Breast Physical Examination Research Articles

Outcome After Treatment of Patients with Mammographically Occult, Magnetic Resonance Imaging—Detected Breast Cancer Presenting with Axillary Lymphadenopathy

Although magnetic resonance imaging (MRI) for patients with mammographically occult breast cancer with axillary lymphadenopathy has been accepted for staging, treatment outcome data in this patient group is lacking. In this study, 16 patients, median age of 45 years (range, 27–66 years), presented with malignant axillary lymphadenopathy, negative mammograms, negative breast physical examination, and abnormal breast MRI. All 16 patients were found to have ≥ 1 suspicious lesions on breast MRI. Ten patients had a solitary enhancing lesion; 1 patient had 2 enhancing lesions; 3 patients had 3 enhancing lesions; 1 patient had a mass lesion and diffuse patchy enhancement in the breast; and 1 patient had regional enhancement but no discrete lesion on MRI. Six patients underwent breast-conservation surgery using MRI-guided wire localization and 10 patients had modified radical mastectomy. Fourteen patients received adjuvant chemotherapy and the remaining 2 patients received neoadjuvant chemotherapy. With a median follow-up of 5 years (range, 1.2–7.6 years), the 5-year actuarial local control was 100%, relapse-free survival was 74%, and overall survival was 87%. Three patients developed distant metastases. Two patients died from distant metastases, and 1 patient is alive with metastatic disease. One patient had a relapse in the contralateral axilla and was treated with paclitaxel and is disease free. Although the patient population is small, the outcome after treatment for this group of patients with a mammographically occult, MRI-detected breast cancer presenting with axillary adenopathy is similar to the expected outcome for patients with breast cancer with positive axillary lymph nodes.

Invasive cancers detected after breast cancer screening yielded a negative result: relationship of mammographic density to tumor prognostic factors.

To evaluate common breast tumor prognostic characteristics, including estrogen receptor (ER) status, grade, size, and method of detection, in relationship to mammographic density. The study involved 121 women who had negative results at both screening mammography and breast physical examination within 17 months before a diagnosis of breast cancer. Mammographic density was classified according to Breast Imaging Reporting and Data System patterns 1 through 4 (where 1 indicates a fatty breast and 4 indicates a dense breast). Axillary nodal status and tumor histologic ER status, histologic grade, size, stage, and method of detection (mammography alone, palpation alone, or both palpation and mammography) were analyzed by density category and tested for statistically significant differences across categories by using analysis of variance. Statistically significant differences (P <.05) by density category were found for the following variables: ER positivity (15 of 15 tumors in category 1 breasts, 32 of 41 tumors in category 2 breasts, 37 of 49 tumors in category 3 breasts, and eight of 16 tumors in category 4 breasts were ER positive), occurrence of grade 1 tumors (eight, 11, 19, and four tumors in category 1, category 2, category 3, and category 4 breasts, respectively, were grade 1), mean tumor size (11.3, 13.0, 14.7, and 19.7 mm for category 1, category 2, category 3, and category 4 breasts, respectively), detection with mammography alone (13, 31, 36, and four tumors in category 1, category 2, category 3, and category 4 breasts, respectively, were detected with mammography alone), and occurrence of stage I tumors (10, 25, 28, and five tumors in category 1, category 2, category 3, and category 4 breasts, respectively, were stage I). In women with negative results at clinical and mammographic screening within 17 months before breast tumor detection, subsequently diagnosed cancers tend to be ER negative, of higher grade, and larger in size in those with dense tissue patterns than in those with fat patterns.

Is mammography screening for breast cancer really not justifiable?

The consensus that breast screening is effective for women aged 50-59 years was shattered when Gotzsche and Olsen suggested that there are no reliable data to support screening by mammography. In practice, their concerns have been difficult to address because for many studies purporting to show effectiveness, adequate data have not been published to confirm that they were valid. Further, the trials in Canada for which such data are available did not show effectiveness of screening mammography. Since the 1990s, there has been an unprecedented reduction in breast cancer mortality in many countries. However, the reductions have no clear link to screening, but are probably due to the implementation of adjuvant treatment with chemotherapy and tamoxifen. Whether screening will have an additional impact in the future is unclear. After reviewing the published evidence, I conclude that the additional contribution of mammography over screening by good breast physical examinations and breast self examination is to detect good prognosis breast cancers, as the benefit of screening derives from the earlier detection of relatively advanced breast cancers, providing good therapy is given. If women choose mammography screening, they should understand that their risk of dying in the next few years may not be reduced.

