Self-detection of a breast mass in adolescent females

JOURNAL OF ADOLESCENT HEALTH CARE 3:15-17, 1982

Self-Detection of a Breast Mass in Adolescent Females* K A R E N H E I N , M . D . , ar R A L P H DELL, M.D., A N D M I C H A E L I. C O H E N , M.D.

The frequency of self-discovered breast masses in adolescent females has not previously been described. The histologic diagnosis rather than the means of detection has been the focus of previous surveys. Seven characteristics of 95 patients admitted from 1968-1979 for the evaluation of a breast mass were delineated. The mean age at hospitalization was 15.9 years (range 12-20). The delay from detection to hospitalization was 7.2 months (range 0.5-72). In 77 cases the mass was detected by the patient; 11 were found during a physician examination, 4 by a family m e m b e r , and 3 by an unrecorded source. Diagnoses were fibroadenoma (71), abscess (11), cyst (9), lipoma (2), and cystosarcoma phyllodes (2). The median length of the masses was 2.6 cm, width 2.3 cm, with a median mass area (diameter x length) of 6 cm 2. When patients were compared for age, delay in hospitalization, means of detection, family history, and mass size, the girls with abscesses were younger and had a shorter time delaybefore hospitalization. Self-discoverywas the means of detection in 77 of 95 (81%). The means of detection is an important factor to consider in weighing the merits of teaching breast self-examination procedures to adolescent females. KEY WORDS:

Breast self-examination Tumor Adolescence The frequency of self-discovery of a breast mass in adolescents has not been systematically evaluated. *Presented in part to the Society for Adolescent Medicine, AnmlaI Research Meeting, Detroit, Michigcm, October 24, 1980. ~-Supported in part by NIH BRSG #RR05-393-19. From the Divisions of Adolescent Medicine, Department of Pediatrics, Babies Hospital, Columbia University, New York, NY, and Montefiore Hospital Medical Center, Albert Einstein College of Medicine, Bronx, NY. Address correspondence to: Karen Hein, M.D. Division of Adolescent Medicine, Department of Pediatrics, Babies Hospital South 1-103, 630 West 168 St. New York, NY 10032. Manuscript accepted 14 February 1982.

In fact, some have assumed that teenagers do not have the requisite skills to permit accurate self-examination and therefore do not advocate teaching breast self-examination (BSE) as demonstrated by this quotation from a 1971 textbook. "It is ridiculous to attempt to teach it [BSE] to girls in their teens. It is doubtful that even young women in their final college years are mature enough for this discipline. It seems reasonable to begin instruction when women are in their early 30's" (1). If this statement is correct, then the proportion of breast masses detected by adolescents should be small. The authors' impression is that, in fact, teenage girls detect the majority of masses themselves and then seek medical care. If self-discovery is a major means of identifying breast masses in young women and if malignancy does occur in this age group then perhaps the importance of teaching BSE to teenagers should be more carefully considered. To test the hypothesis that teenagers are capable of examining their own breasts and reporting their findings to a health professional, a retrospective analysis of the mode of discovery of the breast masses of adolescents admitted for excisional biopsy was conducted.

Method The medical records of all female patients with a breast mass admitted to the adolescent inpatient unit of Montefiore Hospital and Medical Center between 1968-1979 were analyzed. Seven characteristics of the 95 patients were recorded: age at hospitalization; interval of time from detection of the mass to hospitalization; presence of a 1°, 2°, or 3° relative with a history of breast cancer; who detected the mass (patient herself, physician, family member); location; size of the mass; and the histological diagnosis after biopsy.

© Society for Adolescent Medicine, 1982 Published by Elsevier Science Publis]hing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017

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HEIN ET AL.

JOURNAL OF ADOLESCENT HEALTH CARE Vol. 3, No. 1

Of the 95 charts reviewed, information about 5 of the 7 variables was present in 90-100% of the charts. Specific information about family history of breast cancer and mass size was present in 68% and 84% of charts respectively. They were divided into groups according to the major histologic diagnoses. The statistical significance of age, interval from detection to hospitalization, means of detection, family history of malignancy, and size of the mass in distinguishing between groups were tested using a stepwise discriminant analysis.

Results A summary of the six independent variables recorded is provided in Table 1 by major histologic diagnostic category: fibroadenoma, abscess, cyst, and other (lipoma, cystosarcoma phyllodes). The mean age of 15.9 years was similar to the patients admitted with other diagnoses. There was a variable interval of time between report of detection to hospitalization. As expected the patients with abscesses had the shortest delay (mean 0.5 months) whereas those with cysts had the longest (15.5 months). Seventy-seven of the 95 patients (81%) discovered the mass themselves. It is not known whether they had been instructed in BSE. Eleven patients (11%) had the mass diagnosed by a physician. Several of these patients stated that they too had suspected a mass but did not mention it to the physician. In 4 patients (4%) the source of detection was listed as a

family member, usually the patient's mother or sister, and in 3 cases (3%) the source was unrecorded. The physical characteristics of the breast masses were defined by size and location. The size was defined by length (cm), width (cm), and mass a r e a (cm2). The mean length was 2.6 (range 1-5 cm), width 2.3 (range 1-6 cm), and mass 6.0 (range 1-25 cm2). Using stepwise discriminant analysis of four features (age, delay interval, family history, and means of detection) and three physical examination features (location, size, and histologic diagnosis) only patients with abscesses were distinguishable from the others. The group with abscesses were significantly younger (P ( . 0 1 ) and had a shorter delay from detection to hospitalization (P < .05). When age and delay factors were considered together, the patients with abscesses were distinguishable from other girls (P ~ .05). Using the age factor alone or the delay factor alone, the diagnosis of abscess could be predicted correctly 75% of the time.

