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    ACOG Guidelines at a Glance: Diagnosis and management of benign breast disorders

     

    Determining breast cancer risk

    The correct diagnosis for any breast complaint is clearly important for determining correct management, be it simply reassurance or excisional surgery. Another very important aspect of diagnosing a breast pathology is evaluating the patient for her level of risk for breast cancer. As the practice bulletin stresses, there are “benign” pathologies that are associated with moderate to marked risk of eventually developing breast cancer. When an atypical hyperplastic lesion or multiple papillomas are identified on a biopsy prompted by the presence of a breast mass or a mammographic finding, more aggressive treatment and a proactive cancer screening approach are indicated. A unilateral spontaneous nipple discharge also merits a tissue biopsy due to a significant risk of malignancy in the sample. Recent developments with imaging modalities and the current social media hype about celebrities encouraging mastectomies are confusing to patients and provider. Consultation with a breast specialist may be indicated for patients in the higher-risk groups to review the most current ongoing screening, diagnostic and/or treatment options with them. 

    Finally—and just as important—make this visit an opportunity to screen for risk factors for breast cancer such as obesity, family history of breast cancer (especially if BRCA 1 or 2), tallness, menopausal exogenous hormones, nulliparity, increased age at first pregnancy, and exposure to therapeutic ionizing radiation. There are protective factors that may reduce risk, such as breastfeeding. Although most of the risk factors are not modifiable there are behavioral changes a woman can make to minimize certain risks, such as weight loss, exercise, not smoking, minimizing alcohol intake, and possibly adopting a diet that is lower in fat and stresses vegetables and fruit.3 Based on her risk factors, a woman may benefit from additional screening, such as BRCA or earlier imaging. The psychology of cancer screening is challenging. Depending on a woman’s culture, fear of cancer, and anxiety level, she may or may not participate in a regular screening program as typically recommended. With the resolution of her breast complaint may come a window of opportunity to educate a woman on the role of breast cancer screening for her as an individual.4

    ACOG References

    1.   Hereditary   breast   and   ovarian   cancer   syndrome. ACOG Practice Bulletin No. 103. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:957–66. (Level III)

    2.   Breast cancer screening. Practice Bulletin No. 122. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:372–82. (Level III)

    3.   Management of gynecologic issues in women with breast cancer. ACOG Practice Bulletin No. 126. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:666 – 82. (Level III)

     

    Commentary References

     

    1.    Committee on Practice Bulletins—Gynecology. Diagnosis and management of benign breast disorders. Practice Bulletin No. 164. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2016;127:e141-56.

    2.    Sabel MS. Clinical Manifestations and diagnosis of a palpable breast mass. UpToDate 2017.  Accessed Sept 30, 2017.

    3.    Port DR. Your breasts are not a ticking time bomb. Glamour. November 2010. Accessed on Oct 7, 2017 at https://www.glamour.com/story/your-breasts-are-not-a-ticking-time-bomb

    4.    Consedine ND, Magai C, Krivoshekova YS et al.  Fear, anxiety, worry and breast cancer screening behavior: a critical review.  Cancer Epidemiol Biomarkers Prev. 2004;4:501.

     

    Sharon T. Phelan, MD
    Dr. Phelan is a Professor in the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.

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