A Top Health Concern of Most Women

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      William F. Rayburn, MD, MBA, Consulting Editor
      This quarterly issue of Obstetrics and Gynecology Clinics of North America, edited by Patrice Weiss, MD and Jessica Partin, MS, MD, deals with the “Management of Benign and Malignant Breast Disease.” This topic is particularly relevant, since most women identify breast cancer as one of their top health concerns. Breast cancer is the most frequent type of non–skin cancer and the most common cause of cancer death in women worldwide. Both earlier detection through screening and improvements in treatment are responsible for this reduction in breast cancer mortality since the 1970s.
      Screening is of the greatest value for individuals who are most likely to develop breast cancer and for whom early treatment is more effective in reducing mortality. The issue addresses what is important to determine a person’s risk of developing breast cancer and how to use that information both to recommend the modality and frequency of screening and to determine whether referrals are needed for genetic testing and consideration of chemoprevention or prophylactic surgery.
      In advanced countries with established breast cancer screening programs, most patients present due to an abnormal mammogram (usually as a soft tissue mass or density and grouped microcalcifications). Clinicians are often instructed about the lack of value with routine physical breast examination or patient instructions about breast self-examination for average-risk women, since neither has demonstrated efficacy in early cancer detection or improved outcomes. However, up to 30% of women diagnosed with breast cancer noted the presence of a mass either not detected on a mammogram or palpated between mammograms. “Classic” characteristics of a cancerous lesion include a hard, immovable, single dominant mass with irregular borders. More advanced regional disease includes axillary adenopathy or skin findings, such as erythema, thickening, or dimpling of the overlying skin (peau d’orange). Metastatic disease involves the bones, liver, and lungs.
      Most women are at average risk of developing breast cancer, even if there are some risk factors. The patient’s age group (40 to 49, 50 to 74, 75 and older) is probably most important in determining when to be screened, because breast cancer incidence increases with age. Among those women with average risk, mammography is recommended rather than other imaging modalities, either annually or every 2 years based on the preference of the woman. Annual screening is associated with more overdiagnosis and cost than screening every 2 years, and the difference in absolute benefits between screening intervals is believed to be small.
      This issue addresses moderate-risk women, which includes those with breast cancer in a first-degree relative without a known genetic syndrome. Most women with moderate risk undergo the same screening approach as for average-risk women. Women at high risk warrant referral to a more specialized clinic for evaluation and possible intensified surveillance. Examples of high-risk factors described in the issue include those who have a personal history of ovarian, peritoneal, tubal, or breast cancer; family history of ovarian, peritoneal, or tubal cancer; strong family history of breast cancer or ancestry associated with BRCA1 or 2 mutations; genetic predisposition; and prior radiotherapy to the chest.
      Special considerations for breast cancer screening are identified for some populations: those with dense breast tissue, physician examination findings following mastectomy, and during pregnancy or while lactating. Shared decision making should be used in discussing screening and early-stage breast cancer. The diagnosis of breast cancer requires a fine-needle aspiration or core-needle biopsy for histologic evidence of malignant epithelial cells with stromal invasion. Decision pathways can be found when discussing the patient’s risks of developing advanced breast cancer.
      This issue provides the reader with recommendations for evaluating and managing a broad spectrum of benign breast conditions that involve inflammatory processes, shape, size, and function. The described limitations during pregnancy and understanding lactational changes are necessary when counseling nearly all new mothers attempting to breast-feed. The authors discuss certain challenges that affect women with breast asymmetry, macromastia, and limitations with surgically altered breasts.
      Articles in this issue are particularly relevant to obstetrician-gynecologists, since they are frontline providers in breast health maintenance, education, and breast cancer screening. Dr Weiss and Dr Partin have recruited an expert group of contributors who provide a balanced, multidisciplinary approach. Information in these articles should aid all women’s health care providers as they strive to address this top health issue that concerns most women.