Frequently Asked Questions
Breast Cancer FAQs for Primary Care Physicians
As a primary care physician, you play a critical role in your patient’s overall good health. When your patient is facing a serious breast cancer diagnosis, it’s important to be familiar with treatment guidelines, routine preventive screening information, and follow-up care.
Breast Cancer Screening
There seems to be conflicting information about when and how often women should be getting mammograms—especially women over 50. What should I tell my patients?
We recommend the following guidelines for breast cancer screening:
- Mammogram: Yearly mammograms starting at age 40 and continuing for as long as a woman is in good health.
- Physical exam: A clinical breast exam by a primary care provider as part of all regular physical examinations for women 30 and older.
- Self-exam: Monthly breast self-exams help patients become familiar with the normal look and feel of their breasts and making them more likely to notice any changes. If a patient finds a mass, she should be seen promptly for evaluation and possibly diagnostic imaging.
What are some guidelines for a thorough physical breast examination? What sort of questions should I be asking my patient to ensure that nothing is being missed or overlooked?
Guidelines for a complete breast examination include:
- Examine the patient sitting up and lying down
- Document any mass (size, location, mobility, and consistency)
- Note any skin changes (dimpling, retraction, redness or nipple scaling)
- Examine the lymph nodes in the underarm area and document as negative (normal size, soft, mobile) or suspicious (consistency, single or multiple, movable or fixed)
Patients typically don’t have symptoms when screened during an annual physical exam; however some may have a breast mass, pain, skin changes, and nipple changes or discharge. Ask your patient about her symptoms:
- How long have you had the symptoms?
- Are the symptoms related to the timing of your menstrual cycle?
- Have you noticed any nipple discharge?
When should I refer my patient to a breast cancer specialist?
Here are some reasons that indicate your patient should be seen by a breast radiologist or breast surgeon:
Cyst: Typically found in pre- and peri-menopausal women, cysts are not always easy to distinguish as a solid versus a cystic mass, therefore a diagnostic ultrasound or cyst aspiration may be necessary. The breast radiologist will usually recommend observation but will note if the patient should be seen by a clinical breast specialist.
Solid mass: If a solid mass is confirmed by ultrasound the breast radiologist will usually recommend and perform an ultrasound guided core needle biopsy. Core needle biopsy is the procedure of choice for further evaluation of a suspicious finding and is usually performed prior to referral to a breast surgeon.
Vague nodularity: A mass found by your patient may only be slightly lobulated breast tissue that may have been found during the premenstrual phase. If your patient is concerned, schedule additional exams bimonthly or quarterly (at mid-cycle for menstruating women) until you are convinced it is benign. If the mass persists after three months and can be distinguished from the remaining breast tissue, refer your patient to a specialist. At the Swedish True Family Women’s Cancer Center we have a nurse practitioner with extensive expertise in breast disease. Most patients without a cancer diagnosis can be evaluated initially by her and promptly be seen by a surgeon if indicated.
Breast pain: A cyst is the most common cause of a painful mass. However, breast pain symptoms do not preclude a diagnosis of malignancy. Failure to recognize the possible significance of a painful mass is often why a breast cancer diagnosis is delayed. If physical exam and mammography results are negative, breast pain is most likely related to fibrocystic changes or a patient’s menstrual cycle. To reassure your patient, explain how the hormonal cycle is sometimes related to breast pain and consider advising your patient to take ibuprofen, acetaminophen, or aspirin and to wear a good support bra.
Nipple discharge: A patient who has suspicious nipple discharge (spontaneous, clear or bloody, with or without a palpable mass) should be referred to a breast radiologist for diagnostic evaluation that may include mammograms and ultrasound. If the patient has non-suspicious nipple discharge, screening mammography is recommended based on the patient’s age.
