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A 35-y.o. a woman is seen in the office with a chief complaint of a breast mass. She states she found the lump when she was in the shower, and she is quite visibly distressed. Her medical history is unremarkable, although she reports that she has not had a mammogram. She takes no prescription medications.

          Breast cancer is a progressive and invasive disease that results from “damaged DNA and genetic mutations that can be influenced by exposure to estrogen (Alkabban & Ferguson, 2019). Breast cancer risk factors include age; family history; and reproductive factors such as early menarche, late menopause, late age at first pregnancy, and low parity (Sun et al., 2017). Both exogenous and endogenous estrogen, as well as lifestyle factors such as alcohol consumption and too much dietary fat, also increase the risk of breast cancer (Sun et al., 2017).

What additional questions should you ask the patient and why?

          Although the patient’s history is unremarkable, information regarding patient’sage at menarche, the number of pregnancies, if any,  as well as any family history of breast cancer and lifestyle factors precursors of breast cancer,  should be obtained.

What should be included in the physical examination at this visit?

          The American Cancer Society discourages regular breast palpation for screening (American Cancer Society, n.d.), but in this case, since the patient has already identified a mass on her breast, in my opinion, breast examination is granted. The practitioner should document all findings related to the mass, including texture, consistency, mobility, and whether there is tenderness (Alkabban & Ferguson, 2019).

What are the possible differential diagnoses at this time?

Possible diagnosis includes:

• Fibrocystic disease or cyst
• Fibroadenoma
• Breast cancer
• Intraductal papilloma
• Lipoma
• Breast abscess (mastitis)
• Fat necrosis
• Phyllodes tumor

What tests should you order and why?

          According to (Alkabban & Ferguson, 2019), the “evaluation of patients with breast cancer needs triple assessment using clinical evaluation, imaging, and tissue biopsy”. Because of the patient’s age, mammograms may not be sensitive enough, therefore, an ultrasound or an MRI would be better options. Ultrasounds are effective to determine characteristics of the mass such as “consistency and size” whereas MRIs are effective in “in describing abnormalities” and are indicated in “occult lesions or if there is a suspicion of multifocal or bilateral malignancy especially ILC” (Alkabban & Ferguson, 2019).

How should this patient be managed?

          Treatment will depend on the diagnosis. Although at this point the is no definitive diagnosis, the patient should be made aware that in the event the mass turns to be cancer “the 2 basic principles of treatment are to reduce the chance of local recurrence and the risk of metastatic spread (Alkabban & Ferguson, 2019).”

References

Alkabban FM, Ferguson T. Cancer, Breast. [Updated 2019 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482286/

American Cancer Society (n.d.). American cancer society recommendations for the early detection of breast cancer. Retrieved from https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html

Sun, Y. S., Zhao, Z., Yang, Z. N., Xu, F., Lu, H. J., Zhu, Z. Y., … Zhu, H. P. (2017). Risk Factors and Preventions of Breast Cancer. International journal of biological sciences, 13(11), 1387–1397. doi:10.7150/ijbs.21635