Benign and Malignant Conditions of the Breast

A Self-instructional Program for

Primary Health Care Physicians

Designed for:

Competency-based Learning
In- and Off-Campus Learning

Reynaldo O. Joson, MD, MHPEd, MSc Surg

April, 2005

1
 Preface
Dear Learner,

Mabuhay!

Welcome to a learning experience in becoming a health professional.

This program has been especially designed with you, the learner, and the principles of
effective teaching and learning in mind.

As you go through this learning program, please bear in mind the following:

1. I am treating you as an adult learner which

1.1 Assumes you have learning aspirations and expectations and therefore, are
motivated;

1.2 Gives you the privilege to use other learning strategies in achieving the
objectives in this program;

1.3 Welcomes you to go beyond the learning package as you so desire; and

1.4 Expects discipline, honesty, and maturity in fulfilling your learning activities.

2. We shall define learning as a positive observable change (for the better or

improvement) in human behavior, disposition, attitude, performance, or capability which
persists over a period of time.

3. Active learning strategies and activities will be utilized as much as possible.

4. The program will contain learning materials which I think will be relevant to your
being an effective, efficient, and humane health professional.

5. The ultimate goal of the learning program is to produce health professionals who will
contribute to the health development in the Philippines.

6. When I made this program, I tried my best to facilitate your learning. Bear in mind,
however, that I am not infallible. Thus, analyze carefully everything in this program.
Dont hesitate to offer disagreements and constructive criticisms for my own learning and
for the improvement of the program.

Best wishes for a fruitful learning with the help of this program.

Reynaldo O. Joson, MD, MHPEd, MSc Surg

April, 2005

2
 rjoson2001@yahoo.com; rjoson@maniladoctors.com.ph

Guidelines in Studying the Program

Dear Learner,

Mabuhay!

Welcome to an experience in self-instruction.

This program has been designed so that you learn on your own. You can learn at your
own pace - as fast as you can or as slow as you wish. You can choose to study anywhere
and anytime.

For effective learning, however, please follow the guidelines below in studying the
program:

1. Start with the concept map of wellness and illness as influenced by the breast
conditions.
2. Take a glimpse of the study guide.

3. Then, diligently and chronologically go through the following parts as each part
has an important role.

The Introduction gives you an overview and the delimitation of the self-
instructional program.
The Authors Approach to the Topic gives you an idea how I approach the
topic to write the program and it also spells out the General and Specific
Learning Objectives which tell you what you are expected to achieve after
you have finished the program.
The Text, of course, is the learning material.
The Postprogram Assessment self-assesses your competency on the subject
matter after studying the program.
The Student's Assessment of Self-instructional Program will give me a
feedback on my efforts to facilitate your learning.

The estimated study time for the program is one hour.

Best wishes.

3
Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg
April, 2005

Table of Contents

Preface 2
Guidelines in Studying the Program 3
Table of Contents 4
Concept Map of Wellness and Illness as Influenced by the Breast Condition 5
Study Guide on Benign and Malignant Conditions of the Breast 6
Introduction 8
Authors Approach to the Topic with General and Specific Learning 8
Objectives
Common Breast Disorders in the Philippines 10
Clinical Presentation of the More Common Breast Disorders 11
Diagnostic Processes in a Patient With a Possible Breast Disorder 13
Common Paraclinical Diagnostic Procedures in Patients With a Possible 14
Breast Disorder
Primary Goals and Modalities of Treatment of Breast Disorders 19
Some Clinical Issues in the Management of Breast Disorders 21
General Indications for Referral to a Breast Specialist 21
Biopsychosocial Wellness and Illness as Influenced by the Breast Condition 23
Some Social Issues in Breast Health Problems 23
Post-program Assessment 25
Students Self-assessment of the Self-instructional Program 28
About the Author 29

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 CONCEPT MAP OF WELLNESS & ILLNESS
AS INFLUENCED BY THE BREAST CONDITION

BIOPSYCHOSOCIAL WELLNESS

Prevention HOMEOSTASIS Stimuli/insults

Genetic/congenital
Nutrition
BREAST
Endocrine/metabolism
Infectious
FAILURE OF HOMEOSTASIS Psychosocial
Developmental
Differentiation
Maladaptation ILLNESS
Failure of coping

MANIFESTATION OF ILLNESS
SYMPTOMS / SIGNS

PATHOPHYSIOLOGY

BIOPSYCHOSOCIAL ASSESSEMENT
DIFFERENTIALS
DIAGNOSTIC AIDS

DIAGNOSIS

THERAPEUTICS & MANAGEMENT

SURGICAL/MEDICAL
Quality of Life Quality of Dying
Repair
Recovery

HEALTH CHRONIC ILLNESS DEATH

5
 Benign and Malignant Conditions of the Breast
Study Guide

Concept map of wellness and illness as influenced by the breast condition

Specifics based on the concept map of wellness and illness:

State of biopsychosocial wellness as influenced by the breast condition

- criteria for no breast health problem vis--vis criteria for presence of
breast problem

Common symptoms of failure of homeostasis in the breast that leads to illness

Common causes of failure of homeostasis in the breast that leads to illness

(pathophysiology of breast diseases)

