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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Breast Lump Key Feature 1a: Given a well woman with concerns about breast disease, during a clinical encounter (annual or not): Identify high-risk patients by assessing modifiable and non-modifiable risk factors. Skill: Clinical Reasoning, Selectivity Phase: History, Diagnosis Key Feature 1b: Given a well woman with concerns about breast disease, during a clinical encounter (annual or not): Advise regarding screening (mammography, breast self-examination) and its limitations. Skill: Clinical Reasoning, Patient Centered Phase: Treatment Key Feature 1c: Given a well woman with concerns about breast disease, during a clinical encounter (annual or not): Advise concerning the woman’s role in preventing or detecting breast disease (breast self-examination, lifestyle changes). Key Feature 2a: Given a woman presenting with a breast lump (i.e., clinical features): Use the history, features of the lump, and the patient’s age to determine (interpret) if aggressive work-up or watchful waiting is indicated. Skill: Selectivity, Clinical Reasoning Phase: Diagnosis, Treatment Key Feature 2b: Given a woman presenting with a breast lump (i.e., clinical features): Ensure adequate support throughout investigation of the breast lump by availability of a contact resource. Skill: Patient Centered, Professionalism Phase: Treatment, Follow-up Key Feature 2c: Given a woman presenting with a breast lump (i.e., clinical features): Use diagnostic tools (ex: needle aspiration, imaging, core biopsy , referral) in an appropriate manner (i.e., avoid over- or under-investigation, misuse) for managing the breast lump. Skill: Clinical Reasoning Phase: Investigation, Treatment Key Feature 3a: In a woman who presents with a malignant breast lump and knows the diagnosis: Recognize and manage immediate and long-term complications of breast cancer. Skill: Clinical Reasoning Phase: Diagnosis, Treatment Key Feature 3b: In a woman who presents with a malignant breast lump and knows the diagnosis: Consider and diagnose metastatic disease in the follow-up care of a breast cancer patient by appropriate history and investigation. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, History Key Feature 3c: In a woman who presents with a malignant breast lump and knows the diagnosis: Appropriately direct (provide a link to) the patient to community resources able to provide adequate support (psychosocial support). Skill: Patient Centered, Clinical Reasoning Phase: Follow-up, Treatment Cancer Key Feature 3: In patients diagnosed with cancer, offer ongoing follow-up and support and remain involved in the treatment plan, in collaboration with the specialist cancer treatment system. (Don’t lose track of your patient during cancer care.) Skill: Patient Centered, Professionalism Phase: Follow-up, Treatment Key Feature 4: In a patient diagnosed with cancer, actively inquire, with compassion and empathy, about the personal and social consequences of the illness (ex: family issues, loss of job), and the patient’s ability to cope with these consequences. Skill: Patient Centered, Communication Phase: History Key Feature 5: In a patient treated for cancer, actively inquire about side effects or expected complications of treatment (ex: diarrhea, feet paresthesias), as the patient may not volunteer this information. Skill: Clinical Reasoning Phase: History, Follow-up Key Feature 6: In patients with a distant history of cancer who present with new symptoms (ex: shortness of breath, neurologic symptoms), include recurrence or metastatic disease in the differential diagnosis. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 7: In a patient diagnosed with cancer, be realistic and honest when discussing prognosis. (Say when you don’t know.) Skill: Communication, Professionalism Phase: Treatment, Follow-up Many women present to clinic with concern about a breast lump, depending on their age and other risk factors, the risk that their lump is breast cancer varies significantly. Risk factors for breast cancer are:
Besides determining whether the patient has risk factors for breast cancer, it is also important to gather information to decide whether the presentation fits a description of how breast cancer may present, or if it presents in keeping with a manifestation of one of a number of benign processes resulting in a breast lump. To do so, it's useful to know if the breast lump presents as part of a cyclic pattern, and if any activities (ex: trauma) or medications have aggravated or alleviated the lump. If the woman has nipple discharge, it is important to characterize this. It's also important to gather a history regarding whether the woman has constitutional symptoms (ex: fever/chills, general malaise, unintentional weight loss). In terms of physical examination, it is important to do a complete breast examination, examining both breasts by inspection and palpation and examining the adjacent lymph nodes. The entirety of the clinical assessment (history and physical examination) inform whether or not and how intense further workup need be, if needed. First line options include mammography and ultrasound +/- needle aspiration. MRI and core needle biopsies tend to be after at least one initial investigation. In a women under the age of 30 years old without increased risk for breast cancer, holding off a mammography and starting with an ultrasound is totally appropriate. Many breast lumps are not breast cancer. In fact, 90% of the time that women between the ages of 20 and 50 years old present with a lump, it is likely to be benign. I remember this statistic to tell women who present to clinic with a breast lump if they are in this age group, because many women are scared, although chances are, everything else being equal, odds are in their favour. I hope this provides some measured reassurance, while still conveying that there is a realistic chance that a lump could, unfortunately, be on the ominous side. The degree of concern I convey about this latter fact is in