quite often seen in the ambulatory surgical suite.  In addition, the current categories of breast cancer staging are presented as the stage of disease has a profound effect on a patients' prognosis.