Common disorders and diseases of the breast

- Benign and malignant disorders
- Specific conditions under benign and malignant disorders

Usual manifestations of the more common diseases of the breast

Clinical diagnostic process in patients with possible breast disorders

Common paraclinical diagnostic procedures in patients with possible breast

disorders

- Monitoring and observation

- Mammography
- Ultrasound
- Biopsy

Paraclinical diagnostic processes in patients with possible breast disorders

- Indications for paraclinical diagnostic procedure

- Selection
- Interpretation of results

Formulation of pretreatment diagnosis and goal of treatment

Treatment process
Selection of treatment procedure
Monitoring of outcome of treatment

Maintenance of biopsychosocial wellness with respect to breast condition

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 - Maintenance of quality of life of patients with breast concerns

Specific Learning Objectives:

At the end of the study of this document on Benign and Malignant

Conditions of the Breast, the learner must be able to:
a. Enumerate at least 10 more common breast disorders seen in the
Philippines.
b. Classify the breast disorders into benign and malignant conditions.
c. Categorize the breast disorders by primary causes (malignant
neoplasms, benign neoplasms, aberration of normal development and
involution or ANDI and infection).
d. Identify the most probable breast disorder present in patients
presenting with a set of symptoms and signs referable to the breast.
e. Enumerate at least 4 more common paraclinical diagnostic procedures
being done for patients with possible breast disorders.
f. Identify the usual indications for the different diagnostic procedures
commonly used in patients for possible breast disorders.
g. Identify which breast disorders can be monitored and which should be
actively treated.
h. Given a pretreatment diagnosis of a breast disorder with the stage of
the disorder, indicate the usual goal of treatment and its corresponding
recommended primary treatment.
i. Advice patients with nonspecific mastalgia or mastalgia secondary to
hormonal changes.
j. Identify at least two general indications for referral to a breast
specialist.
k. Advice patients on how to achieve and maintain psychosocial well-
being as influenced by the breast condition.
l. Identify two social issues related to the breast health problem in the
community (focusing on breast disorder) and suggest ways on how to
reduce the problem.

Self-instructional Programs

Patient Management Process (see url below)

Benign and Malignant Conditions of the Breast
Management of Patients with Breast Disorders Cases (see url below)

Recommended Reading Materials and Resources:

Breast Health Problems http://breast-health-problems.tripod.com

7
 Benign and Malignant Conditions of the Breast

Reynaldo O. Joson, MD, MHA, MHPEd, MscSurg

April 16, 2005

INTRODUCTION

There are myriads of conditions on the breast that can affect the biopsychosocial
well-being of the individual, particularly the female, as the breast in the male is by and
large destined to be a vestigial organ at birth. The conditions are generally classified into
benign and malignant conditions with malignant conditions being synonymous with
malignant neoplasms or cancers. Benign conditions are anything except cancers. They
include not only the benign neoplasms of the breast but also the non-neoplastic
conditions like developmental abnormalities, exaggerated physiologic and hormonal
changes, and infectious diseases.

Any condition on the breast that affects the biopsychosocial well-being of an

individual can be considered as a breast health problem. There are generally three
categories of breast health problem, namely: breast disorders; breast feeding problem;
and breast sexuality problems.

Breast feeding problem is a predominant concern of lactating mothers. Issues

consist of want to breastfeed but unable to do so; how long to breastfeed; want to stop
breastfeeding; etc. These issues will not be covered in this document.

Breast sexuality problem is usually seen in adult females whose well-being is

influenced by the status of their breasts, particularly in terms of size and functions as a
sexual organ. Again, issues on breast sexuality problem will not be covered in this
document.

This document will cover and focus on breast disorders, which can be
subcategorized into benign and malignant conditions, as defined above.

AUTHORS APPROACH TO THE TOPIC OF BREAST DISORDERS

As the author of this document, I would like to state the following:

1. This document is written with the medical students studying to be

generalist or primary health care physicians in mind.
2. This document does not contain everything there is to know about breast
disorders.
3. This document contains only an overview and general principles needed
by the generalist or primary health care physicians to be able to at least
advice patients with possible breast disorders on diagnosis, treatment,
prevention and health maintenance.

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4. The intended specific learning objectives from this document shall consist
of the following:

At the end of the study of this document, the learner must be able to:
a. Enumerate at least 10 more common breast disorders seen in the
Philippines.
b. Classify the breast disorders into benign and malignant conditions.
c. Categorize the breast disorders by primary causes (malignant
neoplasms, benign neoplasms, aberration of normal development
and involution or ANDI and infection).
d. Identify the most probable breast disorder present in patients
presenting with a set of symptoms and signs referable to the breast.
e. Enumerate at least 4 more common paraclinical diagnostic
procedures being done for patients with possible breast disorders.
f. Identify the usual indications for the different diagnostic
procedures commonly used in patients for possible breast
disorders.
g. Identify which breast disorders can be monitored and which should
be actively treated.
h. Given a pretreatment diagnosis of a breast disorder with the stage
of the disorder, indicate the usual goal of treatment and its
corresponding recommended primary treatment.
i. Advice patients with nonspecific mastalgia or mastalgia secondary
to hormonal changes.
j. Identify at least two general indications for referral to a breast
specialist.
k. Advice patients on how to achieve and maintain psychosocial well-
being as influenced by the breast condition.
l. Identify two social issues related to the breast health problem in
the community (focusing on breast disorder) and suggest ways on
how to reduce the problem.

