General Medical Officer (GMO) Manual: Clinical Section

Management of Common Breast Problems

Department of the Navy
Bureau of Medicine and Surgery

Introduction	Abnormality on Mammogram, non-palpable	Breast Pain
History	Vague Thickening	Palpable Mass
Breast Cancer Screening	Nipple Discharge	Examples for Referral

Introduction

Breast abnormalities are a common problem seen in our patient population. Due to extensive media exposure concerning breast cancer, the presence of symptoms or abnormalities associated with the breast results in the development of anxiety and fear in most women. Also, due to increased awareness, the delayed or missed diagnosis of breast cancer is one of the leading causes of litigation in the United States today. Therefore, it is prudent that all health care practitioners take an aggressive approach to the management of breast problems. This chapter represents clinical pathways for the management of common breast problems.

These pathways are based on the algorithm developed by the Risk Management Foundations' Breast Cancer Advisory Group and published in the Clinics of Surgical Oncology in January 1994. The following pathways are a consensus effort on the part of the Surgical, OB/GYN, and Family Practice communities and are intended as an accepted pathway for use by primary care providers in managing common breast problems. They do not necessarily represent the standard of care or an exclusive course of management. Individual circumstances and good clinical judgement may dictate variation and still be well within the standard of care.

These pathways for the management of common breast problems are provided for primary care providers who perform breast exams but do not perform (breast) surgical procedures. For the purpose of these pathways, a breast specialist is a surgeon with clinical expertise in breast care and who routinely performs breast surgery.

History and initial evaluation

The first step in the management of breast problems should be a complete family history, patient history, and careful physical exam. Attention to risk factors (positive family history, early menarche, late menopause, nulliparous, prior breast cancer, or breast biopsy with atypia), symptoms (pain, tenderness, discharge, or mass) and their description (length of time present, change in character, and associated findings) should be noted. Physical exam should carefully describe the characteristics of any abnormality and location. Close attention should be paid to the presence or absence of palpable nodes in the axillary, supraclavicular, and cervical areas.

Clinical Pathways for the Management of Common Breast Problems

Breast Cancer Screening

A strong program of breast surveillance is to be encouraged. Physical exam and mammography are the currently accepted methods for breast cancer screening.

Physical Exam

Examination of the breasts should be part of all routine physical exams for women. Annual physical exam of the breast should begin at age 35 and continue throughout life.
It is recommended that self breast exam be demonstrated and encouraged.

Mammography

A baseline mammogram should be obtained between ages 35-40.
Between 40 and 50, mammograms are recommended for every 2 years.
Over 50, mammograms should be performed annually. Over the age of 75, mammographic screening should continue for those women who remain in good health.

High Risk Patients

Patients at high risk of breast cancer by family history, prior breast cancer, or atypia on biopsy, prior radiation exposure, or other reasons may require different screening. Consult with a breast specialist.

Abnormality on Mammogram, non-palpable

Refer for biopsy if recommended by radiologist.
If radiologist gives option of follow-up vs. biopsy, refer to breast specialist.
Document recommendations for biopsy, referral, or follow-up interval in patient's chart.

Vague Thickening or Diffuse Nodularity

Obtain mammograms in all patients over 35. Younger women should only have mammograms if judged to be at increased risk for cancer by history or physical exam. Refer for biopsy if suspicious on mammogram.
Re-examine after 1 or 2 menstrual cycles for premenopausal women with a benign mammogram. Refer to specialist if localized abnormalities persist.
Refer equivocal patients to a breast specialist.

Nipple Discharge without Palpable Mass/Nipple-areolar Skin Changes

Obtain mammogram in all patients over 35. Younger women should only have mammograms if judged to be at increased risk for cancer by history or physical exam. Refer for biopsy if suspicious lesion on mammogram.
Unilateral nipple discharge should be referred to a breast specialist.
Bilateral multiple duct discharge is almost always benign. Prolactin levels should be checked if bilateral milky discharge to rule out pituitary adenoma.
Patients with skin breakdown of nipple or areola should be referred to a breast specialist.

Breast Pain

Obtain mammogram in all patients over 35. Younger women should only have mammograms if the patient is judged to be at increased risk for cancer by history or physical exam. Refer to breast specialist for biopsy if suspicious on mammogram.
If negative physical exam and mammogram, and findings are consistent with benign fibrocystic changes, reassure patient and give trial of conservative management. Consider trial of non-narcotic analgesics, reduced caffeine, reduced salt intake, and mild diuretics. Re-examine after 1-2 menstrual cycles.
If the pain persists or localizes and is not responsive to conservative measures, refer to breast specialist.

Discrete Palpable Mass

Obtain mammogram in all patients over 35. Younger women should only have mammograms if the patient is judged to be at increased risk for cancer by history or physical exam.
Masses suspected to be cysts should be confirmed as such by aspiration. If mass resolves and fluid is non-bloody, the fluid may be discarded and patient re-examined in 4 weeks. If the cyst recurs, an ultrasound should be obtained to determine if cyst is simple or complex. A simple cyst may be re-aspirated with good follow-up or referred to a breast specialist. A complex cyst should be referred to breast specialist for biopsy. A simple cyst recurring for a third time should also be referred for excisional biopsy.
If a suspected cystic mass is aspirated and the cyst does not totally resolve, then refer to a breast specialist for excisional biopsy.
If a suspected cystic mass is aspirated and the fluid obtained is bloody, then the fluid should be sent for cytology and the patient referred to a breast specialist for biopsy.
If a mass is solid and suspicious on physical exam, order mammograms and refer to breast specialist for biopsy immediately.
If mass proves to be solid by attempted aspiration, refer to breast specialist.
Any patient with persistent mass and negative mammogram should be referred to a breast specialist for definitive diagnosis.

Example Situations for Referral

Pregnant or Lactating Women with Breast Masses or Areas of Concern on Self Examination

Refer to a breast specialist without delay

The Worried Patient with a Negative Workup

Refer to a breast specialist

When referring for a surgical evaluation, it is very important to document pertinent factors from the history and physical examination as well as any previous mammograms with reports. Due to the possibility of malignancy, an initial health care provider should evaluate all patients with a breast mass as soon as possible and appropriately refer to a general surgeon or other qualified provider so that a definitive diagnosis can be made.

Submitted by CAPT H.R. Bohman, MC, USN, General Surgery Specialty Leader, Naval Hospital Camp Pendleton, CA (1999). Reviewed by CAPT Steven W. Remmenga, MC, USN, Specialty Leader for Obstetrics and Gynecology (1999).

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Operational Medicine 2001

Health Care in Military Settings

Bureau of Medicine and Surgery
Department of the Navy
2300 E Street NW
Washington, D.C
20372-5300

Operational Medicine
Health Care in Military Settings
CAPT Michael John Hughey, MC, USNR
NAVMED P-5139
January 1, 2001

United States Special Operations Command
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MacDill AFB, Florida
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Operational Medicine 2001 GMO Manual

Management of Common Breast Problems

Health Care in Military Settings

Operational Medicine 2001
GMO Manual