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Referring a patient with breast problems? You can manage many common complaints

From the October ACP Observer, copyright 2004 by the American College of Physicians.

By Alison McCook

As internists take a growing role in women's health issues and discover just how challenging breast health problems can be, many face a difficult decision: when to refer patients with symptoms like benign breast pain to a specialist.

The problem is that many breast problems have no clear-cut solutions. For example, how should you handle a patient who feels a lump in her breast—even though a clinical breast exam, mammogram and ultrasound reveal no abnormalities? And how should you manage other problems like breast pain or an abnormal mammogram?

While these problems must be addressed on a case-by-case basis, breast specialists in academic medical centers say that too many primary care physicians are referring run-of-the-mill cases to them. In too many instances, they say, problems like breast pain, nipple discharge and even some palpable lumps can all be handled by primary care physicians.

"There are many problems that generalists can manage themselves without referring," said Elizabeth A. Marcus, MD, a surgical oncologist and chair of the breast oncology division at Chicago's Cook County Hospital. Dr. Marcus was one of four editors of "Breast Health and Common Breast Problems: A Practical Approach," published by ACP earlier this year.

Benign breast pain in the absence of a physical or mammogram finding, she said, is a good example of a symptom that shouldn't automatically generate a referral.

And she urged internists to do a better job of working with patients to assess and manage their individual risk of breast cancer. (See "Tips for assessing breast cancer risk.")

Internists may be reluctant to tackle some problems on their own because of liability issues, but oncologists say that quick referrals are not always the answer. They point out that telling a patient she needs to see a specialist can make her very anxious—and she may never follow through.

Here are some tips to help you decide what types of breast health problems you can manage on your own—and when it's time to refer.

Breast pain

Breast pain is the most common breast complaint encountered in the primary care setting.

Because patients assume breast pain is a symptom of cancer, the condition often causes them anxiety. While internists have largely been taught that cancer isn't a likely cause, exceptions do occur.

"Initially, the physician should take breast pain seriously," said Frances E. Norlock, FACP, assistant director of the breast and cervical cancer screening program at Chicago's John H. Stroger Jr. Hospital of Cook County.

While breast cancer is diagnosed in 2% of women who present with breast pain, she added, breast pain doesn't automatically require a referral. "Once a malignancy has been excluded, benign breast pain can be managed by the internist," said Dr. Norlock, who was also one of the "Breast Health and Common Breast Problems" editors.

Her rule of thumb: First, perform a clinical breast exam to make sure the pain—as in the majority of breast pain cases—is not caused by a mass. In the absence of an abnormality on clinical exam or imaging, you should instruct the patient to keep a breast pain diary. Pain that comes and goes with a woman's period is often caused by normal hormonal fluctuations. Some women who say they have chronic or severe pain realize that it actually fluctuates (and is relatively low on a 10-point pain scale) after they track it daily.

"For patients to see that in a diary over three months is truly eye-opening," Dr. Norlock said.

Initial treatment for benign breast pain begins with reassuring the patient that her breast pain is not caused by cancer. At follow-up, Dr. Norlock said, between 70% and 85% of patients said their breast pain subsided when reassurance was the only treatment offered.

Internists should also counsel patients about lifestyle changes such as wearing a supportive, professionally fitted bra (without underwires), reducing caffeine, and trying relaxation therapy and a low-fat diet.

You can also try a trial of over-the-counter primose oil capsules and/or nonsteroidal anti-inflammatory drugs if the patient's breast pain is persistent. While some breast pain patients need prescription medications—such as tamoxifen or danazol—these medications are rarely prescribed for breast pain in the United States.

And even though the relationship between breast pain and depression or anxiety is unclear, "that does not mean the relationship doesn't exist," Dr. Norlock said. (She pointed out that a relationship between breast pain and other chronic pain disorders has been demonstrated.)

Consider screening breast pain patients for anxiety and depression. And when dealing with a patient with chronic pain that lasts between six and 12 months or longer, "you may want to pursue questioning [about childhood or sexual abuse] when taking a patient history." Although it has not yet been investigated in relation to breast pain, an association has been demonstrated between other chronic pain disorders and a history of childhood abuse and sexual assault.

Nipple discharge

When treating patients with nipple discharge, Louis A. Orlando, MD, a general internist with Jackson County Medical Group in Independence, Mo., relies on a thorough exam and history. He said he tends to handle these cases himself—unless he finds an abnormality, such as a lump—if the discharge is clear, milky or colored.

Clear discharge is common, he said, especially among women taking certain medications, including antihypertensives and antidepressants, and among those who do self-breast exams too frequently.

