The Outpatient Breast Clinic: Aiming at Best Practice

503 Pages·2015·10.78 MB·English

by  Alfonso M. Pluchinotta (eds.)

The Outpatient
Breast Clinic
Aiming at Best Practice
Alfonso M. Pluchinotta
Editor
123
The Outpatient Breast Clinic

Alfonso M. Pluchinotta
Editor
The Outpatient Breast
Clinic
Aiming at Best Practice
Editor
Alfonso M. Pluchinotta
Breast Surgery Department Consultant
Surgeon
Polyclinic Abano Terme
Padova
Italy
ISBN 978-3-319-15906-5 ISBN 978-3-319-15907-2 (eBook)
DOI 10.1007/978-3-319-15907-2
Library of Congress Control Number: 2015938097
Springer Cham Heidelberg New York Dordrecht London
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Foreword
This book is an excellent work by a group of distinguished authors presenting the
diagnosis and treatment of benign and malignant diseases of the breast from the
point of view of a team of multidisciplinary experts. Indeed, the fi rst chapter – The
Breast Clinic – not only discusses basic aspects of breast diseases but portrays the
philosophical and intellectual basis of multidisciplinary care. The chapter discusses
the importance of the outpatient breast unit and the indications and rationale for
referral. Basic but important aspects of clinical care are discussed throughout the
book, emphasizing the importance of teamwork, transparency, and respect. Clear
and honest communication between clinicians and patients is stressed throughout
this work.
Important concepts are discussed with lucidity and intelligence. The approach to
the asymptomatic woman, including the high-risk woman, is a practical and useful
lesson in clinical care. Chapters on the fundamental evaluation of breast diseases
including anatomy, congenital abnormalities, normal physiologic changes, and
signs and symptoms of disease are elucidating. Diagnostic procedures, including
types of biopsies and tissue diagnosis, with a comprehensive chapter on imaging are
discussed in a manner that portrays a systematic approach, yet leaves room for the
infl uence of experience and judgment.
Benign conditions such as breast pain, mastitis, nipple discharge, and prolifera-
tive and non-proliferative lesions are discussed in depth. Excellent chapters on non-
invasive cancer and the diagnosis of special cancers of the breast will be particularly
helpful to clinicians who are not necessarily breast specialists. The authors include
a chapter on male breast disease which is often overlooked and misdiagnosed by the
clinician. The book ends with an excellent chapter which presents a rational plan for
clinical follow-up as well as education for patients.
T he book is a practical treatise on the complex subject of diseases of the breast.
It is a testament to the importance of the outpatient breast unit and the interaction
of the multidisciplinary team and patient. The treatment of breast cancer, although
complex, is portrayed in a thoughtful and systematic manner, allowing the reader
to comprehend the importance of the different approaches and specialties to the
overall management of the patient. Readers of this book – who should include all
physicians and non-physicians involved in patient care – will gain further insight
and knowledge of their specialty. Physicians who do not routinely treat breast
cancer but, of course, will see breast cancer patients in their practice should read
v
vi Foreword
this book to gain a rational, scientifi c, and philosophical approach to their patients.
The authors apply guidelines when appropriate, yet do not attempt a one-size-fi ts-
all approach. The authors are to be congratulated for this contribution to breast
cancer care.

