BENIGN AND MALIGNANT CONDITIONS OF THE BREAST

A Self-Instructional Program for Primary Health Care Physicians Designed for Competency-Based Learning In- and Off- Campus Learning Preface Dear Learner, Mabuhay! Welcome to a learning experience in becoming a health professional. This program has been especially designed with you, the learner, and the principles of effective teaching and learning in mind. As you go through this learning program, please bear in mind the following: 1. I am treating you as an adult learner which 1.1 Assumes you have learning aspirations and expectations and therefore, are motivated; 1.2 Gives you the privilege to use other learning strategies in achieving the objectives in this program; 1.3 Welcomes you to go beyond the learning package as you so desire; and 1.4 Expects discipline, honesty, and maturity in fulfilling your learning activities. 2. We shall define learning as a positive observable change (for the better or improvement) in human behavior, disposition, attitude, performance, or capability which persists over a period of time. 3. Active learning strategies and activities will be utilized as much as possible. 4. The program will contain learning materials which I think will be relevant to your being an effective, efficient, and humane health professional. 5. The ultimate goal of the learning program is to produce health professionals who will contribute to the health development in the Philippines. 6. When I made this program, I tried my best to facilitate your learning. Bear in mind, however, that I am not infallible. Thus, analyze carefully everything in this program. Dont hesitate to offer disagreements and constructive criticisms for my own learning and for the improvement of the program. Best wishes for a fruitful learning with the help of this program. Reynaldo O. Joson, MD, MHPEd, MSc Surg September 2013 rjoson2001@yahoo.com; rjoson@maniladoctors.com.ph

Guidelines in Studying the Program Dear Learner, Mabuhay! Welcome to an experience in self-instruction. This program has been designed so that you learn on your own. You can learn at your own pace - as fast as you can or as slow as you wish. You can choose to study anywhere and anytime. For effective learning, however, please follow the guidelines below in studying the program: 1. Start with the concept map of wellness and illness as influenced by the breast conditions. 2. Take a glimpse of the study guide. 3. Then, diligently and chronologically go through the following parts as each part has an important role. The Introduction gives you an overview and the delimitation of the self-instructional program. The Authors Approach to the Topic gives you an idea how I approach the topic to write the program and it also spells out the General and Specific Learning Objectives which tell you what you are expected to achieve after you have finished the program. The Text, of course, is the learning material. The Postprogram Assessment self-assesses your competency on the subject matter after studying the program. The Student's Assessment of Self-instructional Program will give me a feedback on my efforts to facilitate your learning.

The estimated study time for the program is one hour. Best wishes.

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg September, 2013

Table of Contents
Preface Guidelines in Studying the Program Table of Contents Concept Map of Wellness and Illness as Influenced by the Breast Condition Study Guide on Benign and Malignant Conditions of the Breast Introduction Authors Approach to the Topic with General and Specific Learning Objectives Common Breast Disorders in the Philippines Clinical Presentation of the More Common Breast Disorders Diagnostic Processes in a Patient With a Possible Breast Disorder Common Paraclinical Diagnostic Procedures in Patients With a Possible Breast Disorder Primary Goals and Modalities of Treatment of Breast Disorders Some Clinical Issues in the Management of Breast Disorders General Indications for Referral to a Breast Specialist Biopsychosocial Wellness and Illness as Influenced by the Breast Condition Some Social Issues in Breast Health Problems Post-program Assessment

Students Self-assessment of the Self-instructional Program About the Author

CONCEPT MAP OF WELLNESS & ILLNESS AS INFLUENCED BY THE BREAST CONDITION BIOPSYCHOSOCIAL WELLNESS

Prevention

HOMEOSTASIS

BREAST FAILURE OF HOMEOSTASIS Developmental Differentiation Maladaptation Failure of coping

Stimuli/insults Genetic/congenital Nutrition Endocrine/metabolism Infectious Psychosocial

ILLNESS

MANIFESTATION OF ILLNESS SYMPTOMS / SIGNS PATHOPHYSIOLOGY

BIOPSYCHOSOCIAL ASSESSEMENT DIFFERENTIALS DIAGNOSTIC AIDS DIAGNOSIS

THERAPEUTICS & MANAGEMENT

SURGICAL/MEDICAL Quality of Life Repair Recovery HEALTH CHRONIC ILLNESS DEATH Quality of Dying

