Evaluation of common breast problems: guidance for primary care providers

In 1990, Congress enacted the Breast and Cervical Cancer Mortality Prevention Act, which authorized the Centers for Disease Control and Prevention (CDC) to establish comprehensive cancer screening programs administered through state health departments. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was the first nationwide opportunity for states to build a public health infrastructure for cancer control. State health departments receive funds from the federal government to provide breast and cervical cancer screening tests, diagnostic evaluations, and referral for treatment services to low-income, uninsured women.1 The NBCCEDP ensures that women who have abnormal results of a screening test receive appropriate and timely diagnostic evaluation services. Strategies for the management of abnormal cervical screening tests were available,2, 3 but guidelines useful to primary care providers for evaluating and managing common breast problems were needed. To develop such guidelines, the CDC asked the Commission on Cancer of the American College of Surgeons and the Society of Surgical Oncology to convene a group of general surgeons with the relevant expertise. The group of surgeons expanded upon an algorithm first developed by Dr. Barbara L. Smith and colleagues.4 The governing bodies of both organizations approved the draft guidelines, which were then circulated to professionals experienced in breast evaluation, including persons from several disciplines who were active in state breast cancer screening programs. These guidelines are designed for primary care physicians, nurse practitioners, and physician assistants who evaluate women with common breast problems. The guidelines are summarized in the Appendix at the end of this article. Referral surgeons should be knowledgeable about and experienced in breast disease and evaluation of breast abnormalities. More than 75% of women with newly diagnosed breast cancer have no identifiable risk factors. Evaluation should begin with a thorough risk assessment, although the examiner should realize that more than 75% of women with newly diagnosed breast cancer have no identifiable risk factors.5 The most obvious risk factor is age; the incidence of breast cancer increases as age increases.6 A family history should identify any first-degree relatives (mother, sisters, or daughters) with breast cancer and the age at which they developed cancer. Patients who have a premenopausal first-degree relative diagnosed with breast cancer have a threefold to fourfold greater risk of developing breast cancer than women who do not have such a family history. If a first-degree relative had bilateral cancer before menopause or if more than one first-degree premenopausal relative had breast cancer, the eventual breast cancer risk for the patient may be eight to ten times the risk for the general population.7 Several relatives who are second degree or more distant may transmit risk, including men with breast cancer and women with ovarian cancer, even if these relatives are postmenopausal. Such risk, although not quantifiable, is suggested. The examiner should obtain a specific history from the patient about previous breast biopsies, the pathology discovered, and the presence of a previous breast cancer, as well as any history of endometrial, ovarian, or colon cancer. Ten percent or more of women diagnosed with breast cancer develop a second primary breast cancer during their lifetimes. In the past, after mastectomy, all of these occurred in the contralateral breast.8 As breast-conserving treatment becomes the most common treatment for breast cancer, however, many second cancers are appearing in the same breast. The examiner also should obtain information from the patient about her parity and age at delivery of her first child. A woman who has no children or whose first full-term pregnancy occurred after age 35 has an increased risk of breast cancer6 compared with a woman whose childbearing occurred when she was younger. Other risk factors for breast cancer include early menarche (younger than 12 years) and late age at menopause (older than 53 years). Documentation of hormone or contraceptive use and the possibility of current pregnancy or new symptoms suggesting the onset of menopause may be important in evaluating symptoms and physical findings in the breast. Radiation exposure of the breast area in childhood is associated with a significantly increased risk of cancer. A history of malignant disease in childhood or adolescence, particularly Hodgkin's disease, should alert the physician to the need for screening and evaluation for breast cancer because of the inclusion of breast tissue within the field of radiotherapy. By definition, women are asymptomatic when screened for breast disease. However, many patients present with minor common symptoms, such as breast nodularity; breast tissue thickening; pain, soreness, or sensitivity; changes in the nipples, areola, or surrounding skin; and nipple discharge. If such symptoms are substantial, mammograms are diagnostic, not screening, studies. Screening is performed on asymptomatic populations, not on symptomatic patients. The examiner should determine the duration and fluctuation of symptoms and their association with the menstrual cycle. Any mass in the breast reported by a postmenopausal woman must be considered suggestive of cancer until proven otherwise, even if the patient is taking replacement hormones. Suspicious nipple discharges that require prompt referral to a surgical consultant include spontaneous, unilateral, or postmenopausal discharges; those confined to one duct; and those with clear, serous, bloody, or serosanguineous characteristics. Occasionally patients report vague