Breast Cancer

Breast cancer remainsa significant healthconcern for women. Amongwomen at average risk,breast cancer will develop in1 of 8, and 1 in 30 will die ofthe disease.1 Although therehas been recent excitementabout the potential of geneticscreening to predict individualbreast cancer risk, itis important to keep in mindthat nearly 75% of women inwhom breast cancer hasbeen diagnosed have hadno risk factors other thansex and age.2

We have to let patientsknow that theimpact of mammography isnot that large-especiallyin women aged 40 to 49years. We simply do notknow whether early detectionof breast cancer leadsto improved outcomes inthis age group.

For more than a decade,screeningmammography hasbeen the subject ofintense public scrutinyand debate. Probably atno time has this debatebeen more heated thanduring the last 3 years,which saw the publicationof the now-famous “Danishstudy” as well as a majorexposé of poor quality controland radiologic interpretationerrors in the mammographyindustry (Box).

The incidence of hypertension, diabetes, certain types ofcancer, and other chronic diseases is disproportionatelyhigher in African Americans than in white Americans. Thestatistics presented in the Table illustrate the magnitudeof this disparity. For other diseases, such as breast cancer,the incidence is lower but mortality is higher in AfricanAmericans.

A 73-year-old man is admittedto the hospital with pulmonary tuberculosis.A 3-drug fixed combination-isoniazid, rifampicin, and pyrazinamide-and ethambutol are given.Within an hour, a global urticarialrash erupts (A and B).

Highlights:➤What to tell your patients about thebenefits-and risks-of mammography.➤A realistic look at cancer screening: Arewe overstating the benefits?➤Which screening strategies you canrecommend with confidence.➤How best to bring the patient into thedecision-making process.

SAN ANTONIO, Dec. 19 -- New biologic agents are proving useful in breast cancer treatment, but optimizing therapy requires careful attention to adverse event risk.

SAN ANTONIO -- The success of Herceptin (trastuzumab) in treating HER2-positive breast cancer has led to a search for other targeted therapies, researchers said here, and a range of so-called small molecules is in the pipeline.

During a routine checkup, a middle-aged woman asks you whether she should stop wearing moisturizers and makeup that contain sunscreen. She has read that increased sunlight exposure enhances vitamin D production, which may prevent certain types of cancer. What would you tell her?

A 64-year-old woman presents with persistent, progressively worsening chest pain and dyspnea of 1 month's duration. She also reports orthopnea, bilateral leg swelling, and weight gain. She denies any history of similar symptoms.

A 64-year-old woman presents with persistent, progressively worsening chest pain and dyspnea of 1 month's duration. She also reports orthopnea, bilateral leg swelling, and weight gain. She denies any history of similar symptoms.

A 77-year-old woman who had hadanorexia and weakness for 3 monthswas seen after a syncopal episode. Sheappeared pale but alert. Heart rate was110 beats per minute; respiration rate,22 breaths per minute; and blood pressure,170/70 mm Hg. Her hematologicindices were: hemoglobin level, 4.3 g/dL;mean corpuscular volume (MCV), 60fL; mean corpuscular hemoglobin concentration(MCHC), 29 g/dL; red bloodcell count, 1.6 million/μL; white bloodcell count, 7500/μL; and platelet count,452,000/μL.

A 47-year-old woman who has a history of breast cancer returns to your officefor a routine examination. She has questions about what constitutes optimalfollow-up care for breast cancer survivors; she has read and heard conflictingrecommendations.

In this article, I review several interventions that have been shown or are postulated to reduce breast cancer risk in women with no history of the disease; these include chemoprevention, physical activity, weight control, diet, alcohol use, and avoidance of specific carcinogens.

Are aromatase inhibitors safe and effective as adjuvant therapy for postmenopausal women with estrogen receptor-positive breast cancer?

A 49-year-old woman, severely obese but otherwise healthy, appeared for a preemployment medical examination. She neither smoked cigarettes nor drank alcohol. She had no respiratory problems and recalled no family history of such. A baseline mammogram taken 4 years earlier showed no abnormalities, and the patient was not under care for any medical condition. Results of physical examination were normal, except for the obesity-which made it difficult to determine breast masses with confidence.

Back pain and weakness of both legs had bothered this 60-year-old woman for 1 week. Left breast cancer, stage 2, had been diagnosed 2 years before, and subsequently she underwent a lumpectomy followed by chemotherapy and radiation therapy.

A 54-year-old woman with breast cancer metastatic to the lungs had been treated with four courses of docetaxel, to which she partially responded. Following the first cycle of chemotherapy, the patient experienced arrested growth of her fingernails and toenails. Progressively worsening onycholysis then developed.

A 72-year-old woman first noticed progressive enlargement of the maxillary area of her face 18 years earlier. She denied facial trauma and significant dental caries. Her medical history consisted of breast cancer managed by a mastectomy and type 2 diabetes mellitus of 3 years’ duration.

A slightly pruritic, red, scaly rash on an 8-year-old boy’shands has been progressively worsening since it appeared4 months earlier. Nail pitting also was noted. There are noother rashes on his body. The patient is active in sports;denies any new exposure to soaps, clothing, or other contactants;and spends time in the homes of his recently divorcedparents.

An ulcerated lesion that measured approximately 2 cm in diameter had developed on an 80-year-old woman's scalp. The lesion featured a dark eschar that covered a slightly elevated, erythematous border. According to the patient's husband, a different lesion had been at the site 2 weeks earlier. He described the original as a "ball" that ulcerated, had no drainage, and formed a scab.

For 2 weeks, a 59-year-old woman had experienced weakness on the left side of her face. She described her appearance as "deviated" and complained of dribbling from the corner of her mouth and difficulty in chewing. The patient was unable to close her left eye and said that noises sounded unpleasantly loud and distorted in the left ear. She denied earache, vertigo, fever, headache, and rash.

Many of my older women patients think theyare at much higher risk for breast cancer thancoronary heart disease (CHD). How can we raise women'sawareness about their risks of CHD and therebyencourage them to take measures to prevent it?

Women often forget to perform amonthly breast self-examination.

A 40-year-old woman was concerned about an area of redness and tenderness on her left breast. Despite antibiotic therapy prescribed by another physician, the rash had progressed during the past month to erythema and nodules that involved the anterior chest and right breast.