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Breast Cancer Clinical Presentation

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Breast Cancer Clinical Presentation

Author: Alison T Stopeck, MD; Chief Editor: Jules E Harris, MD more... Updated: Nov 30, 2012

History
Many early breast carcinomas are asymptomatic, particularly if they were discovered during a breast-screening program. Larger tumors may present as a painless mass. Pain or discomfort is not usually a symptom of breast cancer; only 5% of patients with a malignant mass present with breast pain. Often, the purpose of the history is not diagnosis but risk assessment. A family history of breast cancer in a firstdegree relative is the most widely recognized breast cancer risk factor. The lifetime risk is up to 4 times higher if a mother and sister are affected; the risk is approximately 5 times greater in women with 2 or more first-degree relatives with breast cancer; and it is also greater among women with breast cancer in a single first-degree relative, particularly if the relative was diagnosed at an early age (50 y or younger). A family history of ovarian cancer in a first-degree relative, especially if the disease occurred at an early age (< 50 y), has been associated with a doubling of breast cancer risk. The family history characteristics that suggest increased risk of cancer are summarized as follows: Two or more relatives with breast or ovarian cancer Breast cancer occurring in an affected relative younger than 50 years Relatives with both breast cancer and ovarian cancer One or more relatives with 2 cancers (breast and ovarian cancer or 2 independent breast cancers) Male relatives with breast cancer BRCA1 and BRCA2 mutations Ataxia telangiectasia heterozygotes (4-times increased risk) Ashkenazi Jewish descent (2-times greater risk) Neoplastic conditions that increase the risk of breast cancer include the following: Previous breast cancer Ovarian cancer Endometrial cancer Ductal carcinoma in situ (DCIS) Lobular carcinoma in situ (LCIS)
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Breast Cancer Clinical Presentation

Benign breast conditions that increase the risk of breast cancer include the following: Hyperplasia (unless mild) Complex fibroadenoma Radial scar Papillomatosis Sclerosing adenosis Microglandular adenosis Cervical cancer is associated with a decreased risk of breast cancer.

Physical Examination
If the patient has not noticed a lump, then signs and symptoms indicating the possible presence of breast cancer may include the following: Change in breast size or shape Skin dimpling or skin changes (eg, thickening, swelling, redness) Recent nipple inversion or skin change, or nipple abnormalities (eg, ulceration, retraction, spontaneous bloody discharge) Single-duct discharge, particularly if bloodstained Axillary lump To detect subtle changes in breast contour and skin tethering, the examination must include an assessment of the breasts with the patient upright with arms raised. The following findings should raise concern: Lump or contour change Skin tethering Nipple inversion Dilated veins Ulceration Paget disease Edema or peau d'orange The nature of palpable lumps is often difficult to determine clinically, but the following features should raise concern: Hardness Irregularity Focal nodularity Asymmetry with the other breast Fixation to skin or muscle (assess fixation to muscle by moving the lump in the line of the pectoral muscle fibers with the patient bracing her arms against her hips) A complete examination includes assessment of the axillae and supraclavicular fossae, examination of the chest and sites of skeletal pain, and an abdominal and neurologic examination. The clinician should be alert to symptoms of metastatic spread, such as the following: Breathing difficulties Bone pain Symptoms of hypercalcemia Abdominal distention Jaundice Localizing neurologic signs Altered cognitive function The clinical evaluation should include a thorough assessment of specific risk factors for breast cancer. Go to Breast Cancer Risk Factors for more information on this topic.

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Breast Cancer Clinical Presentation

