ACOG Practice Bulletin #164 on benign breast disorders is a comprehensive summary of various benign and pre-malignant breast pathologies that may cause signs or symptoms prompting a woman to seek guidance from her ob/gyn.1 Evaluation and management of breast complaints is complex. The most obvious clinical challenge is that breast complaints may represent problems that are endocrinologic, dermatologic, musculoskeletal, pharmaceutical or neurologic in origin and not just simply breast-related. Given the broad differential diagnoses that must be considered, it is important to approach any breast complaint in a logical and systematic manner.
The first step is to always get a comprehensive history that includes the 7 dimensions of the current complaint (issues around onset, frequency, quality and quantity of pain/discharge/mass, associated symptoms, prior history of similar complaint and so on). It is also important to get a history of medications (source of galactorrhea), physical activity (trauma or stimulation due to poorly fitted bra), family history (evaluate for genetic risks of breast pathology and possible cancer), reproductive history (contraceptive use, pregnancies, and breastfeeding) and detailed review of systems looking for evidence of endocrine, trauma or other sources of the concern. The physical exam needs to determine if the breast complaint is the primary manifestation of a breast problem (e.g., fibroadenoma) or a secondary manifestation of a more systemic process, such as a pituitary adenoma or autoimmune disease with marked eczema. Findings need to be carefully described and documented for follow-up assessments of growth, change or resolution. Typically, if a finding is bilateral, it is more likely to be physiologically normal or manifestation of a more systemic issue (e.g. prolactinoma or fibrocystic changes). The bulletin helps with this process by presenting clear logical algorithms to guide a provider in a systematic cost-effective process to make a diagnosis.
A palpable breast mass is the most common finding of symptomatic breast cancer. Evaluation of a breast mass begins with a detailed history, assessment of breast cancer risk, and physical examination and requires age-appropriate breast imaging. Breast masses are common and typically benign. Certain qualities of a mass (e.g. mobile, unattached to surrounding tissue, discrete, smooth surface) are reassuring to the provider that a mass in a young woman is benign. Based on the history and physical exam, the provider can often make the right diagnosis of benign or malignant but not necessarily to the degree that is reassuring for the provider and/or the patient.2 Cyst aspiration and cytology of the fluid is used in a more limited fashion and primarily only for larger, bothersome simple cysts. If aspiration is done, the fluid is non-bloody and the mass is gone, simple close follow-up is acceptable. If the mass does not totally resolve, recurs or the fluid is bloody with aspiration, a tissue biopsy is indicated. In the setting of a mass seen as solid on ultrasound, further imaging and likely biopsy may be merited. When imaging is ordered in the setting of a breast complaint, it should be diagnostic and not screening. Depending on the imaging unit, they may immediately proceed without additional orders to secondary imaging and even biopsy as indicated by the classification of the initial images. Providers should be aware of the reporting and diagnostic steps of the imaging group and ensure that subsequent reports are tracked and follow-up is performed. A system similar to that for Pap smear tracking may be used. Once the diagnosis is determined the treatment recommendations are nicely outlined in the bulletin.
Nipple discharge can be alarming to a woman. The algorithm in the practice bulletin helps to divide this presentation into 4 groups that guide diagnostic steps. These are based on the nipple discharge being associated with: 1) a breast mass (evaluate per mass algorithm); 2) spontaneous unilateral discharge (needs imaging and biopsy); 3) bilateral milky discharge (likely endocrine); or 4) non-spontaneous, multi-ductal discharge (probably trauma or self-expression). The role of color, consistency, and presence of blood in the discharge, uniductal vs. multiductal will help direct evaluation and management.
Breast pain and skin lesions
Breast pain and skin lesions are commonly manifestations of systemic dermatologic issues (e.g. eczema, monilia, hidradenitis suppurativa), trauma, inflammation and endocrine pathologies. The history and physical exam should specifically explore for these possibilities. Because these lesions may represent an underlying malignancy, recurrent skin lesions, persistent edema, peau d’orange appearance, ulcerations or erythema warrant imaging and tissue confirmation of the diagnosis.
Determining breast cancer risk
The correct diagnosis for any breast complaint is clearly important for determining correct management, be it simply reassurance or excisional surgery. Another very important aspect of diagnosing a breast pathology is evaluating the patient for her level of risk for breast cancer. As the practice bulletin stresses, there are “benign” pathologies that are associated with moderate to marked risk of eventually developing breast cancer. When an atypical hyperplastic lesion or multiple papillomas are identified on a biopsy prompted by the presence of a breast mass or a mammographic finding, more aggressive treatment and a proactive cancer screening approach are indicated. A unilateral spontaneous nipple discharge also merits a tissue biopsy due to a significant risk of malignancy in the sample. Recent developments with imaging modalities and the current social media hype about celebrities encouraging mastectomies are confusing to patients and provider. Consultation with a breast specialist may be indicated for patients in the higher-risk groups to review the most current ongoing screening, diagnostic and/or treatment options with them.
Finally—and just as important—make this visit an opportunity to screen for risk factors for breast cancer such as obesity, family history of breast cancer (especially if BRCA 1 or 2), tallness, menopausal exogenous hormones, nulliparity, increased age at first pregnancy, and exposure to therapeutic ionizing radiation. There are protective factors that may reduce risk, such as breastfeeding. Although most of the risk factors are not modifiable there are behavioral changes a woman can make to minimize certain risks, such as weight loss, exercise, not smoking, minimizing alcohol intake, and possibly adopting a diet that is lower in fat and stresses vegetables and fruit.3 Based on her risk factors, a woman may benefit from additional screening, such as BRCA or earlier imaging. The psychology of cancer screening is challenging. Depending on a woman’s culture, fear of cancer, and anxiety level, she may or may not participate in a regular screening program as typically recommended. With the resolution of her breast complaint may come a window of opportunity to educate a woman on the role of breast cancer screening for her as an individual.4
1. Hereditary breast and ovarian cancer syndrome. ACOG Practice Bulletin No. 103. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:957–66. (Level III)
2. Breast cancer screening. Practice Bulletin No. 122. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:372–82. (Level III)
3. Management of gynecologic issues in women with breast cancer. ACOG Practice Bulletin No. 126. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:666 – 82. (Level III)
1. Committee on Practice Bulletins—Gynecology. Diagnosis and management of benign breast disorders. Practice Bulletin No. 164. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2016;127:e141-56.
2. Sabel MS. Clinical Manifestations and diagnosis of a palpable breast mass. UpToDate 2017. Accessed Sept 30, 2017.
3. Port DR. Your breasts are not a ticking time bomb. Glamour. November 2010. Accessed on Oct 7, 2017 at https://www.glamour.com/story/your-breasts-are-not-a-ticking-time-bomb
4. Consedine ND, Magai C, Krivoshekova YS et al. Fear, anxiety, worry and breast cancer screening behavior: a critical review. Cancer Epidemiol Biomarkers Prev. 2004;4:501.