BREAST HEALTH CARE: A Review

Breast health care was rarely acknowledged in the health and science fields prior to this century and has only begun, in recent years, to receive attention outside of pregnancy/lactation or cancer screening and treatment. Yet much health care is involved with regard to this reproductive and sexual organ. With any group of clients, practitioners of women's health care must address an assortment of breast health matters. This article offers an overview of the history of breast health care, the epidemiology of benign breast conditions and cancer, the anatomy and physiology of the breast, and breast development over the lifespan. Also presented are a review of breast assessment and examination, suggestions for routine care of the breast, and an overview of major health issues related to this reproductive organ. Health issues addressed include, among others, nodular and cystic changes, nipple discharge, breast/nipple pain, mastitis, elective alterations, and cancer. Discussion is focused on the latest approaches to optimal breast health care.     

Genetic testing for breast and ovarian cancer susceptibility: a family experience

The purpose of this article is to provide an overview of current knowledge concerning genetic testing for breast and ovarian cancer susceptibility. This overview includes 1) a brief history of genetic testing for breast and ovarian cancer susceptibility, 2) a review of factors that midwives and other health care providers need to consider before offering this type of testing to their clients, 3) management options for clients at high risk for hereditary breast and ovarian cancers, and 4) a discussion of preliminary findings from an ongoing study concerning the family experience of genetic testing, which illustrates some of the ethical issues that emerge for individuals and families during the family experience of genetic testing for breast and ovarian cancer susceptibility.     

Challenges and Opportunities in Adolescent Gynecology Patients with Surgically-Treated Congenital and Acquired Anomalies: Transition of Care from Pediatric to Adult Surgery

The transition from adolescence to young adulthood in patients with reproductive health care needs such as disorders of sexual development and congenital anomalies is a complex process that occurs over several years. The transition process for these patients is still poorly understood. The patients with disorders of sexual development and reproductive issues have specific and unique issues regarding timing of disclosure of diagnosis, genital examinations, gonadectomy, vaginal treatments, surgical procedures, hormone replacement therapy, use of long-term medication, and potential cancer screening. The purpose of this review is to briefly describe complex genital malformations and their associated anomalies with long-term concerns and then provide an overview of what has been published at this time regarding the transition of care to provide some guidance for providers who care for those patients.     

ACOG Committee Opinion No. 350, November 2006: Breast concerns in the adolescent

Breast disease in the adolescent female encompasses an expansive array of topics. Benign disease overwhelmingly dominates the differential diagnosis and dictates a different protocol for care in the adolescent compared with the adult patient to avoid inappropriately high assessments of risk and unnecessary diagnostic procedures and surgery. There also are emerging issues pertaining to the care of the adolescent breast, such as breast augmentation, nipple piercing, and management of the adolescent patient with a family history of breast cancer.     

The Physical Consequences of Gynecologic Cancer Surgery and Their Impact on Sexual,Emotional, and Quality of Life Issues

IntroductionSurgical management of gynecologic cancer can cause short‐ and long‐term effects on sexuality, reproductive function, and overall quality of life (QOL) (e.g., sexual dysfunction, infertility, lymphedema). However, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae.AimTo provide an overview of the standards of care and major advancements in gynecologic cancer surgery, with a focus on their direct physical impact, as well as emotional, sexual, and QOL issues. This overview will aid researchers and clinicians in the conceptualization of future clinical care strategies and interventions to improve sexual/vaginal/reproductive health and QOL in gynecologic cancer patients.Main Outcome MeasuresComprehensive overview of the literature on gynecologic oncology surgery.MethodsConceptual framework for this overview follows the current standards of care and recent surgical approaches to treat gynecologic cancer, with a brief overview describing primary management objectives and the physical, sexual, and emotional impact on patients. Extensive literature support is provided.ResultsThe type and radicality of surgical treatment for gynecologic cancer can influence sexual function and play a significant role in QOL. Psychological, sexual, and QOL outcomes improve as surgical procedures continue to evolve. Procedures for fertility preservation, laparoscopy, sentinel lymph node mapping, and robotic and risk‐reducing surgery have advanced the field while reducing treatment sequelae. Nevertheless, interventions that address sexual and vaginal health issues are limited.ConclusionsIt is imperative to consider QOL and sexuality during the treatment decision‐making process. New advances in detection and treatment exist; however, psycho‐educational interventions and greater patient–physician communication to address sexual and vaginal health concerns are warranted. Large, prospective clinical trials including patient‐reported outcomes are needed in gynecologic oncology populations to identify subgroups at risk. Future study designs need clearly defined samples to gain insight about sexual morbidity and foster the development of targeted interventions. Carter J, Stabile C, Gunn A, and Sonoda Y. The physical consequences of gynecologic cancer surgery and their impact on sexual, emotional, and quality of life issues. J Sex Med 2013;10(suppl 1):21–34.     