STUDY GUIDE Concept map of wellness and illness as influenced by the breast condition Specifics based on the concept map of wellness and illness: State of biopsychosocial wellness as influenced by the breast condition - criteria for no breast health problem vis--vis criteria for presence of breast problem Common symptoms of failure of homeostasis in the breast that lead to illness Common causes of failure of homeostasis in the breast that lead to illness (pathophysiology of breast diseases) Common disorders and diseases of the breast - Benign and malignant disorders - Specific conditions under benign and malignant disorders Usual manifestations of the more common diseases of the breast Clinical diagnostic process in patients with possible breast disorders Common paraclinical diagnostic procedures in patients with possible breast disorders - Monitoring and observation - Mammography - Ultrasound - Biopsy - Others Paraclinical diagnostic processes in patients with possible breast disorders - Indications for paraclinical diagnostic procedure - Selection - Interpretation of results Formulation of pretreatment diagnosis and goal of treatment Treatment process Selection of treatment procedure Monitoring of outcome of treatment Maintenance of biopsychosocial wellness with respect to breast condition - Maintenance of quality of life of patients with breast concerns Specific Learning Objectives: At the end of the study of this document on Benign and Malignant Conditions of the Breast, the learner must be able to: a. Enumerate at least 10 more common breast disorders seen in the Philippines. b. Classify the breast disorders into benign and malignant conditions. c. Categorize the breast disorders by primary causes (malignant neoplasms, benign neoplasms, aberration of normal development and involution or ANDI and infection). d. Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast. e. Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders. f. Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders. g. Identify which breast disorders can be monitored and which should be actively treated. h. Given a pretreatment diagnosis of a breast disorder with the stage of the disorder, indicate the usual goal of treatment and its corresponding recommended primary treatment. i. Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes. j. Identify at least two general indications for referral to a breast specialist. k. Advice patients on how to achieve and maintain psychosocial well-being as influenced by the breast condition. l. Identify two social issues related to the breast health problem in the community (focusing on breast disorder) and suggest ways on how to reduce the problem.

Self-instructional Programs Benign and Malignant Conditions of the Breast (this SIP) (https://sites.google.com/site/breastconditions/home) Recommended Reading Materials and Resources: Patient Management Process (https://sites.google.com/site/patientmanagementprocess) Breast Self-examination for the Filipino Females (https://sites.google.com/site/rojosonbreastselfexam) Facebook /ROJoson Breast Wellness Clinic (http://www.facebook.com/ROJosonBreastWellnessClinic)

INTRODUCTION There are myriads of conditions on the breast that can affect the biopsychosocial well-being of the individual, particularly the female, as the breast in the male is by and large destined to be a vestigial organ at birth. The conditions are generally classified into benign and malignant conditions with malignant conditions being synonymous with malignant neoplasms or cancers. Benign conditions are anything except cancers. They include not only the benign neoplasms of the breast but also the nonneoplastic conditions like developmental abnormalities, exaggerated physiologic and hormonal changes, and infectious diseases. Any condition on the breast that affects the biopsychosocial well-being of an individual can be considered as a breast health problem. There are generally three categories of breast health problem, namely: breast disorders; breast feeding problem; and breast sexuality problems. Breast feeding problem is a predominant concern of lactating mothers. Issues consist of want to breastfeed but unable to do so; how long to breastfeed; want to stop breastfeeding; etc. These issues will not be covered in this document. Breast sexuality problem is usually seen in adult females whose well-being is influenced by the status of their breasts, particularly in terms of size and functions as a sexual organ. Again, issues on breast sexuality problem will not be covered in this document. This document will cover and focus on breast disorders, which can be subcategorized into benign and malignant conditions, as defined above. AUTHORS APPROACH TO THE TOPIC OF BREAST DISORDERS As the author of this document, I would like to state the following: 1. This document is written with the medical students studying to be generalist or primary health care physicians in mind. 2. This document does not contain everything there is to know about breast disorders. 3. This document contains only an overview and general principles needed by the generalist or primary health care physicians to be able to at least advice patients with possible breast disorders on diagnosis, treatment, prevention and health maintenance. 4. The intended specific learning objectives from this document shall consist of the following: At the end of the study of this document, the learner must be able to: a. Enumerate at least 10 more common breast disorders seen in the Philippines. b. Classify the breast disorders into benign and malignant conditions. c. Categorize the breast disorders by primary causes (malignant neoplasms, benign neoplasms, aberration of normal development and involution or ANDI and infection).

d. Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast. e. Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders. f. Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders. g. Identify which breast disorders can be monitored and which should be actively treated. h. Given a pretreatment diagnosis of a breast disorder with the stage of the disorder, indicate the usual goal of treatment and its corresponding recommended primary treatment. i. Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes. j. Identify at least two general indications for referral to a breast specialist. k. Advice patients on how to achieve and maintain psychosocial well-being as influenced by the breast condition. l. Identify two social issues related to the breast health problem in the community (focusing on breast disorder) and suggest ways on how to reduce the problem. 5. The presentation of learning materials and competency evaluation will be guided by the aforementioned specific learning objectives.

