Benign Breast Disease & Breast Screening

Leah Kelley, MD OPSC Conference

Monterey, CA September, 2018

Why this matters to YOU

• Breast symptoms constitute 3% of all visits by female patients (29.7 per 1,000)

• Breast pain and breast mass are the most common complaints

• Breast complaints are highest among women aged 25 to 44 years (48 of 1,000) and among women aged 65 years and older (33 per 1,000)

• The vast majority of presentations are not breast cancer

• Mammographic screening is a matter of medical and public controversy that generates patient questions

Common Benign Breast Conditions

• Cysts/Fibrocystic change

• Fibroadenoma

• Nipple discharge/Galactorrhea

• Infectious mastitis

• Non-infectious inflammatory conditions

• How to NOT miss a Breast Cancer • Imaging • Clinical findings

To Mammo, or Not to Mammo?

• Mammography screening is the subject of two major data-driven controversies

• Ideal onset and interval of screening • 40? 45? 50?

• Annually or biennially?

• Actual efficacy of mammography in decreasing breast cancer-specific mortality • Why has more stage 0-1 diagnoses not decreased the number of stage 4 diagnoses?

• What is the role of mammography versus improved treatment?

Breast Pain/Mastalgia • Many reproductive age women experience cyclic breast

pain, especially in the week before menses

• Noncyclic breast pain is common around menarche, menopause and pregnancy

• Virtually all non-focal breast pain is hormonal in nature and harmless, however it can be very bothersome

• It is generally (but not absolutely) true that breast cancers are painless

Breast Pain

• Examine the breast for underlying physical findings, taking note of focal symptoms

• Evaluate medications, activity, support

• If no findings, re-evaluate after two menstrual cycles with supportive treatment

• Symptomatic treatment with good support, ice, NSAIDs, decreased stimulation, exclude caffeine • Diclofenac gel 2g tid massage into breast tissue • Vitamin E 400IU qd and EPO (evening primrose oil) 1g tid

• Severe/refractory cases: Tamoxifen 10mg qd

Breast Mass • Common benign masses

• fibrocystic tissue

• fibroadenoma

What is Fibrocystic Change?

• NOT fibrocystic “disease”

• Subset of women with dense breasts who also have a propensity for breast cyst formation

• Breast cysts are non-encapsulated lacunae of fluid within the breast tissue

• Frequently wax and wane

• Not a specific risk factor for breast cancer above increased risk associated with breast density, but can contribute to false-positive imaging

• Variable symptoms

Benign Masses: Cysts

• Mammography • Ultrasound

Managing Breast Cysts

• Observe if not painful

• Cut out caffeine—this works for some women but not others

• Drain if palpable and symptomatic

• Do not send fluid for cytology

• If: • Fluid is bloody • There is still a mass after drainage • Mass does not drain

DIAGNOSTIC IMAGING!

Benign Masses: Fibroadenoma

• Mammography • Ultrasound

Benign Masses: Other

• Phyllodes tumor • More cellular fibroadenoma

• May be recurrent with malignant potential

• Hamartoma • Encapsulated benign breast tissue

• Forms a palpable mass

Evaluation of a Breast Mass

• Careful history and clinical examination

• Age-appropriate imaging • Women > 35: diagnostic MMG and US

• Women 25-35: US +/- MMG, radiologist’s discretion

• Women <25, US only

• Clinical follow up per imaging

• Referral to breast surgeon if needed

Evaluation of a Breast Mass

• REMEMBER: a persistent Palpable mass which is does not appear on imaging Requires a tissue diagnosis

• Why? 10-15% of breast cancers are occult

• How? Palpation-guided fine needle aspiration

• When? Right away

What does this Pathology Report Mean?

• Your patient has an abnormal mammogram, and gets called back for a biopsy…

• Completely benign: • Usual ductal hyperplasia

• Fibrocystic breast tissue

• Psuedoangiomatous stromal hyperplasia (PASH)

• Calcifications associated with benign ducts

• Not completely benign: • Atypical ductal/lobular hyperplasia

• Intraductal papilloma

• Radial scar

• Flat epithelial atypia

• Lobular carcinoma in situ/lobular neoplasia

• Malignant: • DCIS

• Invasive ductal/lobular carcinoma

Atypical pathology

• Excisional biopsy is still the standard of care

• 5-15% will be upstaged to DCIS or invasive disease

• Pathologic distinctions can hinge on quantity/extent as much as quality

• Inter-observer variability is significant

• Women with atypical biopsies have 4-8 times increased risk of invasive disease in both breasts

• Increased screening • Annual mammogram

• Consider annual MRI

• Risk reduction • Lifestyle modifications

• Tamoxifen or Raloxifene for 5 years reduces risk by 30-50%

Nipple Discharge

• Galactorrhea implies bilateral milky discharge, and should only be used to describe that

• Nipple discharge is anything else

• Key historical features: – Unilateral or bilateral?

