1. A 44 year old woman with breast pain……… March 10, 2004 Primary Care Conference Shobhina Chheda MD MPH (no financial disclosures)

2. History of Present Illness SS is a 44 year old woman presents with concerns about pain in her right breast started several days ago after her son jumped on the bed 4/10 in severity, constant, lateral location, non-radiating

3. History of Present Illness (continued) Denies any bruising, redness, mass, Not breastfeeding currently Denies history of breast problems

4. Learning Objectives Recognize frequency of breast pain as complaint Review differential diagnosis of breast pain Discuss the concern of breast cancer in patients with breast pain

5. Breast symptoms Barton et al. (1999) study of 2400 women ages 40-69 enrolled in HMO for 10 years (1983-1993) 16% presented with breast symptom Women 50 Women with positive FHx more likely to present

6. CC: Breast pain vs. other breast symptoms Barton et al. 1999

7. Thinking about breast pain… Cyclic breast pain Noncyclic breast pain Extramammary pain Smith et al. 2004

8. Cyclic Breast Pain –Pain severity > 4/10 –Pain duration > 7 days/month –Starts in luteal phase and dissipates with menses –11% premenopausal women

9. Cyclic Breast Pain (continued) –Diffuse, bilateral Upper, outer breast can radiate to axilla –Onset age 30-40’s –14% spontaneous resolution, 42% resolution with menopause –Unclear etiology

10. Extramammary pain DDX Musculoskeletal –Costochondritis –Chest wall pain –Fibromyalgia –Cervical radiculopathy –Shoulder pain –Herpes zoster

11. Extramammary pain DDX (continued) Coronary artery disease Pulmonary embolism Pleurisy Gastroesophageal reflux Peptic ulcer disease Psychologic

12. Noncyclic breast pain Unilateral, localized to one quadrant Onset age 40-50’s

13. Noncyclic breast pain DDx Trauma Thrombophlebitis Mastitis Medications Benign tumors Cancer

14. Many women seek medical attention for breast pain because of concern about cancer How concerned should we be…..

15. Breast cancer diagnosis according to combination of symptoms Barton et al 1999

16. Back to SS…. G2P2 (age 20 at first birth) Menarche age 13 No family history of breast cancer Tobacco use 2.5ppd quit age 20 Mammogram 18 months ago normal Hodgkin lymphoma age 24 –Treated with full mantle radiation

17. Learning objectives (continued) Review use of Gail/NCI model Recognize Hodgkin disease treatment as risk factor for breast cancer Discuss challenges of providing generalist care to patients with history of prior cancer

18. History: Risk factors for breast cancer in Gail Model Age Age at menarche Number of biopsies Pregnancy history Number 1 st degree relatives with breast cancer Atypical hyperplasia

19. RestartCred its Tool More Information Credits Breast Cancer Risk 5-YEAR RISK:.6%.6%.9%.9% 7.1%7.1% 12.0%12.0% More InformationMore Information Cal culate Risk for New Patient Software © 2000 iCARDINALCal culate Risk for New Patient Calculate Risk for New Patient 5 year risk: Patient (age 44): 0.6% Woman age 44 same race and average risk factors: 0.9% http://brca.nci.nih.gov/brc.

20. Risk of breast cancer in premenopausal women based on smoking initiation Smoking Initiation CasesControlsOR P value Yrs. from onset of menarche < 5 104831.69 (1.13-2.51) 0.01 > 5 58701.05 (0.67-1.65) 0.83 Relation to 1 st pregnancy Before 1461311.47 (1.02-2.10) 0.04 After 11180.83 (0.37-1.85) 0.64 Band et al 2002

21. What about history of Hodgkin Disease (HD) ? Second cancer is the leading cause of death Breast cancer most frequent solid tumor in women Breast cancer risk inversely related to age at treatment

22. How does treatment impact risk? Matched case control study of breast cancer within a cohort of 3817 survivors of HD Matched 105 patients with HD and breast cancer with 266 patients with HD and no breast cancer Travis et al 2003

23. Risk of breast cancer among young women diagnosed with Hodgkin Disease, by Treatment Travis et al 2003

24. Back to SS…….. Breast exam revealed a tender 2 cm mass laterally at 11:00. Hard, mobile and irregular borders. Mammogram : Spiculated mass with irregular calcifications (BI-RADS-5) Infiltrating ductal carcinoma

25. A word on imaging with normal exam and low risk..… Unnecessary for cyclic breast pain Noncyclic breast pain – Studies suggest no difference in mammogram findings and frequency of malignancy between women with pain and those presenting for routine screening –Some consider ultrasound for persistent pain

26. Challenges for us …. Eliciting an accurate history –70% of children with cancer are long-term survivors Understanding increasing data –Latencies between treatment and 2 nd cancers Alkylating agents- 1 st decade out Radiation- 2 and more decades out –Interactions between treatments

27. Challenges for us …. Understanding increasing data (continued) –Interactions of treatments and genetic characteristics –Childhood Cancer Survivor Study Understanding implications for screening and prevention Educating our patients –Discussion of “increases in risk”

28. Challenges for us …. Understanding implications for screening and prevention Educating our patients –Discussion of “increases in risk”

29. Summary Recognize frequency of breast pain as complaint Review differential diagnosis of breast pain Discuss the concern of breast cancer in patients with breast pain

30. Summary (continued) Review use of Gail/NCI model to assess breast cancer risk Recognize Hodgkin disease and treatment as risk factor for breast cancer Discuss challenges of providing generalist care to patients with history of prior cancer

31. References Barton et al. Ann Intern Med, 130(8).1999 651-657 Robinson BMJ 1996 312: 861-862 Travis et al. JAMA 290(4).2003 465-475 Hull et al. JAMA 290(21) 2003 2831- 2837 Smith et al. Mayo Clin Proc. 2004 79:353-372

32. References (continued) Rhodes D. Mayo Clin Proc. 2002 77:355-361 NCI site: http://brca.nci.nih.gov/brc. Shirley R. Up to date(11.3) Breast pain Yahalom J. JAMA 290(4) 2003 529-531 Childhood cancer survivor study site: http://www.cancer.umn.edu/ltfu