All right, so, as I've mentioned, what I'm going to talk to you all today is a little bit different than the usual topics that you guys discuss. We're talking about breast cancer and the clinical evaluation of the breast and how to manage straightforward, quote-unquote, breast findings. So while we're talking about breast cancer and how to diagnose it and how to look at findings and figure out what are the next steps, because breast cancer is the most common cancer diagnosed globally, leading cause of cancer death in women, and we know that a significant number of breast cancer-related deaths can be prevented by early detection and screening. So first things first, kind of just a little bit of a difference between early detection and screening. Screening is basically done in asymptomatic women. So we talk about screening mammograms for the average-risk women after the age of 40. We talk about sometimes breast MRI in high-risk women, which is different than early detection. Early detection is the discovery of breast cancer in women that are already symptomatic. So the workup and the way we go about it is a little bit different. And why it's important for us to do screening and early detection is that it's a paper published over for like almost 20 years ago looking at rate of death from breast cancer in women that received screening alone, screening with therapy, and no screening or therapy at all. So you can see a significant decrease in the rate of death in women that received screening and adjuvant therapy from 60 to less than 40 women per 100,000. So the way we do symptomatic detection with early detection is initially with clinical breast exam, but then that will prompt additional workup with diagnosis and a biopsy. So the most important thing we talk about is when are we doing clinical breast exam or asking women about breast history, how we do it, and why do we do it? So when is every time you have a woman that is between after age of 25. So what we want to do is start like as we do here in some OBGYN clinics is that an OBGYN physician will also ask about a clinical breast exam and perform a clinical breast exam and ask about breast health as far as their visit. How you do it is to perform a clinical breast exam and ask about breast related symptoms. And why you do it is because you want to prevent this. You want to prevent someone showing up with an advanced breast cancer, which is most of the time inoperable and metastatic. So I'm going to focus today on the how you do it. So how you do it, you start by collecting a thorough history with asking if a woman has a complaint. Some women will not start a conversation saying, hey, and I've been feeling this mass for several months. So you need to prompt them. You're going to ask them about their medical and surgical history. Specifically here, I'm going to talk, of course, we talk about everything, but I'm going to focus today on breast. So breast related complaints, previous surgeries or biopsies. When was her last clinical breast exam? And if she had or had any imaging, she had or had any screening or any other diagnostic imaging of the breast. If she's pregnant and if, or there's a risk for pregnancy. If she has any other medical conditions. And importantly, also it's to talk about their family history of breast cancer, ovarian cancer, pancreatic cancer. The clinical, so just a little bit, since I'm a surgeon talking a little bit about anatomy. So breast is made up of ducts and lobules. Ducts carry milk to the nipple, lobules make milk. It's the ducts and lobules are seated in a scaffold of fibroglandular and fibrotic and adipose tissue. That's the, and that's composed the breast parenchymal. And it's all of those structures sit on top of a muscle called the pectoralis major muscle. The breast has a lymphatic drainage and it, most of the time it drains to our axillary lymph nodes and you have different levels of axillary lymph nodes, like level one is lateral to the pec major. Level two is underneath the pec major and level three is a medial to the pec major. You have cervical lymph nodes, supraclavicular lymph nodes and internal mammary lymph nodes. So all lymph nodes can be a source of drainage through the breast and can have the first place that a breast cancer would go to. So when we're talking about clinical encounter, you're going to have, you have to know how to position patients, how to inspect the breast and how to palpate the breast. So you're going to examine the patient in sitting and supine position, ask them to move the arms to this above their head. And you want the provider to be at the same level of the patient. You want to inspect the breast and the nodal basin, look at for symmetry, retractions, bulging, rashes, scars, and you want to palpate first superficially, then deep, and you want to follow the breast landmarks. So when you're palpating the breast, you don't want to only palpate the breast mound. You want to palpate the whole set of landmarks, which is from the clavicle to the lateral border of the sternum, to the inframammary fold, and to the outside border of the latissimus dorsi. And you want to palpate the nodal basins. You cannot palpate infraclavicular nodal basins that well unless you have a really large lymph node. You cannot palpate internal mammary lymph nodal basin, but you can palpate really well a level one and two in a supraclavicular and cervical nodes. Okay, so this is just a few