Care Plan – Breast Mass
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
N63.0 Unspecified lump in unspecified breast
BREAST MASS
I. DEFINITION
A breast mass is a thickening or lump that is felt in a woman’s breast; the lump may or may not have the following characteristics.
a. nipple retraction
B. discharge from nipple
C. skin dimpling
d. inflammation or discoloration
e. skin thickening
F. Palpable axillary or supraclavicular nodes
G. tenderness
H. Change in the size of the breast
II. ETIOLOGY
a. Fibrocystic disease is a catchall term for nonmalignant conditions.
B. Fibroadenoma
C. Carcinoma
d. Mammary duct ectasia
e. intraductal papilloma
F. normal premenstrual breast tissue (i.e., with tenderness and prominent breast tissue secondary to hormone levels—physiologic nodularity, mastoplasia)
G. Mastitis (cellulitis, skin boils, abscess)
H. Cysts
i. Hematoma or fat necrosis
J. superficial phlebitis
K. Phyllodes tumors—painless, solid, smooth, lobular, bulky, stromal hyperplasia
III. HISTORY
a. Woman may present with
1. Lump
2. Pain
3. swelling
4. redness, edema
5. Bruised area that does not resolve
6. discharge from nipple
7. nipple retraction
8. Change in appearance of skin and areola
9. dimpling, scaliness
B. additional information to be considered
1. Last menstrual period (Has patient noticed a relationship to menses?)
2. History of previous breast lumps or breast disease, biopsy (type) or aspiration; breast surgery, including reduction, enlargement, implants, and type
3. recent trauma (may cause hematoma or fat necrosis)
4. recent weight loss (significant weight loss may change the texture of the breasts because of reduced adipose tissue)
5. Birth control method(s) used: hormone therapy (type, dose, duration) and how soon after menopause
6. recent pregnancy, lactation
C. risk factors
1. nonmodifiable risk factors
a. Gender (breast cancer occurs 100 times more frequently in women than men)
b. age (risk increases as women age)
c. Genetics
i. of breast cancers, 5% to 10% are thought to be hereditary.
ii. BrCa1 and BrCa2 (most common cause of hereditary breast cancer is an inherited mutation in the BrCa1 and BrCa2 genes)
a) risk of breast cancer may be as high as 80% for some families.
b) Cancers tend to occur in younger women and, more often, affect both breasts.
c) Mutation carriers are more likely to develop other cancers, especially ovarian cancer.
d) Mutations are most common in families of ashkenazi descent but can occur in any racial or ethnic group.
iii. in women who do not carry a mutation, breast cancer risk doubles with one first-degree relative with breast cancer and triples with two first-degree relatives with breast cancer.
iv. risk increases with family history of male breast cancer
v. Personal history of previous breast cancer
vi. race and ethnicity (risk varies by group)
vii. dense breast tissue on mammography
viii. History of previous biopsy (especially showing proliferative lesions, lesions with atypia, and lobular carcinoma in situ)
ix. Menstrual periods (early menarche [before age 12] and late menopause [after age 55] increase risk because of lifetime exposure to estrogen)
x. Previous chest wall radiation (treatment for Hodgkin’s lymphoma or non–Hodgkin’s lymphoma as child or young adult significantly increases risk)
xi. diethylstilbestrol exposure (mothers have slightly increased risk)
2. Modifiable risk factors
a. Late childbearing (after age 30 or nulliparity)
b. recent oral contraceptive use (within past 10 years)
c. Hormone therapy after menopause (especially combined hormone therapy)
d. Breastfeeding (may slightly lower risk)
e. alcohol use (risk increases with amount of alcohol consumed)
f. Being overweight (excess adipose tissue produces excess estrogen), physical activity (risk decreases with increased activity)
IV. PHYSICAL EXAMINATION
a. Breast physical examination
1. ideal time to examine breasts is 1 week after first day of menstrual cycle
2. examine in both upright and supine positions
3. include the neck, chest wall, both breasts, and axillae in examination
4. examine regional lymph nodes (axillary and supra-/infraclavicular)
5. Begin with inspection and then palpation
B. inspect for
1. new asymmetry of breasts
2. skin changes, such as dimpling, retraction, erythema, or discoloration
3. nipple changes, such as retraction, nipple scaling, excoriation, or spontaneous discharge
C. Palpate for
1. solitary or multiple lesion(s)
2. Consistency of any mass (rubbery vs. firm)
3. Borders of any mass (smooth vs. irregular)
4. size of any mass (in centimeters)
5. tenderness of mass
6. Movable or fixed on chest wall
7. displacement or retraction of nipple
8. retraction or dimpling of skin overlying mass
9. Palpability of regional lymph nodes (axillary or supra-/ infraclavicular)
10. discharge expressed: color, amount, unilateral or bilateral, consistency
11. express breast for any discharge if none is noted on palpation
d. document findings
1. symmetry of breasts (if there is an asymmetry, is it baseline or new?)
2. appearance of skin (dimpling, retraction, or discoloration)
3. appearance of nipple (retraction, scaling)
4. if present, describe nipple discharge (spontaneous vs. elicited, color, amount, unilateral or bilateral)
5. if present, describe palpable mass (position on breast using numbers on a clock, distance from nipple in centimeters, size of lesion in centimeters, and consistency and borders)
V. LABORATORY EXAMINATION
a. Bilateral diagnostic mammogram (if older than age 30)
B. Breast ultrasound and possible diagnostic mammogram (if younger than age 30)
C. targeted ultrasound of area of concern
d. if discharge is present, guaiac test all discharge for occult blood.
VI. DIFFERENTIAL DIAGNOSIS (SEE BREAST MASS, ETIOLOGY, II)
VII. TREATMENT
a. Medication
1. appropriate antibiotic for mastitis, abscess
B. General measures
1. if a suspicious mass is identified, arrange consult with breast specialist (see Breast Mass, Consultation/Referral, IX).
2. if a benign-appearing mass is identified on imaging, consider consult with breast specialist for further guidance.
3. if no discrete lesion is identified on clinical exam or imaging, have the patient return 1 week after next menses for reevaluation and possible referral (4–6 weeks for postmenopausal women).
VIII. COMPLICATIONS
May be grave and extensive if misdiagnosed
IX. CONSULTATION/REFERRAL
a. individuals with the following lesions should be referred immediately to a breast specialist for consideration of biopsy.
1. any abnormal findings on imaging
2. dominant mass despite negative imaging
3. Mass associated with nipple retraction or nipple discharge
4. dimpling of skin; orange peel appearance to skin
5. inflammation, swelling, scaling, or excoriation
6. Palpable axillary or supra-/infraclavicular nodes
7. Cystic mass, for possible aspiration
B. individuals with the following should be referred to a breast specialist on reevaluation.
1. developing/increasing mass despite negative imaging
2. increase in associated symptoms
C. When in doubt, always refer
X. FOLLOW-UP
a. appropriate to Breast Mass, Treatment, VII, and Consultation/Referral, IX See Bibliographies.