COMMON BREAST DISORDERS IN THE PHILIPPINES

There are about ten breast disorders which all generalist or primary health care physicians should be familiar with. These ten breast disorders are listed below in a more or less (not absolute may change over time) decreasing frequency from 1 to 10 in the Philippine setting: 1. Breast cancer 2. Fibroadenoma 3. Macrocyst 4. Galactocoele 5. Mastitis and breast abscess 6. Intraductal papilloma 7. Benign cystosarcoma phyllodes or benign phyllodes tumor 8. Tuberculosis of the breast 9. Pagets disease of the nipple 10. Mammomegaly The ten breast disorders can be classified into benign and malignant conditions and categorized into more specific causes of the disorders in terms of malignant neoplasm, benign neoplasm, aberration of normal development and involution, and infection. Conditions Causes Benign (Non-malignant) Aberration of Infection Benign normal devt neoplasm and involution Malignant Malignant neoplasm

Disorders Breast Cancer Fibroadenoma () Macrocyst Galactocoele Mastitis and breast abscess Intraductal papilloma Benign cystosarcoma phyllodes or phyllodes tumor Tuberculosis of the breast Pagets disease of the nipple Mammomegaly () some scientists would put it here.

CLINICAL PRESENTATION OF THE MORE COMMON BREAST DISORDERS Below is an outline of the usual clinical presentation of the more common breast disorders. The usual clinical presentation can be used for pattern recognition in the diagnostic processes of patients with a possible breast disorder. Note: This part is best studied with illustrations and pictures.

BREAST CANCER AND PAGETS DISEASE OF THE NIPPLE Breast cancer should be suspected in a palpable breast lump of any size that is SOLID and that has ILL-DEFINED BORDERS. This is especially so if any of the following is also present: 1. HARD CONSISTENCY 2. FIXED TO SKIN OR UNDERLYING CHEST WALL 3. SKIN ULCERATION 4. FUNGATING MASS 5. ENLARGED LYMPH NODES IN THE IPSILATERAL AXILLA Pagets disease of the nipple is a special kind of breast cancer. It should be suspected in patients with NIPPLE OR AREOLAR EROSIONS. A sub-areolar mass may or may not be present. Breast cancer usually starts to appear after age 30. Rarely, a younger patient as young as 25 years old or even younger, may be afflicted with breast cancer.

FIBROADENOMA Fibroadenoma should be suspected in a palpable breast lump of any size that is FIRM, SOLID, NONTENDER, VERY MOVABLE, and that has VERY WELL-DEFINED BORDERS. This is especially so if there are no enlarged lymph nodes in the ipsilateral axilla and if the patient is 25 years old or younger.

MACROCYST Macrocyst should be suspected in a palpable breast lump of any size that is CYSTIC in nature and that is seen in a patient with NO HISTORY OF RECENT LACTATION. By cystic nature is meant the wall of the lump is depressible as to suggest a sac containing fluid.

GALACTOCOELE Galactocoele should be suspected in a palpable breast lump of any size that is CYSTIC in nature and that is seen in a patient with a HISTORY OF RECENT LACTATION.

MASTITIS AND BREAST ABSCESS Mastitis should be suspected in any ERYTHEMATOUS, TENDER, and WARM BREAST WITH NO PALPABLE LUMP. Breast abscess should be suspected in a PALPABLE BREAST LUMP of any size that is TENDER, WARM, and associated with ERYTHEMATOUS overlying skin. Mastitis and breast abscess are usually encountered in lactating women. They may also be seen in non-lactating women at any age.

BENIGN CYSTOSARCOMA PHYLLODES Benign cystosarcoma phyllodes (a historical term) or benign phyllodes tumor (a new term) should be suspected in a palpable breast lump that is GIGANTIC, NOT FIXED TO THE UNDERLYING CHEST WALL, AND THAT IS NOT ASSOCIATED WITH ENLARGED LYMPH NODES IN THE IPSILATERAL AXILLA. The tumor may be fixed to the overlying skin.

TUBERCULOSIS OF THE BREAST Tuberculosis should be suspected in a breast with CHRONIC SINUSES. There may or may not be an underlying lump.

INTRADUCTAL PAPILLOMA Intraductal papilloma should be suspected when there is BLOODY NIPPLE DISCHARGE WITH NO PALPABLE BREAST LUMP.

