Académique Documents
Professionnel Documents
Culture Documents
Designed for
Competency-Based Learning
In- and Off- Campus Learning
Preface
Dear Learner,
Mabuhay!
This program has been especially designed with you, the learner, and the principles of effective teaching
and learning in mind.
As you go through this learning program, please bear in mind the following:
1. I am treating you as an adult learner which
1.1 Assumes you have learning aspirations and expectations and therefore, are
motivated;
1.2 Gives you the privilege to use other learning strategies in achieving the
objectives in this program;
1.3 Welcomes you to go beyond the learning package as you so desire; and
1.4 Expects discipline, honesty, and maturity in fulfilling your learning activities.
2. We shall define learning as a positive observable change (for the better or improvement) in human
behavior, disposition, attitude, performance, or capability which persists over a period of time.
4. The program will contain learning materials which I think will be relevant to your being an effective,
efficient, and humane health professional.
5. The ultimate goal of the learning program is to produce health professionals who will contribute to the
health development in the Philippines.
6. When I made this program, I tried my best to facilitate your learning. Bear in mind, however, that I am
not infallible. Thus, analyze carefully everything in this program. Dont hesitate to offer disagreements
and constructive criticisms for my own learning and for the improvement of the program.
Best wishes for a fruitful learning with the help of this program.
Dear Learner,
This program has been designed so that you learn on your own. You can learn at your own pace - as fast
as you can or as slow as you wish. You can choose to study anywhere and anytime.
For effective learning, however, please follow the guidelines below in studying the program:
1. Start with the concept map of wellness and illness as influenced by the breast conditions.
2. Take a glimpse of the study guide.
3. Then, diligently and chronologically go through the following parts as each part has an important
role.
The Introduction gives you an overview and the delimitation of the self-instructional
program.
The Authors Approach to the Topic gives you an idea how I approach the topic to write the
program and it also spells out the General and Specific Learning Objectives which tell you
what you are expected to achieve after you have finished the program.
The Text, of course, is the learning material.
The Postprogram Assessment self-assesses your competency on the subject matter after
studying the program.
The Student's Assessment of Self-instructional Program will give me a feedback on my
efforts to facilitate your learning.
Best wishes.
Table of Contents
Preface
Guidelines in Studying the Program
Table of Contents
Concept Map of Wellness and Illness as Influenced by the Breast Condition
Study Guide on Benign and Malignant Conditions of the Breast
Introduction
Authors Approach to the Topic with General and Specific Learning Objectives
Common Breast Disorders in the Philippines
Clinical Presentation of the More Common Breast Disorders
Diagnostic Processes in a Patient With a Possible Breast Disorder
Common Paraclinical Diagnostic Procedures in Patients With a Possible Breast Disorder
Primary Goals and Modalities of Treatment of Breast Disorders
Some Clinical Issues in the Management of Breast Disorders
General Indications for Referral to a Breast Specialist
Biopsychosocial Wellness and Illness as Influenced by the Breast Condition
Some Social Issues in Breast Health Problems
Post-program Assessment
Students Self-assessment of the Self-instructional Program
About the Author
BIOPSYCHOSOCIAL WELLNESS
MANIFESTATION OF ILLNESS
SYMPTOMS / SIGNS
PATHOPHYSIOLOGY
BIOPSYCHOSOCIAL ASSESSEMENT
DIFFERENTIALS
DIAGNOSTIC AIDS
DIAGNOSIS
SURGICAL/MEDICAL
Quality of Life Quality of Dying
Repair
Recovery
INTRODUCTION
There are myriads of conditions on the breast that can affect the biopsychosocial well-being of
the individual, particularly the female, as the breast in the male is by and large destined to be a vestigial
organ at birth. The conditions are generally classified into benign and malignant conditions with
malignant conditions being synonymous with malignant neoplasms or cancers. Benign conditions are
anything except cancers. They include not only the benign neoplasms of the breast but also the non-
neoplastic conditions like developmental abnormalities, exaggerated physiologic and hormonal changes,
and infectious diseases.
