8/3/2014

Significance

1 in 8 women who live to be 80 years of age will develop breast Breast Health Update cancer in their lifetime (NCI)
Breast cancer is the second-leading cause of cancer death among Kristin Metcalf-Wilson women in the United States DNP WHNP-BC (USPSTF)

Taking a Breast Health History Disclosures

Nothing to disclose
Breast health history should be completed with a WWE
Include family and personal Hx of breast and ovarian cancer
Hx of lobular carcinoma in situ and/or atypical hyperplasia
Hx of radiation to the thoracic cavity

Breast Health Update Breast Health History

Identify evidence based routine screening
There are many risk assessment guidelines for women of all ages.
Identify the elements of a relevant breast tables available. health history for women during a routine www.cancer.gov/bcrisktool/ WWE and counseling women on risk and genetic counseling. PPFA has Breast Cancer Risk screening
Demonstrate comprehensive clinical self Questionnaire breast exam (CBE) and appropriate You should consider incorporating it into documentation, referral and follow up your EHR. actions.
Interpreting mammogram results and For example if you answer yes to specific developing appropriate follow up plans. questions it would prompt further questions or recommend genetic counseling

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Average Risk Screening CBE

• Annual Mammogram starting at age 40(ACS)
Length of exam varies based on size of breast and clinician technique • Clinical Breast Exam (CBE) every 1-3 years from the age of 21-29 then annually
All CBE should include inspection at age 40 and beyond and palpation in different positions. • If it is established that the patient is above average risk the CBE may be more frequent and/or imaging started at an earlier age. • Controversy in screening and BSE

Clinical Breast Exam Inspection

Discover suspicious/ non suspicious
Looking at breast in a seated breast changes position
Evaluate changes discovered by the
Symmetry patient
Skin changes
Nipple changes
Dimpling

CBE Positions

Women in their 20s and 30s should
Arms above the have a clinical breast exam (CBE) Head to check for as part of a periodic (regular) health contour. exam by a health professional
Symmetry preferably every 3 years. Starting at age 40, women should have a CBE by a health professional every year. (ACS)
When a patient has physical symptoms or concerns
As follow up from previous clinical

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Position Examine Breast Tissue

Hands on hips
Patient should be in supine position
Check for dimpling with arm over head. or retractions
Knees may be bent and fall to opposite side for larger breasted women
Pillow or towel under hip for comfort

Supraclavicular and Axillary Nodes Examine Breast Tissue

Breast exam should include:
Blouse seam
Below bra-line
Breast Bone
Collar Bone
Mid Axillary line
Using a vertical strip pattern starting at axilla

Things to remember

Mastectomy get the same exam perimeters including palpating scar tissue
The vertical strip method is like a lawn mower pattern. Using overlapping strips WITH THE ARM DOWN, THESE FOUR AREAS SHOULD BE ASSESSED LIKE A
Pressure should be applied at 3 PYRAMID. THE TOP OF THE PYRAMID levels BEING THE APICAL NODES  Light  Medium  Deep

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Breast Documentation Documenting Breast Mass

Normal findings should include
Symmetry
Tenderness
Presence of a mass
Skin changes
Nipple changes
Lymph nodes Most common reads as ; bilateral breasts are symmetrical, nontender, no suspicious masses, skin or nipple changes or lymphadenopathy are noted on exam.

Documentation Referral and follow up

If there are abnormal findings they
All patients with abnormal finding typically fall into 4 categories should be informed of the plan to
Inspection include: symmetry, further evaluate the findings. retraction, dimpling, color
Chart completeness is essential for
Nipple discharge: color, both quality and continuity of care consistency, number of ducts but also for liability involved, location and unilateral of bilateral
Routine screening and breast self
Lymphadenopathy awareness
Breast Mass

Breast Mass Documentation Managing results

Location and Size are essential
Understanding the BI-RADS system
Shape, Tenderness, Margins,
Utilize both the imaging results and Consistency, and Mobility are additional components to note. the CBE information
The Location description should
Understand the latest evidence- include both a narrative and a based recommendations for further drawing. testing and referring to breast
It should note the side where the mass specialist. was found, its location as a clock face description, and the distance from the areolar edge (in cm). Note the size of the mass in 2 dimensions as 2 measurements (in mm).

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BI RADS Categories Category 4 – Suspicious

BiRads 1- negative
Abnormality – Biopsy Should be
BiRads 2- Benign findings Considered: Findings that do not have the classic appearance of
BiRads 3- Probably benign findings malignancy but have a wide range
BiRads 4- Suspicious abnormality of probability of malignancy. Can be
BiRads 5- Highly suggestive of subdivided into 4A – low suspicion, Malignancy 4B – intermediate suspicion, 4C –
BiRads 6- Know Cancer moderate suspicion.
BiRads 0- Additional evaluation needed

BI RADS 1 and 2 BI RADS 5 and 6

Category 1 – Negative: Nothing to
Category 5 – Highly Suggestive of comment on. Malignancy – Appropriate Action
Category 2 – Benign Findings: Should be Taken: These lesions Normal but the radiologist may have a high probability (greater include a benign finding such as than 95 percent) of being cancer. calcifications, fat-containing lesions,
Category 6 – Proven Malignancy: lymph nodes, etc. Not often used, usually in cases of biopsy-proven cancer prior to definitive therapy

Category 3 – Probably Benign Category 0 – Need Additional

Finding – Initial short-Interval
Imaging Evaluation and/or Prior Follow-up Suggested: Used for a Mammograms for Comparison: This lesion that is not definitely benign & recommendation may include spot can be safely followed with short- compression, magnification views, term imaging surveillance rather special mammographic views than biopsy. These lesions carry a and/or ultrasound. If available, a less that 2 percent likelihood of mammogram should be compared malignancy to previous studies for stability.

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MRI vs Ultrasound

US used to evaluate a palpable mass with
neg mammo,
density of breast is distorting the image of the mass MRI is used to evaluate
extent of the lesion
Determine metastasis, response to treatment
Patients in whom prior studies or clinical findings are inconclusive

References

U.S. Preventive Services Task Force (2009). Screening for breast cancer: USPSTF Recommendation Statement. Annals of Inter Med: 151(10): 716-25.

American Cancer Society http://www.cancer.org/cancer/breastcancer/moreinformation/br eastcancerearlydetection/breast-cancer-early-detection-toc

AHRQ http://www.guideline.gov/syntheses/synthesis.aspx?id=39251

The American College of Radiology BI-RADS® ATLAS, 5 th ed (Updated 6/24/14)

Breast Cancer Screening and Diagnosis Algorithms http://qap.sdsu.edu/

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