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Common benign breast concerns for the primary care physician

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Release date: January 1, 2019
Expiration date: December 31, 2019
Estimated time of completion: 1 hour

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ABSTRACT

Women often visit their primary care physician because of breast concerns such as masses, pain, and nipple discharge. Most breast problems are benign, but it is important to know how to manage these and other breast problems and when to refer patients for further testing.

KEY POINTS

  • The two most common breast symptoms are lumps and pain.
  • Most breast problems are not caused by cancer.
  • Evaluation of any breast problem begins with a focused history followed by a breast examination and, when necessary, imaging.
  • If the results of the breast examination and imaging suggest a benign cause, no further follow-up is necessary.
  • If there is discordance between imaging and breast examination results, or if there is a high clinical suspicion of cancer, then consider serial follow-up examinations at short intervals, referral to a breast surgeon for excision, or both.


 

References

Breast concerns account for approximately 3% of all female visits to a primary care practice.1 The most common symptoms are breast lumps and breast pain.

Benign causes of common breast symptoms

Because breast cancer is the most common malignancy in women in the United States, affecting nearly 1 in 8 women in their lifetime, women with breast problems often fear the worst. However, only about 3.5% of women reporting a concern have cancer; most problems are benign (Table 1).1

Here, we present an evidence-based review of common breast problems in primary care practice and discuss how to evaluate and manage them.

GENERAL APPROACH

The evaluation of a breast concern requires a systematic approach, beginning with a history that documents the onset, severity, and frequency of symptoms. If the concern is a lump or mass, ask whether it becomes more tender or increases in size at any point during the menstrual cycle.

Focus the physical examination on the cervical, supraclavicular, infraclavicular, and axillary lymph nodes and on the breast itself. Assess breast symmetry, note any skin changes such as dimpling, and check the nipples for discharge and inversion. Palpate the breasts for masses.

PALPABLE BREAST MASS: IMAGING NEEDED

If a mass is present, it is more likely to be malignant if any of the following is true:

  • Firm to hard texture or indistinct margins
  • Attached to the underlying deep fascia or skin
  • Associated nipple inversion or skin dimpling.2

Breast masses are more likely benign if they have discrete, well-defined margins, are mobile with a soft to rubbery consistency, and change with the menstrual cycle. However, clinical features are unreliable indicators of cause, and thus additional investigation with breast imaging is warranted.

Mammography remains the diagnostic test of choice for all women age 30 or older who have a palpable breast mass. It is less effective in younger women because they are more likely to have extremely dense fibroglandular tissue that will limit its sensitivity to imaging.

Order diagnostic mammography, which includes additional views focused on the area of concern, rather than screening mammography, which includes only standard cranio­caudal and mediolateral oblique views. A skin marker should be applied over the palpable lump to aid imaging. Because a breast that contains a mass may be denser than the opposite breast or may show asymmetry, both breasts should be imaged. The sensitivity of diagnostic mammography varies from 85% to 90%, so a negative mammogram does not rule out malignancy.2,3

Targeted ultrasonography of the palpable mass helps identify solid masses such as fibroadenomas or malignant tumors, classifies the margins (lobulated, smooth, or irregular), and assesses vascularity. Ultrasonography is particularly useful for characterizing cystic lesions (eg, simple, septated, or clustered cysts) and cysts with internal echoes. It can also identify lipomas or sebaceous cysts.

If the findings on both mammography and ultrasonography are benign, the likelihood of cancer is very low, with an estimated negative predictive value of 97% to 100%.2,3 Additionally, the likelihood of nonmalignant findings on biopsy after benign imaging is approximately 99%.3

Although radiologic imaging can define palpable masses, it is intended as a clinical aid. Suspicious findings on clinical examination should never be ignored even if findings on imaging are reassuring, as studies have documented that about 5% of breast cancers may be detected on clinical breast examination alone.4

Other imaging tests such as magnetic resonance imaging may be considered occasionally if clinical suspicion remains high after negative mammography and ultrasonography, but they cannot confirm a diagnosis of malignancy. In that case, refer the patient to a surgeon for consideration of excisional biopsy.

Patients with an indeterminate lesion can return in 3 to 12 weeks for a follow-up examination and repeat imaging, which helps assess interval clinical stability. The latter option is especially helpful for patients with masses that are of low suspicion or for patients who prefer to avoid invasive tissue biopsy.

Patients with clinical and radiologic findings that suggest a benign cause can return for short-term follow-up in 6 months or in 12 months for their regular mammogram.

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