Talk to Your Patients About Breast Disease

Abstract

You have been caring for a 32-year-old woman for the past several years. She presented to your office 2 years ago because she noticed a new breast nodule. You examined her and noted marked breast density at her area of concern without an obvious mass. To be thorough, you referred her for mammography; the report stated that the breasts were asymmetrically dense without a distinct mass. You reassured her that her evaluation was negative. Two years later, the patient returned with an obvious mass at the same site. Biopsy revealed an infiltrating ductal carcinoma. Over the next 6 months, she is treated with lumpectomy, axillary node dissection, chemotherapy, and radiation. Shortly thereafter, you receive a letter from her attorney asking for your records. The patient claims that your care resulted in a delay in diagnosis of her breast cancer.

Although a fictitious case, this nightmare scenario demonstrates several pitfalls in the management of breast health and disease. Avoidance of this adverse outcome (both for the patient and the practitioner) requires that the nurse practitioner (NP) learn and adhere to accepted principles and practices.

Breast disease encompasses a myriad of different conditions. These disorders can be stratified not only as benign or malignant, but also as potential risk or realized disease. According to the American Cancer Society (ACS), breast cancer is the second leading cause of death among North American women. 1 In 2007, an estimated 178,480 new cases of invasive breast cancer will be diagnosed in U.S. women as well as 62,030 new cases of carcinoma in situ. 1 The number of women diagnosed with benign breast diseases can be counted in the millions. The initial management of breast issues often rests with the NP, whose responsibilities include risk assessment, screening, clinical evaluation, limited treatment, and triage. In patients already diagnosed and treated for breast malignancies, the NP should provide support as well as surveillance for recurrent disease.

The vast amounts of emerging literature and changing treatment algorithms can present a complex array of information. The goal of this article is to provide a reasonable framework for the management of breast disease in the primary care setting.


A Reality Check

Failure to diagnose breast cancer in a timely manner is the most frequent cause of malpractice litigation involving breast disease in the United States. 2 In their report, the Physician Insurer's Association noted that 68% of women who successfully litigated with the claim of a delay in diagnosis of their breast cancer were younger than 50 years of age, and most (59%) had a self-discovered mass that the healthcare provider did not pursue aggressively. 2 In about 80% of the cases in this study, the first mammogram was negative or equivocal. Of the patients who received a second mammogram, 61% of results still failed to diagnose cancer. The average length of time from discovery of the mass to actual diagnosis was 14.4 months.

While most in the medical community know how difficult it can be to diagnose breast cancer in some cases, this concept is frequently lost on the patient population, who are often led to believe that all breast cancers can be detected at a curable stage if the patient has a competent provider and appropriate imaging studies. There is also an expectation that providers should always be able to tell a patient if she has a breast cancer. Therefore, if a cancer is found at a larger size or less treatable stage, this is a reflection of poor care. It follows that regular mammography and breast examination can detect all cancers when they are tiny, and that tiny cancers never behave aggressively.


Figure. Genetic Pedigree of a Patient with Breast Cancer

The fact is that there are limitations to all screening methods. Further, the biology of a given breast cancer may surpass the ability to control it. The most intense screening, the best healthcare providers, and the most aggressive preventive measures will not prevent all breast cancer deaths. Notwithstanding, early diagnosis is often beneficial, and means to obtain it should be encouraged. How then does the NP navigate these waters with patients? Education is the key, beginning with a frank discussion of the realities of breast disease, including the benefits and limitations of screening and treatment.


Risk Factors

All women are at risk for breast cancer. According to the ACS, approximately 1 in 8 women (13%) will be diagnosed with breast cancer in their lifetime, a risk that increases with advanced age. 1 Although nearly 70% of women who develop breast cancer have no identifiable risk factors, it remains important to identify those at higher risk. 3 Women at highest risk are those who have had a previous breast cancer and those who have a family member with the disease, especially a male or premenopausal female relative.

One risk factor for developing breast cancer is dense breasts. The risk is reported to be linear: for every 1% increase in density, the relative risk will increase 2%. 4 Note that most women younger than 40 years of age have dense breasts, which makes this risk factor somewhat confusing.

While some risk factors, such as genetic makeup, are not controllable, others can be modified. These include risk associated with environment, hormonal status, and lifestyle.


