Background Patient Information
Carolyn Cross is a 41-year-old Hispanic-American woman who has come to a medical facility for her wellness visit and regular examination. The woman has two children, and she was pregnant two times overall. She does not have any particular health complaints or worrying symptoms: she came for a standard examination. However, there is a concern that Ms. Cross shares with the medical team: her mother was diagnosed with intraductal breast cancer two months before the addressed examination at age 63.
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Also, Ms. Cross’s first cousin on her mother’s side (a third-degree relative sharing approximately 12.5 percent of Ms. Cross’s genes) was diagnosed with intraductal breast cancer recently, too, at age 44. One year before the examination, the patient’s baseline mammogram was normal. However, with such a family history, Ms. Cross is worried that she has a higher risk of breast cancer than a woman of her age averagely has, and she wants health care providers to consider this risk when performing the examination.
Concerning her family history, it should also be noted that Ms. Cross is concerned about the fact that her mother is diagnosed with diabetes mellitus type 2, and her father is diagnosed with hypertension and hyperlipidemia. She has no sisters; her two brothers are healthy.
The only notable medical condition identified for Ms. Cross before the examination is the fibrocystic breast disease, for which she takes vitamin E. The presence of irregularly located noncancerous lumps in both breasts was confirmed during the examination. Ms. Cross reported slight tenderness to the examination. Also, she occasionally experiences discomfort due to the lumpy consistency throughout both breasts during certain periods of the menstrual cycle. No other symptoms were identified during the examination; Ms. Cross is regarded as a healthy woman.
Ms. Cross’s menarche age was 10.5. She currently has a regular menstrual period without abnormalities. He had her first pregnancy at age 33, and the second at age 35, which is the age at which she also underwent tubes ligation. She breastfed both her sons for four months each. Ms. Cross has no known allergy; she does not smoke and has one glass of wine every night with dinner; she does not take any illegal drugs. Ms. Cross regularly consumes fast food, and she is overweight with a BMI of 27.5.
Most Significant Active Problem
Ms. Cross’s most significant active problem (MSAP) is the risk of breast cancer increased by the fact that two intraductal break cancers were recently diagnosed in her family. It is also noteworthy that part of the MSAP is the issue of the effectiveness of mammographic tests, i.e., whether they can help identify the risk or early development associated with the addressed disease. Studies definitively confirm that the relative risk for a woman to be affected by breast cancer is higher if the woman has relatives affected by it (Bevier, Sundquist, & Hemminki, 2012; Colditz, Kaphingst, Hankinson, & Rosner, 2012).
Several additional circumstances can increase the risk further. For example, women whose first-degree relatives were affected by breast cancer have higher risks of being affected by it, too, than the risks of women whose second-degree or third-degree relatives were affected (Bevier et al., 2012). Also, there are higher relative risks of having breast cancer for those women whose relatives were affected by the disease before 50, and there are lower relative risks for those whose relatives were affected by the disease after 50 (Colditz et al., 2012). Generally, the younger an affected relative was when diagnosed with breast cancer. The higher is the risk for a patient.
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It should not be disregarded that men can be affected by breast cancer, too. However, the data on affected males are sparse, which can significantly complicate the family history analysis as part of risk assessment. In this case, too, no data are available on breast cancer signs or examination of Ms. Cross’s father and brothers, i.e., her adult first-degree relatives. Male breast cancer is significantly rarer than female, and only 0.5 to 1 percent of breast cancer patients in the United States are men (Ruddy & Winer, 2013).
Still, examinations of Ms. Cross’s father and brothers can help specify her risks because it was established that the relative risk of a person having breast cancer is increased ten times if both parents are affected by the disease (Bevier et al., 2012). Without any data on her father and brothers, it can be assessed that Ms. Cross’s risk of having breast cancer is approximately two times higher than the risk of a woman whose first-degree relative is not affected by it. However, a minority of breast cancers are hereditary; having a mother with breast cancer largely increases the risks of a daughter.
Another issue is the assessment of the effectiveness of mammographic screening. Ms. Cross has fibrocystic breast disease, and lumps have been found in both breasts, but it is not expected to become a serious complication in mammographic screening. Fibrocystic breast disease is highly widespread; although definitive epidemiological data have not been obtained, in a sample of 42,818 women who had undergone benign breast biopsy and mammographic screening at least once, Tice et al. (2013) found that almost 70 percent had benign breast diseases, including primarily fibrocystic breast disease.
The presence of lumps can decrease the chances of detecting cancer, but the decrease is not expected to be dramatic because cysts are filled with fluids and are transparent for scanning, unlike malignant tumors. Returning to breast cancer risks, it should be noted that, according to Tice et al. (2013), being affected by a benign breast disease significantly increases the risk of breast cancer, which should be considered in Ms. Cross’s case, too.