Armando E. Giuliano
Executive Vice Chair of Surgery for Surgical Oncology
Co-director of the Saul and Joyce Brandman Breast Center
Cedars-Sinai Medical Center
Los Angeles , USA
Pref ace
Every woman is a biography
and a life plan within and around her
amp
The mind energy generated by the breast unit teamwork . The development of the
breast unit organization has improved the method of treating breast diseases with
considerable results, from a medical as well as from a social and cultural point of
view. The mind energy generated by the breast unit teamwork allows the specialists
involved to deal positively with problems concerning health, modifi cations of body
image, both real and perceived, as well as to implement preventive measures and to
promote changes in life style. This is achieved through the construction of a multi-
faceted culture that ranges from suitable surgery to one aimed at obtaining cosmetic
good results, from predictable risks to targeted therapies, from effective communi-
cation to psychology and ethics.
T he management of common breast diseases represents a major portion of the
dedicated professionals’ responsibility, while it only covers a minor share of their
training. In fact, the range of clinical cases is so broad that it is diffi cult to cover in
a short time all potential clinical and pathological presentations. Moreover diagnos-
tic and therapeutic work-up is steadily changing, becoming more complex, and
making it extremely challenging to keep up with the advancements in biological
knowledge and with the applicative results of clinical trials.
T his book is an intermediate useful resource which enhances the principles and
the practice of the treatment of breast diseases as they turn up in an outpatient clinic.
It provides a comprehensive and up-to-date account of the main symptoms, signs,
and imaging techniques, and offers guidance on the best practices and optimal man-
agement. It also provides some answers to the countless questions that the patient
asks herself about the correct interpretation of worrisome symptoms, the outcome
of surgery, the use of hormone drugs, and even alternative medicine.
An hand-on peripheral brain useful to trainees working in the breast clinic as
well as to established surgeons. It may also be of assistance to other health care
professionals involved in the treatment and support of patients with breast cancer,
such as gynaecologists, general practitioners, healthcare nurses and psychologists.
If anatomy, physiology and pathology of the breast are the basics, the mastery of
a good clinical methodology allows practitioners to choose the shortest route to the
vii
viii Preface
ultimate diagnosis. From a logistical point of view, the outpatient clinic represents
a crossroad from which several therapeutic possibilities spread out, which today are
so complex and particular as to require there to be professionals dedicated to breast
diseases in several specialisations: radiologists, pathologists, medical and radiation
oncologists, plastic surgeons and other professionals.
It is worth reminding that the breast unit does not only deal with tumours of the
breast, but also with benign pathology, frequent and equally alarming, which is improp-
erly considered a less important, little sister of neoplastic pathology. Instead it requires
just as specifi c in-depth knowledge, both to prevent errors in diagnosis and, if possible,
to avoid unpleasant consequences with unnecessary or unwarranted surgery.
A very demanding but fascinating practice . This book aims at giving priority to
suitability, synthesis and established beliefs, the latter founded on evidence-based
bibliography and on guidelines that focus on quality objectives, indicating their
outcome measures. Many tables, key points, and clinical illustrations reinforce the
information in each chapter.
B efore starting our journey in the dazing planet of breast diseases, we would like
to point out some motivating forces that animated our work.
This textbook is the author’s debt to Dr. Guidubaldo Querci della Rovere (named
Uccio, 1946–2009), whose personal remarks expressed during a long period of
friendship are transmitted in these pages [1]. In the same way, it redirects the experi-
ence done with other personal teachers, as Prof. Charles-Marie Gros, who created
modern breast discipline starting from all women’s complaints, including those of
an anthropological and psychological nature. He liked to say “ breast discipline is
the most human of sciences for its countless additional meanings , s ymbolic , s ocial …
and even religious ”.
If Gros in the 1960s and 1970s brought w omen to science , the rapid progress of
breast discipline, especially in its surgical approach, is obliged to the teachings of
Prof. Umberto Veronesi, who brought s cience to women. Veronesi defi nitely placed
women at the core of the decision-making process, and exposed the risks of technol-
ogy by asserting that (i n breast oncology ) …i t is important to separate science from
technology. Science responds to the principles of the search for truth , f or reproduc-
ibility , f or universality. Instead , s heer technology lives an amoral life of its own ,
devoid of intentions and responsibilities .
W e deeply believe all professionals dealing with breast diseases have to follow
the basics of the discipline but also the teaching of their masters, of today and from
the past. In particular, good surgeons stand out because they know which is the right
approach for a specifi c patient at that particular moment in the evolution of her ill-
ness, and so they must also be themselves biologists, imaging experts, clinical
oncologists; in conclusion learned doctors, who are also skilled in surgical as well
non-surgical subjects.
O utpatient breast clinic practice is complex because it involves many fi elds of
medicine, and treatment and care should take patients’ needs and preferences into
account, probably more than other practices. For this reason b reast culture is a very
demanding but fascinating practice , diffi cult however rewarding when effective in
solving many of the problems that are encountered along the way. No greater
Preface ix
opportunity or obligation is given, and open-mindedness is the gratifying outcome.
Talking about oncoplastic breast conservation surgery, Prof. Melvin Silverstein
writes [2]: it is a philosophy that requires vision , p assion , knowledge of anatomy ,
and an appreciation and understanding of aesthetics , symmetry and breast function.
The oncoplastic surgeon must be constantly thinking ‘H ow can I remove this cancer
with large margins of normal tissue while at the same time making the patient look
as good or better than she looks now ?’
Doctors who have the hard task to work in the outpatient breast clinic should
consider themselves l ifelong students of breast cancer , as Prof. Sampson Handley
liked to defi ne himself. The outpatient clinic is a crucial, strategic place, where we
have to apply appropriate directives and acquire different methods that can be cus-
tomised to suit our patients. At the same time it is a place of training based on the
limits of clinical and instrumental tests, but also on the correct consideration of
mistakes that are inevitably made, both personal ones to be transformed into learn-
ing, and collective ones that will require a change in the course of action. This is
what makes medicine an a pplied science and also an art.
The quality of the relationship between the members of the team and the patient
is the ultimate test of medicine as an art . Modern medicine is apparently built on
solid foundations with a robust statistical underpinning and scientifi c rationale. If in
the past medicine was considered more of an art than a science, it can be affi rmed
that it is now more of a science than an art. Technological advances allow improved
outcomes compared with the past, and it is not inconceivable that in the future the
cognitive component of medical diagnosis may become partly dispensable.
Nonetheless, other areas of knowledge remain uncertain and demand more com-
plex decision-making procedures that must draw on personal attitudes and experi-
ence to reach a balanced solution. Furthermore, certain aspects of medical practice
such as communication skills, while being recognized as a valid discipline, are often
not translated into practice because of various individual or cultural obstacles.
A ‘breast philosophy’ animated by ‘vision, passion and knowledge’ cannot be
jailed in detailed guidelines and pathways that should be considered valid for all
doctors and patients. In this text we make a large use of guidelines that have undeni-
able merits, but we do not make the assumption that clinical expertise could be eas-
ily packaged and shipped around the world [3].
We are not the only ones who believe that the o ne size fi ts all approach to patient
care is unsatisfactory if not useless. Prof. Barry B. Lowitz writes: A ttempts to reduce
medical practice into a fi xed set of algorithms that are evidence - based creates one
size fi ts nobody programs and can damage optimal care for individual patients. The
tools of our art are necessary , b ut alone do not determine the quality of the art .
Quality care r equires experience , thoroughness , a ttention to detail , good judgment ,
and , most of all , c aring about the quality of the resulting product [4]. A resulting
product of a medical decision is not solely a physical eradication of the disease. The
optimization of the patient’s physical ability to function, and/or the psychological
comfort of the patient and her signifi cant others are equally important.
Moreover, is it possible to separate knowledge and technology from the individu-
al’s distinctive temperament, as is the case for other disciplines? Perhaps, only when