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OB/GYN Editorial October 2001
A Call for Clarity in Breast Care
Raquel Arias, MD
What does the term fibrocystic breast disease mean to you? It
does not appear in either Stedman's or Dorland's medical dictionaries,
although the word fibrocystic is defined as "pertaining to or characterized
by fibrocysts." Depending on your practice, you may define it as:
- a collection of at least 45 benign histologic diagnoses previously
thought to have premalignant potential (eg, adenosis, mammary
dysplasia, cystic hyperplasia)
- atypical epithelial hyperplasia o dense breasts, which makes
palpation of potential masses difficult
- lumpy breasts
- tender or painful breasts, especially in the absence of pregnancy
or obvious infection
- a diagnosis given to any woman presenting with breast complaints
for which no cause is found
- all or none of the above.
Although women with atypical epithelial hyperplasia ac-count for
only a small pro-portion of those who are given a diagnosis of fibrocystic
breast disease, they are the only ones on this long list with a
clinically relevant increase in breast cancer risk (relative risk,
5.0).
Despite a lack of agreement on the meaning of fibrocystic breast
disease (or perhaps because of it), the term continues to be widely
used to describe a variety of complaints and findings. Use of this
phrase could be forgiven if it were entirely innocuous. Un-fortunately,
however, otherwise healthy women stigmatized with this diagnosis
may believe that they have a disease when in fact they do not. In
addition, these women may incorrectly assume that their contraceptive
and hormone replacement choices are limited by this condition. Anyone
who has attempted a balanced discussion of medical options with
women who have internalized this descriptor knows what a powerful
effect it can have on their perception of risk and benefit.
Also, it doesn't help matters that this vague entity exists as
an ICD-9 billing code, thus immortalizing it on "superbills" everywhere.
Breast disease is a major concern for women. The perception that
a case of breast cancer was not diagnosed in a timely fashion accounts
for an excess number of civil lawsuits. Certainly, in the area of
breast care, the use of vague, misleading, and clinically useless
terminology should be avoided. We can only improve our patients'
understanding of breast complaints by clarifying our own language.
Alternatives to the term fibrocystic breast disease should be specific
to the complaint or finding. Clinicians might consider using the
following:
- mastalgia (plus a descriptor such as cyclic, intermittent,
bilateral, or unilateral)
- dense breast tissue (I suggest omitting such disclaimers as
can be found on mammography reports re-garding the decreased sensitivity
of the exam)
- generally irregular/lumpy texture (no dominant mass).
Patients with mastalgia/dense breasts, like all other women, need
careful documentation of their physical and mammographic findings.
They should be informed that the breast, like other reproductive
organs, exists in a dynamic milieu and, like other reproductive
organs, is subject to many physical and sensory changes.
Dense breasts are not diseased. Tender breasts, in the absence
of palpable or mammographic evidence to the contrary, are not more
likely to harbor cancer. Providing this information to patients
is the first and most important step in the management of benign
breast complaints.
Raquel Arias, MD
Editorial Board Member
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