MAMMOMEGALY Mammomegaly should be suspected of a GIGANTIC BREAST WITH NO UNDERLYING LUMP. Mammomegaly may be unilateral or bilateral. In males, mammomegaly is usually called gynecomastia. In females, the most commonly encountered term is virginal hypertrophy. DIAGNOSTIC PROCESSES IN A PATIENT WITH A POSSIBLE BREAST DISORDER The initial tools used in investigating a breast problem consist of the interview (history) and physical examination. After the interview and physical examination, a clinical impression or a diagnosis should be formulated. Depending on the certainty of the diagnosis formulated, a diagnostic procedure, also known as paraclinical diagnostic procedure, may or may not be instituted. Clinical diagnostic processes The clinical diagnosis is derived from processing the data derived from the interview (symptoms data) and physical examination (signs data) utilizing two processes called pattern recognition and prevalence. Pattern recognition means the realization that the patients presentation conforms to a previously learned picture or pattern of disease. Prevalence means the choice of a diagnosis is based on the frequency of occurrence of the disease in a certain locality, in a certain age and sex group, and in the affected organ and system. Paraclinical diagnostic processes After the clinical diagnosis, the next step to do is to determine whether a paraclinical diagnostic procedure is needed or not. A paraclinical diagnostic procedure is a diagnostic procedure that is done after the clinical diagnosis is arrived at and its objective is to make the diagnosis more definite. To decide whether a paraclinical diagnostic procedure is needed or not, a physician should consider the following factors: how certain he is with the clinical diagnosis and whether a more definite diagnosis is needed or not for some reasons or another. Certainty of diagnosis as indication for paraclinical diagnostic procedure If he is quite certain or very certain, in general, a paraclinical diagnostic procedure is not needed. The quite certain clinical diagnosis becomes automatically the pretreatment diagnosis. If he is not quite certain or uncertain, in general, a paraclinical diagnostic procedure is needed. In general, a clinical diagnosis is said to be quite certain if it is based primarily on signs that are reinforced by the symptoms and prevalence data. A clinical diagnosis is said to be uncertain if it is based primarily on symptoms or on prevalence data. Need for more definite diagnosis as indication for paraclinical diagnostic procedure If the contemplated treatment procedure is mutilating, risky, etc., then a more definite diagnosis is needed. If the treatment for the differential diagnosis is the same as that for the primary clinical diagnosis, then a paraclinical diagnostic procedure may not be needed. If it is different, then a more definite diagnosis is indicated. Once a decision is made that a paraclinical diagnostic procedure is needed, the next step is to choose the most cost-effective procedure for the patient by considering the various factors (tabulate, compare, and analyze): Procedures Benefit Risk Cost Availability

Option1 Option2 Option3 After the paraclinical diagnostic procedure has been done, the next step is to interpret the result. The result of the paraclinical diagnostic procedure must be correlated with the signs and symptoms of the patient to come out with a pretreatment diagnosis. COMMON PARACLINICAL DIAGNOSTIC PROCEDURES IN PATIENTS WITH A POSSIBLE BREAST DISORDER The more common paraclinical diagnostic procedures that are being utilized in patients with possible breast disorder consist of the following: 1. Monitoring (observation) and constant analysis 2. Biopsy (needle evaluation or open biopsy) 3. Mammography 4. Ultrasound MONITORING (OBSERVATION) AND CONSTANT ANALYSIS Repeated observation and palpation of the breasts followed by constant analysis by both the patient and his/her physician can be done to arrive to a more definitive diagnosis after the initial evaluation. This paraclinical diagnostic procedure is usually being done if on initial evaluation, based on the clinical findings, chances are, the breast disorder is of a nature that it is NOT malignant and the treatment is usually by monitoring and observation where no active treatment is needed. For example, if the primary clinical diagnosis on initial evaluation is a fibrocystic change of the breast with more than 90% degree of certainty, then monitoring (observation) and constant analysis can be used as a paraclinical diagnostic procedure. Fibrocystic changes are benign conditions and considered as aberrations in normal development and involution that are usually managed with monitoring and observation. Again, if the primary diagnosis on initial evaluation is a 1-cm fibroadenoma of the breast with a more than 90% degree of certainty, then monitoring (observation) and constant analysis can be used as a paraclinical diagnostic procedure. Fibroadenomas are benign conditions and can be managed by monitoring and observation because they are slowly growing and some can disappear spontaneously over time. NEEDLE EVALUATION Needle evaluation uses a hypodermic needle, usually G 19 and 1.5 inch long attached to a 20cc plastic syringe, to evaluate a lump palpated in the breast. There are three parts in a needle evaluation. One is needling the lump to check its actual presence; to check its nature, whether solid or cystic; and lastly, to determine its real consistency, whether gritty or rubbery. Second is aspirating the lump to get samples for gross examination. Third is preparing a smear out of the samples aspirated for microscopic examination. The third step is what is commonly known as needle aspiration biopsy. Needle evaluation can be done right after the physical examination in the clinic or office. The advantages of a needle biopsy are the following: 1. It can give a more definite diagnosis than the physical examination mammography, and ultrasound. 2. It is a more cost effective diagnostic procedure than mammography and ultrasound. 3. It can give a more definite diagnosis right after or soon after the physical examination. 4. It can avoid an operation. 5. It can be therapeutic in galactocoeles and macrocysts.

A real-life situation is given below: A 45-year-old female presented with a hard nontender breast mass with ill-defined borders. Breast cancer was suspected. A needle evaluation was done and serous fluid was aspirated and the mass completely disappeared and did not recur thereafter. The initial impression of breast cancer was changed right away to a definitive diagnosis of macrocyst.