Skin or nipple changes: A patient who has skin changes on the nipple and areola should be referred to a breast specialist. Paget's disease, a rare form of breast cancer that starts out on the nipple and then extends to the areola, could be the cause. Patients with breast redness, tenderness, and swelling need to be evaluated for mastitis.
Difficult breast examinations
Refer your patient to the ARNP breast specialist at the True Center for evaluation if the breast examination is difficult due to:
- reduction mammoplasty or augmentation implantation
- extremely large or dense multi-nodular breasts
- multiple biopsies with multiple scars
- pregnancy or lactation
What type of information should I provide to my patient regarding risk, if there is breast cancer in her family history? And how does this impact when she should start getting regular mammograms?
While high-risk patients should have a complete risk assessment, it’s important for them to know that the majority of newly diagnosed breast cancer patients have no clearly identifiable risk factors other than being female. Since breast cancer incidence increases with age, a family history should identify any first-degree relatives with breast cancer and the age of cancer onset.
Patients with a history of breast cancer should have regular follow-up visits with a specialist for clinical and possibly imaging exams. Even more thorough screening may be needed for patients at high-risk of developing breast cancer due to a strong family history of:
- pre-menopausal first-degree relatives (mother, sisters, daughters)
- diagnosis of atypia on breast biopsy
- multiple previous biopsies
For these high-risk patients, referral to a breast cancer specialist or a high-risk program such as the one at the True Family Women’s Cancer Center is appropriate.
During Breast Cancer Treatment
What are the most common questions my patients may have about a new or recent diagnosis of breast cancer and where can I refer them for answers?
Recently diagnosed patients are typically scared, anxious, and in search of information. Their questions can range from general information about breast cancer and risk factors, to specifics about their stage of cancer and treatment options. Swedish has a great one-stop resource for newly diagnosed breast cancer patients. Learn more.
Should I encourage my patient to get a second opinion for breast cancer treatment?
It’s important for patients to feel confident that they’ve explored all their treatment options, thoroughly understand their condition and have found the right fit with a cancer treatment team. Patients should not feel bad or feel as if they're hurting the physician’s feelings when asking for another opinion. A second opinion is a good idea if a patient has an unusual cancer that could be better treated by a larger group with more experience specific to that particular type of cancer or if the patient did not have a satisfactory interaction with the first physician. Sometimes a second opinion is even requested by the treating physician, especially for major surgery.
At Swedish, we believe that if a patient has a clear cancer diagnosis that calls for a very standardized treatment plan and the patient is comfortable with the treatment team, there’s typically no need for a second opinion, unless the patient feels that they want one. More women with breast cancer are treated at Swedish than any other hospital system in the region. Learn more about getting a second opinion.
What are the advantages of sending my patients to the Swedish Cancer Institute?
At Swedish, breast cancer patients are treated by an entire team of board-certified surgeons and other specialists collaborating on the best possible care for the patient. This collective experience is far greater than the knowledge and experience of any one or two providers and is leveraged against the cancer in favor of the patient. Swedish Cancer Institute patients benefit from this integrated, multi-disciplinary system that gives them every advantage in cancer treatment, including:
- the latest cancer services, state-of-the-art imaging, technology and equipment under one roof
- board-certified surgeons who specialize exclusively in breast cancer
- more breast cancer surgeries performed at the Swedish Cancer Institute than any other cancer center in the region
- medical oncologists who specialize in treating breast cancer
- access to the new True Family Women’s Cancer Center where top specialists focus exclusively on treating women with cancer
- experienced physicians in an extensive range of specialties, including diagnostic radiologists, pathologists, surgeons, radiation oncologists, medical oncologists, plastic surgeons and cancer rehabilitation physicians
- specialists closely collaborating with the same electronic medical record; using evidence-based medicine and best medical practices including regular tumor boards and personalized follow-up
- integrated care services including genetic counseling, educational classes, podcasts, support groups, education resource center, an American Cancer Society Patient Navigator, nutritional care, physical therapy, and naturopathic medicine
How can I best support my patient during their breast cancer treatment?
