A 44-year-old female mathematician presents to clinic with a complaint of a
mass in the right breast. Her partner noticed this mass 2 days ago, and the
patient feels guilty because she has only had one mammogram and does not
engage in breast self-examination (BSE) on any regular basis. She has no
family history of breast cancer, and her prior mammogram was ordered as a
routine screening test at age 43 years after a brief discussion with her primary
care provider. After a thorough investigation reveals a benign cyst, what
advice should be given to this patient about screening for breast cancer in her
age group?
a. BSE is well evidenced, and all recommending agencies agree that it should
be taught and reinforced.
b. Clinical breast examination (CBE) is superior to BSE and should be a
routine part of annual examinations starting at age 30 years.
c. This patient was in compliance with the U.S. Preventive Services Task Force
(USPSTF)
recommendations for her age group and risk factors prior to her current
complaint.
d. Mammography is most sensitive and specific for women in their 40s, when
breast tissue is still dense enough to image accurately.
e. Breast cancer screening is extremely well st
c. This patient was in compliance with the U.S. Preventive Services Task Force
(USPSTF)
recommendations for her age group and risk factors prior to her current complaint.
A 42-year-old female website developer presents for an annual preventive
examination with questions about breast cancer screening. She is concerned
about the radiation exposure associated with mammography and is interested
in magnetic resonance imaging (MRI) as a possible alternative for routine
screening. She is otherwise healthy with no family history of breast, ovarian,
or colon cancer. Which of the following is true about MRI as a screening
modality for breast cancer in the general population?
a. Breast cancer screening by MRI has been well studied in the general
population.
b. Sensitivity of screening for breast cancer increases with breast MRI at the
expense of specificity.
c. This patient is an ideal candidate for screening via breast MRI based on
current evidence
d. Women at low lifetime risk of breast cancer (<20%) are recommended to
undergo screening MRI.
,e. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening
with breast MRI.
b. Sensitivity of screening for breast cancer increases with breast MRI at the
expense of specificity.
A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral
nipple discharge. This discharge started several weeks ago and has occurred
at irregular intervals since that time. She does not complain of local
tenderness, redness, fever, or any other systemic symptoms aside from
slightly irregular periods over the last few months. On examination, she is able
to express a small amount of discharge, which is sent to the laboratory and
found to be consistent with breast milk but without any signs of blood or pus.
Screening laboratories are also sent, which reveal a normal blood count,
metabolic panel, thyroid-stimulating hormone, and human chorionic
gonadotropin (HCG) level. Further laboratories are still pending. Which of the
following is the most likely diagnosis?
a. Mastitis
b. Ductal carcinoma in situ
c. Paget disease of the breast
d. Occult pregnancy
e. Prolactinoma
e. Prolactinoma
A 22-year-old G0P0 undergraduate student presents to clinic after finding a
breast mass on breast self-examination (BSE) at home. The mass is nontender
without skin changes, erythema, or overlying swelling. She has heard that
most breast cancers are found by patients themselves, and she is very
concerned that she may have breast cancer. Which of the following is true
about BSE and self-detection of breast cancer?
a. Most masses that women find at home and bring to a provider's attention
turn out to be malignant.
b. This patient is more likely to find a fibroadenoma than a cancer on self-
examination.
c. The most likely breast mass this patient is likely to find in herself is an
abscess complicating underlying mastitis.
d. Because of this patient's age, breast masses should not be pursued with
imaging and diagnosis because the risk of cancer is so low.
e. BSE is universally recommended because of very high sensitivity and
specificity for finding cancerous lesions.
b. This patient is more likely to find a fibroadenoma than a cancer on self-
examination.
A 48-year-old female psychologist presents to clinic with concerns about her
breast cancer risk after an age-matched cousin was recently diagnosed with
this disease. This cousin is the third family member on her father's side in as
many years to be diagnosed with breast cancer, including the patient's own
father, who had surgery and subsequent treatment 3 years ago for breast
cancer. The patient has little other knowledge of her family history, only that
her grandparents independently arrived from Eastern Europe near the end of
World War II and were among very few members of their family that survived
the war. The patient has read about testing for the breast cancer genes
,(BRCA1 and BRCA2) and desires further information about whether this would
be appropriate for her. Which of the following is true about this patient's
indications for BRCA testing?
a. Her familial lineage is irrelevant to her risk of BRCA genes and should be
discounted in assessing her risk for these genes.
b. Breast cancer in a male relative does not add significant weight to the
decision to test for the BRCA genes in this patient.
c. The BRCAPRO calculator does not add any further clinical information to
this patient
d. This patient carries several risk factors that together justify BRCA testing.