or poorly defined changes in breast texture, sensation, outline, or appearance that should be noted and evaluated. An obvious infection with abscess should be treated with incision and drainage or repeated aspiration by needle and consideration of antibiotic use. An inflammatory appearance in any woman older than 40 years should be considered inflammatory breast cancer until proven otherwise. The first evaluation in such a patient should include a biopsy of the breast and skin. Physical examination of the breast and its interpretation are subject to variation among observers. The examination may be difficult to perform and may lead to diagnostic uncertainty because breast tissue is naturally diffusely lobulated, and irregularity to palpation may not be abnormal. The examination is frequently uncomfortable for sensitive patients, particularly during menstrual cycle periods of breast stimulation. The venue and conduct of the examination are critical. It should be done unhurriedly in a setting that allows for minimal distraction and complete patient privacy. The examination gown should be adjusted to reduce unnecessary or unintended exposure. The patient should be examined in both supine and upright positions, and the examination should be conducted coherently and comprehensively. The examiner first inspects the breasts visually, looking for distortions, asymmetry, or masses. The patient may be asked to bend forward so that pendulous breasts may be examined for skin retraction or distortions. The patient should lie in the supine position first, with the corresponding arm put over the head to stretch out the breast tissue over the chest wall. When sitting, the patient should place both arms over her head or press her hands together to create tension on the pectoral muscles and to stretch out the breast tissue. When the axilla is examined for lymph nodes, support of the arm with relaxation of the shoulder girdle musculature is important. The examiner next slides his or her fingers over the breast to compress the tissue against the chest wall. Circular, up-and-down, or back-and-forth motions to cover sequentially all breast tissue are most effective. The breast skin must be dry to provide the best sliding motion for evaluation of the underlying breast tissue. The approximate measured or estimated size, location, mobility, and consistency of any mass or abnormal area should be recorded. Each nipple should be inspected and gently squeezed to show any reported discharge. Sequential radial compression may show discharge from one duct or area. Lymph nodes in the axillae and supraclavicular space should be examined. The examiner should note whether any nodes are palpable, and if so, whether the nodes are clinically negative (normal size, soft, and mobile) or suggestive of malignant disease (large, firm, hard, or fixed). The consistency of palpable nodes and whether they are single, multiple, movable, or fixed also should be noted. The breast and regional nodal examination should be carefully documented even if findings are normal. A clinically suspicious mass is solitary, discrete, and firm or hard; it may or may not be fixed to adjacent tissue. A clinically suspicious mass is solitary, discrete, and firm or hard; it may or may not be fixed to adjacent tissue. A suspicious mass is unilateral and usually not tender, but it may be sensitive. Only about 1% of breast cancers are bilateral at presentation. Therefore, bilateral masses are usually less suggestive of malignant disease. Breast cancers present clinically in considerably varied ways; thus, if a mass is found, it is important to consider relevant clinical factors such as patient age, menstrual cycle, hormone use, trauma, duration, changes over time, and risk factors. Many areas of thickening, nodularity, irregularity, and lumpiness that are not suspicious clinically do occur, many of which may be described by patients as a “mass” because their technical vocabulary is not adequate to describe these changes. The American Cancer Society and the National Cancer Institute now recommend mammography every year for asymptomatic women 40 years and older, regardless of risk group. Although some experts do not support screening mammography in women from 40 to 49 years old, recent analyses9, 10 do show a significant reduction in mortality from screening women in this age group.11 Scientific data previously clearly supported screening mammography in women 50 to 75 years old because it substantially reduces the death rate from breast cancer.12 Controversy exists concerning the frequency of examination and the ages at which to start and stop.13 No reduction in deaths from breast cancer has been associated with screening women older than 75 years,12 although the number of women in this age range is small in reported trials. Women younger than 40 years should not undergo routine screening mammography unless they have risk factors for early-onset breast carcinoma; cancer is more difficult to detect in dense, active breast tissue than in fatty breast tissue. More frequent screening of younger women (yearly) and less frequent screening of older women (every other year) may prove to be most efficacious, but such a screening schedule has not been totally validated; thus, yearly screening is standard. Examination of the breast should be part of all routine physical examinations for women 30 years of age and older and should be encouraged for younger women. Routine physical examination by primary care providers such as internists, family practitioners, gynecologists, obstetricians, and nurse practitioners should include examination of the have a significant reduction in mortality from screening mammography in women 40 to 49 years The of breast in early of breast cancer has not been from and on women to