Early detection of breast cancer is improved by risk assessment, clinical breast examination, screening mammography, and magnetic resonance imaging in selected patients.
Triple-test concordance requires agreement between results of clinical breast examination, breast imaging, and tissue diagnosis. In the absence of concordance, further diagnostic intervention is required.
The most common benign breast problems include fibrocystic changes and mastalgia. These problems are usually best treated by reassurance. Pharmaceutic agents are available but have side effects that usually are not well tolerated.
Histologic differences exist between fibroadenomas and phyllodes tumors; phyllodes tumors require excision, whereas small asymptomatic fibroadenomas can be observed if the diagnosis is confirmed by histologic or cytologic assessment and there is no evidence of growth.
Spontaneous, unilateral, bloody discharge requires histologic evaluation to exclude malignancy, but symptoms usually are caused by a benign process such as intraductal papilloma or duct ectasia.
Breast abscesses are managed with fine needle aspiration and antibiotics; the use of incision and drainage is reserved for recurrence.
Benign breast diseases are among the most common diagnoses that the busy obstetrician-gynecologist will see in practice. An ability to accurately and promptly diagnose both benign and malignant breast diseases is within the purview of the practicing gynecologist (1). Benign breast disease is a complex entity with a range of physiologic changes and clinical manifestations that have an impact on a woman’s health independent of breast cancer risk (2).
History Evaluation of a new breast symptom begins with assessment of symptoms based on a thorough clinical history (3). The history should include questions regarding current symptoms, duration of the condition, ﬂuctuation of the signs and symptoms, and factors that aggravate or relieve the symptom. Assessment of breast problems should focus on the following points:
Nipple discharge  Characteristics of discharge (spontaneous or nonspontaneous, appearance, unilat eral or bilateral, single or multiple duct involvement)  Breast mass (size and change in size, density, or texture)  Breast pain (cyclic versus continuous)  Association of symptoms with menstrual cycle  Change in breast shape, size, or texture  Previous breast biopsies  History of breast trauma
The patient should be questioned about the following risk factors for breast cancer (see Chapter 40 for more details):
Increasing age (approximately 50% of breast cancers occur after age 65)  Age of menarche less than 12 years  Nulliparity or first pregnancy at greater than 30 years of age  Late menopause (older than 55 years of age)  Family history of breast cancer (especially premenopausal or bilateral disease)  Number of first-degree relatives with breast cancer and their ages when diagnosed  Family history of male breast cancer  Inherited conditions associated with a high risk for breast cancer, including BRCA1 and BRCA2 genes, Li-Fraumeni syndrome, Cowden’s disease, ataxia telangiectasia syndrome, and Peutz-Jeghers syndrome  Other malignancies (ovary, colon, and prostate)  Pathology of previous breast biopsy showing atypia or lobular or ductal carcinoma
Hormone therapy  Alcohol consumption  Postmenopausal weight gain  Personal history of breast cancer
Breast cancer risk can be determined by the Gail Risk assessment model, which is available electronically (4). The Gail Risk assessment model calculates risk based on patient race, age, age of menarche, age of first live birth, number of first-degree relatives with breast cancer, number of previous breast biopsies, and presence of atypia on the biopsy.