Challenges in the Management of Breast Disease

      In this issue of Obstetrics and Gynecology Clinics of North America, we have recruited contributors with expertise in a variety of arenas to provide a multidisciplinary perspective—recognizing that multiple specialists make up the team of providers who care for women with breast disorders, especially breast cancer.
      This issue begins with a thorough discussion of imaging of the patient with a breast problem. This section assists the reader to understand the clinical significance of the available breast imaging modalities and their impact on breast care. In addition to describing the most up-to-date breast cancer screening guidelines, the authors also explain imaging modalities that are not standard but are often asked about by patients. This should provide a foundation for the initial steps in breast cancer screening and diagnostic workup. A new article also reviews the less commonly seen clinical breast exam findings that can pose a challenge, including women with significant asymmetry and those who have undergone surgical procedures that significantly alter the normal breast.
      As obstetrician-gynecologists are the front-line providers for patients during pregnancy and breastfeeding, an article is dedicated to the management of lactational changes. We also address the less common occurrence of breast cancer in young patients during pregnancy or in the early postpartum period, and these patients have unique needs in terms of treatment and support.
      While breast cancer poses a risk to all patients, there are subgroups of women who are at increased risk of developing breast cancer; risk is multifactorial, and risk factors range from estrogen exposure to benign breast biopsies to family history and genetic predispositions. Management of high-risk patients requires a thorough understanding of individual risk assessment to best tailor screening guidelines. There are two articles that cover the topics of risk assessment, high-risk management, and the most common hereditary breast and gynecologic cancer syndromes.
      Breast cancer represents a spectrum of disease. Treatment is evidence based, and regimens vary significantly based on tumor subtype, stage, and individual patient factors. Advancements in molecular studies allow for the application of genomic profiling to guide therapy for certain subtypes, and family history screening helps identify patients who would benefit from genetic testing, which may affect their treatment decisions in addition to screening recommendations for at-risk family members. A broad review of breast cancer subtypes, systemic, and locoregional therapy options is provided to illustrate the variety of treatment approaches.
      Breast cancer treatment requires a multidisciplinary approach to provide tailored and evidence-based care to include genomic profiling and genetic testing and to ensure patients have basic needs met. A key team member is the patient navigator, who coordinates care and ensures patient and caregiver support from diagnosis through survivorship, and the concept of patient navigation is reviewed. A separate article is dedicated to a discussion of health disparities, including their impact on breast cancer care and outcomes as well as on other aspects of medicine.
      Finally, patients who complete therapy for breast cancer must often grapple with long-term side effects of those treatments, which, while improving survival, can nevertheless negatively affect quality of life. With greater focus on survivorship, it is vital to recognize the physical, social, financial, and psychological challenges that patients need help navigating once they are through with treatment and in a survivorship program, and the concept of survivorship is explored. As primary care providers for women, obstetrician-gynecologists have the opportunity to provide patients with the information and resources available for support with these long-term effects.
      We hope you find this issue both educational and enlightening. We also hope you can use this information to enhance your skills and confidence to counsel patients as well as assess risk, provide appropriate screening recommendations, offer preventive therapies, and work collaboratively with other breast care health providers.