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Amy J. Keenum, DO, PharmD, Editor, Osteopathic Family Physician
The lead topic of my personal life this calendar year has been the female breast mass. My closest friends, (friends of twenty years variety) have been diagnosed with breast cancer as well as some of my dearest patients. They all had one thing in common, caring physicians who immediately ordered the correct diagnostic testing with timely biopsy. One smart doctor sent my friend back for another biopsy fearing the negative initial result was due to the biopsy of the wrong area of the breast and he was unfortunately correct. This careful attention to detail likely saved her life.
The lead article this issue is the evaluation of a breast mass. After a mass is discovered by the patient or by the physician the process is a diagnostic process and not a screening process. Screening mammograms have no place in the evaluation of a breast mass. The article mentions that 90% of breast masses are benign. I sometimes mention this fact when my discovery of a mass on a more routine exam is causing great anxiety. At the same time, it is that worry that may be pushing the patient to get all the needed imaging, biopsies and treatment. This is a scary ordeal.
The article mentions the use of ultrasound in young women. No adverse effects have ever been attributed to ultrasound. There is no radiation, no contrast- but it can be uncomfortable from the pressure applied by the operator. In patients with palpable dense breast tissue I send the ultrasound order with the diagnostic mammogram order. It makes the referral to the breast center go more smoothly.
Some breast cancers are only visualized with magnetic resonance imaging (MRI) and are not seen with other imaging modalities. MRI may also reveal more tumors that are not palpated. A breast cancer risk calculator at www.cancer.gov can aide in the determining the risk of breast cancer. If the patient is high risk the insurance company should more likely approve MRI imaging.
The patient who is lactating is not mentioned in the article. (Oh yes, I had a pregnant friend diagnosed with breast cancer this year too.) While clogged milk ducts and mastitis can cause masses in nursing patients, malignancy can also be present. Some common sense is needed in this scenario. Breastfeeding may reveal a mass that is not palpated at the end of pregnancy when the breasts are dense and enlarged. Diagnosis of breast cancer during pregnancy is challenging and mammography is not very useful as the images are all white, (there is calcium everywhere.) In cases of breast mass in a lactating patient ultrasound and/or MRI should be ordered. As many women delay pregnancy to complete their education, more women of advanced maternal age find themselves in this scenario.
Men do get breast cancer. The rate is thought to be 1 in 100 cases of breast cancer. The diagnosis algorithm is the same as in women. They get the pink ribbon too.
I hate cancer.