Evaluation of the quality of care in the clinical care centers of the National Centers of Excellence in Women’s Health

This study evaluated the quality of primary care services provided in 15 National Centers of Excellence in Women’s Health (CoE) clinical sites in operation in 2001 using self-reported clinical preventive services and patient satisfaction as indicators of quality of care. A sample of 3,111 women served by the CoE program was surveyed and compared with quality of care benchmarks from national and local community surveys. The benchmark surveys were: a nationally representative sample of 2,075 women from the 1998 Commonwealth Fund Survey of Women’s Health; a community sample of women who lived within a geographical catchment area for three CoEs; and a sample of 71,438 women in the 1999 Consumer Assessment of Health Plans Study (CAHPS) of commercial managed care plans. Adjusting for region, age, education, perceived health status, and managed care enrollment, women in the CoEs weremore satisfied with their care and had received significantly more screening tests and counseling services than women in the benchmark samples. The largest effects among primary care services were for physical breast examination, mammogram (ages 50+), and counseling for smoking, domestic violence, and sexually transmitted diseases.

HEALTH CARE SERVICES FOR LESBIAN AND BISEXUAL WOMEN: SOME CANADIAN DATA

Specific health needs and health services for lesbian and bisexual women are relatively invisible in existing research, with little Canadian data on these topics. To redress such gaps, data were selectively analyzed from a larger study with 98 lesbian/bisexual women living in a Maritime Province in Canada. As part of a semistructured interview, women were asked to indicate whether a particular health care service was important to them. General physical examination, Pap smear, breast examination, and holistic medicine were the four services chosen with the highest frequency. HIV/AIDS information/screening and safer sex information were judged important by over half of the participants. When asked to rank their top three services, however, participants chose the physical examination, holistic medicine, and psychological counseling. Our results are discussed in terms of barriers to basic health care, accessibility of services, and the importance of accurate information about AIDS and safer sex.

Magnetic resonance imaging of breast cancer: Clinical indications and breast MRI reporting system

Magnetic resonance imaging (MRI) is well suited to the investigation of breast cancer by virtue of its noninvasive nature and its multiplanar imaging abilities. MRI investigations showed high sensitivity but modest specificity for breast cancer detection and diagnosis. Most early studies tested the ability of MRI to evaluate and diagnose findings in the breast discovered by other imaging tests or by breast physical examination (1-4). When it was discovered that MRI identified small breast cancers undetected by mammography or breast ultrasound, MRI was used to estimate breast cancer extent in known cancer cases for surgical planning (5,6). These investigations led to the use of MRI in a multitude of breast imaging applications, raising further questions about the use of MRI in everyday practice: What are the indications for breast MRI in general practice? What is its role in light of other imaging tests? What are its benefits and limitations in each setting? How do I report these studies? The purpose of this article is to review the clinical background regarding indications for the use of MRI and relevant cases in which MRI can impact patient management in breast disease, and to describe new developments in reporting breast MRI studies. J. Magn. Reson. Imaging 2000;12:975-983.

Underusers of Mammogram Screening: Stage of Adoption in Five U.S. Subpopulations

Background. The purpose of this report is to describe the characteristics of women ages 50 to 80 who do not follow commonly accepted mammography screening guidelines. It provides unique understanding of the robustness of characteristics of underusers across five different U.S. subpopulations.Methods. The data are from the baseline surveys of the five studies of the NCI Breast Cancer Screening Consortium. Stage of adoption of mammography screening and other characteristics of underusers are presented. Polytomous logistic regression analysis was used to explore multivariable associations with stage of adoption in each study site.Results. The five samples studied by the Consortium range in size from 259 to 4,477 women (n= 11,292). The relationship of the perceptions of the pros and cons of mammography with stage of adoption was strikingly similar across the five samples. Other variables consistently associated with stage were a recent receipt of a breast physical examination and recommendation for mammography by a physician.Conclusions. The findings suggest a need to encourage regular screening through effective communication from a health care provider. Intervention messages should be designed to increase the pros of mammography, decrease the cons, and highlight these differentially according to the woman's stage of adoption.

Mammography of the postreconstruction breast.

Experience with mammographic examination of the reconstructed breast after mastectomy is limited. Typical mammographic changes associated with breast reconstruction are described. When these changes are identified on mammography, they can prevent patients from having unnecessary biopsies and can alleviate patient anxiety. A retrospective review of all mammograms performed in our breast center was made to identify typical as well as unusual findings on the postreconstruction mammogram. The findings were correlated with the type of reconstruction and the physical examination findings. Mammography after mastectomy and breast reconstruction was performed in patients with palpable abnormalities, a suspicion for implant failure, or for patient anxiety. In the postreconstruction patient with a palpable mass, features characteristic of fat necrosis were the most frequent abnormal findings on mammography. Unusually placed implants or focal implant ruptures may explain a mass discovered on breast physical examination. Imaging of the reconstructed breast after mastectomy yields typical mammographic findings. Fat necrosis can be identified on mammography and may explain a new palpable mass on physical examination. Mammography continues to be useful to identify a postoperative complication or implant failure and to differentiate it from tumor recurrence.

