About 178,000 new cases of breast cancer and 43,000 deaths in 1999 and one out of every 8 or 9 women will develop breast cancer during their lifetime. Early detection definitely leads to better prognosis.

Screening options include (1) Breast self-examination; (2) Physical examination; and (3) Mammography

BREAST SELF EXAMINATION. Breast self-examination should be done by all women over age 20 every month. The best time is 5-7 days after menstruation. The breasts should be inspected in front of the mirror with the hands at the sides, overhead, and pressed on the hips to contract pectoralis muscles. In supine position, place a pillow under the right shoulder and right hand under the head. Using the three middle fingers of the left hand palpate the entire breast in circular, up and down line or wedge pattern. Repeat the same sequence on the left side with fingers of right hand. Repeat the examination of both breasts while standing, with one arm behind the head. It is harmless, inexpensive and may be beneficial.

BREAST SELF-EXAMINATION

The breasts should be inspected in front of the mirror with the hands overhead...

hands on the side and pressed on the hips to contract pectoralis muscles...

In supine position, place a pillow under the right shoulder and right hand under the head..

Using the three middle fingers of the left hand palpate the entire breast...

in circular...

in wedge pattern...

or in up and down line.

PHYSICAL EXAMINATION. About 40% of early breast cancers can be discovered physical examination. Change in size, shape, contour ,color of the skin and nipple discharge should be noticed. Palpation of the breast done with the patient seated and supine is done. Palpation of supraclavicular and axillary area should also be the part of physical examination.

PHYSICAL EXAMINATION

Inspection of the breast done with the patient seated and supine is done....

In supine position palpate the breast starting from the outer quadrants...

then the inner quadrants of the breast...

Palpation of supraclavicular and axillary area should also be the part of physical examination...

Change in size, ...

Change in shape and contour, ...

Change in color and consistency of the skin, ...

and nipple discharge should be noted. ...

MAMMOGRAPHY. About 35-50% of early breast cancers can be discovered by mammography Slowly growing breast cancers can be identified at least 2 years before clinically palpable. Two methods commonly in use: (1) Ordinary film radiography (less radiation exposure; (2) Xeroradiography. V- or Y-shaped clusters of calcifications vs. mass density with or without calcification are identified. Mammographic findings should be correlated with physical examination.

WHEN TO SCREEN. National Cancer Advisory Board (March 1997) and the American Cancer Society proposes that screening be done every 1-2 years for women in their 40s with average risk and women with high risk should seek expert medical advice on when to begin screening. Screen every year for asymptomatic women starting at age 40 and screen every year for all the women > 50 years old. Efficacy of screening in women above 70 years of age is controversial.

OTHER SCREENING OPTIONS. (1) Ultrasonography; (2) Biopsy, which can include Fine-needle aspiration cytology, Large-needle biopsy, Open biopsy. Other imaging modalities include (1) Ductography, (2) Diaphanography, (3)Thermography. Cytology of the nipple discharge should be done

DIFFERENTIAL DIAGNOSIS: (1) Mammary Dysplasia (Fibrocystic Disease; (2) Fibroadenoma of the breast; (3) Cystosarcoma phyllodes; (4) Lipoma; (5) Breast abscess; (6) Fat necrosis; (7) Galactocele; (8) Carcinoma of the breast.

MAMMARY DYSPLASIA. Painful, often multiple, usually bilateral masses. Rapid fluctuation in size is common. Frequently, increase in pain and size of the masses is noted in the premenstrual phase. Most common age is 30-50 years old. It is rare in post-menopausal women not receiving hormonal replacement. Aspiration of fluctuant masses may be needed for symptomatic treatment of pain and to rule out malignancy.

Sometimes, biopsy is needed to confirm the diagnosis Supportive treatment: (a) Good breast support; (b)Eliminate caffeine consumption; (c) Vitamin E 400 IU QD; (d) Danazol 100-200 mg BID for severe pain. The risk of breast cancer is higher in these women. These women should be followed periodically by physical examination and mammography.

FIBROADENOMA. It is the most common benign neoplasm. It usually occurs within 20 years after puberty.It does not normally occurs after menopause except in women on hormonal replacement. Typical tumor is round, rubbery, discrete, relatively movable, nontender mass 1-5cm in size. Sometimes, excision biopsy under local anesthesia is needed to confirm the diagnosis.

CYSTOSARCOMA PHYLLOIDES. Fibroadenoma-like tumor with cellular stroma that tends to grow rapidly. It may reach a large size and if inadequately excised will recur locally. The lesion is rarely malignant. In general, complete removal of the tumor should avoid recurrence. Simple mastectomy is sometimes needed to achieve complete control.

BREAST ABSCESS. During nursing, an area of redness, tenderness and induration not infrequently develops in the breast. Most commonly associated organism is S.Aureus. In the earlier stages, infection can often be controlled by oral antibiotics, dicloxacillin or oxacillin 250mg QID. You may continue nursing. If the lesion progresses to form a mass, abscess should be drained and nursing discontinued.

FAT NECROSIS. Rare lesion but often produces mass often accompanied by skin or nipple retraction. Trauma is presumed to be the cause. Tenderness may or may not be present. If untreated, the mass gradually disappears. As a rule, excision biopsy should be done to rule out malignancy.

BREAST CANCER. RISK FACTORS include:

(a) White race
(b) Increased age
(c) Family history in mother, sister or daughter
(d) BRCA1 or BRCA2 mutation
(e) Previous history of endometrial cancer, some forms of mammary dysplasia and cancer in the other breast
(f) Early menarche or late menopause
(g) Nulliparous or late first pregnancy