A 40-year-old woman presents to discuss breast cancer prevention. Her mother was diagnosed with breast cancer at the age of 45, and the patient carries a BRCA gene. The patient is menstruating regularly. In addition to recommending daily exercise and minimal alcohol use,
what is your best advice to this patient?
(USPSTF guidelines at www.uspreventiveservicestaskforce.org/recommendations.htm; Fife, p 30.) The addition of annual MRI to mammogram in women with BRCA mutations improves the sensitivity, but also the false-positive rate, of screening programs. MRI should not replace a screening mammogram. This combination should begin at age 30. Raloxifene is indicated for breast cancer prevention only in high-risk postmenopausal women. Tamoxifen can be used for prevention in high-risk premenopausal women, but has been associated with the development of uterine cancer in women ages 50 and older. Both of these medications are associated with a twofold increased risk of thromboembolic events. Bioidentical hormones have no proven advantage over FDA-approved hormones. Premenopausal women with BRCA gene mutations who undergo prophylactic oophorectomy reduce their risk of breast cancer by 75%, and their risk of ovarian cancer by 85% to 95%. Carrying the BRCA gene increases the likelihood that this patient has passed the gene to her children. BRCA mutations in men convey increased risk for breast and prostate cancer, and possibly an increased risk of pancreatic cancer.
A 40-year-old woman presents to your office regarding a breast lump she found on self-examination 2 weeks ago. The patient does not regularly examine her breasts. Her last clinical breast examination was 2 years ago; she had a normal mammogram 9 months ago. She has no family history of breast cancer. Her father had colon cancer diagnosed at age 50. She takes no medications regularly. On examination, she has a well-localized nontender nodule in the left breast at 2 o’clock. It is 1.5 cm in diameter with irregular borders. Diagnostic breast imaging includes a negative mammogram and a sonogram showing solid area in the left breast at the site of the palpable abnormality.
What is the most appropriate next step in the management of this woman’s breast abnormality?
Evaluation of a breast nodule should determine whether the patient has a true mass or prominent physiologic glandular tissue. The next step is to determine whether the dominant mass represents a cyst, a benign solid mass, or cancer. Worrisome characteristics of this patient’s mass include irregular borders, size larger than 1 cm, and location in the upper outer quadrant of the breast. Her age (> 35) also places her at slightly higher risk. Even with a negative mammogram, a noncystic mass on ultrasound should be examined and biopsied by a breast surgeon or a comprehensive breast radiologist. Six months is too long to wait for reevaluation. In a younger woman (< 35 years), repeat examination after the next menstrual cycle might be warranted (ie, < 1-month reevaluation). To assume breast changes are benign without further investigation is not appropriate. CT scanning does not provide useful information in the evaluation of palpable breast mass. MRI of the breast is useful in complicated cases, especially in a woman with dense breasts on mammography. To treat the patient for fibrocystic disease of the breast without further evaluation would be risky.
A 57-year-old white woman with past history of breast cancer stage II, ER+, PR+, presents to the emergency room complaining of the sudden onset of chest pain and shortness of breath. The pain is sharp and stabbing in the left posterior lung area. The pain does not increase on exertion but increases with deep breathing. The patient denies any history of cardiovascular or pulmonary disease. Her only medication is tamoxifen for 2 years and OTC vitamins. Pulse is 110, RR 26, and BP 150/94; lungs are clear bilaterally. Cardiovascular examination shows regular rate and rhythm with fixed splitting of S2 . ECG shows S wave in lead I, Q wave in lead III, and inverted T in lead III. Pulse oximetry is 90% on room air. Chest x-ray is unremarkable.
Which factor is most likely to be contributing to this patient’s respiratory distress?
This patient’s history and physical are consistent with a diagnosis of pulmonary embolus (PE). The combination of respiratory distress, mild hypoxia, sinus tachycardia, clear chest x-ray, and typical ECG changes warrants emergent treatment and testing to confirm the diagnosis. Tamoxifen, a selective estrogen receptor modulator, is associated with an increased risk of thromboembolic events. Myocardial infarction is less likely with this ECG pattern, which is classic for PE. Asthma rarely presents with pleuritic chest pain. An anxiety attack would not cause hypoxia or these ECG changes. There is no evidence on chest xray suggesting an infiltrate.
A 46-year-old woman presents for her annual examination. Her main complaint is frequent sweating episodes with a sensation of intense heat starting at her upper chest and spreading up to her head. These have been intermittent for the past 6 to 9 months but are gradually worsening. She has three to four flushing/sweating episodes during the day and two to three at night. She occasionally feels her heart race for about a second, but when she checks her pulse it is normal. She reports feeling more tired and has difficulty with sleep due to sweating. She denies major life stressors. She also denies weight loss, weight gain, or change in bowel habits. Her last menstrual cycle was 3 months ago. Physical examination is normal.
Which treatment is most appropriate in alleviating this woman’s symptoms?
The differential diagnosis for palpitations and sweating is broad, but major consideration should be given to hyperthyroidism, panic attacks, cardiac arrhythmias, malignancy, and vasomotor instability. This patient denies symptoms of malignancy such as weight loss. She does not have symptoms of clinical depression such as decreased concentration, apathy, weight changes, sleep changes, sadness, irritability, or suicidal thoughts. She reports no change in bowel habits or weight, which would indicate a thyroid disorder. The most likely diagnosis for this patient is vasomotor symptoms associated with the menopause transition. The best treatment option for this patient is a combination estrogen and progesterone low-dose oral contraceptive. Her symptoms are more suggestive of hyperthyroidism than hypothyroidism; so levothyroxine would be of no benefit. Estrogen alone would increase the risk of endometrial hyperplasia and cancer. Fluoxetine and gabapentin have been used to treat hot flushes but are much less effective than hormone replacement.
A 77-year-old diabetic woman presents to the emergency room with a 45-minute history of chest pain with radiation to the arms and jaw. The pain is relieved with nitroglycerin and morphine. She has ECG changes of ischemia; her second serum troponin level (obtained 6 hours after onset of pain) is elevated. Compared to a similar male patient,
which of the following is more likely to occur in this female patient?
Women have higher rates of mortality during hospitalization for MI than men. In the setting of an acute MI, women are also more likely to present with cardiac arrest, hypotension, or cardiogenic shock. In addition, women are less likely to receive diagnostic and therapeutic cardiac procedures, such as angioplasty, thrombolytic therapy, coronary artery bypass grafts, beta-blocker therapy, or aspirin. The incidence of depression is higher among women in general, and evidence has surfaced that women suffer from depression after MI more than men. Hypertriglyceridemia exerts an equally deleterious effect toward cardiovascular disease in women and men.
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