5. The presentation of learning materials and competency evaluation will be

guided by the aforementioned specific learning objectives.

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COMMON BREAST DISORDERS IN THE PHILIPPINES

There are about ten breast disorders which all generalist or primary health care
physicians should be familiar with. These ten breast disorders are listed below in a
more or less decreasing frequency from 1 to 10 in the Philippine setting:

1. Breast cancer
2. Fibroadenoma
3. Macrocyst
4. Galactocoele
5. Mastitis and breast abscess
6. Intraductal papilloma
7. Benign cystosarcoma phyllodes or phyllodes tumor
8. Tuberculosis of the breast
9. Pagets disease of the nipple
10. Mammomegaly

The ten breast disorders can be classified into benign and malignant conditions
and categorized into more specific causes of the disorders in terms of malignant
neoplasm, benign neoplasm, aberration of normal development and involution, and
infection.

Conditions Benign (Non-malignant) Malignant

Causes Aberration of Infection Benign Malignant
normal neoplasm neoplasm
development
Disorders and involution
Breast Cancer
Fibroadenoma
Macrocyst
Galactocoele
Mastitis and breast
abscess
Intraductal papilloma
Benign cystosarcoma
phyllodes
Tuberculosis of the breast
Pagets disease of the
nipple
Mammomegaly

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CLINICAL PRESENTATION OF THE MORE COMMON BREAST DISORDERS

Below is an outline of the usual clinical presentation of the more common breast
disorders. The usual clinical presentation can be used for pattern recognition in the
diagnostic processes of patients with a possible breast disorder.

Note: This part is best studied with illustrations and pictures.

BREAST CANCER AND PAGETS DISEASE OF THE NIPPLE

Breast cancer should be suspected in a palpable breast lump of any size that is
SOLID and that has ILL-DEFINED BORDERS. This is especially so if any of the
following is also present:

1. HARD CONSISTENCY
2. FIXED TO SKIN OR UNDERLYING CHEST WALL
3. SKIN ULCERATION
4. FUNGATING MASS
5. ENLARGED LYMPH NODES IN THE IPSILATERAL AXILLA

Pagets disease of the nipple is a special kind of breast cancer. It should be

suspected in patients with NIPPLE OR AREOLAR EROSIONS. A sub-areolar mass
may or may not be present.

Breast cancer usually starts to appear after age 30. Rarely, a younger patient as
young as 25 years old or even younger, may be afflicted with breast cancer.

FIBROADENOMA

Fibroadenoma should be suspected in a palpable breast lump of any size that is

FIRM, SOLID, NONTENDER, VERY MOVABLE, and that has VERY WELL-
DEFINED BORDERS. This is especially so if there are no enlarged lymph nodes in the
ipsilateral axilla and if the patient is 25 years old or younger.

MACROCYST

Macrocyst should be suspected in a palpable breast lump of any size that is

CYSTIC in nature and that is seen in a patient with NO HISTORY OF RECENT
LACTATION. By cystic nature is meant the wall of the lump is depressible as to
suggest a sac containing fluid.

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GALACTOCOELE

Galactocoele should be suspected in a palpable breast lump of any size that is

CYSTIC in nature and that is seen in a patient with a HISTORY OF RECENT
LACTATION.

MASTITIS AND BREAST ABSCESS

Mastitis should be suspected in any ERYTHEMATOUS, TENDER, and

WARM BREAST WITH NO PALPABLE LUMP.

Breast abscess should be suspected in a PALPABLE BREAST LUMP of any

size that is TENDER, WARM, and associated with ERYTHEMATOUS overlying skin.

Mastitis and breast abscess are usually encountered in lactating women. They
may also be seen in non-lactating women at any age.

BENIGN CYSTOSARCOMA PHYLLODES or PHYLLODES TUMOR

Benign cystosarcoma phyllodes should be suspected in a palpable breast lump

that is GIGANTIC, NOT FIXED TO THE UNDERLYING CHEST WALL, AND
THAT IS NOT ASSOCIATED WITH ENLARGED LYMPH NODES IN THE
IPSILATERAL AXILLA. The tumor may be fixed to the overlying skin.

TUBERCULOSIS OF THE BREAST

Tuberculosis should be suspected in a breast with CHRONIC SINUSES. There

may or may not be an underlying lump.

INTRADUCTAL PAPILLOMA

Intraductal papilloma should be suspected when there is BLOODY NIPPLE

DISCHARGE WITH NO PALPABLE BREAST LUMP.

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MAMMOMEGALY

Mammomegaly should be suspected of a GIGANTIC BREAST WITH NO

UNDERLYING LUMP. Mammomegaly may be unilateral or bilateral.

In males, mammomegaly is usually called gynecomastia. In females, the most

commonly encountered term is virginal hypertrophy.

DIAGNOSTIC PROCESSES IN A PATIENT WITH A POSSIBLE BREAST

DISORDER

The initial tools used in investigating a breast problem consist of the interview
and physical examination. After the physical examination, a clinical impression or a
diagnosis should be formulated. Depending on the certainty of the diagnosis formulated,
a diagnostic procedure, also known as paraclinical diagnostic procedure, may or may not
be instituted.