The macrocyst, although a cyst, did not feel cystic on palpation. It felt hard because it was a tense cyst filled with fluid. If a needle evaluation was not done and an operation (open biopsy) was performed, the patient would end up with an operation which would be considered unnecessary. The needle evaluation performed had avoided the operation, scar, pain, expenses, and other problems that would accompany the operation if it were instituted. If a mammography were done, it would just show the shadow of the lump. No definite diagnosis could be given. The patient would be spending more than Php 1000.00 (as of 2013) and be exposed to radiation. If an ultrasound were done, it should show a cystic lump. A needle aspiration would still have to be done. Also, it would take sometime before a definitive diagnosis and treatment could be gotten. With needle evaluation, the diagnosis and treatment were completed soon after the physical examination. CORE NEEDLE AND OPEN BIOPSY A core needle or open biopsy may be done if the needle evaluation is inconclusive and there is a need to do a biopsy prior to a definitive treatment. A core needle biopsy utilizes a special instrument that costs more than a hypodermic needle biopsy, is not as readily available in the Philippines, but which can obtain more samples and still does not produce a scar. If available, it may be used after the initial hypodermic needle biopsy. Open biopsy entails an incision and can either be a section or an excision biopsy. A part of the mass is removed in section biopsy whereas the whole mass is removed in excision biopsy and the specimen is sent for biopsy or microscopic examination. The open biopsy may be done either through a paraffin or a frozen technique depending on how fast the biopsy result is needed. In the frozen technique, biopsy result can be obtained within 15 to 30 minutes whereas in the paraffin technique, usually three days. For all breast masses, it is recommended that a needle evaluation be tried first before considering a core or open biopsy. The needle evaluation may be sufficient to establish a definitive diagnosis that a core or open biopsy is not necessary anymore. MAMMOGRAPHY Plain mammography (analog or digital mammography) is a radiologic examination of the breasts. Scintimammography uses radioisotopes in imaging the breasts. Plain mammography is a more painful procedure because it necessitates compression of the breasts to get the imaging result. Scintimammography does not need compression of the breasts in its procedure. Scintimammography is 2 to 3 times more expensive. The diagnostic reliability and limitations are practically the same for the two procedures. Mammography, whether plain or using radioisotopes, is used in screening patients with no palpable breast lump for possible cancer. They are usually not done in evaluating patients with a palpable breast mass as biopsy is considered the preferred initial diagnostic procedure. A finding on mammography in patients with no palpable breast lumps that should arouse suspicion for possible cancer consists of a cluster of microcalcifications. In patients with palpable mass, the presence of stellate border on mammography is a reliable sign for cancer. ULTRASOUND Ultrasound uses sound waves to make an imaging of the breast. It can detect breast lumps and it can easily determine whether a breast lump is solid or cystic. Finding cystic lumps on ultrasound usually gives a diagnosis of benign conditions whereas finding solid lumps does NOT have a diagnostic implication. COMPARISON OF PARACLINICAL DIAGNOSTIC PROCEDURES IN PATIENTS WITH A PALPABLE BREAST LUMP IN WHICH A MORE DEFINITIVE DIAGNOSIS IS NEEDED IN A PATIENT SUSPECTED TO HAVE A BREAST CANCER Goal: to be more definite on the diagnosis of a palpable breast lump suspected of cancer. Procedures Benefit Risk Cost (examples and estimates) Availability

Needle evaluation and biopsy Open biopsy

Direct examination and sampling Diagnostic yield and accuracy rate of more than 90% Direct examination and sampling Diagnostic yield and accuracy rate of more than 98%

Pain Hematoma No scar Pain Hematoma Side effects of anesthestic agents Scar Pain on compression Radiation

P1,500

Readily available in the clinic Readily available in the community

P8,000

Mammography

Indirect study Plain P1500 Readily imaging - P2000 available in the Diagnostic yield and Scinti P5000 community accuracy rate of more than 80% if stellate lesion is present Ultrasound Indirect study Painless Php1,200 Readily imaging available in the Reliable for benign community cyst Unreliable for cancer Thus, in a patient with a breast mass and whose clinical diagnosis is uncertain and a paraclinical diagnostic procedure is needed other than observation and monitoring, the initial procedure is needle evaluation and biopsy. PRIMARY GOALS AND MODALITIES OF TREATMENT OF BREAST DISORDERS Malignant breast conditions are usually treated using standard cancer treatment modalities like surgery, radiotherapy, and chemotherapy/hormonal therapy, singly or in combination. Benign neoplasms are usually treated with excision with rooms for observation/monitoring. Infectious benign conditions of the breasts are usually treated with antibiotics and drainage and/or debridement. Aberrations in normal development and involution are usually treated with observation and monitoring. Breast disorders based on causation Aberrations of normal development and involution Primary goals in treatment To allay anxiety and fear that the breast condition is cancer Primary modalities of treatment Advice and tempered assurance Monitoring and observation Analgesics, if needed Aspiration for cysts Excision for solid mass as a last resort Antibiotics Drainage / debridement Excision Monitoring and observation for small fibroadenomas Surgery, radiotherapy, chemotherapy, hormonal therapy, singly or in combination