Any condition on the breast that affects the biopsychosocial well-being of an individual can be
considered as a breast health problem. There are generally three categories of breast health problem,
namely: breast disorders; breast feeding problem; and breast sexuality problems.
Breast feeding problem is a predominant concern of lactating mothers. Issues consist of want to
breastfeed but unable to do so; how long to breastfeed; want to stop breastfeeding; etc. These issues will
not be covered in this document.
Breast sexuality problem is usually seen in adult females whose well-being is influenced by the
status of their breasts, particularly in terms of size and functions as a sexual organ. Again, issues on
breast sexuality problem will not be covered in this document.
This document will cover and focus on breast disorders, which can be subcategorized into benign
and malignant conditions, as defined above.
The ten breast disorders can be classified into benign and malignant conditions and categorized
into more specific causes of the disorders in terms of malignant neoplasm, benign neoplasm, aberration
of normal development and involution, and infection.
Pagets disease of the nipple is a special kind of breast cancer. It should be suspected in patients
with NIPPLE OR AREOLAR EROSIONS. A sub-areolar mass may or may not be present.
Breast cancer usually starts to appear after age 30. Rarely, a younger patient as young as 25
years old or even younger, may be afflicted with breast cancer.
FIBROADENOMA
Fibroadenoma should be suspected in a palpable breast lump of any size that is FIRM, SOLID,
NONTENDER, VERY MOVABLE, and that has VERY WELL-DEFINED BORDERS. This is especially so
if there are no enlarged lymph nodes in the ipsilateral axilla and if the patient is 25 years old or younger.
MACROCYST
Macrocyst should be suspected in a palpable breast lump of any size that is CYSTIC in nature
and that is seen in a patient with NO HISTORY OF RECENT LACTATION. By cystic nature is meant the
wall of the lump is depressible as to suggest a sac containing fluid.
GALACTOCOELE
Galactocoele should be suspected in a palpable breast lump of any size that is CYSTIC in nature
and that is seen in a patient with a HISTORY OF RECENT LACTATION.
INTRADUCTAL PAPILLOMA
Intraductal papilloma should be suspected when there is BLOODY NIPPLE DISCHARGE WITH
NO PALPABLE BREAST LUMP.
MAMMOMEGALY
Mammomegaly should be suspected of a GIGANTIC BREAST WITH NO UNDERLYING LUMP.
Mammomegaly may be unilateral or bilateral.
In males, mammomegaly is usually called gynecomastia. In females, the most commonly
encountered term is virginal hypertrophy.
Need for more definite diagnosis as indication for paraclinical diagnostic procedure
If the contemplated treatment procedure is mutilating, risky, etc., then a more definite diagnosis is
needed.
If the treatment for the differential diagnosis is the same as that for the primary clinical diagnosis,
then a paraclinical diagnostic procedure may not be needed. If it is different, then a more definite
diagnosis is indicated.
Once a decision is made that a paraclinical diagnostic procedure is needed, the next step is to
choose the most cost-effective procedure for the patient by considering the various factors (tabulate,
compare, and analyze):
Procedures Benefit Risk Cost Availability
Option1
Option2
Option3
After the paraclinical diagnostic procedure has been done, the next step is to interpret the result.
The result of the paraclinical diagnostic procedure must be correlated with the signs and symptoms of the
patient to come out with a pretreatment diagnosis.
NEEDLE EVALUATION
Needle evaluation uses a hypodermic needle, usually G 19 and 1.5 inch long attached to a 20cc
plastic syringe, to evaluate a lump palpated in the breast. There are three parts in a needle evaluation.
One is needling the lump to check its actual presence; to check its nature, whether solid or cystic; and
lastly, to determine its real consistency, whether gritty or rubbery. Second is aspirating the lump to get
samples for gross examination. Third is preparing a smear out of the samples aspirated for microscopic
examination. The third step is what is commonly known as needle aspiration biopsy.