Family History

As mentioned, women who have a family or personal history of breast cancer are at increased risk, especially with disease on the maternal side of the family and with the number of women affected. Genetic alterations contribute to 5% to 10% of all breast cancers; 5 another 15% to 20% of breast cancers have a strong family history without genetic abnormalities (see Table : “Genetic Pedigree of a Patient with Breast Cancer”).


Table. Genetic Diseases that Can Cause Breast Cancer

In the last 2 decades, two breast cancer genes have been discovered and characterized, BRCA1 and BRCA2. These serve as tumor suppressor genes; both produce large proteins that repair damaged DNA. The autosomal dominate inheritance of one defective allele is enough to promote tumorigenesis. 6 Women who have the BRCA1 gene mutation tend to have a high incidence of breast cancer (often at a young age), have bilateral cancers, and are at increased risk for ovarian cancer. The BRCA2 gene mutation is less common, but affects both men and women later in life. Women carrying the BRCA1 or BRCA2 mutations have a lifetime risk of breast cancer as high as 80% and a 10% to 15% incidence of ovarian cancer. 7

If the woman is at risk for an inherited genetic alteration, genetic testing can be considered. The American Society of Clinical Oncology recommends that cancer predisposition testing be offered only when: 1) the patient has a strong family history of cancer or very early onset of the disease; 2) the test can be adequately interpreted; and 3) the results will influence the medical management of the patient or family member. 8 If a woman decides to undergo genetic testing, she may be referred to a genetic counselor and/or an oncologist. Genetic testing raises a multitude of medical, social, psychological, and ethical issues which are best managed by a trained and experienced professional.

There are several other known genetic conditions that predispose a woman to increased risk of developing breast cancer, although the risk is minimal (see Table : “Genetic Diseases that Can Cause Breast Cancer”).

In addition, the National Cancer Institute (NCI) reports white, non-Hispanic women have the highest incidence of breast cancer among U.S. racial/ethnic groups, while American Indians have the lowest incidence. African-American women have the highest incidence of mortality from breast cancer; Asian-American women have the lowest mortality from breast cancer. 9


Hormonal Factors

Because of their unique role in relation to pregnancy and lactation, the breasts are exquisitely sensitive to their hormonal environment, which plays a role in the development of breast cancer. Evidence suggests that some breast cancers may be caused by long periods of uninterrupted exposure to estrogens. For example, women with a history of early menarche, menopause at an older age, and women who are nulliparous have had longer exposures to estrogen. The Gail model 10 is a risk assessment tool that calculates a composite relative risk of developing invasive breast cancer. This model is weighted to the hormonal and family history factors that place a woman at higher risk for breast cancer. These risk factors include age, age at menarche, age at the first live birth, family history of breast cancer, and the number of previous benign breast biopsies. Women are considered to be at high risk with values of 1.67% or greater.

The Gail model has several limitations in the assessment of genetic risk factors for breast cancer. These can be addressed with the risk assessment tools for BRCA1 and BRCA2 at http://www.myriadtest.com .

Women who use hormone replacement therapy (HRT) are also at higher risk for breast cancer. The Women's Health Initiative studied more than 160,000 postmenopausal women with an intact uterus; one group took estrogen and progesterone HRT and a control group did not take HRT. 11 The results at 5 years showed an increased risk of breast cancer as well as myocardial infarction, stroke, and thrombosis in the HRT-treated group compared to the control. According to this study, the absolute excess risk per 10,000 women-years attributable to estrogen plus progesterone HRT were: seven more coronary heart disease events, eight more strokes, eight more pulmonary emboli, and eight more invasive breast cancers. 11 These findings present a dilemma; what is the best way to treat the sometimes debilitating symptoms of menopause?

Many studies have assessed the risk of developing breast cancer and oral contraceptive (OC) use. Meta-analysis of 54 studies found only a slight relative risk of breast cancer (1.24) and OC if used less than 10 years. Ten years after the cessation of OC use, the relative risk equaled that of women who had not used OC. A persistent increased risk of breast cancer was found among women who started OC before the age of 20 years and used them over 10 years (1.22). 12


Lifestyle Issues

Recent research has found some correlations between lifestyle factors and the risk of breast cancer. Fortunately, this is an area where risk can be reduced.