Clinical diagnostic processes

The clinical diagnosis is derived from processing the data derived from the
interview (symptoms data) and physical examination (signs data) utilizing two processes
called pattern recognition and prevalence. Pattern recognition means the realization that
the patients presentation conforms to a previously learned picture or pattern of disease.
Prevalence means the choice of a diagnosis is based on the frequency of occurrence of
the disease in a certain locality, in a certain age and sex group, and in the affected organ
and system.

Paraclinical diagnostic processes

After the clinical diagnosis, the next step to do is to determine whether a

paraclinical diagnostic procedure is needed or not. A paraclinical diagnostic procedure is
a diagnostic procedure that is done after the clinical diagnosis is arrived at and its
objective is to make the diagnosis more definite. To decide whether a paraclinical
diagnostic procedure is needed or not, a physician should consider the following factors:
how certain he is with the clinical diagnosis and whether a more definite diagnosis is
needed or not for some reasons or another.

Certainty of diagnosis as indication for paraclinical diagnostic procedure

If he is quite certain or very certain, in general, a paraclinical diagnostic

procedure is not needed. The quite certain clinical diagnosis becomes automatically the
pretreatment diagnosis. If he is not quite certain or uncertain, in general, a paraclinical
diagnostic procedure is needed.

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 In general, a clinical diagnosis is said to be quite certain if it is based primarily on
signs that are reinforced by the symptoms and prevalence data. A clinical diagnosis is
said to be uncertain if it is based primarily on symptoms or on prevalence data.

Need for more definite diagnosis as indication for paraclinical diagnostic procedure

If the contemplated treatment procedure is mutilating, risky, etc., then a more

definite diagnosis is needed.

If the treatment for the differential diagnosis is the same as that for the primary
clinical diagnosis, then a paraclinical diagnostic procedure may not be needed. If it is
different, then a more definite diagnosis is indicated.

Once a decision is made that a paraclinical diagnostic procedure is needed, the

next step is to choose the most cost-effective procedure for the patient by considering the
various factors (tabulate, compare, and analyze):

Procedures Benefit Risk Cost Availability

Option1
Option2
Option3

After the paraclinical diagnostic procedure has been done, the next step is to
interpret the result. The result of the paraclinical diagnostic procedure must be correlated
with the signs and symptoms of the patient to come out with a pretreatment diagnosis.

COMMON PARACLINICAL DIAGNOSTIC PROCEDURES IN PATIENTS

WITH A POSSIBLE BREAST DISORDER

The more common paraclinical diagnostic procedures that are being utilized in patients
with possible breast disorder consist of the following:

1. Monitoring (observation) and constant analysis

2. Biopsy (needle evaluation or open biopsy)
3. Mammography
4. Ultrasound

MONITORING (OBSERVATION) AND CONSTANT ANALYSIS

Repeated observation and palpation of the breasts followed by constant analysis by both
the patient and his/her physician can be done to arrive to a more definitive diagnosis after
the initial evaluation. This paraclinical diagnostic procedure is usually being done if on
initial evaluation, based on the clinical findings, chances are, the breast disorder is of a
nature that it is NOT malignant and the treatment is usually by monitoring and
observation where no active treatment is needed. For example, if the primary clinical

14
diagnosis on initial evaluation is a fibrocystic change of the breast with more than 90%
degree of certainty, then monitoring (observation) and constant analysis can be used as a
paraclinical diagnostic procedure. Fibrocystic changes are benign conditions and
considered as aberrations in normal development and involution that are usually managed
with monitoring and observation. Again, if the primary diagnosis on initial evaluation is
a 1-cm fibroadenoma of the breast with a more than 90% degree of certainty, then
monitoring (observation) and constant analysis can be used as a paraclinical diagnostic
procedure. Fibroadenomas are benign conditions and can be managed by monitoring and
observation because they are slowly growing and some can disappear spontaneously over
time.

NEEDLE EVALUATION

Needle evaluation uses a hypodermic needle, usually G 19 and 1.5 inch long
attached to a 20cc plastic syringe, to evaluate a lump palpated in the breast. There are
three parts in a needle evaluation. One is needling the lump to check its actual presence;
to check its nature, whether solid or cystic; and lastly, to determine its real consistency,
whether gritty or rubbery. Second is aspirating the lump to get samples for gross
examination. Third is preparing a smear out of the samples aspirated for microscopic
examination. The third step is what is commonly known as needle aspiration biopsy.

Needle evaluation can be done right after the physical examination in the clinic or
office.

The advantages of a needle biopsy are the following:

1. It can give a more definite diagnosis than the physical examination

mammography, and ultrasound.
2. It is a more cost effective diagnostic procedure than mammography and
ultrasound.
3. It can give a more definite diagnosis right after or soon after the physical
examination.
4. It can avoid an operation.
5. It can be therapeutic in galactocoeles and macrocysts.

A real-life situation is given below:

A 45-year-old female presented with a hard nontender breast mass with ill-defined
borders. Breast cancer was suspected. A needle evaluation was done and serous fluid
was aspirated and the mass completely disappeared and did not recur thereafter. The
initial impression of breast cancer was changed right away to a definitive diagnosis of
macrocyst.