Needle evaluation can be done right after the physical examination in the clinic or office.
MAMMOGRAPHY
Plain mammography (analog or digital mammography) is a radiologic examination of the breasts.
Scintimammography uses radioisotopes in imaging the breasts. Plain mammography is a more painful
procedure because it necessitates compression of the breasts to get the imaging result.
Scintimammography does not need compression of the breasts in its procedure. Scintimammography is
2 to 3 times more expensive. The diagnostic reliability and limitations are practically the same for the two
procedures.
Mammography, whether plain or using radioisotopes, is used in screening patients with no
palpable breast lump for possible cancer. They are usually not done in evaluating patients with a
palpable breast mass as biopsy is considered the preferred initial diagnostic procedure.
A finding on mammography in patients with no palpable breast lumps that should arouse
suspicion for possible cancer consists of a cluster of microcalcifications. In patients with palpable mass,
the presence of stellate border on mammography is a reliable sign for cancer.
ULTRASOUND
Ultrasound uses sound waves to make an imaging of the breast. It can detect breast lumps and it
can easily determine whether a breast lump is solid or cystic. Finding cystic lumps on ultrasound usually
gives a diagnosis of benign conditions whereas finding solid lumps does NOT have a diagnostic
implication.
The table below shows the usual treatment for specific breast disorders.
Breast conditions Observe/Monitor Surgery Drugs Radiotherapy
and specific (chemotherapy,
breast disorders hormonal
therapy
and antibiotics)
Malignant
Breast Cancer
(including (subtotal / total
Pagets disease mastectomy,
of the nipple) modified radical
mastectomy)
Benign
Fibroadenoma
(excision)
Macrocyst
(needle aspiration)
Galactocoele
(needle aspiration)
Mastitis and
breast abscess (needle
aspiration/incision
and drainage)
Intraductal
papilloma (excision)
Benign
cystosarcoma (wide excision)
phyllodes or
phyllodes tumor
Tuberculosis of
the breast (needle
aspiration/incision
and drainage /
debridement)
Mammomegaly
(reduction
mammoplasty)
Patient
without breast symptom (breast check)
with breast symptom- pain, lump, nipple discharge
Physician
+/- Pain
Pain Discharge
POST-PROGRAM ASSESSMENT
Pls. assess yourself by trying to answer the following questions as indicated in the specific learning
objectives:
A. Enumerate at least 10 more common breast disorders seen in the Philippines.
B. Classify the breast disorders into benign and malignant conditions.
C. Categorize the breast disorders by primary causes (malignant neoplasms, benign neoplasms,
aberration of normal development and involution or ANDI and infection).
D. Identify the most probable breast disorder present in patients presenting with a set of symptoms and
signs referable to the breast. (see exercises below)
E. Enumerate at least 4 more common paraclinical diagnostic procedures being done for patients with
possible breast disorders.
F. Identify the usual indications for the different diagnostic procedures commonly used in patients for
possible breast disorders.
G. Identify which breast disorders can be monitored and which should be actively treated.
H. Given a pretreatment diagnosis of a breast disorder with the stage of the disorder, indicate the usual
goal of treatment and its corresponding recommended primary treatment.
I. Advice patients with nonspecific mastalgia or mastalgia secondary to hormonal changes.
J. Identify at least two general indications for referral to a breast specialist.
K. Advice patients on how to achieve and maintain psychosocial well-being as influenced by the breast
condition.
L. Identify two social issues related to the breast health problem in the community (focusing on breast
disorder) and suggest ways on how to reduce the problem.
Identify the most probable breast disorder present in patients presenting with a set of symptoms
and signs referable to the breast. Check your answers in the key provided.
