REASON FOR CONSULTATION:
Newly-diagnosed breast cancer.
REFERRING PHYSICIAN: This is as part of the multi-disciplinary
cancer care with referring physician, Dr. Landreville.
HISTORY OF PRESENT ILLNESS: Patient is a premenopausal, 48-yearold female who on a routine bilateral screening mammogram on
January 14, 2009, was noted to have no suspicious findings on the
left breast, but in the right inner breast a cluster of
microcalcifications. Spot compression views on February 18, 2009,
confirmed a cluster of irregular pleomorphic with the suggestion
of a few branching forms in addition to linear grouping of
calcifications nearby with the dominant cluster measuring 5 x 7
mm, considered suspicious. Stereotactic local-guided needle
biopsy on February 4, 2009, revealed intermediate grade ductal
carcinoma in situ with necrosis. The patient is now here for
further discussion of the roll of systemic therapy. With regard
to how she is feeling, she is still in shock of the diagnosis.
In retrospect, she had not noticed any changes in her breast
including nipple retraction, masses, skin changes.
Her 14-point review of systems is negative other than some
longstanding joint pain.
PAST MEDICAL HISTORY: Status post right total hip replacement and
cord decompression in the right hip. History of vascular
thrombosis, status post resection of a benign tumor in her
shoulder as a teenager. History of alcohol abuse.
ALLERGIES:
VICODIN causes a rash.
SULFA causes nausea.
MEDICATIONS:
1. Effexor.
2. Microgestin for migraines.
3. Trazodone.
4. Ativan.
5. Synthroid.
6. Maxalt.
7. Ibuprofen.
8. Promethazine for nausea associated with migraines.
ETHYL AND TOBACCO: History of alcohol abuse, quit 6 months ago,
but since then with this diagnosis has had 2 lapses.
SOCIAL HISTORY: Lives alone and has no children. She has been
trained as a radiation technologist but used to do office work
and is currently not working.
FAMILY HISTORY: Grandfather died of lung cancer in his 70s.
aunt had ovarian cancer in her 50s.
PHYSICAL EXAM:
An
ECOG performance status is zero.
VITAL SIGNS: Per EPIC.
GENERAL: She is an obese woman, somewhat anxious understandably.
HEENT: Clear oropharynx.
LYMPH NODES: No adenopathy.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR EXAM: Regular rate and rhythm. No murmurs.
ABDOMEN: Soft, nontender, nondistended. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
BREASTS: Left: Normal contour. Normal nipple areolar complex.
No dominant masses palpated. Right breast: Well-healed incision
from needle biopsy with no dominant masses palpated. No skin
changes. Normal nipple areolar complex.
LABORATORY DATA:
None.
IMAGING STUDIES:
Mammogram is as per above.
ASSESSMENT AND PLAN: 48-year-old, premenopausal woman found to
have a suspicious-appearing group of microcalcifications on a
routine screening mammogram with stereotactic needle biopsy
showing intermediate grade DCIS. We talked about the natural
history of this disease and emphasized the curability of this
disease. Explained that the patient needs to go in for a
resection. She appears to be a candidate for breast conservation
therapy, but is also of course a candidate for mastectomy and
right now patient is opting for breast conservation therapy. I
talked about the role of radiation therapy and reducing the
chances of local recurrence. Spoke then about the role of the
tamoxifen for prevention of recurrence of the ipsilateral and
contralateral breast and told her that tamoxifen decreases the
chances of a further breast cancer episode by almost 50 percent.
Spoke about the adverse effects of tamoxifen including but not
limited to weight gain, hot flashes, changes in mood, and the
potentially serious risk of thromboembolic disease and uterine
cancer. Explained to her that she would have to take tamoxifen
for 5 years. The patient will think about these issues. For now
I counseled her with regard to the risks of taking an oral
contraceptive pill in the context of newly diagnosed breast
cancer and I suggested that she find an alternative not
containing estrogen. The patient will set up lumpectomy and then
will see me 1 week after her surgery to discuss final pathology.
Questions were answered, her concerns were addressed.
Greater than 50 percent of this 40-minute was spent in
consultation.