Infections Benign neoplasms Malignant neoplasms

To resolve the infection To resolve the mass To control the cancer

The table below shows the usual treatment for specific breast disorders. Breast conditions Observe/Monitor Surgery Drugs

Radiotherapy

and specific breast disorders Malignant Breast Cancer (including Pagets disease of the nipple) Benign Fibroadenoma Macrocyst Galactocoele Mastitis and breast abscess

(chemotherapy, hormonal therapy and antibiotics) (subtotal / total mastectomy, modified radical mastectomy) (excision) (needle aspiration) (needle aspiration) (needle aspiration/incision and drainage) (excision) (wide excision) (needle aspiration/incision and drainage / debridement) (reduction mammoplasty)

Intraductal papilloma Benign cystosarcoma phyllodes or phyllodes tumor Tuberculosis of the breast

Mammomegaly

SOME CLINICAL ISSUES IN THE MANAGEMENT OF BREAST DISORDERS 1. All females have a risk of developing breast cancer during their lifetime. The risk is not confined to females with a family history of breast cancer. So, all females should be on the look-out. 2. The phrase fibrocystic diseases should be discarded. Fibrocystic changes is a better term. 3. Fibrocystic changes do not lead to cancer. Fibrocystic changes are physiologic changes. Operations done on the breast for fibrocystic changes are unnecessary. 4. Breast pain without a breast lump is mastalgia. This is analogous to the dysmenorrhea in the uterus. Mastalgia, just like dysmenorrhea, is due to some hormonal mechanism the details of which are not known. 5. Mastalgia is often wrongly associated by laymen with breast cancer. This wrong association and fear of cancer can aggravate the mastalgia. The approach to patients with mastalgia is first, to tell them they have no lump, therefore no cancer. Second, to explain the cause of mastalgia (see no.4). Third, to correct the mistaken association of pain and cancer. Lastly, to give a standby prescription of analgesics. With an adequate advice and explanation, the analgesics may not be needed at all. 6. The presence of fibroadenoma (established clinically and by needle evaluation) does not constitute an absolute indication for excision. Operation is indicated when the fibroadenoma is big (at least 3 cm) and, in cases of smaller fibroadenomas, when patients wish to, despite the proper explanation by the physician. If no operation is decided upon, monitoring should be done. The rationale for

monitoring with option to operate is that some fibroadenomas regress and if more fibroadenomas occur in the future, they can be excised in one sitting. This has the advantage of less scar and less expense. GENERAL INDICATIONS FOR REFERRAL TO A BREAST SPECIALIST Breast specialists in the Philippines are primarily general surgeons who have focused their practice in breast disorders. The general surgeons breast specialists may request the medical oncologists for assistance in administering chemotherapy and the radiation oncologists in administering radiation therapy. The ultimate indication for referral to a breast specialist by the generalist or primary health care physicians can be summed up in this statement: Conscience and ethics dictate they need to refer in fairness to the patients because of the limitation of their capability in order to uphold the motherhood principle of primum non nocere. For more specific indications, they need to refer all patients whom they suspect to have breast cancer and those conditions that will need surgical treatment. Outline of Clinical Breast Evaluation by the Primary Health Care Physician Patient without breast symptom (breast check) with breast symptom- pain, lump, nipple discharge