pictures, because pictures are better than a thousand words. So basically a woman is sitting, arm to the side to inspect, lift the arm, put the arm on the waist, and then you're inspecting. Then you ask them to leave their arms and hands on their waist, and then you're going to examine the breast first. You're going to put your hand in the inframammary fold, as you can see in this fifth picture, and then slowly palpate the upper pole of the breast. Sitting position is really the best position to palpate upper pole. Lower pole is a lot easier when the patient is laying flat. And then you're going to start palpating superficially and then deep. As you can see in the picture with the lady laying down, you can see all the landmarks of the breast and then another sort of palpation superficial and deep as the patient lays down and then focus on the lower pole. I find it's important to not forget any part of the breast. So there are several techniques for you to do breast exam or several approaches. We have the radial approach, a concentric approach, or a vertical approach. I personally do the radial approach, because it's basically you palpate from the nephariolar complex outward. So you kind of go all the way to the quadrants of the breast. The important, it doesn't matter which approach you choose, it's just not to miss any parts of the breast and follow all of those landmarks. Additionally, when the woman is sitting, you're going to ask the woman to put their arm on your shoulder or you're going to hold their arm and ask them to drop the weight and you're going to feel the axillary nodal basin, as you can see in picture number four. So you want to basically use the palm of your hand and kind of roll the lymph node against the chest wall. Women would feel uncomfortable with this exam. So it needs to be kind of deep, because some women, especially if they have adipose tissue under their arm, you do need to go a little bit deeper to feel lymph nodes. When you do find lymph findings in the breast, it's important to document location. So breast divided in quadrants and then as a clock. So for instance, this picture here shows a finding a mass or skin thickening at the one o'clock position in the left breast, and then it wants to also mention the distance from the nipple. I'm going to skip that just for sake of time. So always important to document the findings, how big the findings are, measurement, distance from the nipple, o'clock position. When you document lymph nodes, you want to document if they are mobile, fixed, matted. If you can count them, you can say, I populated three lymph nodes. And I always mention, a picture is better than a thousand words sometimes. So if you have something, a patient that shows up with a finding that's really, you find it hard to describe, taking a picture and put it in her chart, or even saving it if there's no way to put it in chart, so you have something to compare it to. I'm just going to go over a few examples here of findings in the breast and what the next steps would be. So this is, as you can see in this first picture, you can see a bulging in the circular areola area, upper outer quadrant, and there's no skin involvement, but you can see definitely a bulging and it's right there. This one, of course, more obvious with a nipple retraction, and those are warning signs of breast cancer. So if you have a mess that's bulging, a mess that is causing nipple retraction, if you have an impalpable mess, that mess needs to be worked up. And the way you do it is with imaging and biopsy. Now I'm just going to show a few things that can be misleading. So the first picture is actually a benign scab. So this patient had chronic drainage mastitis from the breast that causes some distortion and caused that area of that scab in the circular areola region. The second picture is actually one of my patients who showed up after a mastectomy with a local recurrence, and you can see the local recurrence in the center with the scab, and then you can see skin nodules satellite to this local recurrence. And again, all of those need to be biopsy. And when you are seeing the first woman in doubt, you always want to get breast imaging and biopsy because the reason for this talk is to realize that benign findings sometimes are not that obvious, and malignant findings are not that obvious. So having a high level of suspicion helps a lot for breast cancer to be identified and for early detection. So you can see this is obvious, right? You have a fungating mass, that's the most obvious, like there's no way to doubt this is breast cancer. But also looking at the second picture, the importance to looking at the breast as a whole, so the area where the serostrips are, it's actually this huge palpable mass. But then if I just focus on that area, I would have ignored that in this bottom where you have my pencil marking, you have some skin lesions here and dermal deposits of cancer. So always look at the breast as a whole, don't forget to check the skin because if you focus in what is the obvious, you may miss little findings that, for instance, this lady, she would need to have that area of skin excised, and if I didn't document that, I probably would have done not the correct surgery. The patient that has previous surgery is also challenging, this patient presented after a lumpectomy, she had a change on her exam, she had some thickening and then got worse with more retraction