Observer Agreement of Mammographic Interpretation

: The purpose of this study was to determine the inter- and intraobserver agreement of mammographic interpretation among three board-certified radiologists with different levels of expertise in mammography who interpret mammograms, and to use the data to improve quality assurance of mammography. Four hundred and ninety-five randomly selected mammograms from a pool of 9, 326 mammograms performed between 1987 and 1990 were reexamined by three board certified radiologists without prior knowledge of the original interpretations. Each radiologist was asked to assign the mammogram to any of the three categories of normal, indeterminate, and suspicious for malignancy, and also to provide recommendations for further workup (breast physical examination, short-term follow-up mammography, ultrasound, etc.). In addition, 120 mammograms were reinterpreted for the second time by the same radiologist in order to determine the intraobserver variability. Results were also compared with the original readings. Kappa statistics was used in the analysis of the agreement. The interobserver agreement for the overall diagnosis was 83.6% between radiologists #1 and #2, 86.5% between #1 and #3, and 81% between radiologist #2 and #3. The intraobserver agreement was 98.7%, 89.1%, and 100% for radiologists #1, #2, and #3, respectively. The overall agreement between the three radiologists for the interpretation of 495 mammograms was good to excellent. Some disagreement was seen in detecting suspicious calcifications, short-term follow-up recommendations, and further diagnostic workup. The study demonstrated that the overall reading of mammograms by each radiologist was significantly different from the original interpretation (p < 002). The p-value indicates that the agreement was significantly greater than would be expected by chance alone.?

Effectiveness of screening for breast cancer in women under 50 years at entry: The Kotka pilot project in Finland

It is still uncertain whether mammography is beneficial to women under 50 years of age. We report a follow-up of 4 1-year birth cohorts in 13 Finnish municipalities subjected to service screening. The women in these cohorts were born in even calendar years and they were 40-47 years old at the time of first screening, which was repeated every other year. At the beginning, 4,163 women were invited and 86% attended. Women were screened with mammography, physical breast examination and information on detection and early diagnosis of breast cancer by breast self-examination (BSE) was given. Incident cases of breast cancer and breast-cancer deaths were recorded. The expected numbers of incident breast-cancer cases and deaths from breast cancer were derived from control women who were residents of the same municipalities but who were born in adjacent calendar years (odd years) to those screened. In the screened cohorts 13 cancers were screen-detected, 32 cancers were interval cases and 8 cases were diagnosed among the non-attenders, while in the controls 85 cancers were detected during a 9-year follow-up from 1982 to 1990. One death from breast cancer occurred in the screened cohorts among cases diagnosed between 1982 and 1990, against 10 expected breast-cancer deaths during a 10-year follow-up from 1982 to 1991 of women initially free of breast cancer. Breast-cancer mortality in the screened cohorts was significantly lower than in the controls (Rate Ratio 0.11), but it is not clear how much of the reduction in mortality could be accounted for by the mammography itself and how much to other activities included in the screening programme (especially training in BSE) or to chance variation. It is unlikely that a programme sensitivity of 25% (13/53) would have resulted in 89% (100-11) effectiveness or reduction in the risk of death from breast cancer.

Breast cancer diagnosis in women with subglandular silicone gel-filled augmentation implants.

To determine whether breast augmentation implants interfere with detection of breast cancer and to characterize the projections that offer an improvement in the detection of disease. The mammographic examinations, clinical presentation, and pathologic findings were retrospectively reviewed in 18 patients who underwent breast augmentation with silicone gel-filled implants. At diagnosis, 16 patients (89%) had palpable abnormalities. Standard mammographic views were negative in 17 patients (94%). Modified implant compression views (used with implant displacement) showed abnormalities in 12 patients (67%). Sixteen (89%) of the 18 patients had invasive carcinomas, and seven (39%) had positive axillary lymph nodes. Standard mammographic views are inadequate for breast cancer screening in patients with silicone gel-filled implants. Although additional modified compression views offer a moderate improvement in breast cancer detection, imaging with tangential mammographic views, sonography of palpable areas, and breast physical examination in conjunction with mammography will offer additional benefit in breast cancer detection.