Physician

COMPLETE BREAST EXAMINATION

Definite Lump

Lumpy Breast Nodular Breast +/- Pain Pain

No Lump

Discharge Intraductal papilloma Cancer

Cancer Fibroadenoma Macrocyst Gatactocoele Others

Fibrocystic changes

Hormonal cause Fibrocystic Changes Others

Breast Specialist

Advice (allay fear) Analgesics Monitor (Self-Exam) Check-up Second opinion

Breast Specialist

(Breast Specialist) BIOPSYCHOSOCIAL WELLNESS AND ILLNESS AS INFLUENCED BY THE BREAST CONDITION A female person is in a state of biopsychosocial wellness as influenced by the breast condition if she considers herself as having no breast health problem. She may have a real breast disorder which she may not be aware of. On the other hand, a female person is NOT in a state of biopsychosocial wellness if she considers herself as having a breast health problem or she keeps on worrying about a potential breast problem. Her breast health problem may be real or imaginary (perceptual). Real breast health problem consists of those conditions that can cause death such as breast cancer and those that will need active treatment, such as an operation. Those with aberrations of normal development and involution that need only advice to allay fear do not have real breast health problem. Imaginary breast health problems are usually seen in people who think they have but in reality they dont have real breast disorders. In the Philippines, the lot of the female populations who are aware of the magnitude of the breast cancer problem, who have family history of breast cancers, and who have been subjected to routine screening with mammography and ultrasound suffer from imaginary breast health problem. Here are some specific scenarios: 1. My breast is painful. I may have breast cancer. 2. I have a family history of breast cancer. I may have breast cancer. 3. I have breast cancers because there are findings (nodules, complex cysts) on my mammography and ultrasound. The solution to reduce the magnitude of the imaginary breast health problem among the Filipino female population is a combination of intense public health education to dispel myths and to allay fear, and a judicious use of mammography and ultrasound as well as the usage of words in the interpretation by the radiologists and ultrasonographers. SOME SOCIAL ISSUES IN BREAST HEALTH PROBLEMS Breast cancer is the main concern in breast disorders. Breast cancer is the most common cancer among females in the Philippines. Despite the presence of mammography and ultrasound during the past 30 years and despite the intensive public health education, majority of the Filipino patients with breast cancer still consult at the advanced stage. About 70% are still in stages III and IV. The exact reasons are not established. They could be a combination of poverty, ignorance, fatalistic mentality, denial, and excessive fear of the disease itself. The solution to this problem has to be spearheaded and addressed by the Department of Health. With the advent of mammography and ultrasound compounded by the undue fear for breast cancer among the female population, there is a tendency for excessive performance of unnecessary mammography and ultrasound. Not only has this excessive use of unnecessary mammography and ultrasound led to high prevalence of imaginary breast health problems thereby causing biopsychosocial illness, it has also caused unnecessary medical expense on the part of the paying patients and drain on government resources. The solution to this problem is a proper education of the public and the physicians on the rational use of the diagnostic procedures. Likewise, because of the undue fear of cancer, there is a tendency for excessive unnecessary open biopsy on the breast on the basis of just to be sure. A lot of these biopsies would turn out to be fibrocystic changes which strictly speaking do not need to be operated on as they are just aberrations of normal development and involution. The solution to this problem is a proper education of the public and the physicians on the rational indications for an open biopsy of the breast.

POST-PROGRAM ASSESSMENT
Pls. assess yourself by trying to answer the following questions as indicated in the specific learning objectives: A. Enumerate at least 10 more common breast disorders seen in the Philippines. B. Classify the breast disorders into benign and malignant conditions.

C. Categorize the breast disorders by primary causes (malignant neoplasms, benign neoplasms, aberration of normal development and involution or ANDI and infection). D. Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast. (see exercises below) E. Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with possible breast disorders. F. Identify the usual indications for the different diagnostic procedures commonly used in patients for possible breast disorders. G. Identify which breast disorders can be monitored and which should be actively treated. H. Given a pretreatment diagnosis of a breast disorder with the stage of the disorder, indicate the usual goal of treatment and its corresponding recommended primary treatment. I. Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes. J. Identify at least two general indications for referral to a breast specialist. K. Advice patients on how to achieve and maintain psychosocial well-being as influenced by the breast condition. L. Identify two social issues related to the breast health problem in the community (focusing on breast disorder) and suggest ways on how to reduce the problem. Identify the most probable breast disorder present in patients presenting with a set of symptoms and signs referable to the breast. Check your answers in the key provided. 1. A 29-year-old female patient presents with a very movable non-tender solid breast mass with welldefined border. There is no palpable axillary lymph node. The primary clinical diagnosis is: A. breast abscess B. breast cancer C. fibroadenoma D. fibrocystic changes E. phyllodes tumor 2. A female patient presents with mastalgia and nodular breast tissues with NO dominant mass. There is NO axillary node. The primary clinical diagnosis is: A. breast abscess B. breast cancer C. fibroadenoma D. fibrocystic changes E. mastitis 3. A female patient presents with a hard breast mass with ill-defined border, fixed, with a palpable ipsilateral axillary lymph node. The primary clinical diagnosis is: A. breast abscess B. breast cancer C. fibroadenoma D. fibrocystic changes E. tuberculosis of the breast 4. A breast mass is fluctuant associated with erythema and tenderness. The most likely diagnosis is A. Mastitis B. Breast abscess C. Tuberculosis of the breast D. Gross cyst E. Inflammatory breast cancer 5. A female patient has marked asymmetry of the breasts but without a palpable mass on the enlarged breast. The most likely diagnosis for the enlarged breast is A. Virginal hypertrophy B. Galactocoele C. Breast cancer

