Introduction

Breast cancer is the most common cancer in women and second only to lung cancer as a cause of cancer death in women. The ideal breast cancer detection program should include a combination of routine mammograms, monthly self-breast examination, and routine clinical examination by a health care provider. Routine exam by provider not part of USPSTF. Early detection provides women with the best chance of cure and/or reduced mortality.

The presenting complaint in 70% of women with breast cancer is a lump, with 90% of all breast masses discovered by the patient themselves. The following information is intended for use as a guideline for the management of a patient with a palpable breast mass.

General Recommendations

All symptomatic women should undergo a thorough history and diagnostic evaluation,

1. Patient history with documentation of risk factors, which include:

• late age greater than 50,
• personal history of breast cancer,
• family history of breast cancer in first generation maternal relative,
• previous history of endometrial cancer,
• presence of hyperplasia or proliferative fibrocystic disease,
• early menarche, prior to age 12,
• late menopause, after age 50,
• 40% or more overweight,
• childless or first pregnancy after age 30,
• duration and temporal relationship of mass to menses,
• prior history of breast problems,
• date of last mammogram.

2. Clinical breast examination documenting:

• Assessment of the entire breast and the opposite breast,
• mass characteristics: approximation of size, location, shape, consistency, delineation, tenderness to palpation, and mobility,
• nipple inversion and/or drainage,
• secondary signs: skin changes, asymmetry, or retraction,
• nodal status in axilla and supraclavicular regions.

A non-suspicious mass in a premenopausal woman, presumed to be fibrocystic disease, may be observed for one or two menstrual cycles. Observation is only appropriate for vague asymmetry or nodularity if it is uncertain that a dominant mass exists. Dominant masses are characterized by persistence throughout the menstrual cycle. In postmenopausal women, masses should be considered for prompt aspiration and/or biopsy.

The initial objective in evaluation is often to distinguish simple cysts from solid lesions. If the mass is at least 1 cm in diameter and easily palpable the PCP may consider aspirating the mass. A simple breast cyst has a low probability of being malignant, but many women will be more comfortable if a cystic mass is treated and resolved.

Patients with a palpable, dominant breast mass that does not resolve on aspiration or if aspiration is not done, should be referred for a mammogram (with possible ultrasound) as soon as possible (within seven days).

If the mammogram/ultrasound shows only a simple cyst with low probability of malignancy and the patient and the physician agree that the cyst does not require aspiration, the mass may be followed by serial physical exams to confirm it is resolving or not enlarging over time.

In women age 35 and under the decision to order a mammogram/ultrasound should be discussed with the radiologist before ordering the exam due to the technical difficulties interpreting the test in these patients. Consider a direct referral to surgery for these patients.

Dominant breast masses suspicious for malignancy either on exam and/or mammography should be seen by a general surgeon within two weeks of the primary care physician exam.

If the patient has a discreet solid mass visible on a mammogram without a palpable mass on examination, refer for a stereotactic needle biopsy (performed by a specially trained provider) or a surgeon for needle directed biopsy, within two weeks of the abnormal mammogram. A follow-up referral can be made to surgery after the biopsy results are available.

Women with a palpable breast mass and/or a suspicious mammogram should be followed closely to assure that the mass/abnormality has been evaluated and found to be nonmalignant or has resolved. The use of a tickler system is strongly recommended. Do not rely solely on the member to schedule a follow-up visit and/or future mammogram.

Evaluation Techniques

Needle Aspiration:
Needle aspiration is a safe, simple, inexpensive means of distinguishing simple cysts from solid lesions, especially in pre-menopausal women. Typically, fluid from a simple cyst is not bloody, the mass disappears, and the mammogram is normal.

Fluid that is non-bloody on visual examination does not have to be examined cytologically. It remains imperative that reexamination is done to confirm that the cyst has resolved. A one-time breast exam for a patient with a breast complaint is inadequate.

If the aspirate is bloody, the mass does not completely resolve after aspiration, or the same cyst recurs multiple times, biopsy may be indicated. Cytologic evaluation of aspirate has a false-negative rate of approximately 10%. Approximately 1% of breast carcinomas are cystic.

If the patient and the physician agree that a simple cyst with a low probability of malignancy does not require aspiration, the mass may be followed by serial physical exams to confirm it is resolving or not enlarging over time.

Mammography:
The primary role of mammography is to screen the remainder of the affected breast and the contralateral breast for clinically occult malignancy and/or to reinforce clinical impressions. Mammography cannot be used to exclude cancer in the presence of a palpable abnormality or to avoid biopsy. False negative mammography results as high as 15 - 22% have been reported. A negative mammogram in the presence of a palpable mass does not preclude the possibility of malignancy. This is especially true in women age 50 and younger.

Ultrasonography:
Sonography may be done to differentiate cystic from solid lesions. If aspiration is done before mammography and the mass resolves, ultrasound is probably unnecessary.

Biopsy techniques:
Fine-needle aspiration, large-needle biopsy, and excisional or incisional biopsy of a breast mass under general or local anesthesia are available for the diagnosis of breast masses with low morbidity and essentially no mortality. Patients with a dominant or suspicious solid mass must undergo biopsy despite mammographic findings.

References:
Carcinoma of the Breast. Current Medical Diagnosis and Treatment, 1994.
American Cancer Society Offers Specific Guidelines for Detecting and Managing Breast Abnormalities. Nurse Practitioner, 1992.
Breast Imaging and the Standard of Care for the Symptomatic Patient. Radiology, 1993.
Breast Cancer. American Cancer Society Textbook of Clinical Oncology, 1991.
Mammography and Palpable Cancer of the Breast. Cancer, 1988.
Evaluation of a Palpable Breast Mass. The New England Journal of Medicine, 1992.
Diseases of the Breast. ConnÕs Current Therapy, 1993.
Cancer of the Breast. Cancer, Principles and Practice of Oncology, 1993.