15
 The macrocyst, although a cyst, did not feel cystic on palpation. It felt hard
because it was a tense cyst filled with fluid.

If a needle evaluation was not done and an operation (open biopsy) was
performed, the patient would end up with an operation which would be considered
unnecessary. The needle evaluation performed had avoided the operation, scar, pain,
expenses, and other problems that would accompany the operation if it were instituted.

If a mammography were done, it would just show the shadow of the lump. No
definite diagnosis could be given. The patient would be spending about Php 2000.00 and
be exposed to radiation.

If an ultrasound were done, it should show a cystic lump. A needle aspiration

would still have to be done. Also, it would take sometime before a definitive diagnosis
and treatment could be gotten. With needle evaluation, the diagnosis and treatment were
completed soon after the physical examination.

CORE NEEDLE AND OPEN BIOPSY

A core needle or open biopsy may be done if the needle evaluation is inconclusive
and there is a need to do a biopsy prior to a definitive treatment.

A core needle biopsy utilizes a special instrument that costs more than a
hypodermic needle biopsy, is not readily available in the Philippines, but which can
obtain more samples and still does not produce a scar. If available, it may be used after
the initial hypodermic needle biopsy.

Open biopsy entails an incision and can either be a section or an excision biopsy.
A part of the mass is removed in section biopsy whereas the whole mass is removed in
excision biopsy and the specimen is sent for biopsy or microscopic examination.

The open biopsy may be done either through a paraffin or a frozen technique
depending on how fast the biopsy result is needed. In the frozen technique, biopsy result
can be obtained within 15 minutes whereas in the paraffin technique, usually three days.

For all breast masses, it is recommended that a needle evaluation be tried first
before considering a core or open biopsy. The needle evaluation may be sufficient to
establish a definitive diagnosis that a core or open biopsy is not necessary anymore.

MAMMOGRAPHY

Mammography or plain mammography is a radiologic examination of the breasts.

Scintimammography uses radioisotopes in imaging the breasts. Plain mammography is a
more painful procedure because it necessitates compression of the breasts to get the
imaging result. Scintimammography does not need compression of the breasts in its

16
procedure. Scintimammography is 2 to 3 times more expensive. The diagnostic
reliability and limitations are practically the same for the two procedures.

Mammography, whether plain or using radioisotopes, is used in screening patients

with no palpable breast lump for possible cancer. It is usually not done in evaluating
patients wit a palpable breast mass as biopsy is considered the preferred initial diagnostic
procedure.

A finding on mammography in patients with no palpable breast lumps that should

arouse suspicion for possible cancer consists of a cluster of microcalcifications. In
patients with palpable mass, the presence of stellate border on mammography is a reliable
sign for cancer.

ULTRASOUND

Ultrasound uses sound waves to make an imaging of the breast. It can detect
breast lumps and it can easily determine whether a breast lump is solid or cystic. Finding
cystic lumps on ultrasound usually gives a diagnosis of benign conditions whereas
finding solid lumps does NOT have a diagnostic implication.

The needle evaluation has made the use of ultrasound in patients with a breast
mass obsolete. The determination of solid versus cystic in a breast mass can be done
using the needle right after the physical examination and with less cost.

17
COMPARISON OF PARACLINICAL DIAGNOSTIC PROCEDURES IN
PATIENTS WITH A PALPABLE BREAST LUMP IN WHICH A MORE
DEFINITIVE DIAGNOSIS IS NEEDED IN A PATIENT SUSPECTED TO HAVE A
BREAST CANCER

Goal: to be more definite on the diagnosis of a palpable breast lump suspected of cancer.

Procedures Benefit Risk Cost Availability

Needle Direct Pain PhP 1,500 Readily
evaluation and examination Hematoma available in the
biopsy and sampling No scar clinic
Diagnostic
yield and
accuracy rate of
more than 90%
Open biopsy Direct Pain PhP 8,000 Readily
examination Hematoma available in the
and sampling Side effects of community
Diagnostic anesthestic
yield and agents
accuracy rate of Scar
more than 98%
Mammography Indirect study Pain on Plain - PhP Readily
imaging compression 2000 available in the
Diagnostic Radiation Scinti PhP community
yield and 5000
accuracy rate of
more than 80%
if stellate lesion
is present
Ultrasound Indirect study Painless Php1,500 Readily
imaging available in the
Reliable for community
benign cyst
Unreliable for
cancer

Thus, in a patient with a breast mass and whose clinical diagnosis is uncertain and a
paraclinical diagnostic procedure is needed other than observation and monitoring, the
initial procedure is needle evaluation and biopsy.

18
PRIMARY GOALS AND MODALITIES OF TREATMENT OF BREAST
DISORDERS

Malignant breast conditions are usually treated using standard cancer treatment
modalities like surgery, radiotherapy, and chemotherapy/hormonal therapy, singly or in
combination.

Benign neoplasms are usually treated with excision with rooms for
observation/monitoring.

Infectious benign conditions of the breasts are usually treated with antibiotics and
drainage and/or debridement.

Aberrations in normal development and involution are usually treated with

observation and monitoring.