D. Physiologic asymmetry E. Fibroadenoma 6. There is a lesion on the nipple of one breast in a 50-year-old female patient. The most likely diagnosis is A. Allergy B. Dermatitis C. Pagets disease of the nipple D. Human bite E. Infection of the Montgomery glands 7. A patient has a sanguinous nipple discharge with NO palpable mass. The most likely diagnosis is A. Intraductal carcinoma B. Intraductal papilloma C. Pagets disease of the nipple D. Fibrocystic changes E. Ductal ectasia 8. A well-defined mass which is movable and nontender is palpated in the breast of this 18-year-old female patient. The most likely diagnosis is A. Virginal hypertrophy B. Macromastia C. Fibroadenoma D. Macrocyst E. Phyllodes tumor 9. The left breast mass is hard solid with ill-defined border. It has contracted the left breast. The most likely diagnosis is A. Tuberculosis of the breast B. Invasive ductal carcinoma C. Lobular carcinoma D. Fungal infection of the breast E. Phyllodes tumor 10. The patient has a huge multinodular breast with NO axillary nodes. The most likely diagnosis is A. Ductal carcinoma B. Lobular carcinoma C. Fibroadenoma D. Cystosarcoma phyllodes E. Tuberculosis of the breast

Answer key: 1. C 2. D 3. B 4. B 5. A 6. C 7. B 8. C 9. B 10. D

STUDENTS ASSESSMENT OF THE SELF-INSTRUCTIONAL PROGRAM

Title/Name of Self-instructional Program: Benign and Malignant Conditions of the Breast Author: Reynaldo O. Joson, MD, MHPEd, MSc Surg Evaluator: Date: INSTRUCTIONS: Pls. assess the self-instructional program through the following statements. Use the key below: 5 - Strongly agree 4 - Agree 3 - Not certain; not observed 2 - Disagree 1 - Strongly disagree Statements on the Self-instructional Program The objectives were clear. The objectives were "must knows" in the practice of the profession. The objectives were too heavy. The content was appropriate based on the stated objectives. The content was adequate based on the stated objectives. The content was clear. The content was presented in logical sequence. The learning activities were appropriate based on the objectives. The learning activities were effective in facilitating learning. The assessment was appropriate. 5 4 3 2 1

1. 2. 3 4. 5. 6. 7. 8. 9. 10.

Comments and suggestions (pls. submit a copy to the author personally or through email rjoson2001@yahoo.com / rjoson@maniladoctors.com.ph)

About the Author September, 2013

Present Academic Positions Dr. Reynaldo O. Joson is presently a permanent professor at the Department of Surgery of the University of the Philippines, College of Medicine with a rank of Professor V. He is a former Chief of the Division of Head and Neck, Breast, Esophagus, and Soft Tissue Surgery at the Philippine General Hospital (presently renamed as Division of Surgical Oncology, Head and Neck, Breast, Skin and Soft Tissue and Esophago-Gastric Surgery). Academic Degrees He obtained his Doctor of Medicine from the University of the Philippines College of Medicine in 1974; his Master in Hospital Administration from the UP College of Public Health in 1991; his Master in Health Profession Education from the UP National Teachers Training Center for Health Profession in 1993; his Master of Science in Clinical Medicine (General Surgery) from the UP College of Medicine in 1998. His finished his residency in General Surgery at the Philippine General Hospital in 1981 after which he became a Diplomate of the Philippine Board of Surgery. Academic and Professional Honors and Awards 1. Most Outstanding Medical Educator in the Philippines, University of the Philippines Medical Alumni Association, 2003 2. Most Outstanding Physician Award, University of the Philippines Alumni Association, 2004 3. Dr. Lino Ed Lims Outstanding Medical Teacher Award in Clinical Sciences, University of the Philippines College of Medicine, 2004 4. Most Outstanding Teacher in Oncology, Philippine Society of Oncology (October, 2006) 5. Centennial Professorial Chair, University of the Philippines Manila (2008) Education for Health Development in the Philippines One of his missions in life is to contribute to the health development in the Philippines through education. This mission started in 1990 when, as Director of the UPCM Postgraduate Institute of Medicine, he designed a structured Department of Health-UPCM Postgraduate Circuit Courses in four provincial hospitals in the Philippines (Ilagan, Isabela in Luzon; Aklan in the Visayas; and Koronadal, South Cotobato and Oroquieta, Misamis Occidental in Mindanao). He then went on to develop a structured general surgery training program using a distance education mode from 1991 to 1994 in Zamboanga City Medical Center. With this program, he added 7 trained general surgeons to the pool of 2 that served the 3 million population of Western Mindanao. In 2004, he helped established the Zamboanga School Medical Foundation (now Ateneo de Zamboanga Medical School). See also Writings below. Hospital Administration He is currently the Senior Vice-President for Corporate Affairs at the Manila Doctors Hospital. He is a past chairperson of the Department of Surgery of Ospital ng Maynila Medical Center (20012009). Writings He started writing books, primers, self-instructional programs, and course packs in medicine, surgery, hospital administration, and medical education in 1985. As of July 2013, he has more than 100 finished products. He started publishing his writings in the Internet in 1990. As of July 2013, he has more than 198 websites. Contact Numbers Dr. Reynaldo O. Josons main email address is rjoson2001@yahoo.com His cellphone number is 09188040304. R.O. Josons Website: http://sites.google.com/site/rojosonwebsites