– Clear/serous, yellow/green or bloody?

– Spontaneous or expressed?

– Associated mass, pain, events

– Medications

Galactorrhea

• Multiple etiologies

• Bilateral, milky discharge, spontaneous or expressed

• Virtually always benign

• Often related to medications, esp anti-psychotics

• Check: TSH and Prolactin

• Conservative management and correction of any underlying metabolic or hormonal issues

• If a medication side effect, evaluate in light of risks/benefits

Nipple discharge

• Serous or bloody discharge requires evaluation

• Start with diagnostic mmg and ultrasound

• If negative, consider breast MRI

• If persistent with negative imaging, refer to breast surgery for consideration of central duct excision

• Most common cause is intraductal papilloma

• Can be associated with DCIS or invasive carcinoma

Infectious Mastitis

• Most common organisms: skin flora, MSSA, MRSA

• Risk factors: Lactation, surgery, injury, obesity, diabetes, prior radiation

Infectious Mastitis

• Textbook treatment is dicloxacillin 500 qid

• Significant antibiotic resistance now present the community

• For higher risk patients, consider starting with Keflex 500 qid and Bactrim DS 2 tablets bid • Safe for breast-feeding patients with term infants (avoid in preterm infants or family

history of G6PD) • Alternative: Doxycycline 100 bid (not compatible with breast-feeding) or

Clindamycin 300mg tid

• Monitor closely for clinical response • Poor response should trigger ultrasound for abscess and consideration of biopsy to

rule out carcinoma

Breast Abscess

• Infectious mastitis can evolve into an abscess

Breast Abscess

• Superficial abscess may be treated with small I&D and ½” wicking

• Deep abscess should be treated with image-guided IR drainage and indwelling drain placement

• Drainage and adequate antibiotic coverage will clear the vast majority of breast abscesses

• Surgical intervention is rarely warranted

• In lactating breast, prompt removal of the drain (3-5 days) is important to avoid milk fistula formation

The pregnant and lactating breast

• Extensive hyperplasia, increased metabolic activity, thickened texture create a difficult exam

• Do not ignore masses in the pregnant or lactating woman!

• Evaluation by ultrasound is always safe

• Pregnancy-associated breast cancer: – 1 in 3000 pregnancies

– Breast cancer during pregnancy or first postpartum year

– Most common pregnancy-associated malignancy

Non-Infectious Mastitis

• AKA idiopathic granulomatous mastitis (IGM)

• Inflammatory autoimmune condition of the breast tissue

• Etiology poorly understood • May be be linked to Corynebacterium infection • Trauma to the tissue may precede presentation

• Presents with multiple, waxing/waning, sterile abscesses

• Typical patient is premenopausal and otherwise healthy; affects Latinas disproportionately

Non-Infectious Mastitis

• Management is conservative

• Core biopsy to establish diagnosis and rule out malignancy

• Wound care and pain control, allow spontaneous drainage

• AVOID SURGERY

• DID I MENTION AVOID SURGERY?

• High dose prednisone taper for severe cases

• Most cases are self-limited

Don’t Miss a Clinical Breast Cancer

• Hard, fixed, enlarging mass

• Skin or nipple puckering/retraction

• Enlarged axillary lymph node

• Rash on nipple/areolar complex

• Bloody nipple discharge

• Atypical breast infection

Don’t Miss a Clinical Breast Cancer

• When in doubt, IMAGE • Diagnostic mammogram and ultrasound

• Carefully describe focal findings on imaging order

• When in doubt, REFER • Negative imaging with persistent mass

• Worrisome examination

• Worried patient

• High risk family history

American Society of Breast Surgeons: www.breastsurgeons.org

Screening Mammography

• Two view x-ray examination of an asymptomatic person

• “Digital” refers to the image quality • Most mammos are now digital

• “3D” (aka “tomosynthesis”) refers to new technology allowing multiple views of the breast • Decreases false negative and false

positives, esp in women with dense breasts

Mammo: Who? How Often?

• USPSTF, ACS, and ACR all DISAGREE

• Average risk women may start at 40 and should start by 50

• Repeat every 1-2 years • Annual examinations save more life/years and also increase the number of false positives

• Stop at 75 or life expectancy < 10 yrs

• Women at increased risk should start at 40 and have annual studies • Family history • Personal risk factors: nulliparous, overweight, sedentary, dense breasts with prior biopsies,

postmenopausal hormone replacement therapy • Tyrer-Cuzick modeling

How to Talk to Patients about Mammographic Screening

• FIRST: know her risk • Tyrer-Cuzick can be run in about 90 seconds with patient participation and

produces a printable risk assessment

• SECOND: assess her risk tolerance • Increased screening decreases false negatives and increases false positives • Which “false” seems worse to her?

