A 35-year-old white gravida 2 para 1 sees you for her initial prenatal visit. Since delivering her first child 10 years ago, she has developed type 2 diabetes mellitus. She has kept her disease under excellent control by taking metformin. A recent hemoglobin A1C level was 6.5%.
You should now treat her diabetes with:
Correct Answer D:
The safety of most oral hypoglycemics in pregnancy has not been established with regard to their teratogenic potential. However, all oral agents cross the placenta (in contrast to insulin), leading to the potential for severe neonatal hypoglycemia. For these reasons, plus the requirement for exquisitely tight glucose control to reduce fetal macrosomia and organ dysgenesis, the current guidelines advocate the use of human insulin for pregnant women. Insulin requirements generally increase throughout gestation, but the precise dosage is unimportant as long as it is sufficient to maintain glucose control.
A 70-year-old woman presents to your office with a lump in her breast.
Which one of the following is the greatest risk factor for cancer?
Correct Answer E: The primary risk factor for breast cancer in most women is older age. Overall, 85 percent of cases occur in women 50 years of age and older, while only 5 percent of breast cancers develop in women younger than age 40.
→ Nulliparity (choice A): women who have never given birth are more likely to develop breast cancer after menopause than women who have given birth multiple times.
→ Family history (choice B): women who have a family history of breast or ovarian cancer are at a higher risk for breast cancer than those who lack such a history.
→ Hormone replacement therapy (HRT) (choice C): Studies have shown that long-term use of combined estrogenprogestin (approximately five years) in women ages 50 to 79 increases a woman's risk of breast cancer.
→ Early menarche (choice D): during a woman's reproductive years, estrogen stimulates cells of the breast's glandular tissue to divide. The longer a woman is exposed to estrogen, the greater her risk for breast cancer. Estrogen exposure is increased if a woman began menstruating at or before 11 years of age, or if she experiences menopause at age 55 years or older.
A 51-year-old white female presents for her yearly health maintenance examination and Papanicolaou (Pap) test. She has been in good health and has no family history of significant medical disorders. Her examination is normal, and she asks about screening for breast cancer.
Which one of the following screening methods would be most appropriate?
Correct Answer E:
Of all modalities that are used for screening, the only level A (strong clinical evidence for effectiveness in screening) technology is screen-film mammography. Ultrasonography and MRI have level B evidence, while a dedicated CT scan has level C. There is little clinical evidence that thermography is effective as a screening tool.
A 48-year-old female who recently relocated to your area presents as a new patient. A review of her medical records reveals that she underwent a right mastectomy 1 year ago for a 1.5 cm invasive ductal carcinoma. The procedure included axillary lymph node dissection and all nodes studied were reported as negative for tumor. She received a course of radiation therapy and chemotherapy and has been advised to continue a tamoxifen (Nolvadex) regimen for a total of 5 years. She had a negative mammogram, physical examination, and Papanicolaou (Pap) test just prior to moving last month, and has been faithfully performing monthly self-examination of her surgical site and left breast.
According to current recommendations, which one of the following surveillance methods would be most appropriate in addition to mammography for this patient?
Breast cancer survivors have an increased chance of developing a second malignancy, compounding their risk of recurrence and metastatic spread of the treated malignancy. Currently accepted recommendations for routine surveillance after breast cancer surgery include physical examinations every 3 to 6 months for the first 3 years, every 6 to 12 months for years 4 and 5, and annually thereafter. For women who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly mammographic evaluation should be performed. The use of complete blood counts, chemistry panels, bone scans, chest radiographs, liver ultrasounds, pelvic ultrasounds, computed tomography scans, fluorodeoxyglucose–positron emission tomography scans, magnetic resonance imaging, and/or tumor markers is not recommended for routine follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination.
In patients with breast cancer, the most reliable predictor of survival is:
Correct Answer B:
The most reliable predictor of survival in breast cancer is the stage at the time of diagnosis. Tumor size and lymph node involvement are the main factors to take into account. Other prognostic parameters (tumor grade, histologic type, and lymphatic or blood vessel involvement) have been proposed as important variables, but most microscopic findings other than lymph node involvement correlate poorly with prognosis. Estrogen receptor (ER) status may also predict survival, with ER-positive tumors appearing to be less aggressive than ER-negative tumors.
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