Physical Diagnosis, M2 Course

Heme Onc

Devin Nickol, M.D.

OBJECTIVES

Following today's lecture, students should understand the following:

     1. The scope and importance of breast cancer as a medical problem.

     2. The qualities of a disease which may make screening desirable.

     3. The basic concepts of cost-effectiveness as it relates to screening.

     4. The value and limitations of clinical breast exam as a screening tool.

     5. A standardized approach to clinical breast exam.

 

CASE PRESENTATION

     A 48-year-old female presents to clinic for a routine annual exam. She had a screening mammogram performed last week which did not show any abnormalities.

     On exam, you note a palpable lump in the lower outer quadrant of her left breast. She reports that she performs self breast exams “occasionally”, but had not noticed the lump.

     What do you do?

 

BREAST CANCER: BACKGROUND

- How common is it?

 

- What are some risk factors?

 

- What's the deal with the "breast cancer gene"?

 

 

- What is the prognosis for invasive breast cancer?

WHEN SHOULD WE SCREEN FOR DISEASE?

- What criteria should the disease meet?

 

 

- How much is life worth?

 

- How cost-effective are common screening tests and treatments?

Antihypertensive therapy to prevent stroke:

CABG (one vessel disease, moderate angina):

Colon cancer screening:

Cholesterol screening and treatment:

Screening for Type II DM:

Cervical cancer screening:

Breast cancer screening (mammo + CBE):

 

DOES SCREENING FOR BREAST CANCER WORK?

- What's the evidence?

 

 

 

- How precise is the clinical breast exam?

 

 

- How accurate is the clinical breast exam?

 

- What techniques are typically used in clinical breast exam? Which have been shown to have value?

 

- How should a patient be positioned?

- What area should be examined?

 

- What technique should be used?

 

 

- How long should it take?

- What about nipple discharge?

 

- How do you tell cancerous from noncancerous lesions? How accurate is this?

 

 

- What are some take home points about CBE?

 

CASE PRESENTATION

- Consider the woman in the previous case presentation: what approach should you take?

 

 

BIBLIOGRAPHY/FURTHER READING

Does this patient have breast cancer? Barton, Mary B.; Harris, Russell; Fletcher, Suzanne W. JAMA 10/6/1999; 282:1270-1280