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Am Fam Physician. 1999;60(2):612-615

Breast symptoms are a common complaint among women presenting to primary care practices. Concern about both breast symptoms and the occasional delay by the practitioner in evaluating these symptoms is intense. Barton and associates retrospectively studied breast symptoms and evaluations at a large health maintenance organization in New England.

A computer search gathered data for all visits related to breast symptoms over a 10-year period. The study population was sampled in a random, age-stratified manner to include 1,200 women who were 40 to 49 years of age, 600 women 50 to 59 years of age and 600 women 60 to 69 years of age. Patient symptoms were classified as: (1) a mass (a single lump or nodule); (2) pain (report of pain or tenderness in either the breast or the nipple); (3) a change in the skin or nipple (including nipple discharge); (4) multiple lumps or nodules (often described by the patient as “lumpiness”); or (5) other symptoms (such as increasing size of the breast). Findings of the physical examination were recorded in a manner corresponding to this categorization.

Clinicians' diagnostic interpretations were classified as normal, abnormal-benign, indeterminate or suspicious for cancer. Clinicians' recommendations for further diagnostic evaluation were recorded, as were the results of these evaluations.

A total of 372 women (16 percent) presented with breast symptoms in 539 separate episodes. Women younger than 50 years of age presented at twice the rate of older women. Women with a family history of breast cancer were significantly more likely to present with breast symptoms than those without a family history. The most common symptom was pain, followed by mass, skin or nipple change, lumpiness and other symptoms. Clinicians recommended further evaluation in 391 episodes of breast symptoms (73 percent). Breast cancer was diagnosed in 23 of the 372 women who presented with breast symptoms (6.2 percent) and in 4.5 percent of all episodes (some women reported more than one breast symptom to the clinician). These women had higher tumor stages at diagnosis than the 58 women whose breast cancer was detected by screening mammography during the study period. A report of a mass was associated with a 10.7 percent chance of breast cancer, whereas a report of pain led to a diagnosis of cancer in 1.8 percent of episodes. Each symptom alone, however, was associated with a significantly higher risk of cancer than is present among the population at large.

The authors conclude that breast symptoms are common in patients in primary care and result in substantial rates of cancer detection. Evaluation of any woman over 40 years of age who presents with breast symptoms is important, and continued unexplained symptoms, even after a negative imaging test, must be closely followed to rule out cancer.

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Copyright © 1999 by the American Academy of Family Physicians.

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