In this issue of American Family Physician, Morrow¹ discusses the evaluation of three common breast problems: breast pain, nipple discharge and breast mass. I agree with the author's assertion that the goal of the evaluation is to exclude cancer and treat symptoms.

It seems prudent to include a review of risk factors in the efforts to exclude breast cancer. Risk factors include age, family history of breast cancer, early menarche, older age at first full-term pregnancy, nulliparity, presence or history of benign breast disease, and late menopause. Potentially modifiable risk factors include higher body mass index, heavy use of alcohol, use of oral contraceptives and not having breast-fed.²

The psychosocial impact of breast problems on patients is a frequently overlooked aspect of the evaluation of common breast problems. Because breast problems cause such a high level of distress for patients, particularly before a definitive diagnosis is obtained,³ physical examination alone may not provide adequate reassurance. Therefore, I disagree with the assertion that imaging studies are unnecessary in the evaluation of breast pain, except as would otherwise be indicated by screening guidelines. In women younger than 35 years of age, mammography has a low yield because of the low rate of breast cancer and the density of breast tissue. However, an ultrasound examination can demonstrate a variety of causes of breast pain, most of which are benign. This examination may also delineate subclinical masses that can be obscured by dense tissue or that can be difficult to palpate in pendulous breasts.

Guidelines for the evaluation of nonpuerperal galactorrhea should also include inquiry about previous pregnancy or lactation. It is not uncommon for small amounts of milk or serous fluid to remain expressible for years after pregnancy or breast-feeding.⁴ The family physician also needs to be aware of other frequent causes of galactorrhea, including thyrotoxicosis, some contraceptives and copper-containing intrauterine devices.⁵

Finally, an aspect that the article did not discuss is the evaluation of breast pain or a breast mass during lactation. The evaluation of breast problems encountered while a woman is breast-feeding must be tailored to the situation and should not interfere any more than absolutely necessary with the process of providing nourishment and immunologic benefits to the infant.

Pain in the lactating breast may be caused by engorgement or a plugged duct. It may also be the first sign of mastitis, ductal candidiasis or another infectious process.

The differential diagnosis of a dominant mass in the lactating breast includes plugged duct, mastitis, abscess and galactocele, as well as the disease processes mentioned in Morrow's article.¹ If a dominant mass in a lactating breast does not respond as expected after a few days of conservative treatment, aspiration, fine-needle biopsy, or even open biopsy can be performed to rule out cancer. All of these procedures can be done under local anesthesia without interrupting breast-feeding.

Because 3 percent of women diagnosed with breast cancer are pregnant or lactating,⁶ diagnostic delay should be avoided. If a surgical procedure is necessary, care should be taken to preserve breast function by using a radial incision, which has less chance of severing the nerve supply or lactiferous ducts than the usual circumareolar incision.