Discussion Self-discovery was the means of detection in 81% of our patients hospitalized for evaluation of a breast mass. Patients discovered masses as small as 0.5 cm. All of our patients were less than 20 years of age. Most reports of breast diseases in young women refer to patients under the age 30 years (2). These reports usually describe the incidence of malignancy, not the means of detection. Our seven characteristics were chosen because they were found to

Table 1. Summary of Six Independent Variables Recorded in 95 Hospitalized Adolescent Females with Four Histologic Diagnoses. a Patient (Number) Age (Years) Delay interval (Months) Means of detection Self Family MD Unknown Family history Positive Negative Unknown Location Right Left Bilateral ~( +_ SD

All groups

Fibroadenoma

Abscess

Cyst

Other

95 15.9(1.9)

71 15.9(1.9)

11 14.6(5.4)

9 17.4(1.0)

4 16.2(2.3)

7.2(11.7)

7.1(11)

0.5(0.0)

15.5(20)

9.4(15.1)

77 4 11 3

57 4 8 2

10 0 0 1

7 0 2 0

3 0 1 0

5 56 34

3 42 26

0 5 6

1 6 2

1 3 0

51 37 7

42 25 4

4 7 0

3 3 3

2 2 0

August 1982

SELF-DETECTED BREAST MASSES IN ADOLESCENTS

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be important in assessing the risk of developing breast carcinoma or in analyzing reasons for delay in diagnosis until advanced stages of breast carcinoma in adult women. Delay in hospitalization was usually attributed to patient's denial of the presence of a mass or to fear of a maliignancy being diagnosed. In our study of adolescent females, the decision to follow a patient for several months before hospitalization was made by the physician. Surgery was scheduled at a convenient time for the adolescent, often during summer recess or a school holiday. In only one case was the delay in hospitalization caused by the adolescent's reluctLance to seek evaluation. Confirmation of a positive family history was sought since the adolescent might be more aware of the occurrence of a breast mass and the need for selfexamination. The location of the mass was included because the examination of pubescent females often involves more manipulation of the left breast in listening to the heart. It was thoughtL that perhaps a preponderance of left masses would be diagnosed but, in fact, more masses were located on the right. The size of the masses varied from very small to large. The tumors were not recorded as being visible and could therefore only be detected by examination. None had nipple retraction, breast asymmetry, or edema; therefore, palpation was required. Stepwise discriminant analysis distinguished only those girls with abscesses. They were younger and as expected had a shorter time delay from diagnosis to hospitalization. The rapid hospitalization was undoubtedly due to the associated pain. Other surveys of adolescent breast masses did not include the abscesses so no comparison with previous data is possible (3). Accessory diagnostic modalities such as xeroradiography or mammography are contraindicated in adolescent-aged patients (4). The low prevalence rate of breast malignancy, breast consistency (higher fibrous tissue to fat ratio), and the radiation dose required make their use unwarranted in the adolescent patient. Therefore, reliance on palpation for breast mass detection is essential. An earlier report of breast tumors in teenage females reported that the majority were discovered during the administration of a general physical examination (3). Whether the physician or patient is better suited to conduct a periodic breast examination is not the issue since adolescents often do not see physicians for long intervals. It would appear that this screening technique would therefore be best performed by the patient herself. The goals of BSE educational programs for older

w o m e n have been to alert them to the possibility that an asymptomatic mass may be malignant and to encourage early detection by repeated self-palpation at regular intervals. There appears to be an effect in decreasing mortality in adult women with increased patient and physician awareness of the need for breast examination (5). The goals and required maneuvers for proper BSE in teenagers may differ. In our study self-detection was the usual means of discovery. It is not known whether these teenagers used the technique of the American Cancer Society for adults. It seems likely that many discovered the mass inadvertently or without performing all the recommended maneuvers. Since the prevalence and types of malignancy differ in adult and adolescent females, perhaps a modification of the procedure for adults should be made and tested before any assumption about the usefulness of BSE for the detection of breast masses in adolescents is made. In adolescents, as compared to adult women, it appears that the physician, rather than the patient delays hospitalization for excisional biopsy because the majority of masses are benign. When the characteristics of adolescents with breast masses were analyzed, the features of the history and physical examination were not useful in predicting the pathologic diagnosis except for abscesses. The observation that two patients had a malignancy (cystosarcoma phyllodes) underscores the importance of performing exdsional biopsies in young patients with a painless breast mass. Due to the small numbers in our series, it was not possible to perform discriminant analysis to determine if there were any features of their history or physical examination which would have allowed a prediction of malignancy. Despite recommendations and reports to the contrary, females in the adolescent range can discover a breast mass (1). It appears to be worthwhile to instruct teenage girls to become aware of and familiar with their own breast conformation and consistency and report any abnormality to a health professional.

References 1. Haagensen CD: Diseases of the Breast. Philadelphia, Saunders, 1971, p. 96 2. SeltzerMH, Skiles MS: Diseases of the breast in young women. Surg Gynecol Obstet 150:360-362, 1980 3. Daniel WA, Matthews MD: Tumors of the breast in adolescent females. Pediatrics 41:743-749, 1968 4. Lesnick GL: Detection of breast-cancer in young women. J Amer Med Assoc 237:967-969, 1977 5. Greenwald P, Nasca PC, Lawrence CE, et al.: Estimated effect of breast self-examination and routine physician examinations on breast-cancer mortality. N Engl J Med 299:271-273, 1977