Accreditation of Mammography Facilities by the American College of Radiology: Results of a National Survey

Mammographic screening for the early detection of breast cancer is rapidly becoming an increasingly common practice in the United States. With more than 20 million mammograms estimated to be performed annually by more than 11,000 units, ongoing quality assurance and evaluative programs have gained importance. Recent federal legislative and regulatory efforts augment a patchwork of state mandates establishing or encouraging specific quality control requirements for mammography facilities, personnel, equipment, and radiation exposure. Many of these requirements are based on the American College of Radiology's (ACR) voluntary accreditation program that has been offering facility certification since 1987. The ACR collects and maintains detailed data on the characteristics of accredited facilities; however, little is known about facilities not participating in the ACR program. This article describes national results from the 1992 National Mammography Facilities Survey, a representative sample of 1,057 mammography facilities. We found statistically significant (P < .05) differences between accredited and nonaccredited facilities in type of mammography practices, cost, personnel standards, variables linked to accessibility, and corollary screening practices (availability of breast self-examination instruction and breast physical examination). Other variables showed minor or little variation between accredited and nonaccredited facilities. The results of this study suggest that, although all facilities engage in various components of "good" quality assurance practices, ACR-accredited facilities reported conducting these programs more frequently. Further, despite the substantially increased costs associated with these programs, ACR-accredited facilities reported lower average charges for screening mammograms and were more likely to participate in reduced fee programs.

Desogestrel versus gestodene in oral contraceptives: influence on the clinical and histomorphological features of benign breast disease

Forty-four female volunteers asking for oral contraception, affected by symptomatic benign breast disease (BBD) were evaluated to compare the effects on mastalgia and breast nodularity of two different low dose oral contraceptives (OCs), containing 200 μg ethinylestradiol + 150 μg desogestrel (EE+ D) and 30 μg ethinylestradiol + 75 μg gestodene (EE+ G), respectively. Physical examination, bilateral thermography, X-ray and/or ultrasonography of breast, and needle and screw-needle biopsies of mammary tissue were performed in all patients before OCs administration and after six cycles of treatment. OCs administration caused an overall improvement of mastalgia in 53%. Breast nodularity improved only in 8% of patients in both groups. Epithelial tissue modifications in mammary biopsies were observed, with involutive and/or secretory histomorphological and ultrastructural changes, frequently coexisting in different areas of the same breast.

The combination of aspiration needle biopsy with fine needle aspiration in the preoperative evaluation of breast tumors

During a period of 10 years. 2906 women (mostly asymptomatic) were referred to us for physical breast examination. Fine needle aspiration (FNA) was used to examine a nodule or a breast thickening in 860 of these patients. One hundred and ten of these patients also underwent a large needle biopsy (LNB) to add a pre-operative histological evaluation. LNB was performed with 18–20 gauge needles. without cutting the skin and without adding any significant pain or discomfort to that caused by FNA (aspiration needle biopsy. ANB). Diagnostic sensitivity for cancer was 89% for FNA and 100% for ANB. ANB allowed us to correctly identify two cancers with post-operative stage T 1N 0M-0, which were diagnosed pre-operatively as benign by FNA. The combination of the two needle aspiration techniques (FNA and ANB) allowed us to diagnose 51 of all the 54 cancers (95%). The predictive value of a diagnosis of definite malignancy was 100% for either FNA or ANB. The predictive value of a diagnosis of suspected malignancy showed a predictive value of 72% for FNA and 70% for ANB. Three benign nodules with pre-operative ANB findings of suspected cancer were correctly diagnosed by FNA. Of the 12 cancers with inadequate ANB findings. II were correctly diagnosed by FNA. Sixteen of the cancers correctly identified by ANB showed a post-operative size of 2 cm or less (ten cases) or no metastatic axillary lymph-nodes (nine cases). In ten patients with advanced cancer. ANB was performed for pre-operative determination of hormone receptors and thymidine labeling index; one of the two determinations or both, were obtained in five cases. Therefore, we have described a complementary technique which. combined with FNA. can increase diagnostic accuracy of cancer; it provides tissue fragments for a more precise and complete pre-operative evaluation of breast nodules. it does not require skin incision. it is painless and risk free. Our data suggest that the practice of performing FNA or CNB in the pre-operative evaluation of breast tumors can be largely substituted by combining ANB with FNA in the daily clinical activity.

Paget disease of the nipple: radiologic-pathologic correlation.