A 68-year-old former paleontologist presents to clinic with concerns about her
breast cancer risk. Her mother developed the disease in her 50s and died from
it in her 60s. A younger cousin developed the disease a few years ago before
the age of 50 years, but this individual was not tested for the BRCA1 and
BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and
had radiation to the chest. She did take hormone replacement therapy for a
few years before data emerged that this may contribute to breast cancer risk.
She has had several abnormal mammograms in her 50s for persistently dense
breasts with subtle findings, but follow-up biopsies never showed any
malignant pathology. Which of the following is true regarding magnetic
resonance imaging (MRI) screening of this patient?
a. No agency recommends breast MRI for a patient such as this one, who has
moderately but not extraordinary risk factors for breast cancer.
b. The U.S. Preventive Services Task Force (USPSTF) recommends against
screening with MRI for patients with such risk factors.
c. Regardless of recommendations, the high sensitivity of breast MRI comes at
the expense of markedlydecreased specificity (i.e., the a
c. Regardless of recommendations, the high sensitivity of breast MRI comes at the
expense of markedlydecreased specificity (i.e., the ability to rule out disease in
healthy breasts).
A 66-year-old female museum curator presents for a routine annual
examination. On examination, a notably enlarged supraclavicular lymph node
is appreciated on the right side. The lymph node is nontender and feels firm
and rubbery. She denies any localized or systemic symptoms such as breast
lumps, fevers, or night sweats. She has been taking conjugated estrogen
tablets for 9 years since menopause, though she has not taken progestin
compounds since she had a hysterectomy for heavy bleeding at age 45 years.
Which of the following is true about this presentation of lymphadenopathy?
a. Breast cancer always presents with axillary lymphadenopathy because the
lymphatics of the breast uniformly drain into the axilla.
b. Supraclavicular nodes are generally considered benign and require no
further evaluation or follow-up.
c. Supraclavicular nodes are found along the anterior edge of the trapezius
muscle in the neck.
d. Firm, rubbery lymph nodes are generally considered to be benign.
e. Metastatic breast cancer cells may spread directly into the infraclavicular
, and then supraclavicular nodes without first causing notable changes in the
axillary nodes.
e. Metastatic breast cancer cells may spread directly into the infraclavicular and then
supraclavicular nodes without first causing notable changes in the axillary nodes.
A 24-year-old graphic designer presents to clinic with a concern for a breast
mass. A rubbery, mobile, nontender mass is palpated in the right breast as
described by the patient, which is consistent with a firbroadenoma. In
describing the location of the mass, the examiner notes that it is 3 cm proximal
to and 3 cm to the left of the nipple. Which of the following would be the most
appropriate way to report this finding?
a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30
position from the nipple"
b. "Rubbery, mobile, nontender mass located in right breast, in the lower outer
quadrant"
c. "Rubbery, mobile, nontender mass located in right breast, in the upper inner
quadrant"
d. "Rubbery, mobile, nontender mass located in the left breast, upper outer
quadrant"
e. "Rubbery, mobile, nontender mass located in right breast, in the 1:30
position from the nipple"
a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position
from the nipple"
A 54-year-old female dietician presents for a routine annual examination. On
review of systems, she reports that she has had many breast findings over
several years, including one biopsy with normal pathology. She feels that her
breasts have become far less lumpy since she underwent menopause 3 years
ago. Which of the following is true regarding changes in the breasts with
menopause?
a. Transformation of breasts to primarily fatty tissue with menopause
decreases the sensitivity and specificity of mammograms.
b. Estrogen in hormone replacement therapy (HRT) has no effect on breast
density after menopause.
c. Glandular tissue of the breast atrophies with menopause, primarily due to
decrease in the number of lobules.
d. Breast density has no genetic component and is entirely due to estrogen
dose from endogenous and exogenous sources over the lifetime.
e. Mammography performs most poorly in the menopausal and
postmenopausal age group and should be limited for that reason.
c. Glandular tissue of the breast atrophies with menopause, primarily due to
decrease in the number of lobules.
An overweight 26-year-old public servant presents to the Emergency
Department with 12 hours of intense abdominal pain, light-headedness, and a
fainting episode that finally prompted her to seek medical attention. She has a
strong family history of gallstones and is concerned about this possibility. She
has not had any vomiting or diarrhea. She had a normal bowel movement this
morning. Her βhuman chorionic gonadotropin (β-hCG) is positive at triage.
She reports that her last period was 10 weeks ago. Her vital signs at triage are
pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation,