Refugee women's reproductive health in early resettlement

OBJECTIVE: To describe reproductive health needs and screening rates for breast and cervical cancer for newly arrived (less than 90 days) refugee women in the United States. DESIGN: A retrospective study of existing medical charts from 1996 to 2000. SETTING: Refugee health screening clinic, central Texas. PATIENTS: Refugee women (n = 283) newly arrived in the United States from Cuba (31.1%), Bosnia (26.1%), Vietnam (24.7%), and other countries (18.0%); age range = 18 to 74 years, mean age = 34.4 years. MAIN OUTCOME MEASURES: Frequency of reproductive health problems and breast and cervical cancer screening rates. RESULTS: Twenty-five percent of women in the sample were pregnant or had a reproductive health problem. A significant percentage older than 40 (86%) had never had a mammogram when compared to American women of the same age (33%). Only 24% reported having had a Pap test within the previous 3 years. CONCLUSIONS: The risk of not receiving adequate reproductive health care is higher among newly arrived refugee women compared to nonrefugee women in the United States. For refugee women to enjoy optimum health, their individual needs and health care system issues must be addressed.     

Gynecological management of the breast cancer survivor

Survival from breast cancer has continued to increase since the 1990's, and quality of life and gynecologic issues have been an increasingly important part of overall care. Common women's health issues such as contraception, pregnancy, menopause, and sexual functioning are uniquely affected by breast cancer diagnosis and treatment. Two-thirds of breast cancers are hormone-sensitive and adjuvant hormonal therapies like tamoxifen or aromatase inhibitors have substantially decreased the disease recurrence and contralateral breast cancer. These hormonal therapies can cause menopausal and sexual side effects, and women's healthcare providers need to understand safe and effective treatment options to manage them. Providing counseling and evidence-based education is important for primary care providers and gynecologists who care for those women who have or previously had breast cancer. This review will focus on specific women's health issues pertaining to breast cancer and treatment.     

A review of fertility preservation in patients with breast cancer

Breast cancer remains the most common cancer diagnosed in women and causes more lost disability-adjusted life years (DALYs) than any other cancer worldwide; however, improvements in therapies have led to increased survival and therefore a new focus on quality of life following treatment. Fertility is an important concern among cancer survivors of reproductive age. The purpose of this article is to contextualize the importance of oncofertility services for women with breast cancer and review options for fertility preservation, including oocyte/embryo cryopreservation, GnRH agonist therapy, and ovarian tissue cryopreservation. We also discuss special considerations for preimplantation genetic testing for women with germline pathogenic mutations associated with breast cancer, as well as issues related to endocrine therapy. Finally, we review barriers to accessing fertility preservation services, including cost of treatment and lack of referral to reproductive care providers or fertility preservation programs.     

Review of fertility preservation issues for young women with breast cancer

It is well documented that cancer treatment may temporarily or permanently impair childbearing potential of young women with breast cancer. Given that many patients have not initiated or completed their families when diagnosed, fertility issues are of utmost importance in this clinical population. This review addresses the importance of incorporating fertility issues into the clinical care of young breast cancer patients, focusing on recent knowledge and counselling practices about fertility-related issues and the complexity of fertility-related decisions in this population. Multiple studies report cancer-related infertility may have serious psychological consequences and reduce Quality of Life for some patients. To guide health care providers and patients regarding appropriate, safe, and cost-effective fertility care for women who desire biological children, several professional organizations have developed clinical practice guidelines. However, the extent to which health professionals use these guidelines and provide timely and appropriate fertility-related information to patients is questionable. Fertility should not be neglected by health care providers and a multidisciplinary team is needed to target fertility issues at diagnosis and into survivorship care, providing timely, clear information that includes support, resources, and appropriate referral to fertility specialists. This information will assist in making well-informed decisions about fertility after breast cancer.     