To correlate the range of clinical presentations with mammographic and histologic findings in patients with Paget disease of the nipple. The clinical, pathologic, and mammographic records of 58 patients who had biopsy-proved Paget disease of the nipple were retrospectively reviewed. The results of two previous studies were also included. Among 34 patients who had typical findings of Paget disease, the mammograms of 17 (50%) showed normal findings, those of 10 (29%) showed nipple, areolar, or subareolar abnormalities, and those of seven (21%) showed evidence of masses or calcifications. Of the mammograms of 24 women with Paget disease but without clinical findings, 19 (79%) showed evidence of suspicious masses or calcifications, four (17%) showed nipple or areolar abnormalities, and one was negative. Nonspecific findings of nipple-areolar complex thickening should be correlated with findings at breast physical examination to confirm or exclude Paget disease.

Invasive Lobular Carcinoma Imaging Features and Clinical Detection

Mammographic findings and method of detection of 52 cases of invasive lobular carcinoma (ILC), the second most common breast carcinoma, are reported. Preoperative mammograms and clinical records of all patients with ILC not associated with a second mammary carcinoma (other than lobular carcinoma in situ) from 1979-1991 at the authors' institution were retrospectively reviewed. Abnormal mammographic findings were present in 48/52 (92%) and included irregular spiculated masses (33/52, 63%), asymmetric densities (7/52, 13%), architectural distortion (5/52, 10%), microcalcifications (2/52, 4%), and well circumscribed masses (1/52, 2%). The mean mammographic diameter was 2.1 cm. The tumor was most often best visualized in the craniocaudal projection. At the time of diagnosis, 54% of women had coexistent suggestive breast physical findings and 35% had metastatic carcinoma in axillary lymph nodes. The infrequency of microcalcifications in pure ILC may hinder mammographic detection and contrasts markedly with ductal carcinoma. Mammography and breast physical examination play complementary roles in the detection of ILC.

Mammographic Patterns and Breast Cancer Risk Factors Among Women Having Elective Screening

We assessed the association between Wolfe mammographic patterns and breast cancer risk factors among 239 women who attended the Breast Evaluation Unit screening program of the Comprehensive Cancer Center of Alabama, University of Alabama at Birmingham, from November 1984 through April 1986. Evaluation consisted of a breast cancer risk assessment based on a questionnaire concerning commonly accepted breast cancer risk factors, along with a physical breast examination and mammogram. Increased age, weight, and parity were associated with a low-risk pattern; late age at first birth, alcohol consumption, and oral contraceptive use were associated with a high-risk pattern. Our findings support those of previous studies, except for those concerning use of oral contraceptives. Further exploration is needed to ascertain whether the association of oral contraceptive use with high-risk patterns indicates a pathway through which estrogens may increase the risk of breast cancer.

Breast imaging. A practical look at its capabilities and its limitations.

The film-screen technique is evolving as the standard for mammography. Sonography is the only other method that currently has a defined role in breast imaging. Mammography should be performed at facilities that have received American College of Radiology accreditation or its equivalent, because technical quality assurance is an important part of mammographic practice. Interpretive quality may be assured by outcome audits performed by mammography facilities. Primary care physicians are best suited to encouraging eligible women to undergo screening studies and should consider these recommendations: Refer patients for screening mammography to accredited facilities according to established guidelines. Educate patients about the need for regular screening. Provide annual breast physical examination. Refresh your knowledge on breast health and the techniques of physical examination if necessary. Teach patients breast self-examination techniques. Demand low-cost, high-quality screening mammography; be aware of local variability of charges and quality.

BREAST CANCER SCREENING

Breast cancer, as the second leading form of cancer death among women, causes significant morbidity and mortality. The primary care physician can help raise the survival rate of women with breast cancer by providing important screening procedures that will lead to early diagnosis and treatment. Screening mammography and regular breast physical examinations are the current screening procedures of choice. Although there is still considerable debate over the age and interval at which women should undergo screening (see Table 1 for recommendations from various organizations), the primary care physician's recommendation is the single most important factor and will certainly lead to a higher screening rate for women in the greater at-risk age groups. Judicious use of these screening procedures should allow primary care physicians to catch more breast cancers at an early, curable stage.

Changes in knowledge, attitudes and behavior of women participating in a community outreach education program on breast cancer screening

A community-based intervention project on Long Island was supported by the National Cancer Institute to increase the use of mammography and breast physical examination among older women. During a 1-year period 526 women aged 50 and older attended educational sessions presented by the project staff conducted in the community in a variety of settings. Sixty-eight percent (355) of the women who participated provided identifying data and completed pre- and post-session surveys while 40% (210) also completed a mail survey 6–12 months later. Screening behavior improved subsequent to the intervention, at follow-up 61% had taken some related action. More than half of the 109 women who had a mammogram after attending the session indicated that the presentation influenced them to do so. The use of a game created a positive atmosphere for conveying information about a sensitive subject and encouraged discussion among women who had a variety of experiences with screening.