Editorials - April 15, 2000 - American Academy of Family Physicians

Editorials

Evaluation of Common Breast Problems in Family Practice

REBECCA B. SAENZ, M.D.
University of Mississippi Medical Center
Jackson, Mississippi

See article in this issue.

In this issue of American Family Physician, Morrow¹ discusses the evaluation of three common breast problems: breast pain, nipple discharge and breast mass. I agree with the author's assertion that the goal of the evaluation is to exclude cancer and treat symptoms.

It seems prudent to include a review of risk factors in the efforts to exclude breast cancer. Risk factors include age, family history of breast cancer, early menarche, older age at first full-term pregnancy, nulliparity, presence or history of benign breast disease, and late menopause. Potentially modifiable risk factors include higher body mass index, heavy use of alcohol, use of oral contraceptives and not having breast-fed.²

The psychosocial impact of breast problems on patients is a frequently overlooked aspect of the evaluation of common breast problems. Because breast problems cause such a high level of distress for patients, particularly before a definitive diagnosis is obtained,³ physical examination alone may not provide adequate reassurance. Therefore, I disagree with the assertion that imaging studies are unnecessary in the evaluation of breast pain, except as would otherwise be indicated by screening guidelines. In women younger than 35 years of age, mammography has a low yield because of the low rate of breast cancer and the density of breast tissue. However, an ultrasound examination can demonstrate a variety of causes of breast pain, most of which are benign. This examination may also delineate subclinical masses that can be obscured by dense tissue or that can be difficult to palpate in pendulous breasts.

Guidelines for the evaluation of nonpuerperal galactorrhea should also include inquiry about previous pregnancy or lactation. It is not uncommon for small amounts of milk or serous fluid to remain expressible for years after pregnancy or breast-feeding.⁴ The family physician also needs to be aware of other frequent causes of galactorrhea, including thyrotoxicosis, some contraceptives and copper-containing intrauterine devices.⁵

Finally, an aspect that the article did not discuss is the evaluation of breast pain or a breast mass during lactation. The evaluation of breast problems encountered while a woman is breast-feeding must be tailored to the situation and should not interfere any more than absolutely necessary with the process of providing nourishment and immunologic benefits to the infant.

Pain in the lactating breast may be caused by engorgement or a plugged duct. It may also be the first sign of mastitis, ductal candidiasis or another infectious process.

The differential diagnosis of a dominant mass in the lactating breast includes plugged duct, mastitis, abscess and galactocele, as well as the disease processes mentioned in Morrow's article.¹ If a dominant mass in a lactating breast does not respond as expected after a few days of conservative treatment, aspiration, fine-needle biopsy, or even open biopsy can be performed to rule out cancer. All of these procedures can be done under local anesthesia without interrupting breast-feeding.

Because 3 percent of women diagnosed with breast cancer are pregnant or lactating,⁶ diagnostic delay should be avoided. If a surgical procedure is necessary, care should be taken to preserve breast function by using a radial incision, which has less chance of severing the nerve supply or lactiferous ducts than the usual circumareolar incision.

Rebecca B. Saenz, M.D., is assistant professor of family medicine at the University of Mississippi Medical Center, Jackson.

Address correspondence to Rebecca B. Saenz, M.D., Department of Family Medicine, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216.

REFERENCES

Morrow M. The evaluation of common breast problems. Am Fam Physician 2000;61:2371-8,2385.

McTiernan A, Gilligan MA, Redmond C. Assessing individual risk for breast cancer: risky business. J Clin Epidemiol 1997;50:547-56.

Andrykowski MA, Curran SL, Studts JL, Cunningham L, Carpenter JS, McGrath PC, et al. Psychosocial adjustment and quality of life in women with breast cancer and benign breast problems: a controlled comparison. J Clin Epidemiol 1996;49:827-34.

Riordan J. Anatomy and physiology. In Riordan J, Auerbach KG, eds. Breastfeeding and human lactation 2d ed. Boston: Jones and Bartlett, 1999:93-119.

Lawrence RA, Lawrence RM. Breastfeeding: a guide for the medical profession. 5th ed. St. Louis: Mosby, 1999:510-1.

Hoover HC. Breast cancer during pregnancy and lactation. Surg Clin North Am 1990;70:1151-63.

Improving Adherence to Asthma Therapy: What Physicians Can Do

STUART W. STOLOFF, M.D.
University of Nevada School of Medicine
Reno, Nevada

See article in this issue.