of the nipple areolar complex, so we also order imaging and biopsy. Patients with previous surgeries, your level of threshold needs to be low because especially if you haven't seen that patient ever in your life and you're examining her for the first time, it's good to know what her baseline is so you know if there's a change. The danger of inflammatory breast cancer, so inflammatory breast cancer sometimes get missed because physicians think the woman comes in with mastitis, they treat and it doesn't get better and they keep treating. I think a good rule of thumb is if a woman presents and you think it's mastitis and there's this diagnostic question, you can give antibiotic, but if it doesn't resolve, a biopsy, a punch biopsy of the skin or breast imaging and breast biopsy would be necessary, don't keep treating it. So this is what happens with Padgett's disease and I'm going to show a picture in a little bit. This is a lady that actually, this was benign and then again you can see that sometimes it's hard to tell benign and malignant, so this is a lady that had a chronic inverted nipple, had drainage, had also mastitis, developed this area of induration and skin thickening on the side and when I saw her for the first time, I was like, I had to be convinced that she didn't have cancer because I was like, oh this looks like cancer, but she didn't and so it was serial exams, imaging, making sure that there's no area in the breast that needed to be biopsied. So again, suspicion is really important and to not miss a cancer diagnosis. This is just a local recurrence after treatment, a lady present with a bunch of skin changes, so that's the obvious. Just looking at nipples, so we have an inverted nipple, averted nipple, nipple discharge, different kinds, but again, I'm sorry I'm rushing just for the sake of time. This is something important, Paget's disease of the nipple. So it starts with the first picture, right, and then you think, oh she has a little bit of a scab and it's an infection, an eczema of the breast and then it gets bigger and bigger and we see, I've seen, we've seen that quite a bit as patients show up with like months and months of this progression of this eczema in the breast and being treated with steroid, topical steroid or antibiotics and that person didn't even have a breast biopsy or a skin punch biopsy yet, so that would be the easiest way to diagnose this, is to do a little punch biopsy of the area and that will show Paget's disease of the breast. Just to, some things and I'm using my practice and I find it really helpful, in doubt, I always get additional imaging and ask if the radiologist thinks it's worth biopsying. If there is something that's clinically visible on my exam, I will do a punch biopsy in the office. Always work on palpable masses. Unless you've seen that patient for 10 years and the palpable mass is already there and you already did the workup, you always want to do the workup with additional imaging. Clinical exam is a learned skill like anything else in medicine, so the more you do it, the better you get, so exam, exam, exam. I always talk to the fellows and to medical students, you want to examine as many normal breasts as possible. Don't take those for granted because you will know then when you see something abnormal. Always use the other breast as a comparison. This is like something we cheat, right? If you have, and that's great for us to do clinical breast exam for a living, having another breast that you can compare it to. Breasts are not 100% symmetrical, but if you have something in one breast that you don't have on the other, something to think about, right? It's probably not the usual, probably not, it's the expected and normal. And always have, be aware of the pregnant patient. Don't assume it's pregnancy changes. The young patient that, oh, this cannot be breast cancer, she's 26 and it's a mass that needs additional workup. The patient with chronic symptoms is the older lady that comes in, she's 70 and it's like, oh, but I had this mass for several years, or does not remember when she had it. So those patients need additional workup as well. And the most important thing that we see all the time, even here in the U.S. and in Houston, is patients who had signs on exam and clinical findings that were suspicious. They got a biopsy, that biopsy came back negative and the clinician just thought, oh, the biopsy was negative and so it must be nothing. So if you are suspicious of whatever you found on that exam and that biopsy came back benign, it's worth chasing it because biopsies are not 100%. The radiologist can, or not appropriately and inaccurately, so that can cause a benign biopsy with an obvious finding of a breast cancer. And also for specifically for inflammatory breast cancer, the infection that does not improve. So if you have mastitis and you give a course on antibiotics, there's no change. Go dig that, like get more information on that patient and get additional workup to make sure that she doesn't have inflammatory breast cancer. And I always have patients coming in and physicians asking about pain and not having pain or having patient having breast pain or not having breast pain associated with the mass. That is irrelevant. Pain or no pain, you have a finding, you work that out. Pain becomes just an irrelevant piece of information. Thank you.

breast cancer

early detection

screening

clinical breast exams

symptoms