Studies have shown that even moderate alcohol consumption can increase the risk of breast cancer. A study of more than 51,000 women found that alcohol consumption over 10 grams/day (one or more drinks) was associated with an increased relative risk (2.36) of estrogen-positive breast cancer. 13

Obesity is also a risk factor for developing breast cancer. Eliassen et al. continued the work of the Nurses' Health Study that correlated weight gain with postmenopausal breast cancer mortality. The current study followed women age 18 years and older into menopause. The survey studied weight gain or loss as well as the use of HRT and found that compared to women who maintained weight, women who gained more than 25 kg since age 18 years had an increased risk of postmenopausal breast cancer of 1.4; those who gained more than 10 kg since menopause had an increased risk of 1.18. Those who had never taken HRT or who lost more than 10 kg had a decreased relative risk of 0.43. 14


Figure. Breast Examination Techniques

Regular exercise can reduce the risk of developing breast cancer and may be attributed to decreased BMI in individuals who exercise regularly. Friedenreich reviewed 23 published cohort studies and 32 case studies which analyzed the association between physical activity and the risk of breast cancer. Estimates of protection ranged from 30% to 40%. Most of these studies found the largest risk reduction in postmenopausal women. 15 The amount of exercise varied between studies.

While the NP has many valid reasons to encourage patients not to smoke, there has been no credible evidence that tobacco use increases the risk of breast cancer.

Radiation exposure, in certain circumstances, has been associated with breast cancer. This is especially a problem for young women whose breasts are developing. Each breast lobule originates from a singe cell. If one of these cells is damaged by radiation, then the cell division that occurs during puberty could increase the risk of developing breast cancer. A cohort study of more than 1,800 female survivors of a childhood cancer, who received a mean dose of 5.06 cGy (an average of 20 sessions) of radiation during treatment, found 2.8% and 5.1% cumulative incidence of breast cancer in the ensuing 30 and 40 years respectively. 16 In this study, the risk of developing breast cancer was higher for children who had been treated for Hodgkin's disease or neuroblastoma.

To put the risk of radiation exposure into perspective: the average dose of radiation used for mammography is 0.4 cGy for the total examination, the total dose for a chest X-ray is 0.025 cGy, and the average dose for a head computerized tomography is 2 cGy. If a woman received yearly mammograms for 10 years, the average total radiation dose would be 4 cGy. 17


Screening

While the benefits of screening for a disease may appear obvious, screening is only appropriate if the following conditions are met:
1. Effective treatment for the disease exists, and the outcome is improved with early detection.
2. There is a high incidence of the disease.
3. There is serious morbidity and mortality associated with the disease. 18

It is important to remember that all screening examinations have significant limitations, and NPs and patients must be realistic about the information that each exam can offer.


Self-breast Examination

Screening should begin with a self-breast examination (SBE) and patient education is essential. Among women who practice SBE, breast cancers can be detected at an earlier stage and are smaller than in women who do not do SBE. Women who regularly and competently practice SBE are more likely to find breast masses than women who do not. Note though, that there is insufficient evidence to determine whether SBE affects overall survival of breast cancer, and a SBE is no longer mandated by the ACS and American College of Surgeons. Additionally, the consistent practice of either SBE or clinical breast exam (CBE) will increase the incidence of biopsies, most of which are benign.

Document that the patient was instructed on SBE and whether or not it is performed. This documentation may be helpful if there is an allegation of diagnostic delay.


CBE

Screening should also include a CBE. The ACS recommends CBE as part of the physical examination every 3 years for women in their 20s and 30s, and yearly for women 40 years and older. Though its value is often underestimated, CBE can detect up to 45% of breast cancers. 19 CBE not only helps evaluate the patient's specific complaint, but also may identify other abnormalities of the breast or associated lymphatics. If a breast mass is detected by either the NP or the patient, it should be assumed to be malignant until proven otherwise.

A diagram of the patient's breasts should be incorporated into the medical record, which will help identify the location of the patient's lump, nipple discharge, skin changes such as erythema, dimpling, peau d'orange, or areas of pain. It is also necessary to document if the breasts were difficult to examine because of size, density, or nodularity. The exam may also be impaired by patients who are uncooperative, mentally impaired, have severe breast pain, or have breast implants.