1. A 29-year-old female patient presents with a very movable non-tender solid breast mass with well-
defined border. There is no palpable axillary lymph node. The primary clinical diagnosis is:
A. breast abscess
B. breast cancer
C. fibroadenoma
D. fibrocystic changes
E. phyllodes tumor
2. A female patient presents with mastalgia and nodular breast tissues with NO dominant mass. There is
NO axillary node. The primary clinical diagnosis is:
A. breast abscess
B. breast cancer
C. fibroadenoma
D. fibrocystic changes
E. mastitis
3. A female patient presents with a hard breast mass with ill-defined border, fixed, with a palpable
ipsilateral axillary lymph node. The primary clinical diagnosis is:
A. breast abscess
B. breast cancer
C. fibroadenoma
D. fibrocystic changes
E. tuberculosis of the breast
4. A breast mass is fluctuant associated with erythema and tenderness. The most likely diagnosis is
A. Mastitis
B. Breast abscess
C. Tuberculosis of the breast
D. Gross cyst
E. Inflammatory breast cancer
5. A female patient has marked asymmetry of the breasts but without a palpable mass on the enlarged
breast. The most likely diagnosis for the enlarged breast is
A. Virginal hypertrophy
B. Galactocoele
C. Breast cancer
D. Physiologic asymmetry
E. Fibroadenoma
6. There is a lesion on the nipple of one breast in a 50-year-old female patient. The most likely diagnosis
is
A. Allergy
B. Dermatitis
C. Pagets disease of the nipple
D. Human bite
E. Infection of the Montgomery glands
7. A patient has a sanguinous nipple discharge with NO palpable mass. The most likely diagnosis is
A. Intraductal carcinoma
B. Intraductal papilloma
C. Pagets disease of the nipple
D. Fibrocystic changes
E. Ductal ectasia
8. A well-defined mass which is movable and nontender is palpated in the breast of this 18-year-old
female patient. The most likely diagnosis is
A. Virginal hypertrophy
B. Macromastia
C. Fibroadenoma
D. Macrocyst
E. Phyllodes tumor
9. The left breast mass is hard solid with ill-defined border. It has contracted the left breast. The most
likely diagnosis is
A. Tuberculosis of the breast
B. Invasive ductal carcinoma
C. Lobular carcinoma
D. Fungal infection of the breast
E. Phyllodes tumor
10. The patient has a huge multinodular breast with NO axillary nodes. The most likely diagnosis is
A. Ductal carcinoma
B. Lobular carcinoma
C. Fibroadenoma
D. Cystosarcoma phyllodes
E. Tuberculosis of the breast
Answer key:
1. C
2. D
3. B
4. B
5. A
6. C
7. B
8. C
9. B
10. D
STUDENTS ASSESSMENT OF THE SELF-INSTRUCTIONAL PROGRAM
INSTRUCTIONS: Pls. assess the self-instructional program through the following statements. Use
the key below:
5 - Strongly agree
4 - Agree
3 - Not certain; not observed
2 - Disagree
1 - Strongly disagree
Comments and suggestions (pls. submit a copy to the author personally or through email
rjoson2001@yahoo.com
About the Author
October 2014
Academic Degrees
He obtained his Doctor of Medicine from the University of the Philippines College of Medicine in 1974;
his Master in Hospital Administration from the UP College of Public Health in 1991; his Master in Health
Profession Education from the UP National Teachers Training Center for Health Profession in 1993; his Master of
Science in Clinical Medicine (General Surgery) from the UP College of Medicine in 1998.
His finished his residency in General Surgery at the Philippine General Hospital in 1981 after which he
became a Diplomate of the Philippine Board of Surgery.
Hospital Administration
He is a past Senior Vice-President for Corporate Affairs at the Manila Doctors Hospital (2009-2014).
He is a past chairperson of the Department of Surgery of Ospital ng Maynila Medical Center (2001-
2009).
Writings
He started writing books, primers, self-instructional programs, and course packs in medicine, surgery,
hospital administration, and medical education in 1985. As of July 2013, he has more than 100 finished
products. He started publishing his writings in the Internet in 1990. As of July 2013, he has more than 198
websites.
Contact Numbers
Dr. Reynaldo O. Josons main email address is rjoson2001@yahoo.com
His cellphone number is 09188040304.