Breast Pain in a Non-Lactating Woman ~ Algorithm 6
Breast Cancer Diagnostic Algorithms for Primary Care Providers
(Third Edition, June 2005)
Mastalgia
(breast pain) is the most common breast-related
complaint at both primary care clinics and
breast referral centers.
Introduction to the work-up of Breast Pain in a Non-Lactating Woman ~ Algorithm 6
Mastalgia (breast pain) is the most common breast-related complaint at both primary care clinics and breast referral centers. Most of these complaints are cyclic in nature. Cyclic pain usually is normal in menstruating women or in postmenopausal women on hormone replacement therapy. Fibrocystic changes represent the most common cause of cyclic breast pain and symptoms are typically bilateral and described as diffuse, dull, full, achy, and heavy.
Non-cyclic causes include a ruptured cyst, a non-ruptured cyst under tension, fat necrosis, cervical radiculitis, intercostal neuritis, shingles, Tietze’s Syndrome (costochondritis), mastitis/abscess, Mondor’s disease, trauma, post-radiation syndrome and rarely cancer. Non-cyclic pain tends to be unilateral and described as localized, sharp, throbbing, stabbing, or burning.
The differential diagnosis of breast pain requires a CBE and careful assessment:
- Is it cyclic or non-cyclic?
- Is it bilateral or unilateral?
- Is the pain diffuse or focal?
- Is it associated with a mass?
- Is hormone replacement therapy ongoing?
- Is there a history of trauma?
Non-cyclic pain is initially investigated with a diagnostic imaging evaluation. If the patient is a young woman, an ultrasound may be the preferred imaging modality. Additional follow-up depends on the diagnostic imaging final assessment category. The risk of most cancer after a negative clinical and imaging evaluation for breast pain is less than 1% (ICSI, 2003).
Mastalgia is reported by up to 15% of women diagnosed with breast cancer, and 7% present with pain alone (Morrow, 2000). Therefore, a diagnosis of cancer must be considered in patients with well-localized breast pain of recent onset. The pain associated with breast cancer is often unilateral, persistent, and constant in position.
If there are changes consistent with mastitis such as erythema, fever >102 degrees, skin tenderness, abscess, or pus expressed from the nipple, refer to Algorithm #5 on skin changes/nipple retraction.
Although this algorithm addresses the non-lactating woman, a similar work-up of breast pain in the lactating woman is recommended. However, the lactating woman may need referral to a breast specialist.
For most women presenting with breast pain, treatment consists of relieving symptoms and reassuring the patient that there is no underlying carcinoma or other serious disorder. Non-narcotic analgesics and supportive bras may be helpful. Some women may find relief by using oil of primrose (3 grams a day). Elimination of caffeine, chocolate or salt from the diet has not been scientifically proven to be beneficial. The etiology of breast pain remains unclear, and no satisfactory treatment exists for some women (Khan, 2002).
Flowchart Notes and Footer
NOTE 6A: Distinguish between cyclic and non-cyclic breast pain. Cyclic pain is typically bilateral and described as diffuse, dull, full, achy, and heavy. Non-cyclic pain tends to be unilateral and described as localized, sharp, throbbing, stabbing, and burning.
NOTE 6B: As with other algorithms, a BI-RADS® category 3 result requires a differential assessment of risk. See Algorithm #1, Risk Assessment, to determine if the patient is at increased risk for breast cancer. If so, refer to a breast specialist.
NOTE 6C: For BI-RADS® category 3, the vast majority of findings will be managed with an initial short-term follow-up imaging examination in 3-6 months, followed by additional examinations until stability is demonstrated (2 years or longer). There may be occasions where biopsy is done (i.e. patient request or clinical concerns). Evidence from all the published studies indicates the need for biopsy of a lesion that increases in size or undergoes morphologic change (ACR, 2003).
Footer:
*Diagnostic Imaging Evaluation should be accompanied by standard screening mammography of both breasts if screening mammography has not been conducted within the recommended timeframe. Diagnostic Imaging Evaluation will often include diagnostic mammogram and breast ultrasound, but can also include any radiographic imaging procedure recommended by the radiologist. A final BI-RADS category will be assigned to the case based on the results of all diagnostic imaging procedures. Women should return to routine screening once the diagnostic and/or treatment cycle is completed.
References
American College of Radiology (ACR). (2003). Appropriate imaging work-up of palpable breast masses. ACR Appropriateness Criteria. Retrieved Sept. 29, 2005, from http://www.acr.org/s_acr/sec.asp?CID=1200&DID=15041 *
American College of Radiology (ACR). (2003). BI-RADS® - Ultrasound. Reston, VA: Author.
American College of Radiology. (2003). Breast
imaging reporting and data system (BI-RADS) (4th
ed.). Reston, VA: Author.
Institute for Clinical Systems Improvement. (2003). Breast Disease, Diagnosis of (formerly Breast Cancer Diagnosis). ICSI Healthcare Guideline. Retrieved from http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=168.
Khan, S. A., Apkarian, A. V. (2002). The characteristics of cyclical and non-cyclical mastalgia: a prospective study using a modified McGill pain questionnaire. Breast Cancer Research and Treatment, 5(2), 147-157.
Morrow, M. (2000). Physical examination of the breast. In J. R. Harris, M. E. Lippman, M. Morrow, & C. K. Osborne, (Eds.), Diseases of the breast (2nd ed., pp. 67-70). Philadelphia: Lippincott, Williams and Wilkins.
*Denotes online Algorithm Booklet content update: September 2005.
Updated: May, 2008. |