The timing of the breast exam in premenopausal women is important. The latter half of the menstrual cycle is influenced by the secretion of progesterone, which causes the breast vasculature and ductal structures to dilate with resultant tissue engorgement. This will make the breasts very nodular and tender for some women. Thus, the optimal time for examination is within the first 5 to 10 days after the onset of menses. Pregnancy or lactation should not preclude CBE. Breast cancer is second only to cervical cancer as the most frequent malignancy in pregnancy and lactation. 20 It is important to perform a baseline breast exam of the pregnant patient, and to repeat periodic breast exams during the pregnancy and into lactation (where it is best performed 10 to 15 minutes after emptying the breast).


Imaging Studies

Imaging studies may be used as screening methodologies or to evaluate a specific area of concern. They are discussed in the screening section for convenience.


Mammography

The mammogram is the most common breast imaging modality and can be used for screening or to evaluate a specific concern. The efficacy of mammography in women younger than 50 years is controversial; these women frequently have marked breast density, as opposed to older women whose breast tissue has been largely replaced by fat. On mammography, fat is radio-opaque (gray) and denseness is radio-dense (white). Tumor masses are radio-dense as well and can easily be lost in the background of dense breast tissue. Approximately one-fourth of all invasive breast cancers in women between the ages of 40 to 49 years are missed by mammography. A large Canadian study raised further doubts on the utility of routine mammography in 40 to 50-year-old women. 21 The authors looked at women without prior mammography or a history of breast cancer. These women were randomized for several screening modalities including mammography and the effect of each modality on breast cancer death rate was measured. The authors found that screening mammography did not significantly decrease the rate of breast cancer. In contrast, an American study touted a survival advantage in breast cancer deaths in women between the ages of 40 to 49 years who received screening mammography, albeit less than those between 50 to 74 years of age. 18 At present, the current recommendations of the ACS include a yearly mammogram starting at age 40 and continuing for as long as a woman is in good health. 22

Imaging studies may be particularly problematic in the nearly two million women in the United States who have undergone breast augmentation mammoplasty. All implants appear radiopaque on film, which hides a portion of the adjacent parenchymal tissue. Breast tissue is displaced and condensed, hindering the detection of abnormalities. Breast implants are less compliant than breast tissue, making the level of compression required during mammography nearly impossible. Finally, implants can cause artifacts that may be confused with breast malignancies. NPs should refer patients with implants to appropriate centers certified in the special needs of these patients. In some circumstances, magnetic resonance imaging (MRI) may be a more appropriate imaging study in this population.

Mammography does have potential harms. False-positive results increase surgical interventions for biopsies and lumpectomies. False-negative results can delay the diagnosis of breast cancer. As previously mentioned, there is also a small dose of radiation associated with mammography, which should not be dangerous if guidelines are followed.

The NP needs to document a referral for mammography and its results. If the study was obtained to evaluate a palpable mass, the NP should make follow-up appointments and/or referrals as needed; these should not be precluded by a negative mammography result.


Figure. Aspiration


Ultrasound

Although ultrasound (US) is not a primary screening tool in the detection of breast cancer, it can help evaluate breast lesions. US can distinguish whether a mass is cystic or solid (which mammography cannot), and can identify lesion characteristics suspicious for malignancy. Occult lesions that were missed on mammography may be found using sonography, particularly in women with dense breasts. US and mammography may also be used synergistically. A study conducted by Kolb and colleagues found US in combination with mammography had a sensitivity of 97% in detecting lesions with dense breasts. 19

US is not without limitations; the quality of a study is notably operator-dependent. US views only a small section of the breast at a time because it is time consuming to evaluate the entire breast, particularly in women with larger breasts. If the radiologist is not present during the exam, the segmental nature of the images renders the study more difficult to interpret.


MRI

MRI has an advantage over US in the evaluation of the entire breast. Over the past 2 decades, breast MRI has made remarkable advances. MRI can be very helpful in high-risk patients suspected of having breast cancer whose mammogram and US results are negative or difficult to interpret. MRI can also detect lymph nodes that may be enlarged and are suspicious for malignancy. The ACS has developed recommendations for MRI screening based on the woman's lifetime risk of breast cancer. 22

MRI has distinct disadvantages and should not be used as a first-line screening test for breast cancer. It is far more expensive and requires specialized training to interpret; MRI is sensitive in detecting lesions of the breast, but the enhancement characteristics and morphologic appearance of benign and malignant lesions are similar, which increases the potential for negative biopsies; the usefulness of MRI in detecting invasive lobular carcinoma remains unproven; and finally, unlike mammography or US, it is still technically difficult to biopsy a suspicious lesion under MRI guidance.