perform breast may not its use and frequently patient Breast should be and encouraged but not If a patient the of breast in breast cancer screening, however, and is and in its use, the should be and A woman who a mass or during breast should be for appropriate clinical The of a patient with a mass should include a bilateral and may also include or In this the primary of the is to the surrounding breast tissue and the breast for not to a of the palpable for a palpable mass should not be performed on women younger than 30 to 35 Cancer is in this age and the examination is because of increased breast may occur, such as a woman with a clinically suspicious a family history of premenopausal breast cancer, or a proven breast cancer whose breast tissue should be A at any age not the need for evaluation of a palpable suspicious The of an examination is its to and masses. may be useful when a palpable mass is or poorly on a in a a if the are or defined of and A in a by should of a or adjacent to a is for routine breast cancer screening because of its to has no in breast cancer screening or diagnostic and other are not appropriate for routine screening or of breast is useful in that be or otherwise. A at any age not the need for evaluation of a palpable suspicious aspiration for is useful as an to clinical evaluation of a palpable aspiration and a or tissue for evaluation of a Many palpable and all suspicious masses should be considered for which and and provide for examination of masses. However, and patients need to the of Although the rate is the rate may be as as to Any mass after aspiration of a should be findings of aspiration in the presence of a suspicious mass and should not diagnostic of are biopsy a of tissue for needle which is now less frequently for the of biopsy is not but its use is in all breast by mammography is and its use in obvious cancers to before surgical is not because it an biopsy is to obtain tissue in is an area of on a and considered suspicious that cancer has to be The other is a that has a risk of cancer but has during repeated mammograms in a patient who to in which the risk of cancer is but not also may be by biopsy to patient or physician in biopsy part of the the same area of may be present in mammograms and require repeated biopsy or needle or by biopsy suspicious which usually have a or greater risk of a cancer, and at of those that are cancers are in The tissue should undergo to of some of biopsy should the number of for to its has a small but risk of a its use should be carefully until its is clearly The complete of a breast is surgical or biopsy be on to appropriate for its use, its and whether for biopsy substantially because of patient or physician need to and its be biopsy is less than results in less and no is in for of needle biopsies, and do not require biopsy The complete of a breast is an surgical biopsy The may be performed on palpable or on after or biopsy or of suggestive of cancer should the of a that they should be with at a of that are but require need minimal In be out of the surrounding breast tissue. the within the breast of by mammography is of these which needle may be more than that of clearly palpable should be by a to that on the screening and mammograms were mammography may be considered to complete of or for palpable or breast should a single, tissue should not be done In the of the breast tissue should be with with several after the is is best done by the so that the any cancer be The tissue should be by a if is of the may be because of tissue from with patients should be documented in about clinical assessment, test associated and management is important for are in premenopausal and women older than 40 Physical examination not and masses. A palpable mass of a be most and by If the primary care not perform needle the patient should be to a The association of with a mass not the possibility of cancer. If a is the patient should be for If a after the patient should be for surgical also be diagnostic but is more and and no more diagnostic information than If the mass not with aspiration or if the is bloody, the should be for and the patient should be for and surgical should be The most and of a should be If a woman has a physical examination that a needle aspiration be done because it is both diagnostic and should a If the a mass that may be a be If the is and the patient should be about but no should be aspiration for of A patient with a palpable, mass should be to a even when the findings are surgical biopsy is for any aspiration biopsy may be an diagnostic if it is that negative results of aspiration of a suspicious mass and an biopsy is Many reported by patients, however, are not by physical examination by a physician or primary care Such patients should be encouraged to after a for a women in their or with a palpable mass most have a cancer is in this age group. aspiration or may be done to complete the diagnostic Such a mass should be if the patient to have it for her of the age of the a clinically suspicious should be palpable, discrete, solitary, or suspicious masses should be unless they undergo An area of that is not a suspicious mass and that is to be clinically negative by the negative malignant in the aspiration and negative may be by the until it or is However, the and patient should the possibility of a of breast cancer and the area is appropriate for surgeons and experienced in the evaluation of breast masses. The of any skin on the should be considered suggestive of cancer, and the patient should be to a A may the patient to be a breast mass and the examiner on physical examination of the breast. the patient a the examiner may breast tissue. The patient may note the during the It may be a poorly defined or an area of irregularity or such as but breast tissue