After a patient is diagnosed, treatment is typically handled efficiently by a team of specialists at a cancer center such as the Swedish Cancer Institute. However, as a primary care physician, you can enhance your patient’s cancer treatment by continued involvement and support by:
- participating as a member of the treatment team
- collaborating with your patient’s oncologists regarding treatment options; recognizing and managing complications of cancer and treatment therapies; helping with pain management
- providing mental health support
- continuing preventive care
- finding clinic and community resources.
Cancer-related symptoms and adverse effects of treatment may include:
- nausea, febrile neutropenia, pain, fatigue, depression, and emotional distress
- cachexia (megestrol can improve weight gain and appetite)
- anemia, several weeks after chemotherapy treatment onset
- diarrhea, typically 7 to 10 days after chemotherapy treatment onset
- hair loss, 7 to 10 days after chemotherapy
- diarrhea associated with bowel irradiation (can be managed with a low-residue diet)
Cancer-related pain, depression, and fatigue are sometimes overlooked and left untreated. You may consider providing screening for patients to evaluate fatigue and emotional distress. Therapies useful for treating cancer-related fatigue may include exercise prescription, activity management, and psychosocial interventions.
For patients undergoing chemotherapy and radiation therapy, you may prescribe exercise to help reduce fatigue. Cancer-related fatigue may also respond to psychosocial intervention and massage may relieve anxiety and improve psychological well-being.
The Swedish Cancer Institute offers specialists in psycho oncology, cancer rehabilitation, and physical therapy for cancer patients. Swedish offers many complementary therapies that can be part of a patient’s cancer treatment plan, including meditation, massage, art and music therapy, nutrition, and naturopathic medicine. Learn more about integrated care options at the Swedish Cancer Institute.
Survivorship: Breast cancer follow-up care
My patient was recently treated for breast cancer. Moving forward, what types of things should I be aware of in terms of their ongoing primary care?
Follow-up cancer care includes regular checkups, review of your patient’s medical history, a complete physical exam and overall check for cancer recurrence or metastasis. You may be asked to do this in conjunction with regular follow-up visits to the treating specialists. Follow-up care visits are also important in the prevention or early detection of other types of cancer, identification of ongoing problems due to cancer or its treatment, and detection of psychosocial effects that may develop long after treatment ends.
Be sure to ask your patient about:
- symptoms that may indicate the cancer has returned
- fatigue; difficulty with bladder, bowel, or sexual function; difficulty concentrating; memory changes; trouble sleeping; weight gain or loss
- medications, vitamins, or herbs
- mental health problems such as anxiety or depression
- changes in family medical history, such as new cancers
- changes in uterine bleeding if taking Tamoxifen
Make sure your patient knows how to perform regular breast self-exams after breast cancer treatment and to watch for symptoms such as:
- changes in breasts, including new lumps
- bone pain or tenderness that does not go away
- skin rashes, redness, or swelling
- new lumps in the breasts or chest
- shortness of breath or chest pain
- persistent abdominal pain
- unexplained weight loss
Many times, cancer recurrences are found by patients themselves between scheduled checkups. That’s why it’s so important for patients to be aware of any health changes and see their primary care provider if they have concerns.
What is the typical timing of a follow-up care schedule?
Your patient’s follow-up care plan depends on her overall health, the type of cancer and the cancer treatment received. Patients typically return for follow-up appointments every 3-4 months during the first 2-3 years following treatment, and then just 1-2 times a year.
Follow-up appointments may include tests to check for cancer recurrence or other types of cancer. These tests may not be needed if your patient is in good health and is symptom-free. This is something you can discuss with your patient and the medical oncologists.
You have an essential role as a member of your patient’s treatment team. Please don't hesitate to call or e-mail any of the specialists involved in your patient’s care. Good communication with the treating specialists is crucial for excellent patient outcomes.
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