Clinical evaluation of women previously treated for breast cancer: an algorithm for the primary care physician

Breast cancer is an extremely prevalent disease that is estimated to affect one of every nine women, as predicted by lifetime risk in the year 2002. Diagnostic efforts to detect early disease and therapeutic advances including adjuvant therapies have contributed to an increased 5-year survival rate. Therefore, a gynecologist must be prepared for the diagnosis and treatment of typical sequelae after the treatment of breast cancer, as well as aware of health maintenance guidelines particular to this patient group. There are both intrinsic sequelae of breast cancer and side effects of breast cancer treatment, including depression, decrease of libido, vasomotor complaints, vaginal symptoms, and mechanical issues secondary to surgery. Additionally, the primary care physician must consider long-term health consequences of low estrogen states in women who experience menopause as a result of chemotherapy and adjuvant therapies such as aromatase inhibitors. There is need for an algorithm to direct continuing care by the primary care physician, including the gynecologist.     

Beratung zu sexuellen Problemen bei Patientinnen mit Mammakarzinom

This article provides an overview of the biopsychosocial consequences of breast cancer and its treatment. It is an accepted view that sexual problems are common in both patient and partner. However, many gynecologists fail to address sexuality in the clinical setting and feel more comfortable focusing on treatment outcomes, such as the management of treatment side effects, than in addressing issues related to sexual behavior. Perhaps this is because many gynecologists are uncomfortable about initiating a topic regarding a person’s sexuality or because they are unsure of their knowledge relating to changes in a person’s sexuality after the management of cancer. Cultural issues in our society, such as the myth that older women with breast cancer are no longer interested in sexuality and intimacy, and the presumption that issues of survival overshadow sexuality constitute barriers to open communication about sexuality in women with breast cancer. Sexology should be an integrated part of women’s health. Gynecologists need to know about models of human sexuality, classification systems, and diagnostic and therapeutic concepts and processes.     

Legal and ethical implications of surrogate mother contracts

Numerous legal and ethical issues are raised by the use of surrogate arrangements as a reproductive alternative. The purpose of this article is to provide physicians and other health care professionals with a basic overview of the legal issues and to outline some of the ethical considerations so that they might make more well-informed decisions about their personal involvement in surrogate arrangements and to better counsel their patients who might be considering such arrangements.     

Reproductive health in women with eating disorders

Medical complications are often the precipitants that lead women with eating disorders to seek health care. Complications can be wide ranging but frequently include symptoms associated with reproductive health. Unfortunately, because of the denial, embarrassment, shame, and secrecy associated with these psychiatric illnesses, the underlying cause of these complications can often go unacknowledged, delaying assessment and intervention. This article provides an overview of anorexia nervosa and bulimia nervosa, identifies the reproductive health issues that may occur in women with these disorders, and discusses the associated clinical implications for nursing practice.     

The politics of priority setting for reproductive health: breast and cervical cancer in Ghana

Priority setting for reproductive health is affected by health sector reform policies, the often politically charged nature of issues such as abortion, decreasing funding for reproductive health activities and the broad agenda of the ICPD Programme of Action. This paper examines the influence of political and organizational factors on national priority setting for reproductive health and argues that existing priority setting tools such as disability-adjusted life years and cost-effectiveness analysis do not consider the influence of politics on the priority setting process or account for the interpretation of evidence in priority setting. It suggests that priority setting tools can be strengthened by incorporating empirical measures of political and organizational attention to an issue, and through a new measure – policy priority. The paper applies this new measure to a case study of attention to breast and cervical cancer in Ghana from 1990–97, illustrating how traditional priority setting methods cannot explain the priority given to breast cancer in Ghana. It demonstrates how local politics can trump scientific and economic evidence and suggests that the priority setting process can have unforeseen equity and social implications. It concludes by arguing that the policy priority measure provides a more complete picture of reproductive health priorities and is useful for better understanding the implications of the priority setting process for reproductive health.     

