Common Breast Problems

 

Am Fam Physician. 2019 Apr 15;99(8):505-514.

Author disclosure: No relevant financial affiliations.

Palpable breast masses, mastalgia, and nipple discharge are commonly encountered symptoms in outpatient practice, causing significant patient anxiety and precipitating medical consultation. The initial workup includes a detailed clinical history and physical examination. Women presenting with a breast mass will require imaging and further assessment to exclude cancer. Diagnostic mammography is usually preferred, but ultrasonography is more sensitive in women younger than 30 years. Any suspicious mass detected on physical examination, mammography, or ultrasonography should undergo biopsy. In most cases, a core needle biopsy should be performed with imaging guidance for evaluation of a suspicious mass. Mastalgia is usually not an indication of underlying malignancy. Oral contraceptives, hormone therapy, some psychotropic drugs, and some cardiovascular agents have been associated with mastalgia. Focal breast pain should be evaluated with diagnostic imaging. Targeted ultrasonography localized to discrete areas of the breast can be used alone to evaluate focal breast pain in women younger than 30 years, and as an adjunct to mammography in women 30 years and older. Topical nonsteroidal anti-inflammatory drugs, such as diclofenac, are a first-line treatment option. The first step in the diagnostic evaluation of patients with nipple discharge is classification of the discharge as pathologic or physiologic. Nipple discharge is classified as pathologic if it is spontaneous, bloody, unilateral, or associated with a breast mass. Patients with pathologic discharge should undergo diagnostic imaging. Galactorrhea is the most common cause of physiologic discharge not associated with pregnancy or lactation. It occurs as a result of an endocrinopathy (hyperprolactinemia or thyroid dysfunction) or from the use of dopamine-inhibiting medications.

Common breast problems include breast mass, pain, and nipple discharge. Breast symptoms were reported in about 3% of all visits by female patients to family physicians.1 Over a 10-year period, 16% of women 40 to 69 years of age had breast problems, and 10% reported breast symptoms at the time of mammography.2,3 The prevalence of cancer among women who report breast symptoms is estimated to be less than 10%, and those with breast lumps have a higher risk of malignancy than those with breast pain.13 Although most breast symptoms have benign causes, symptoms can cause significant anxiety. Breast cancer is the most common cause of noncutaneous cancer and the second most common cause of death from cancer in the United States.4 Assessment and workup of breast symptoms are distinct from and do not supplant recommendations for breast cancer screening.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasonography is the preferred imaging modality in women younger than 30 years with a palpable breast mass.

C

69

Core needle biopsy with imaging guidance is the preferred method of tissue sampling for suspicious palpable breast masses.

C

69

Ultrasonography is the preferred imaging modality in women younger than 30 years with noncyclic, focal mastalgia and no palpable mass.

C

12, 22, 23

Diagnostic mammography should be performed in all women 30 years and older who have noncyclic, focal mastalgia and no palpable mass, and in all women 40 years and older who have noncyclic, nonfocal mastalgia and no palpable mass.

C

12, 22, 23

Diagnostic imaging is not needed in patients with cyclic mastalgia if routine screening mammography is up to date and physical examination findings are normal.

C

7, 12, 24

Topical nonsteroidal anti-inflammatory drugs such as diclofenac are first-line treatments for mastalgia.

B

13, 14

Diagnostic imaging is not needed in patients with physiologic nipple discharge if routine screening mammography is up to date and physical examination findings are normal.

C

7, 9, 30

Radiologic investigation should be performed in patients with nipple discharge that is spontaneous, unilateral, clear, serous, bloody, or associated with a mass.

C

7, 30


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasonography is the preferred imaging modality in women younger than 30 years with a palpable breast mass.

C

69

Core needle biopsy with imaging guidance is the preferred method of tissue sampling for suspicious palpable breast masses.

C

69

Ultrasonography is the preferred imaging modality in women younger than 30 years with noncyclic, focal mastalgia and no palpable mass.

C

12, 22, 23

Diagnostic mammography should be performed in all women 30

The Authors

show all author info

BROOKE SALZMAN, MD, is an associate professor in the Department of Family and Community Medicine at Thomas Jefferson University, Philadelphia, Pa....

ELIZABETH COLLINS, MD, is a geriatric fellow in the Department of Family and Community Medicine and Division of Geriatrics and Palliative Care at Thomas Jefferson University.

LAUREN HERSH, MD, is an assistant professor in the Department of Family and Community Medicine and Division of Geriatrics and Palliative Care at Thomas Jefferson University.

Address correspondence to Brooke Salzman, MD, Thomas Jefferson University, 833 Chestnut St., Ste. 301, Philadelphia, PA 19107 (e-mail: brooke.salzman@jefferson.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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