Contributor Information and Disclosures

Author Alison T Stopeck, MD Associate Professor of Medicine, Arizona Cancer Center, University of Arizona Health Sciences Center; Director of Clinical Breast Cancer Program, Arizona Cancer Center; Medical Director of Coagulation Laboratory, University Medical Center; Director of Arizona Hemophilia and Thrombosis Center Alison T Stopeck, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Clinical Oncology, American Society of Hematology, Hemophilia and Thrombosis Research Society, and Southwest Oncology Group Disclosure: Genentech Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; AstraZeneca Grant/research funds Other Coauthor(s) Patricia A Thompson, PhD Assistant Professor, Department of Pathology, University of Arizona, Tucson Disclosure: Nothing to disclose. Chief Editor Jules E Harris, MD Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research Disclosure: Nothing to disclose. Additional Contributors Leona Downey, MD Assistant Professor of Internal Medicine, Section of Oncology and Hematology, University of Arizona, Arizona Cancer Center Leona Downey, MD is a member of the following medical societies: American Geriatrics Society, American Society of Clinical Oncology, and Southwest Oncology Group Disclosure: Nothing to disclose. Manjit Singh Gohel, MD, MRCS, MB, ChB Specialist Registrar, Division of Breast and Endocrine Surgery, Northwick Park Hospital Disclosure: Nothing to disclose. Harold Harvey, MD Professor, Department of Medicine, Pennsylvania State University Disclosure: Nothing to disclose. Kanchan Kaur, MBBS, MS (General Surgery), MRCS (Ed) Consulting Breast and Oncoplastic Surgeon, Medanta, The Medicity, India Disclosure: Nothing to disclose. Julie Lang, MD Assistant Professor of Surgery and the BIO5 Institute, Director of Breast Surgical Oncology, University of Arizona College of Medicine Julie Lang, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, American Society of Clinical Oncology, Association for Academic Surgery, and Society of Surgical Oncology Disclosure: Genomic Health Grant/research funds Speaking and teaching; Agendia Grant/research funds Speaking and teaching; Surgical Tools Grant/research funds Research; Sysmex Grant/research funds Research Robert B Livingston, MD Professor of Clinical Medicine and Director, Clinical Research Shared Services,
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Robert B Livingston, MD Professor of Clinical Medicine and Director, Clinical Research Shared Services, Arizona Cancer Center Robert B Livingston, MD is a member of the following medical societies: American Association for Cancer Research, American Federation for Clinical Research, and American Society of Clinical Oncology Disclosure: Nothing to disclose. Hanan Makhoul, MD Staff Physician, Department of Internal Medicine, University of Arkansas School of Medicine Disclosure: Nothing to disclose. Issam Makhoul, MD Associate Professor, Department of Medicine, Division of Hematology/Oncology, University of Arkansas for Medical Sciences Issam Makhoul, MD is a member of the following medical societies: American Society of Clinical Oncology and American Society of Hematology Disclosure: Nothing to disclose. Robert C Shepard, MD, FACP Associate Professor of Medicine in Hematology and Oncology at University of North Carolina at Chapel Hill; Vice President of Scientific Affairs, Therapeutic Expertise, Oncology, at PRA International Robert C Shepard, MD, FACP is a member of the following medical societies: American Association for Cancer Research, American College of Physician Executives, American College of Physicians, American Federation for Clinical Research, American Federation for Medical Research, American Medical Association, American Medical Informatics Association, American Society of Hematology, Association of Clinical Research Professionals, Eastern Cooperative Oncology Group, European Society for Medical Oncology, Massachusetts Medical Society, and Society for Biological Therapy Disclosure: Nothing to disclose. Hemant Singhal, MD, MBBS, FRCSE, FRCS(C) Senior Lecturer, Director of Breast Service, Department of Surgery, Imperial College School of Medicine; Consultant Surgeon, Northwick Park and St Marks Hospitals, UK Hemant Singhal, MD, MBBS, FRCSE, FRCS(C) is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada and Royal College of Surgeons of Edinburgh Disclosure: Nothing to disclose. Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose. Wiley Souba, MD Chairman, Professor, Department of General Surgery, Pennsylvania State College of Medicine; Chief Surgeon, The Milton S Hershey Medical Center Disclosure: Nothing to disclose. Rachel Swart, MD, PhD Assistant Professor of Medicine, Department of Hematology and Oncology, Arizona Cancer Center, University of Arizona Rachel Swart, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Society of Clinical Oncology, Arizona Medical Association, and Southwest Oncology Group Disclosure: Roche Grant/research funds Other

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Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Simon Thomson, MB, BCh, MD, FRCS Specialist Registrar, Department of Breast and Endocrine Surgery, Northwick Park Hospital, UK Simon Thomson, MB, BCh, MD, FRCS is a member of the following medical societies: British Medical Association Disclosure: Nothing to disclose.

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Breast Cancer Clinical Presentation

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