Breast disorders based Primary goals in treatment Primary modalities of

on causation treatment
Aberrations of normal To allay anxiety and fear Advice and tempered
development and that the breast condition is assurance
involution cancer Monitoring and
observation
Analgesics, if needed
Aspiration for cysts
Excision for solid mass as a
last resort
Infections To resolve the infection Antibiotics
Drainage / debridement
Benign neoplasms To resolve the mass Excision
Monitoring and
observation for small
fibroadenomas
Malignant neoplasms To control the cancer Surgery, Radiotherapy,
chemotherapy, hormonal
therapy, singly or in
combination

19
The table below shows the usual treatment for specific breast disorders.

Breast Observe/Monitor Surgery Drugs Radiotherapy

conditions and (chemotherapy,
specific breast hormonal
disorders therapy
and antibiotics)
Malignant
Breast Cancer
(including (subtotal / total
Pagets disease mastectomy,
of the nipple) modified radical
mastectomy)

Benign
Fibroadenoma
(excision)
Macrocyst
(needle
aspiration)
Galactocoele
(needle
aspiration)
Mastitis and
breast abscess (needle
aspiration/incision
and drainage)
Intraductal
papilloma (excision)
Benign
cystosarcoma (wide excision)
phyllodes
Tuberculosis of
the breast (needle
aspiration/incision
and drainage /
debridement)
Mammomegaly
(reduction
mammoplasty)

20
SOME CLINICAL ISSUES IN THE MANAGEMENT OF BREAST DISORDERS

1. All females have a risk of developing breast cancer during their lifetime. The
risk is not confined to females with a family history of breast cancer. So, all females
should be on the look-out.

2. The phrase fibrocystic diseases should be discarded. Fibrocystic changes

is a better term. For laymen, a humpy breast is easier to understand and using this
terminology can facilitate allayance of fear.

3. Fibrocystic changes do not lead to cancer. Fibrocystic changes are physiologic

changes. Operations done on the breast for fibrocystic changes are unnecessary.

4. Breast pain without a breast lump is mastalgia. This is analogous to the

dysmenorrhea in the uterus. Mastalgia, just like dysmenorrhea, is due to some hormonal
mechanism the details of which are not known.

5. Mastalgia is often wrongly associated by laymen with breast cancer. This

wrong association and fear of cancer can aggravate the mastalgia. The approach to
patients with mastalgia is first, to tell them they have no lump, therefore no cancer.
Second, to explain the cause of mastalgia (see no.4). Third, to correct the mistaken
association of pain and cancer. Lastly, to give a standby prescription of analgesics. With
an adequate advice and explanation, the analgesics may not be needed at all.

6. The presence of fibroadenoma (established clinically and by needle evaluation)

does not constitute an absolute indication for excision. Operation is indicated when the
fibroadenoma is big (at least 3 cm) and, in cases of smaller fibroadenomas, when patients
wish to, despite the proper explanation by the physician. If no operation is decided upon,
monitoring should be done. The rationale for monitoring with option to operate is that
some fibroadenomas regress and if more fibroadenomas occur in the future, they can be
excised in one sitting. This has the advantage of less scar and less expense.

GENERAL INDICATIONS FOR REFERRAL TO A BREAST SPECIALIST

Breast specialists in the Philippines are primarily general surgeons who have
focused their practice in breast disorders. The general surgeons breast specialists may
request the medical oncologists for assistance in administering chemotherapy and the
radiation oncologists in administering radiation therapy.

The ultimate indication for referral to a breast specialist by the generalist or

primary health care physicians can be summed up in this statement: Conscience and
ethics dictate they need to refer in fairness to the patients because of the limitation of
their capability in order to uphold the motherhood principle of primum non nocere.

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 For more specific indications, they need to refer all patients whom they suspect to
have breast cancer and those conditions that will need surgical treatment.

Outline of Clinical Breast Evaluation by the Primary Health Care Physician

Patient
without breast complaint (breast check)
with breast complaint - pain, lump, nipple discharge

Physician

COMPLETE BREAST EXAMINATION

Definite Lump Humpy Breast No Lump

Nodular Breast

+/- Pain

Pain Discharge

Cancer Fibrocystic Hormonal Intraductal

Fibroadenoma changes cause papilloma
Macrocyst Fibrocystic Cancer
Galactocoele Changes
Others Others

Breast Specialist Advice (allay fear) Breast Specialist

Analgesics
Monitor (Self-Exam)
Check-up
Second opinion
(Breast Specialist)

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BIOPSYCHOSOCIAL WELLNESS AND ILLNESS AS INFLUENCED BY THE
BREAST CONDITION

A female person is in a state of biopsychosocial wellness as influenced by the breast

condition if she considers herself as having no breast health problem. She may have a real
breast disorder which she may not be aware of.

On the other hand, a female person is NOT in a state of biopsychosocial wellness if she
considers herself as having a breast health problem or she keeps on worrying about a
potential breast problem. Her breast health problem may be real or imaginary
(perceptual). Real breast health problem consists of those conditions that can cause death
such as breast cancer and those that will need active treatment, such as an operation.
Those with aberrations of normal development and involution that need only advice to
allay fear do not have real breast health problem.