Because some brain tumors can cause an increase in prolactin levels, Dr. Orlando said he may also run a blood test to check those levels. And if the discharge is bloody, he "almost always" refers out.

According to Seema Khan, MD, director of the Bluhm Family Breast Cancer Early Detection and Prevention Program at Chicago's Northwestern University, a bilateral, multiduct nipple discharge that occurs only when you squeeze the nipple and is multicolored—either blue/green or yellow/white—is usually normal. Experts point out that it is rare that an invasive cancer produces discharge without any clinically detectable mass, although the association between cancer and nipple discharge increases with age.

One study found that 32% of women who presented with nipple discharge as their only symptom were diagnosed with cancer. However, the type of discharge among those patients was unilateral, from a single duct, serous or sanguineous, and/or spontaneous rather than expressed.

Handling palpable masses

Palpable breast masses can provoke a lot of anxiety, both for you and your patients.

If a lump does not initially appear suspicious—if it does not appear to stand out from the rest of the tissue, for example—Mary B. Barton, ACP Member, an assistant professor in the ambulatory care and prevention department at Boston's Harvard Pilgrim Health Care and Harvard Medical School, said she asks patients to return in six weeks, at a different point in their menstrual cycle.

This helps rule out simple cysts, she said, which can appear and disappear throughout the month. If she finds the lump has persisted or enlarged when the patient returns, she will order imaging tests.

Dr. Orlando said that he immediately refers patients with masses to a surgeon if those masses are hard or fixed, or if the skin is red or thickened over the lump. He will follow lumps that are shown through mammogram or ultrasound to be cysts, particularly if the patient is not at high risk and has no family history of cancer.

Diane M. London, ACP Member, a general internist with Charles River Medical Associates in Natick, Mass., said she becomes very concerned about patients who feel a lump, especially when a mass is not detectable on clinical exam and the patient's mammogram and ultrasound are normal.

"I send those patients to a breast specialist," Dr. London said. "I trust my patients when something's different, and I don't want to blow off their complaints."

Cook County's Dr. Marcus said she counsels internists to take every lump seriously, even in the face of negative imaging. "If you feel something, you have to establish a diagnosis, no matter what the mammogram shows," she said.

Refer patients to a specialist if you can't evaluate them, if they have something benign that may need to be removed or if they have suspicious masses. Dr. Marcus included in her definition of "suspicious" those masses where the "pieces don't add up," such as women whose pathology from fine needle aspiration "is not concordant with results from her clinical breast exam or imaging."

If you do find a mass in a woman who is 35 or older, "tissue is the issue," Dr. Norlock said. In addition to a mammogram, a fine needle aspiration or core biopsy should be performed to rule out cancer. (Women under 35 should receive ultrasound because of the density of their breast tissue.)

And if you find a mass in a very young patient-someone in her teens, for instance, or early 20s—an ultrasound can be performed to characterize the mass. A biopsy may not be needed if the mass has benign—like characteristics on ultrasound, Dr. Norlock advised-and you should remind the patient that her chance of cancer is "very low."

Abnormal mammograms

Unfortunately, some suspicious lumps will produce mammograms with suspicious results, which may or may not mean cancer. Kelly D. Ford, ACP Member, an instructor of medicine at Harvard University and an internist at Boston's Beth Israel Deaconess Medical Center, said she warns patients before they get mammograms that the test is an imperfect one, its sensitivity varying according to a woman's breast tissue.

She added that internists can also explain many abnormal mammogram results by following the recommendations of the breast imaging reporting and data system, or BI-RADS. The recommendations are online, which has made the process much more straightforward.

However, Northwestern's Dr. Khan said mammograms that reveal new densities, nodules, calcifications or clusters of calcifications should raise "red flags" for internists.

She added that internists should refer a patient to a specialist if the patient has a new mammogram finding that cannot be resolved, or if a physical exam reveals a new lump that cannot be diagnosed, even if imaging suggests there is nothing abnormal.

"These are issues," she said, "where the threshold should be low for referral."

Other breast health issues

Internists should also be knowledgeable about breastfeeding issues, such as maternal diet and exercise, alcohol and tobacco use, medications, and contraception during lactation. Internists should, for instance, keep track of what medications nursing mothers are taking, said Dr. Norlock.

"Not all drugs that are safe to take in pregnancy are safe during breastfeeding," she said, citing metronidazole and nitrofurantoin as examples. Internists should also be able to manage problems that arise during breastfeeding such as breast and nipple infections, and sore nipples.

And one of the most important things internists can do for their patients regarding breast health is to remind them of the importance of follow-up, said Dr. London.