Asthma is a serious chronic inflammatory airway disease affecting more than 15 million Americans, one third of whom are children. If managed appropriately, hospitalization is rare, yet over 40 percent of costs are related to emergency services and hospitalizations that result from the failure to effectively use preventive treatment. Studies have found that patients who follow the recommended management program tend to do well clinically; however, objective measures show that fewer than 50 percent of patients with asthma take their inhaled medication as prescribed.¹

Growing evidence reveals that many patients with severe asthma do not adhere to their treatment. Across various chronic diseases, including asthma, adherence improves as disease severity increases from mild to moderate but appears to reverse with severe illness.² We would expect that patients would find emergency department visits and hospitalizations to be unpleasant and costly, and therefore they would improve their adherence; this assumption is often incorrect. Nonadherence is often high among patients who receive their treatment for asthma in the emergency department or hospital. There are no studies in patients with asthma to show that urgent care services increase or sustain subsequent adherence to management programs.

Given this significant problem with nonadherence to recommended asthma management, what can physicians do to improve asthma control for their patients? How do physicians change patients' behavior so they assume responsibility for their disease management?

It used to be called "bedside manner." It was a term that everyone understood as the warm, reassuring, interpersonal style of good physicians. At the core of the concept was an unstated value: the relationship between physician and patient. The patient and the family knew, liked and trusted the physician, and this bond motivated adherence. This relationship was and still is the single most powerful tool for changing patient health care behavior.

Any attempts to improve adherence are unlikely to succeed if the patient does not like and trust the doctor. Patients will not reveal concerns about their asthma or any other illness if they believe that their doctor is hurried, disinterested or impatient. Adherence is enhanced by making direct eye contact, transmitting genuine interest in what the patient has to say, explaining all recommendations thoroughly and in a language understood by the patient, praising treatment adherence and problem solving, and expressing willingness to modify the treatment plan in accordance with concerns expressed by the patient.³

The central focus of a successful asthma management plan is a "partnership in care,"⁴ which should begin at the time of diagnosis and is continuously integrated into every step of asthma therapy. Once this relationship is established, other adherence improving changes may be negotiated, including prescribing medications that are less costly or that do not have side effects of concern to the patient or family.

The 1997 National Heart, Lung, and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma⁴ recommends that the primary physician give the patient a written, individualized treatment plan and indicates that this management plan, as well as all other educational efforts, remain sensitive to the patient's language and cultural differences. When the physician takes the time to provide an individualized, daily self-management plan as part of the overall educational effort for the patient and his or her family, it sends a powerful message about the importance of being knowledgeable in self-management of asthma.

The article by Mellins and colleagues⁵ in this issue of American Family Physician represents a pharmacologically derived long-term treatment plan for children with asthma. The authors believe that it can also be effective in adults. The chart system described provides the framework for adjusting medications based on changing clinical conditions. Their self-management plan includes recommendations to improve adherence in the management of children with asthma within the framework of a continuous educational effort by the primary physician responsible for the patient's care.

In April 1999, a combined effort of the NHLBI and its European counterpart developed a science base committee to review the world asthma research literature. Using a systematic, evidence-based methodology through the Agency for Healthcare Research and Quality (formerly called the Agency for Health Care Policy and Research) and its 12 evidence-based practice centers, key questions have been identified. One of the questions to be answered through this rigorous process is "What is the evidence that written asthma management plans (either daily asthma management plans or action plans to handle exacerbations) improve patient outcomes?" It is anticipated that a draft report will be available by the middle of this year.

Stuart W. Stoloff, M.D., has a private practice in Carson City, Nev. Dr. Stoloff is also a clinical associate professor of family medicine at the University of Nevada School of Medicine, Reno.

Address correspondence to Stuart W. Stoloff, M.D., 1200 N. Mountain St., Ste. 220, Carson City, NV 89703.

REFERENCES

Rand CS, Wise RA, Nides M, Simmons MS, Bleecker ER, Kusek JW, et al. Metered-dose inhaler adherence in a clinical trial. Am Rev Respir Dis 1992; 146:1559-64.

Bender B, Milgrom H, Rand CS. Nonadherence in asthmatic patients: is there a solution to the problem? Ann Allergy Asthma Immunol 1997;79:177-86.

Stoloff SW, Janson S. Providing asthma education in primary care practice. Am Fam Physician 1997; 56:117-26, 131-4, 142.

National Asthma Education and Prevention Program (National Heart, Lung, and Blood Institute). Guidelines for the diagnosis and management of asthma: expert panel report 2. Bethesda Md.: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, 1997. Publication no 97-4051.

Mellins RB, Evans D, Clark N, Zimmerman B, Wiesemann S. Developing and communicating a long-term treatment plan for asthma in the primary care setting. Am Fam Physician 2000;61:2419-28,2433-4.

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