Imaginary breast health problems are usually seen in people who think they have but in
reality they dont have real breast disorders.

In the Philippines, the lot of the female population who are aware of the magnitude of the
breast cancer problem, who have family history of breast cancers, and who have been
subjected to routine screening with mammography and ultrasound suffer from imaginary
breast health problem. Here are some specific scenarios:

1. My breast is painful. I may have breast cancer.

2. I have a family history of breast cancer. I may have breast cancer.
3. I have breast cancers because there are findings (nodules, complex cysts) on
my mammography and ultrasound.

The solution to reduce the magnitude of the imaginary breast health problem among the
Filipino female population is a combination of intense public health education to dispel
myths and to allay fear, and a judicious use of mammography and ultrasound as well as
the usage of words in the interpretation by the radiologists and ultrasonographers.

SOME SOCIAL ISSUES IN BREAST HEALTH PROBLEMS

Breast cancer is the main concern in breast disorders. Breast cancer is the most
common cancer among females in the Philippines.

Despite the presence of mammography and ultrasound during the past 20 years
and despite the intensive public health education, majority of the Filipino patients with
breast cancer still consult at the advanced stage. About 70% are still in stages III and IV.
The exact reasons are not established. They could be a combination of poverty,
ignorance, fatalistic mentality, denial, and excessive fear of the disease itself. The
solution to this problem has to be spearheaded and addressed by the Department of
Health.

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 With the advent of mammography and ultrasound compounded by the undue fear
for breast cancer among the female population, there is a tendency for excessive
performance of unnecessary mammography and ultrasound. Not only has this excessive
use of unnecessary mammography and ultrasound led to high prevalence of imaginary
breast health problems thereby causing biopsychosocial illness, it has also caused
unnecessary medical expense on the part of the paying patients and drain on government
resources. The solution to this problem is a proper education of the public and the
physicians on the rational use of the diagnostic procedures.

Likewise, because of the undue fear of cancer, there is a tendency for excessive
unnecessary open biopsy on the breast on the basis of just to be sure. A lot of these
biopsies would turn out to be fibrocystic changes which strictly speaking do not need to
be operated on as they are just aberrations of normal development and involution. The
solution to this problem is a proper education of the public and the physicians on the
rational indications for an open biopsy of the breast.

POST-PROGRAM ASSESSMENT

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Pls. assess yourself by trying to answer the following questions as indicated in the
specific learning objectives:

a. Enumerate at least 10 more common breast disorders seen in the

Philippines.
b. Classify the breast disorders into benign and malignant conditions.
c. Categorize the breast disorders by primary causes (malignant neoplasms,
benign neoplasms, aberration of normal development and involution or
ANDI and infection).
d. Identify the most probable breast disorder present in patients presenting
with a set of symptoms and signs referable to the breast. (see exercises
below)
e. Enumerate at least 4 more common paraclinical diagnostic procedures
being done for patients with possible breast disorders.
f. Identify the usual indications for the different diagnostic procedures
commonly used in patients for possible breast disorders.
g. Identify which breast disorders can be monitored and which should be
actively treated.
h. Given a pretreatment diagnosis of a breast disorder with the stage of the
disorder, indicate the usual goal of treatment and its corresponding
recommended primary treatment.
i. Advice patients with nonspecific mastalgia or mastalgia secondary to
hormonal changes.
j. Identify at least two general indications for referral to a breast specialist.
k. Advice patients on how to achieve and maintain psychosocial well-being
as influenced by the breast condition.
l. Identify two social issues related to the breast health problem in the
community (focusing on breast disorder) and suggest ways on how to
reduce the problem.

Identify the most probable breast disorder present in patients presenting with a set
of symptoms and signs referable to the breast. Check your answers in the key
provided.

1. A 29-year-old female patient presents with a very movable non-tender solid breast
mass with well-defined border. There is no palpable axillary lymph node. The primary
clinical diagnosis is:

A. breast abscess
B. breast cancer
C. fibroadenoma
D. fibrocystic changes
E. phyllodes tumor

2. A female patient presents with mastalgia and nodular breast tissues with NO dominant
mass. There is NO axillary node. The primary clinical diagnosis is:

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 A. breast abscess
B. breast cancer
C. fibroadenoma
D. fibrocystic changes
E. mastitis

3. A female patient presents with a hard breast mass with ill-defined border, fixed, with a
palpable ipsilateral axillary lymph node. The primary clinical diagnosis is:

A. breast abscess
B. breast cancer
C. fibroadenoma
D. fibrocystic changes
E. tuberculosis of the breast

4. A breast mass is fluctuant associated with erythema and tenderness. The most likely
diagnosis is

A. Mastitis
B. Breast abscess
C. Tuberculosis of the breast
D. Gross cyst
E. Inflammatory breast cancer

5. A female patient has marked asymmetry of the breasts but without a palpable mass on
the enlarged breast. The most likely diagnosis for the enlarged breast is

