Breast cancer is being detected at earlier stages due to improvements in imaging and increased public awareness of the breast health guidelines. The American Cancer Society recommends monthly self-breast exams, an annual clinical breast exam (CBE), and annual screening mammography for women over 40.1 With increased compliance, primary care physicians are being overwhelmed with self-reported breast lumps or changes in the CBE or mammogram. Prompted in part by fear of litigation of missed breast cancer coupled with patient demand for expertise in breast diseases, referrals to breast specialists or diagnostic breast clinics (DBCs) are increasing. In fact, a whole new generation of breast surgeons is cropping up to meet this demand.
Despite specialization, the foundation of any new patient evaluation begins with a comprehensive history and physical examination. The information gained will then guide the ordering of appropriate imaging studies. This chapter's goal is to outline the necessary information for an appropriate evaluation of common breast problems.
Evaluation of common breast problems at our institution occurs in diagnostic breast clinic that has on-site imaging including a dedicated breast MRI. Our 3 advanced registered nurse practitioners (ARNPs) see over 1500 patients per year under the supervision of 4 breast surgeons. The ARNP performs a complete history and physical examination, has any outside films reviewed by our on-site breast radiologist, obtains any additional imaging needed, and designs a plan with the breast surgeon. Image-guided core biopsies are performed a few days later to allow for insurance approval, cessation of blood-thinning agents, and to accommodate the patient's schedule. Rarely excisional biopsies are used as the primary diagnostic procedure. Biopsy results are given by the ARNP and patients with benign results are followed for 2 years with CBE and diagnostic imaging. Excisional biopsies are performed if the core biopsy revealed atypia.
The first step in the evaluation of a new patient involves obtaining a thorough history and physical examination in a patient and supportive manner, as many women will present with significant anxiety. The patient must be considered the expert on her own body, and her concerns must be given every consideration. She must feel empowered to perform breast self-exams and feel comfortable seeking evaluation for changes. Fortunately for most, the outcome will be benign, but the initial approach is similar for all patients.
The essential elements of the history should include the chief complaint (symptoms) such as skin changes, nipple inversion/retraction, nipple discharge, redness, breast pain, and palpable changes. Detailed analysis of symptoms should include onset, duration, precipitating/alleviating factors, recent trauma or infection, changes in medications, changes in weight, changes in medical conditions. Additionally, previous breast history should be recorded including details of prior breast biopsies, breast augmentation/reduction, breast problems, compliance with screening guidelines, and imaging history. Exploring the past medical history can elicit relevant risk factors or comorbidities. In addition, certain conditions such as diabetes mellitus or congestive heart failure ...