proportion to my pretest clinical assessment of probability. In any case, I make a point of letting all women know that we won't know for sure what the lump is until we have the results back from the investigations, and I remind them to always return to clinic if they are feeling they could benefit from support in the meantime. Sometimes breast lumps are malignant, although nowadays breast cancer is often treatable for cure depending on the stage at which someone presents. In fact, many women are now living long lives after a diagnosis of breast cancer. However, there are some for whom this is not the case. It is important when delivering a diagnosis of cancer to do so while keeping in mind how to break bad news with honesty and compassion, striking a balance between maintaining realistic hope that is not false. Telling a patient about a new diagnosis of breast (or any other) cancer can cause a lot of harm through loss of hope, and this could even be seen as the first possible negative consequence of being diagnosed with cancer. There are, of course, many other more traditionally thought of complications of cancer that may arise and that we must keep in mind as we care for our patients with breast cancer. Many of these occur as short-term consequences of treatment for cancer, but we now also have to think about the long term concerns, part of the phenomenon of breast cancer survivorship. The table below provides an overview of the short- and long-term complications of breast (and colorectal) cancer, as well as various recommendations for the primary care physician in collaboration with the patient's oncology team. It is important that the primary care provider maintain follow-up with the patient despite them also having other health care providers, including an oncologist who is highly knowledgeable about their disease; much benefit can be provided by constant relationships of care. Included below is a list of supportive resources for patients and their health care providers, considering the many medical and psychosocial considerations that come along with a diagnosis of breast cancer. Apart from the fact that women are living longer and are at greater risk of long-term complications from breast cancer treatment, there's also a higher risk of recurrence and secondary metastasis. Anytime a patient with a history of breast cancer presents with new onset bony pain or neurologic symptoms, consider the possibility of bone or brain metastasis, just like you would consider cancer recurrence or metastasis in any patient with a past history of cancer in general and symptoms that could present accordingly. The list below is not exhaustive for all of the possible complications of breast cancer; different patients may have a very different physical and emotional illness experience and associated repercussions. To be a compassionate and patient-centered holistic primary care provider, it necessitates asking patients how they as individuals are impacted by their diagnosis. Just like side effects of medical therapy, which we too must ask about, not all patients will have the same physical effects and complications that ensue. Breast cancer often presents without the finding of a breast lump. With screening programs, we are able to detect breast cancer at an earlier stage, with improved outcomes for the affected women. Currently, it is recommended that women between the ages of 50 and 74 years old be screened every 2-3 years for breast cancer with mammography. This applies to the general population of asymptomatic women without a breast lump, and without higher risk due to personal history of breast cancer, history of breast cancer in first degree relative, known BRCA1/BRCA2 mutation, or prior chest wall radiation. A handful of years ago, women were also advised to perform breast self-examination to screen for breast cancer, but it was realized that this does more harm than good, as many breast lumps are not breast cancer, and this creates much worry for patients and over-investigation for benign processes. Occasionally women present to clinic for breast cancer screening (without a breast lump) and inquire about breast examination. Screening recommendations always change, and counseling patients about current recommendations for screening based on the most up to date evidence is a continuous process. Although breast self-examination is no longer recommended for early detection of breast cancer, there are things women can do to prevent her risk of getting breast cancer. Namely, these are the lifestyle choices that can modify their risk per the list of risk factors above, some more realistic and logical to strive for than others. The only lifestyle choice I routinely advise patients at average risk (without significant increased baseline risk of breast cancer) to adhere to is moderate alcohol consumption (ideally no greater than 1 drink daily). I also want to make a small plug here about how men can also develop breast cancer. Although this is of course a rare phenomenon, it happens, so any man presenting with gynecomastia or a chest wall mass must also be considered for a work up for possible breast cancer. UpToDate provides an overview algorithm that is useful in working up a concern of gynecomastia/chest wall mass. For any suspicion for breast carcinoma, mammography is more sensitive, but ultrasound is more specific.  And then there are the other lumps that males only may present with, testicular and scrotal masses. Sometimes, males may also present with pain in these areas without a mass or concern for one. It's important to do a focused clinical assessment, and then ultrasound is pretty much always ordered first-line in these situations, along with other investigations depending on the suspected etiology. If infection is a concern, order a urinalysis along with urine culture and sensitivity and urine NAAT for sexually transmitted infections. Give analgesia for pain, antibiotics for infections, and refer to surgery for disease processes requiring procedural repair.
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