Office Management

The assessment of breast health and disease begins with a complete history. The NP should ascertain the patient's risk factors for breast cancer, prior biopsies, and previous breast screening results. Any specific complaint should be thoroughly explored. Appropriate breast examination requires strict adherence to detail. 23 A chaperone should be present for all breast exams.

The exam begins with the patient sitting with arms at her side. The examiner will look at the size, shape, symmetry, color, texture of the breasts, the presence of skin retraction or peau d'orange, and conditions of the nipples. This is also done with the patient's arms over her head. In the sitting position, the examiner will palpate the axillary, supraclavicular, and infraclavicular lymph nodes. Next, the patient is examined in the supine position, placing the ipsilateral arm up and under her head. Using the pads of the fingers, examine the entire breast selecting a pattern of search: circular, wedge, vertical, or a horizontal pattern. The nipples and areola complex should be gently squeezed to elicit a discharge. Thoroughly document the results of the exam, using a drawing of the breasts to illustrate the location of any findings. The examiner can provide patient teaching while conducting the exam. Demonstrate and discuss how the SBE should be conducted as well.


Breast Mass

If a mass has been discovered by CBE or SBE, attempt to determine the nature of the lesion. Ask how long the mass has been present, if it has changed in size, or if it is tender. Typically, a benign mass is more mobile and will have defined borders. Malignant masses tend to be harder, have irregular borders, and are less mobile. Fine needle aspiration may be performed on the mass. After cleansing the skin, (local anesthetic is not needed), the lesion is pierced using a 22- or 23-gauge needle attached to a 3 to 5 mL syringe. If fluid is aspirated, is yellow or green, and the lesion disappears, it is a benign breast cyst and no further action is required. If the fluid is bloody, the lesion is still present, or if it recurs, surgical consultation is necessary. If no fluid can be aspirated, the needle may be passed several times through the lesion with a constant suction applied to the syringe. The goal is to disperse cells from the mass into the barrel of the needle. These cells are then expelled onto a slide, sprayed with a fixative, and sent to cytology. Imaging studies should be performed unless the lesion was a simple cyst. The tests should be scheduled 2 to 3 weeks after aspiration to allow any bruising to resolve, which would otherwise confuse the interpretation of the study. These women should then be referred to a general surgeon with experience in the management of breast disease or a breast surgeon.


Mastalgia

An estimated 70% of women will experience breast pain at some point in their lives. Mastalgia is a common complaint in premenopausal women, and is typically caused by hormonal fluctuations and usually cyclical. Most mastalgias will resolve spontaneously in a few months. Breast pain and tenderness begin with ovulation and continue through menses. Noncyclic pain is more difficult to evaluate and treat than cyclic pain. The differential diagnosis includes pain of cardiac, musculoskeletal, pulmonary, or gastrointestinal origin. Women 40 years and older with mastalgia should have a screening mammogram; this can be avoided if women are under 40 years, not high-risk, and have a normal clinical exam. Giron et al. reported on data from 6,047 breast cancer patients surveyed by the National Comprehensive Cancer Network. Mastalgia alone was the reason for evaluation in 186 patients. Of those, 60% had an abnormality on physical exam and 24% had a radiologic abnormality demonstrating cancer at the site of pain. 24 This suggests that mastalgia alone is an unusual symptom of breast cancer but does need to be fully evaluated.

Many treatments have been recommended for mastalgia, such as vitamins A, E, and B, low-fat diets, and evening primrose oil (gamolenic acid). The literature has been mixed on all of these treatments. Most practitioners would recommend a well-fitting bra, regular exercise, and elimination of methylxanthines (tea, coffee, cola, and chocolate).

The Food and Drug Administration (FDA) has approved only two medications for the treatment of mastalgia, bromocriptine (Parlodel) and danazol (Danocrine). Use of both drugs should be limited to women who are not pregnant or taking OC or other hormones. Bromocriptine is a dopaminergic agonist that inhibits the release of prolactin from the pituitary. Its side effects include headaches and dizziness. Danazol is a synthetic testosterone and side effects include hirsutism and acne.

Tamoxifen is an effective treatment for mastalgia. This indication for tamoxifen has not been approved by the FDA due to significant side effects seen with long-term use of the drug (see Table : “Tamoxifen Side Effects”). The use of tamoxifen for pain beyond 3 months is not recommended.