Further, there is a connection between the age of menarche and the breast cancer risks: the younger a woman was during her first menstruation, the higher the risk of having the disease in the future is (Collaborative Group on Hormonal Factors in Breast Cancer, 2012). The risk is significantly higher for women who had their first menstruation before they were 12, as those women were more exposed to estrogen, which is a risk factor.
Concerning pregnancy, women who were first pregnant before they were 30 have lower risks of breast cancer in comparison with women whose first pregnancy was after 30 (relevant for Ms. Cross, who was first pregnant at age 33). Finally, being overweight increases the risk of breast cancer, too (Amadou et al., 2013). Therefore, Ms. Cross’s risks are associated with her BMI, family history, fibrocystic breast disease, early menarche, and late first pregnancy. However, one factor can also be identified that reduces Ms. Cross’s risks: she breastfed both her sons, although not for a long time, which decreases the risk of breast cancer due to reduced exposure to estrogen.
Recommended Disease Screenings
First of all, it is recommended to Ms. Cross to undergo mammographic screening, which is the primary purpose of her wellness visit. Expected complications include difficulties in detecting malignant tumors due to the patient’s fibrocystic breast disease, but this complication was found to be not critical (see Most Significant Active Problem). When recommending screening, appropriate agencies take into consideration the gender, age, ethnicity, and family history of a person, and based on Ms. Cross’s background. It is identified that she has relevant risks.
Concerning her ethnicity, it is debatable that her Hispanic-American identity is a relevant consideration. On the one hand, studies show that the breast cancer incidence rate has been demonstrating a downward trend among Hispanic women (DeSantis, Ma, Bryan, & Jemal, 2014); on the other hand, it should not be neglected that “Hispanic” is not necessarily an indication of race, and people who have this identity may come from many different ethnic backgrounds. For example, Amadou et al. (2013), in their study of the correlation between obesity and breast cancer, considered the participants’ race and did not include Hispanics in their classification, using only African, Asian, and Caucasian races.
Ms. Cross might need a genetic analysis to identify whether she has genes inherited from her mother that are associated with breast cancer, as it was established that breast cancer could be hereditary. Also, it is recommended to examine Ms. Cross’s father and brothers as her first-degree relatives to specify the risks. The patient’s diet and possible sun exposure can be risks, too, and they also contribute to the recommendation of screening.
Since the presented case requires screening for the presence of conditions for prevention, differential diagnoses are those that can be suspected and screened for; the need for this is justified by the identified risks. Based on Ms. Cross’s family history, lifestyle, pregnancy history, and current condition, differential diagnoses include the following: cervical neoplasm, hyperlipidemia (family history on her father’s side), breast cancer (family history on her mother’s side, menarche age, pregnancy history, weight, and fibrocystic breast disease), and diabetes mellitus type 2 (family history on her mother’s side).
For effective prevention, screenings should be performed for each of these conditions. The most significant issue, i.e., the one for which the most risks were identified, is breast cancer, and it is recommended to Ms. Cross to increase the frequency of her regular mammographic screenings.
Amadou, A., Ferrari, P., Muwonge, R., Moskal, A., Biessy, C., Romieu, I., & Hainaut, P. (2013). Overweight, obesity and risk of premenopausal breast cancer according to ethnicity: A systematic review and dose-response meta-analysis. Obesity Reviews, 14(8), 665-678.
Bevier, M., Sundquist, K., & Hemminki, K. (2012). Risk of breast cancer in families of multiple affected women and men. Breast Cancer Research and Treatment, 132(2), 723-728.
Colditz, G. A., Kaphingst, K. A., Hankinson, S. E., & Rosner, B. (2012). Family history and risk of breast cancer: Nurses’ health study. Breast Cancer Research and Treatment, 133(3), 1097-1104.
Collaborative Group on Hormonal Factors in Breast Cancer. (2012). Menarche, menopause, and breast cancer risk: Individual participant meta-analysis, including 118 964 women with breast cancer from 117 epidemiological studies. The Lancet Oncology, 13(11), 1141-1151.
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DeSantis, C., Ma, J., Bryan, L., & Jemal, A. (2014). Breast cancer statistics, 2013. CA: A Cancer Journal for Clinicians, 64(1), 52-62.
Ruddy, K. J., & Winer, E. P. (2013). Male breast cancer: Risk factors, biology, diagnosis, treatment, and survivorship. Annals of Oncology, 24(6), 1434-1443.
Tice, J. A., O’Meara, E. S., Weaver, D. L., Vachon, C., Ballard-Barbash, R., & Kerlikowske, K. (2013). Benign breast disease, mammographic breast density, and the risk of breast cancer. Journal of the National Cancer Institute, 105(14), 1043-1049.