• THIRD: present options in terms of balance of risks and benefits • The decision is a choice to tolerate one of those risks over the other • Cost of false negatives/no screening: increased stage at diagnosis • Cost of false positives: anxiety, intervention, procedural risks, possible over-

diagnosis

What about Radiation exposure? • Minimal exposure from screening and

diagnostic studies

• Annual mammo x 40yrs = one PET/CT scan

• Significantly greater exposure from daily activities and background

• Risk of cancer from mammographic radiation exposure 1:125000

What about “DENSE” breasts?

• Breast density is the ratio of fibroglandular to fatty tissue in the breast

• It is a fixed characteristic, independent of body weight and breast size

• Breast density will decrease slightly with age in the absence of HRT

• Important for two reasons: • Increased density = decreased mammographic sensitivity (more false negatives)

• Dense breasts are an independent risk factor for breast cancer

• Women with dense breasts should still have mammograms • Improved detection with 3D mammo

Breast Density

What does this mammogram report mean?

• Type of mammogram

• Breast density

• Location and size of any findings

• Interval change from priors, if available

• BIRADS score • Recommendation for additional

management

Ultrasound for breast imaging

• Ultrasound is a powerful diagnostic tool

• Ideally used in the setting of a palpable finding or a known imaging target (abnormal screening study)

• As a screening tool, it has significant disadvantages • High false positive rate • Very operator dependent • Some false negatives (esp calcifications)

• Safe and reasonable for diagnosis in virtually every circumstance: children/adolescents, pregnancy/lactation, very elderly/disabled

Screening MRI

• Breast MRI is a powerful tool due to contrast enhancement and high level of resolution

• Screening MRI: lowest false negatives, highest false positives of any screening approach • Therefore reserved for high risk

women

• Adjunct to mammography, not replacement, in this population

Does Breast Screening Save Lives?

YES

• Population based studies of mammography demonstrate ~30% decreased disease-specific mortality in randomly selected screened populations

• Breast cancer specific mortality has declined by 39% from 1989 to 2015

• Women aged 40-74 who have mammograms are less likely to die of breast cancer than those who do not screen

NO

• Localized breast cancers have increased in incidence without a commensurate decline in advanced cancers, suggesting over-diagnosis

• 10 year survival is 23% better in regional (stage 2B-3C) cancers but only 10% better in local (stage 1A-2A) cancers, suggesting better treatment is mostly responsible

Does Breast Screening Save Lives?

• There is likely more overall benefit in screening women at increased risk of breast cancer

• Younger women have higher risks from screening but more life-years saved

• Annual mammography uptake may be a proxy for better overall health participation, including better breast cancer treatment for women who are diagnosed

• Early detection can reduce the burden of treatment even if overall mortality is unchanged

• Over-diagnosis is real, but identifying women who can forgo or have minimal treatment is a work in progress

Take Home Messages

• Most breast symptoms are not breast cancer, AND not missing a breast cancer is critically important

• Stepwise, clinically-driven evaluation of all symptoms

• Annual screening mammogram is still the standard of care • Individualized discussion based on risk and risk tolerance

• Know your friendly neighborhood breast surgeon and local multidisciplinary breast cancer program

Case #1: 43yo with family history

• 43yo G3P2, otherwise healthy, comes in with pneumonia. She describes prolonged stress due to caring for her mother who is undergoing chemotherapy for breast cancer

• She reveals a family history of breast cancer in her mother at 68, maternal aunt at 61 and a maternal first cousin at 48

• Normal screening breast examination today

• She has never had a mammogram

Case #2: 62yo with palpable mass

• 62 yo G0, postmenopausal on HRT since age 51, presents with a palpable right breast mass. She is not sure how long it has been there and reports it is painless

• Mass is 2cm, indistinct, no adenopathy. Exam complicated by extensive bilateral nodularity consistent with her known history of fibrocystic change

• Last mammo 3 years prior was normal

Case #3: 22yo with a palpable mass

• 22yo G0, college student, on OCPs, presents with a left breast mass

• First noted 3 months prior, painful at times

• On exam: 2cm firm, smooth, round, mobile mass in left outer central breast. Otherwise normal examination bilaterally

Case #4: 35yo with breast pain

• 35yo G3P3 with bothersome bilateral breast pain for 6-12 months, right greater than left

• Not sure if her pain is cyclic since she has a Mirena IUD for contraception. Bothers her while exercising. Does not want her kids to hug her due to pain. Interfering with her sex life

• Examination normal, bilateral tenderness to palpation

Case #5: 55yo with abnormal mammogram

• 55yo G2P2 postmenopausal not on HRT

• Normal screening breast examination at last clinic visit

• Abnormal mammogram showing 1.5cm of microcalcifications

• Biopsy shows atypical lobular hyperplasia

Case #6: 47yo with bloody nipple discharge

• 47yo G1P1 noticed dark staining inside her right bra a few times over last 1-2 months, now with one episode of frank bloody nipple discharge in the shower

• No history of breast trauma or surgery. No family history

• Normal examination except expressible, dark, hemoccult-positive, uniductal right nipple discharge

• Last mammogram normal 18 months ago