Table. Tamoxifen Side Effects


Nipple Abnormalities

Nipple discharge is the third most common breast complaint. Nipple discharge that is worrisome for malignancy is typically unilateral, spontaneous, and bloody (either grossly or by hemoccult testing) and may occur in conjunction with a palpable breast mass or asymmetric thickening. Bloody nipple discharge is associated with a malignancy in approximately 75% to 80% of cases, and the incidence increases with age. 25 Green or yellow nipple discharge is usually representative of fibrocystic changes and does not require biopsy. Patients with watery or bloody nipple discharge should be referred to a general surgeon. An excoriated nipple may be secondary to trauma or a benign dermatologic condition such as eczema. However, if the skin lesion persists, Paget's disease of the breast, which is a malignancy of the nipple, should be considered and the patient referred to a surgeon.


Breast Inflammation

Women with inflammation of the breast can present a diagnostic dilemma. Inflammatory breast cancers (IBC) are often initially misdiagnosed, leading to a delay in diagnosis. Women with IBC present with pain and a rapidly progressing tender, firm, enlarged breast. The skin over the breast is warm and thickened with erythema and peau d'orange appearance. These women may or may not have a palpable breast mass. These symptoms can be confused with cellulitis, mastitis, or a breast abscess.

IBC accounts for only 0.5% to 2% of invasive breast cancers; however, IBC is a rapidly progressive tumor with a high propensity for early metastatic spread. The median survival of women with IBC versus women with other types of locally advanced breast cancers is 2.9 versus 6.4 years. 26

Women with these symptoms need to be monitored closely; if there is any doubt about the diagnosis, refer promptly to a breast surgeon.



Figure. Paget's Disease of the Nipple


Abnormal Imaging Studies

On occasion, a patient will present solely on the basis of abnormal imaging studies. Breast lesions found by mammography can range from benign to suspicious to highly suggestive of a malignancy. Radiologists use the Breast Imaging Reporting and Database System (BI-RADS) to categorize mammograms.
Category 0 = additional imaging needed
Category 1 = negative
Category 2 = benign-appearing abnormality
Category 3 = probably benign/possibly malignant
Category 4 = suspicious for malignancy
Category 5 = malignant until proven otherwise.

In the absence of a suspicious finding on examination or an area of concern to the patient, a mammogram categorized as BI-RADS 1 or 2 can be followed at routine intervals, BI-RADS 3 studies should be repeated in 3 months, and BI-RADS 4 or 5 should be referred to a general surgeon.

Likewise, if a US has been utilized to assess a breast mass or an area of asymmetric density on exam or mammography, a positive result should prompt a surgical referral.


Prevention

To be complete, an evaluation of breast health should include patient education about the methods and limitations of prevention and screening strategies.

Preventive measures controlled by the patient include maintaining ideal body weight, regular exercise, limiting alcohol intake, and avoiding HRT (if possible). Although regular screening does not prevent breast cancer, it may prevent an early death caused by breast cancer. There is much controversy surrounding the use of SBE, CBE, and mammography to reduce mortality from breast cancer. If a breast malignancy is diagnosed before a tumor spreads to the lymph nodes or other areas, the chance for long-term survival is improved. The biology of the breast malignancy may be the ultimate determining factor in overall mortality. Some tumors are so aggressive that no matter how early the breast mass is found or how aggressive the treatment, the outcome will be poor.

If your patient is at significantly increased risk for developing breast cancer, chemoprevention or surgical options can be considered. The only drug the FDA has approved as a chemoprevention agent for the reduction of the incidence of breast cancer in high-risk women is tamoxifen. It is important to note that tamoxifen does not eliminate the risk of developing breast cancer. In a study of more than 13,000 women whose risk of developing breast cancer was more than 1.6%, tamoxifen reduced the risk of invasive breast cancer at 5 years by 49%. 24 The reduction of estrogen receptor-positive tumors was 69%, and there was no difference in the reduction of estrogen receptor-negative tumors. The difference in the risk of invasive breast cancer in the tamoxifen group at 7 years was only 14%, however. This difference was due to the decrease in breast cancer in the placebo group, not an increase in breast cancer in the tamoxifen group. 24