While some patients are extremely nervous about breast health, others aren't nervous enough. Unfortunately, she pointed out, it often ends up being the physician who has to remind patients to reschedule another round of imaging or come in for another clinical breast exam. To keep up with these patients, Dr. London said she keeps a list of patients who need to come back for breast health issues.

"The key to any breast complaint," she said, "is follow-up."

Alison McCook is a freelance writer in Brooklyn, N.Y., who specializes in health care.

The information included herein should never be used as a substitute of clinical judgment and does not represent an official position of ACP.

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Tips for assessing breast cancer risk

For many women, breast cancer is a significant source of anxiety, prompting internists to perform risk assessments and counsel patients about their individual risk of disease. Assessing patients' risk can often ease patients' anxiety—and generate information that can tell you how to follow your patients, said Kelly D. Ford, ACP Member, an instructor of medicine at Harvard University and an internist at Boston's Beth Israel Deaconess Medical Center.

To assess risk, Dr. Ford said she uses the Gail Model, which consists of only five questions, including the number of a patient's first-degree relatives who've had breast cancer and a patient's age at her first period, and takes only a minute or two to complete. The model is online. According to Diane M. London, ACP Member, a general internist with Charles River Medical Associates in Natick, Mass., the Gail Model is also an easy tool she uses to calm the fears of younger women about their breast cancer risk.

According to Dr. Ford, statistics can also reassure women about their risk of developing the disease. She points out to patients that an average woman has only a 3.5% lifetime risk of developing breast cancer, as opposed to a more than 65% chance of developing vascular disease. She reminds them, too, that breast cancer, when caught early, is highly curable.

As part of assessing risk, internists should consider whether patients may be at risk for an inherited form of breast cancer. If they have suspicions, physicians should discuss the option of genetic testing. (See "When should you consider genetic testing?")

And while the U.S. Preventive Services Task Force claims there is insufficient evidence to recommend for or against using only routine clinical breast exams to screen for breast cancer, doing a clinical breast exam should be "absolutely part of the examination" of women patients who present with breast health problems, said Mary B. Barton, ACP Member, an assistant professor in the department of ambulatory care and prevention at Boston's Harvard Pilgrim Health Care and Harvard Medical School.

Dr. Barton, who has researched and written about clinical breast exams, said she recommends that physicians perform yearly exams on patients as part of a routine check-up, taking between one and three minutes to examine each breast.

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When should you consider genetic testing?

Within the last 10 years, genetic testing for gene mutations has become an important tool in the fight against breast cancer—one that internists are being increasingly called upon to consider for their patients.

When should you think of referring a patient for gene testing? It takes only a minute to do a brief family breast cancer history, and only a moment more to decide whether a patient needs to be tested for the presence of breast cancer (BRCA) gene 1 or 2 mutations, associated with a higher risk of breast or ovarian cancers. Here are some red flags in a family history that suggest a woman may be at risk for inherited cancers, according to oncologist Mary Daly, FACP, who specializes in medical oncology at Fox Chase Cancer Center in Philadelphia:

  • Breast or ovarian cancer occurred "across the ages" in different generations.
  • Family members developed cancer at a relatively early age.
  • The cancer was bilateral.
  • The patient is an Ashkenazi Jew.

"If anything about the family history makes the physician think this woman could benefit from genetic testing, that's the time to send her to a cancer risk counseling center," said Dr. Daly.

She noted, however, that the vast majority of patients an internist sees will not appear to have any inherited risks of breast cancer. For women who have only one first-degree relative with breast cancer, for example, an internist should feel comfortable discussing ways to stay healthy, with regular screening, weight loss, moderate alcohol intake and no hormone replacement therapy, if possible, Dr. Daly said.

But just because a woman with a strong family history doesn't appear to have BRCA1 or 2 doesn't mean she is totally out of the woods, said Kelly D. Ford, ACP Member, an internist at Beth Israel Deaconess Medical Center in Boston. She considers any woman with a strong family history to be at high risk, because there may be other genetic markers for the disease that researchers have not yet discovered. This is particularly important if it is not known whether her relatives carried BRCA, Dr. Ford noted.

Dr. Daly recalled a woman she treated for breast cancer who was the first person diagnosed with the disease in her family, so Dr. Daly did not test her for BRCA1 or 2. However, when both her mother and her sister developed the disease, Dr. Daly tested her patient, and found she carried one of the mutations. Knowing this helped, she said, because it suggested her patient may be at higher risk for a second breast cancer or ovarian cancer. It also gave the patient's children the option of being tested themselves, when they get older.

"It was keeping track of what was going on in the family that told us that genetic testing was the thing to do," Dr. Daly said.

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