Читать книгу Prevent, Survive, Thrive - John G. West - Страница 17
ОглавлениеIT’S BREAST PAIN that most often brings patients to our clinic. Although the majority of such women will not have cancer, it is still essential for the physician to keep in mind that pain can be an early cancer symptom—and it’s his or her responsibility to identify the rare patient whose pain is triggered by a hidden malignancy.
Breast soreness is most common in young women. It typically starts several days before the onset of menstruation and gets worse until the beginning of the period. That discomfort is generally associated with rising hormone levels, whereas the onset of the period is followed by a reduction in the intensity of the pain.
We refer to this pattern of pain as cyclic breast pain and it is considered normal. However, pain that occurs independent of the menstrual cycle is referred to as noncyclic breast pain and often requires medical attention.
A careful history is our starting point. I usually begin with the statement, “Describe the nature of your pain.” I then become more specific: “How long have you had it? Is it stable or getting worse? Is it intermittent or continuous?”
A combination of symptoms raises my concern about the possibility of a developing breast cancer. The first clue is when the woman is precise about the location of concern. If the patient then informs me that the discomfort has been getting progressively worse over the past several weeks, I assume the pain is due to breast cancer until proven otherwise.
However, most women with discomfort have difficulty pointing to an area of maximum concern. Not only does its location seem vague, but the history is often difficult for the patient to describe. The big clue that the pain is not of malignant origin is when the pain does not increase in severity over a period of several weeks.
After taking a history, the next step is the physical exam. I ask the patient to point to the sensitive area before I start. Usually she finds it difficult to locate the exact area. With vague area of distribution, I am reassured the pain is not likely to be of malignant origin.
In most cases, the exam will be negative, but occasionally a lump will be noted of which the woman was not aware. Ultrasound will readily differentiate between cystic and solid masses. As stated earlier, we usually aspirate cysts. Solid masses require a more extensive evaluation, and some will require a core needle biopsy to make an accurate diagnosis. Fortunately, most will prove to be benign.
Assuming the physical examination is negative, I prefer to do an ultrasound directed to the areas of maximum soreness, which in most cases is normal. I have the patient look at the ultrasound image of the area and then study other areas of the breast that are pain free. It is reassuring for her to see that the area of worry looks exactly like the other normal areas in her breast.
For women in their mid-thirties and older, I either do a baseline mammogram or repeat the diagnostic mammogram if it has been more than six months. If all is normal, I recommend she return two, four, and six months following her first visit. I advise menstruating women to schedule the appointment five to ten days after the onset of their period. In most cases the pain is either gone or the pattern of discomfort remains stable and the patient can return to routine screening.
There is a small but important group of patients with breast pain who do not fit into this neat little pattern. In these rare instances, though both the physical exam and imaging may be normal, the pain progresses over time.
The next step, then, is to order a breast MRI. For practical purposes, a normal MRI essentially rules out the possibility of a hidden cancer as the cause of pain.
OTHER CAUSES OF BREAST PAIN
With some women, the cause of breast pain is not due to changes in the breast but is caused by structures or organs near the breast.
Discomfort can arise from the bones, muscles, and tendons of the chest wall, the shoulder joint, or the cervical spine. Soreness can also be caused by medical conditions, such as esophageal reflux or coronary artery disease.
In those few instances where the breast evaluation is negative and the pain persists, consideration should be given to seeing other specialists, such as an orthopedist or an internist. We have also seen benefits in referral to a pain center where nerve blocks or steroid injections are effective in relieving pain in the area of the breast. In other situations, acupuncture had significant benefits.
TREATMENT OF BREAST PAIN
Once we have established that the pain is not due to a definable problem within the breast, or to structures or organs near it, the treatment is designed to reduce the patient’s symptoms. Women with cyclic breast pain are advised to take acetaminophen or their favorite anti-inflammatory, such as ibuprofen.
Women on birth control should think about switching to another brand of pill or even to another method, such as IUDs. Menopausal women on hormone replacement therapy might consider reducing the dose of their hormones.
Caffeine restriction is generally recommended, but studies to prove the value of this approach have been inconclusive. In my experience, women who are consuming four to five cups of coffee per day get relief when they minimize their caffeine intake. The benefit is typically less apparent in women who drink one or two cups a day.
The studies on vitamin E and evening primrose oil have also been inconclusive, but I still recommend them. Both are inexpensive and well tolerated, and many patients seem to benefit from taking them. It’s a bit like taking chicken soup for a cold. It can’t hurt, and with many patients it helps.
The one medication proven to be effective is danazol. Studies have demonstrated that this drug can reduce breast pain in about 70 percent of patients. The problem with danazol is its side effects, which include abnormal growth of body hair and lowering of the voice. In my experience, women who read the package insert rarely go on to take the medication. It is a reasonable, but temporary, choice for women with major breast pain that is unresponsive to other treatments.
Occasionally, one simple solution to relieve pain is to find a good-fitting bra. I remember one patient, Judy, who bought a twelve-dollar bra at Target. To her surprise, it was a “perfect fit” and was very effective in minimizing her discomfort. She even wore it at night. For some women, just finding the right bra seems to be all it takes.
Surgery for pain alone is rarely an option. However, I know many large-breasted women who have undergone breast reductions and subsequently noted significant pain relief. Yet this is a benefit that cannot be guaranteed. Mastectomy is virtually never done for pain relief, since the results are too unpredictable.
WHAT I’D TELL MY DAUGHTER
• Breast pain is common and rarely associated with malignancy.
• Breast pain associated with a lump should be reported to a physician.
• Localized breast pain that seems to be increasing in intensity should be reported to a physician.
