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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

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


October 2014
rjoson2001@yahoo.com
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.

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg


October 2014

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

CONCEPT MAP OF WELLNESS & ILLNESS


AS INFLUENCED BY THE BREAST CONDITION

BIOPSYCHOSOCIAL WELLNESS

Prevention HOMEOSTASIS Stimuli/insults


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

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


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 lead to illness
Common causes of failure of homeostasis in the breast that lead 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
- Others
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
- 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

Benign and Malignant Conditions of the Breast (this SIP)


(https://sites.google.com/site/breastconditions/home)

Recommended Reading Materials and Resources:

Patient Management Process (https://sites.google.com/site/patientmanagementprocess)


Breast Self-examination for the Filipino Females
(https://sites.google.com/site/rojosonbreastselfexam)
Facebook /ROJoson Breast Wellness Clinic
(http://www.facebook.com/ROJosonBreastWellnessClinic)

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.
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.

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 (not absolute may
change over time) 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 benign 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 devt neoplasm neoplasm
Disorders and involution
Breast Cancer
Fibroadenoma ()
Macrocyst
Galactocoele
Mastitis and breast abscess
Intraductal papilloma
Benign cystosarcoma
phyllodes or phyllodes tumor
Tuberculosis of the breast
Pagets disease of the nipple
Mammomegaly
() some scientists would put it here.

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.

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


Benign cystosarcoma phyllodes (a historical term) or benign phyllodes tumor (a new term) 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.

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 (history) and
physical examination. After the interview and 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.
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 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.
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 more than Php 1000.00 (as of 2013) 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 as 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 to 30
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
Plain mammography (analog or digital 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 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. They are usually not done in evaluating patients with 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.

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


(examples and
estimates)
Needle Direct examination and Pain P1,500 Readily
evaluation and sampling Hematoma available in the
biopsy Diagnostic yield and No scar clinic
accuracy rate of more
than 90%
Open biopsy Direct examination and Pain P8,000 Readily
sampling Hematoma available in the
Diagnostic yield and Side effects of community
accuracy rate of more anesthestic
than 98% agents
Scar
Mammography Indirect study Pain on Plain P1500 Readily
imaging compression - P2000 available in the
Diagnostic yield and Radiation Scinti P5000 community
accuracy rate of more
than 80% if stellate
lesion is present
Ultrasound Indirect study Painless Php1,200 Readily
imaging available in the
Reliable for benign community
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.

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 on Primary goals in treatment Primary modalities of


causation treatment
Aberrations of normal To allay anxiety and fear that Advice and tempered
development and the breast condition is cancer assurance
involution 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

The table below shows the usual treatment for specific breast disorders.
Breast conditions Observe/Monitor Surgery Drugs Radiotherapy
and specific (chemotherapy,
breast disorders hormonal
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 or
phyllodes tumor
Tuberculosis of
the breast (needle
aspiration/incision
and drainage /
debridement)
Mammomegaly
(reduction
mammoplasty)

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.
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.
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 symptom (breast check)
with breast symptom- pain, lump, nipple discharge

Physician

COMPLETE BREAST EXAMINATION

Definite Lump Lumpy Breast No Lump


Nodular Breast

+/- Pain

Pain Discharge

Cancer Fibrocystic Hormonal Intraductal


Fibroadenoma changes cause papilloma
Macrocyst Fibrocystic Cancer
Gatactocoele Changes
Others Others

Breast Specialist Advice (allay fear) Breast Specialist


Analgesics
Monitor (Self-Exam)
Check-up
Second opinion
(Breast Specialist)
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 populations 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 30 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.
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
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:
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
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
2. D
3. B
4. B
5. A
6. C
7. B
8. C
9. B
10. D
STUDENTS ASSESSMENT OF THE SELF-INSTRUCTIONAL PROGRAM

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
About the Author

October 2014

Present Academic Positions


Dr. Reynaldo O. Joson is presently a post-retirement clinical faculty of the Department of Surgery of the
University of the Philippines, College of Medicine. He retired on January 31, 2014 from the University of the
Philippines Manila with a rank of Professor V.
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 Surgical Oncology, Head and Neck, Breast,
Skin and Soft Tissue and Esophago-Gastric Surgery).

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
4. Most Outstanding Teacher in Oncology, Philippine Society of Oncology (October, 2006)
5. Centennial Professorial Chair, University of the Philippines Manila (2008)

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).
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.
In 2004, he helped established the Zamboanga School Medical Foundation (now Ateneo de
Zamboanga Medical School).
See also Writings below.

Hospital Administration
He is a past Senior Vice-President for Corporate Affairs at the Manila Doctors Hospital (2009-2014).
He is a past chairperson of the Department of Surgery of Ospital ng Maynila Medical Center (2001-
2009).

Writings
He started writing books, primers, self-instructional programs, and course packs in medicine, surgery,
hospital administration, and medical education in 1985. As of July 2013, he has more than 100 finished
products. He started publishing his writings in the Internet in 1990. As of July 2013, he has more than 198
websites.

Contact Numbers
Dr. Reynaldo O. Josons main email address is rjoson2001@yahoo.com
His cellphone number is 09188040304.

R.O. Josons Website:


http://sites.google.com/site/rojosonwebsites