Building coalitions to support women's health and rights in the United States: South Carolina and Florida

There is a health care crisis in the United States and women, particularly low-income women and women of colour, are paying the price. The politicisation of pregnancy, sexuality and women's reproductive rights has created a uniquely contradictory situation in many states. Policymakers are working to control women's reproductive choices and sexuality, and restricting sex education, but doing little to address the overall lack of access to quality reproductive health care. This article describes a new reproductive rights advocacy model that was implemented starting in 2003 in two US states, South Carolina and Florida. In-depth research on the status of reproductive health and rights in each state, analysed by race, economic status, county and state policy initiatives relevant to women's health, showed that in both states access to contraception and abortion, cervical and breast cancer screening and treatment, HIV/AIDS-related care and pregnancy care were poor, with African American and Hispanic women faring even worse than white women. Implementing the advocacy model involved identifying and bringing together a diverse set of health care professionals, academics and activists who formed coalitions and are now working together and developing advocacy strategies in support of policies to improve access to reproductive health care and protect reproductive rights in both states.     

Benign breast disease

Benign breast disease includes all nonmalignant conditions of the breast, including benign tumors, trauma, mastalgia, mastitis, and nipple discharge. Benign tumors include pathologic changes that do not increase a patient's risk for developing cancer, lesions that confer a slightly increase risk, and lesions that are associated with an up to 50% risk of developing breast cancer. Both benign and malignant breast disorders can present with a palpable mass; skin dimpling, thickening, or erythema; pain; nipple discharge and inversion or distortion; or an abnormal screening mammogram with no clinical findings. Tools available to investigate breast problems include clinical breast examination, mammogram, and ultrasound. This article discusses the gynecologist's role in maintaining breast health, the clinical evaluation of breast problems, and management of benign breast disease.     

Breast cancer during pregnancy

The terms gestational breast cancer (GBC) and pregnancy-associated breast cancer are given to breast cancer that occurs during pregnancy and up to one year post-partum. It is an uncommon event, and for even the most experienced clinician, whether oncologist, obstetrician or primary health worker, the complex issues that surround a diagnosis of breast cancer during pregnancy make management difficult. The prognosis overall for women diagnosed with GBC is poor, possibly due to delays in diagnosis. Primary physicians and obstetricians can play an important role in the early detection of GBC by promoting breast awareness in premenopausal women, including women who are pregnant or lactating; and by undertaking prompt and appropriate referral of pregnant and lactating women with breast abnormalities. Even in pregnant or lactating women, clinicians should always investigate a breast abnormality using triple assessment--clinical assessment, imaging and tissue biopsy. Breast cancer during pregnancy requires a multidisciplinary approach to ensure optimal care for both the mother and the baby. Breast cancer management can be adapted to protect the fetus, but this will be dependent on the gestation and disease status at diagnosis. Pregnancy after breast cancer does not appear to affect either cancer prognosis or pregnancy outcome. Obstetricians have a vital role to play in the care of these women by supporting them through their pregnancy, providing reassurance of fetal health and maintaining good communication with their other health providers.     

The impact of cancer treatment on reproductive health in young women

The diagnosis of cancer can precipitate a re-evaluation of life at all ages. In children, adolescents and young adults, a cancer diagnosis and its treatment poses specific challenges that can affect all aspects of reproductive health resulting in considerable physical, psychological and psychosexual burden. Improved survival means that this cohort of patients is expanding and with an improving life span, the resulting morbidity is also extended. The demands of this group of patients are often not fully integrated in the operational functions of the health service with considerable variation in care. This review discusses the common reproductive morbidities amongst survivors of childhood, adolescent and young adult cancer whilst planning, delivering and following cancer treatment. This includes the current issues on the assessment of ovarian reserve and preservation of fertility.