that may or may not be in the breast. The and the area the may small palpable of breast tissue that are not suspicious and do not require If the patient is or she should be to or for until she and the examiner are of the of the In should at If the after 3 and be from the breast the patient should be to a If the patient or examiner is about the of a vague mass or thickening, or should be should be considered before because aspiration may which in a or The presence of a negative may be to both patient and The of mammography results by the American College of are in the The patient should be to a if her mammography results are reported as or If evaluation with compression or is or if is the should be before surgical referral because many may be with If the is 3 the is with a possibility of The patient should have a breast examination before the is to with because clinically suspicious masses associated with any may for these patients may include physical examination and the should determine the and of technical The but risk of a of breast cancer should be clearly to the If she is to this risk or if she is a she should be to a by mammography and to be by need not be for of A that not the for a should be with If that the mass has suspicious an biopsy or should be The of biopsy appropriate for a by mammography or should be by a in with a and to the The that should be with the patient include or or surgical biopsy after needle Breast is a common and usually The most common of an uncomfortable or area or mass is a or of A common for in the of breast cancer, however, is to the of a associated with a mass not the possibility of cancer. If results of the physical examination and mammography are not suggestive of cancer, the most of breast is changes or menstrual cycle An of the of menstrual or postmenopausal most patients. A of such as or and the use of a that support are suggested. or from the has no proven although some women to less when or with has no The patient should be to a if and not to The patient with a suspicious nipple discharge should be to a even if no palpable mass is present or mammography findings are normal. Patients with any nipple discharge and a palpable mass should be to a should be done for a suspicious nipple discharge even results are If a nipple discharge is screening mammography should be as appropriate for the of nipple discharge is useful and is not of to is not and is of because results of may be appropriate for the of but are or discharge that is unilateral or bilateral and from several is and not suggestive of cancer. Referral of the patient is not A nipple discharge in the of pregnancy may not be suspicious but is Such an abnormal discharge that after delivery should be carefully evaluated. of any skin on the should be considered suggestive of cancer, and the patient should be to a disease of the nipple presence of in or breast cancer with in of the may be the of this may the areola, but it is Patients with skin should undergo screening A patient who has no clinically diagnosed breast problems should be to a for a second A patient should be to a for evaluation when breast examination is difficult because of reduction or or from biopsies, or Any or woman with a clinically suspicious should be to a in or women has breast cancer, and 1% to of breast cancers are diagnosed in or aspiration of a palpable mass or a or a or a mass Patients with a history of breast cancer should have with clinical and Other patients at risk of developing breast cancer include those with a of on breast biopsy and those with a family history of breast cancer among premenopausal first-degree relatives or several both first and second These patients also may require screening In such a referral to a or physician who is in breast cancer is The evaluation of common breast problems not an of patient and symptoms and a physical examination but when appropriate referral to a or breast and use of The of breast cancers and the of unnecessary and mortality associated with and malignant breast disease should be the primary of health care providers when evaluating breast problems. with patients about all management their and all test as well as of these is important to the of or aspiration is useful to mass and if mass not or is bloody, for and to be breast in for If to patient to for mass because biopsy is A patient with a suspicious mass should have a bilateral to the of both breasts for A not need for evaluation of a clinically suspicious However, if mass is clinically on breast and this is by examination and patient may be by a every 3 until biopsy or of Women younger than 30 years most have or or needle aspiration may be to to for mass because biopsy is If significant exists about of consider or first and then aspiration for If mass breast tissue or poorly defined not in or If mass after 3 and be from of breast to American College of biopsy should be and suggestive of to 3 patient may be with at an by the to woman need for clinical and is evaluation obtain to the by do not need aspiration for suspicious need to be clinical breast examination and if age If examination and mammography are is most a of a and recommend use of a If do not symptoms, referral to is Women with skin on the nipple or should be to a with palpable mass and any nipple discharge should be to a If discharge suggestive of confined to duct; in older clear, bloody, serous, or patient for mammography and surgical if bilateral or or or not suggestive of cancer and no If discharge is for may be patient to a for a second to if woman has had reduction or if breasts or or if several have the women who are or and have a breast mass or area of patient should be to a breast cancer for a woman with history of breast cancer, first-degree family or history of or Such women may need