Management of Common
Breast Problems
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
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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
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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
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Refer for biopsy if recommended by radiologist.
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If radiologist gives option of follow-up vs. biopsy, refer to breast
specialist.
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Document recommendations for biopsy, referral, or follow-up interval in
patient's chart.
Vague Thickening or Diffuse Nodularity
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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.
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Refer equivocal patients to a breast specialist.
Nipple Discharge without Palpable
Mass/Nipple-areolar Skin Changes
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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.
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Unilateral nipple discharge should be referred to a breast specialist.
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Bilateral multiple duct discharge is almost always benign. Prolactin
levels should be checked if bilateral milky discharge to rule out pituitary adenoma.
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Patients with skin breakdown of nipple or areola should be referred to a
breast specialist.
Breast Pain
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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
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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.
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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
The Worried Patient with a Negative Workup
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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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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