Several other drugs have been studied for chemoprevention of breast cancer. 27 Raloxifene (Evista), a drug used for women with osteoporosis, was postulated to prevent breast cancer. A 5-year study comparing tamoxifen to raloxifene was conducted by the National Surgical Adjuvant Breast and Bowel Project that included 19,747 postmenopausal women who were at an increased risk of developing breast cancer. At a follow-up of 4 years, there were 57 invasive breast cancers among women taking tamoxifen and 81 among women taking raloxifene. The side effects of raloxifene were less than those seen with tamoxifen. There were 36 cases of uterine cancer in the tamoxifen group compared to 23 in the raloxifene group. Furthermore, there were 141 thromboembolic events in the tamoxifen group versus 100 in the raloxifene group. 27

Aromatase inhibitors, anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin), are another class of drugs under investigation for chemoprevention of breast cancer. Aromatase inhibitors are currently approved for the treatment of women with metastatic breast cancer and in the adjunct setting, they have been slightly more effective then tamoxifen. 28 They will likely demonstrate efficacy in the prevention of breast cancer in postmenopausal women.

If your patient is a candidate for chemoprevention, refer her to an oncologist. The timing, possible side effects, and duration of treatment may be better managed by a specialist.

Surgery is another modality that can be used in the prevention of breast cancer in a high-risk patient. The NCI has provided guidelines for prophylactic mastectomy available at http://www.cancer.gov/cancertopics/factsheet/prevention . The indications for consideration of prophylactic mastectomy include: a personal history of breast cancer; two first-degree relatives with premenopausal breast cancer; lobular or ductal carcinoma in situ; proliferative atypical hyperplasia; severe dysplasia; and radiation therapy before 30 years of age.

A recent study of women 18 to 80 years of age with one or more risk factors for developing breast cancer according to the Gail model was conducted to determine the benefits of prophylactic mastectomy. The study compared 276 women at risk with bilateral mastectomies to 196 women with the same risk without mastectomies. Results showed a 95% reduction in the incidence of breast cancer with prophylactic mastectomy. 29

Another consideration for women who are at risk for developing breast cancer is prophylactic oophorectomy. The risk reduction of developing breast cancer in women who carry the BRCA1 gene with bilateral oophorectomy was 62%. 30


Management of Patients with Breast Cancer

There are approximately 2,407,943 women alive with a history of breast cancer. 9 Therefore, most NPs will have patients who have been diagnosed and treated for breast cancer. While many of these women will be followed by oncologists and surgeons, the NP will usually continue to follow these patients for routine healthcare as well as sick visits.

The NP can provide ongoing support by maintaining genuine concern. Breast cancer after initial treatment is managed like a chronic illness. The NP should be knowledgeable about surveillance for recurrences and the late effects of treatment. Recurrences can be local (the breast or chest wall), regional (axilla), or metastatic. Metastases from breast cancer occur most commonly in the bones, lungs, and liver, but may occur nearly anywhere (see Table : “Signs and Symptoms of Breast Cancer Recurrence”).


Table. Signs and Symptoms of Breast Cancer Recurrence

One of the common effects from surgery and radiation treatments is lymphedema of the ipsilateral arm. Women who have had axillary lymph nodes removed or who have undergone radiation treatments to the lymph nodes are at risk for developing lymphedema. Lymphedema can occur shortly after surgery or years later. Lymphedema can result in significant disability so early treatment is imperative. The NP needs to be vigilant and observe for any swelling in the arm, hand, or chest wall of patients who are risk for developing lymphedema. Patients with or at risk for lymphedema should not have blood drawn or blood pressures taken from the affected arm.

This is not a cure for lymphedema, but early treatment can minimize swelling. Specialized centers can provide treatment for women who develop lymphedema. 31

The NP also should be aware of the late effects of chemotherapy, as well as the side effects of hormonal treatments (see Table : “Possible Late Effects of Chemotherapy”).



Table. Possible Late Effects of Chemotherapy


Conclusion

The NP plays a crucial role in the maintenance of breast health and the diagnosis of breast disease for their patients. NPs will be the “first responders” using educational, clinical, and judgmental tools to benefit the patient and their practice.

Michaela A. Barron CNRP, MSN
Rhonda S. Fishel FACS, MD

SOURCE: The Nurse Practitioner: The American Journal of Primary Health Care
October 2007
Volume 32 Number 10
Pages 22 - 32
http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=744511