A. Virginal hypertrophy
B. Galactocoele
C. Breast cancer
D. Physiologic asymmetry
E. Fibroadenoma

6. There is a lesion on the nipple of one breast in a 50-year-old female patient. The most
likely diagnosis is

A. Allergy
B. Dermatitis
C. Pagets disease of the nipple
D. Human bite
E. Infection of the Montgomery glands

7. A patient has a sanguinous nipple discharge with NO palpable mass. The most likely
diagnosis is

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 A. Intraductal carcinoma
B. Intraductal papilloma
C. Pagets disease of the nipple
D. Fibrocystic changes
E. Ductal ectasia

8. A well-defined mass which is movable and nontender is palpated in the breast of this
18-year-old female patient. The most likely diagnosis is

A. Virginal hypertrophy
B. Macromastia
C. Fibroadenoma
D. Macrocyst
E. Phyllodes tumor

9. The left breast mass is hard solid with ill-defined border. It has contracted the left
breast. The most likely diagnosis is

A. Tuberculosis of the breast

B. Invasive ductal carcinoma
C. Lobular carcinoma
D. Fungal infection of the breast
E. Phyllodes tumor

10. The patient has a huge multinodular breast with NO axillary nodes. The most likely
diagnosis is

A. Ductal carcinoma
B. Lobular carcinoma
C. Fibroadenoma
D. Cystosarcoma phyllodes
E. Tuberculosis of the breast

Answer key:

1. C 6. C
2. D 7. B
3. B 8. C
4. B 9. B
5. A 10. D

STUDENTS ASSESSMENT OF THE SELF-INSTRUCTIONAL PROGRAM

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Title/Name of Self-instructional Program: Benign and Malignant Conditions of the Breast
Author: Reynaldo O. Joson, MD, MHPEd, MSc Surg
Evaluator: Date:

INSTRUCTIONS: Pls. assess the self-instructional program through the following statements.
Use the key below:
5 - Strongly agree
4 - Agree
3 - Not certain; not observed
2 - Disagree
1 - Strongly disagree

Statements on the Self-instructional Program 5 4 3 2 1

1. The objectives were clear.

2. The objectives were "must knows" in the practice of the profession.

3 The objectives were too heavy.

4. The content was appropriate based on the stated objectives.

5. The content was adequate based on the stated objectives.

6. The content was clear.

7. The content was presented in logical sequence.

8. The learning activities were appropriate based on the objectives.

9. The learning activities were effective in facilitating learning.

10. The assessment was appropriate.

Comments and suggestions (pls. submit a copy to the author personally or through email
rjoson2001@yahoo.com / rjoson@maniladoctors.com.ph)

About the Author

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 2005

Present Academic Positions

Dr. Reynaldo O. Joson is presently a permanent professor at the Department of

Surgery of the University of the Philippines, College of Medicine with a rank of
Associate Professor VI.

He is at the same time an affiliate associate professor of the University of the

Philippines Open University as well as a faculty in the University of the Philippines
College of Public Health.

He is a former Chief of the Division of Head and Neck, Breast, Esophagus, and
Soft Tissue Surgery at the Philippine General Hospital (presently renamed as Division of
Head and Neck, Breast, and Surgical Oncology).

Academic Degrees

He obtained his Doctor of Medicine from the University of the Philippines

College of Medicine in 1974; his Master in Hospital Administration from the UP College
of Public Health in 1991; his Master in Health Profession Education from the UP
National Teachers Training Center for Health Profession in 1993; his Master of Science
in Clinical Medicine (General Surgery) from the UP College of Medicine in 1998.

His finished his residency in General Surgery at the Philippine General Hospital
in 1981 after which he became a Diplomate of the Philippine Board of Surgery.

Academic and Professional Honors and Awards

1. Most Outstanding Medical Educator in the Philippines, University of the

Philippines Medical Alumni Association, 2003
2. Most Outstanding Physician Award, University of the Philippines Alumni
Association, 2004
3. Dr. Lino Ed Lims Outstanding Medical Teacher Award in Clinical Sciences,
University of the Philippines College of Medicine, 2004

Education for Health Development in the Philippines

One of his missions in life is to contribute to the health development in the

Philippines through education. This mission started in 1990 when, as Director of the
UPCM Postgraduate Institute of Medicine, he designed a structured Department of
Health-UPCM Postgraduate Circuit Courses in four provincial hospitals in the
Philippines (Ilagan, Isabela in Luzon; Aklan in the Visayas; and Koronadal, South
Cotobato and Oroquieta, Misamis Occidental in Mindanao).

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 He then went on to develop a structured general surgery training program using a
distance education mode from 1991 to 1994 in Zamboanga City Medical Center. With
this program, he added 7 trained general surgeons to the pool of 2 that served the 3
million population of Western Mindanao.

Hospital Administration

He is currently an assistant medical director at the Manila Doctors Hospital in

charge of its quality assurance program.

He is also currently the chairperson of the Department of Surgery of Ospital ng

Maynila Medical Center trying to establish a model department of surgery in the
Philippines, model in governance, service, training, and research.

Writings

He started writing books, primers, self-instructional programs, and course packs

in medicine, surgery, hospital administration, and medical education in 1985. As of
December of 2004, he has more than 80 finished products.

Contact Numbers

Dr. Reynaldo O. Josons email address is rjoson2001@yahoo.com

His telephone number is 522-4713.

R.O. Josons Website (started in 1999)

Theme: Education for Health Development in the Philippines

http://edhedephi.tripod.com

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