Aquifer Family Medicine
A 34-year-old cisgendered female who has no past medical problems and is not
currently taking any medications comes into your office because she noticed a
tender lump in her left breast starting approximately one month ago. She is
worried because she has a maternal aunt who had breast cancer that was BRCA
positive, though her mother is BRCA negative. Her periods have been regular
since they started at the age of 13 and occur every 32 days. She is currently
menstruating. She has three children, aged 12, 9, and 4. On exam, her BMI is
32, up from 28 three years ago, and her other vital signs are stable. On breast
exam, you note a mobile rubbery mass approximately 1 x 1cm that has regular
borders and is tender to palpation. You appreciate no axillary adenopathy. The
rest of her physical exam is unremarkable. Of the information provided, which of
the following puts this patient at increased risk for breast cancer?
A. Age
B. Age of menarche
C. Family history of cancer
D. Parity history
E. Weight
E. Weight
With a BMI of 32, obesity is the one risk factor for this patient based on the
information given. Other risk factors for breast cancer include family history of
breast cancer in a first-degree relative (mother or sister—not aunt), prolonged
estrogen exposure (menarche before age 12, menopause after 45, advanced
age at first pregnancy), genetic predisposition (BRCA 1 or 2 mutation), advanced
age (breast cancer risk increases with age, and this patient is relatively young),
female sex, increased breast density and certain exposures (diethylstilbestrol,
hormone or radiation therapy, heavy smoking). Breast cancer risk also decreases
with increasing parity. With three children, this patient's risk is slightly reduced.
A 64-year-old cisgendered female who is overweight with well-controlled
hypertension comes to your office with concerns of a lump in her breast that she
noticed while showering. She reports having no pain, tenderness, or skin
,changes. A pertinent review of systems is negative. Menarche began at the age
of 10. Her first child was born when she was 31 and she had her second and last
child at the age of 33. She experienced menopause at the age of 44. Her mother
died of colon cancer when she was 65 and her father passed away from
metastatic prostate cancer at the age of 70. She has no history of tobacco use
ever and occasionally drinks a glass of wine with dinner. Her BMI is 34. Which of
the information provided thus far puts the patient at decreased risk for breast
cancer?
A. Age
B. Age at first birth
C. Age at menarche
D. Age at menopause
E. Weight
D. Age at menopause
The patient experienced menopause at the age of 44, which shortens her time of
estrogen exposure, thereby reducing her risk of breast cancer. Factors
associated with decreased breast cancer risk include pregnancy at an early age
(20 or younger), late menarche (13 or older), early menopause (45 or younger),
high parity, and medications such as selective estrogen receptor modulators
along with NSAIDs and aspirin. Risk factors for breast cancer include family
history of breast cancer in a first-degree relative, prolonged estrogen exposure
(menarche before age 12, menopause after 55, advanced age at first pregnancy,
obesity after menopause), female sex, genetic predisposition (BRCA 1 or 2
mutation), advanced age (breast cancer risk increases with age), increased
breast density and certain exposures (diethylstilbestrol, hormone or radiation
therapy, smoking).
A 63-year old cisgendered female comes into your office for her annual
preventive exam. She has hypertension and type 2 diabetes. She is not sexually
active. Her blood pressure is 125/80 and her physical exam otherwise is within
normal limits. You recommend influenza and zoster vaccination. Her last
colonoscopy was eight years ago and her last mammogram one year ago; both
were normal. She has never had an abnormal Pap test. At the age of 45 she had
,a total hysterectomy for fibroids. Of the details provided about this patient, which
is an appropriate reason to explain why she does not need a Pap test today?
A. She experienced menopause more than 10 years ago
B. She had a total hysterectomy for fibroids
C. She has never had an abnormal Pap test
D. She is 63 years old
E. She is not sexually active
B. She had a total hysterectomy for fibroids
The patient described above underwent a total hysterectomy (total removal of the
uterus and cervix with or without oophorectomy) for benign reasons (fibroids).
USPSTF guidelines recommend against continued cervical cancer screening in
patients whose uterus has been removed for benign disease. Evidence has
shown cytologic screening to be low yield in detecting vaginal cancers or
improving health outcomes in females after hysterectomy for benign disease.
Cervical cancer screening should begin at the age of 21. Females between the
ages of 65 and 70 who have had three or more normal Pap tests or two negative
co-tests (Pap and HPV) in the past 10 years may choose to stop cervical cancer
screening. Not being sexually active, age 63, only having had normal Pap tests,
and years since menopause are not reasons to stop screening for cervical
cancer.
A 47-year-old cisgendered female comes into your office for a health care
maintenance exam. She has hypertension and type 2 diabetes. She is not
sexually active and has not yet experienced menopause. There is no family
history of cancer. Her blood pressure is 118/78, her BMI is 34, and the remainder
of her physical exam is within normal limits. Her vaccinations are up to date, and
she has a Pap test today and will have labs drawn. According to USPSTF, which
of the following is the best recommendation to give her concerning
mammography?
A. Should have started at age 40 and every year thereafter
B. Should have started at age 40 and every 2 years thereafter
C. Should have started at age 45 and every year thereafter
, D. Start at age 50 and every year thereafter
E. Start at age 50 and every 2 years thereafter
E. Start at age 50 and every 2 years thereafter
Mammography has a sensitivity of 60% to 90% for detecting breast cancer and
decreases breast cancer mortality. According to the most recent USPSTF
guidelines, routine mammography is not routinely indicated for females younger
than 50 except as based on patient context (history) and beliefs about
risks/benefits. The USPSTF recommends biennial testing for females between
the ages of 50 and 74. There is insufficient evidence to assess the benefits
versus risk of screenings in females after the age of 75. The American Cancer
Society (ACS) recommends yearly mammograms starting at age 45, and
American College of Obstetricians and Gynecologists (ACOG) recommends
engaging in shared decision-making about mammograms starting at age 40.
They also recommend that all females at age 50 commence annual or biennial
mammography.
A 25-year-old patient presents to the office for follow-up on anxiety and tobacco
dependence. She reports she is doing well on her new medication to help with
both her mood and smoking, though she continues to smoke. She recently
started her first sexual relationship with a new female partner. She received a
tetanus vaccine at the age of 18, and she received her flu vaccine this year. Her
blood pressure is 122/70, and her physical exam is within normal limits. You
review her recent Pap test, which was negative. Which of the following indicates
the vaccines she should receive today?
A. HPV vaccine alone
B. HPV vaccine and pneumococcal conjugate vaccine (PCV13)
C. HPV vaccine and pneumococcal polysaccharide vaccine (PPSV23)
D. HPV vaccine and Zoster vaccine
E. No vaccines are needed
C. HPV vaccine and pneumococcal polysaccharide vaccine (PPSV23)
The pneumococcal polysaccharide vaccine (PPSV23) is recommended for adults
who smoke (like this patient); have chronic heart, lung, or liver illness; have
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