Approach to Breast Lumps

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Mammography

Mammography is recommended as part of the evaluation of any woman age 35 or older who has a breast mass, primarily to search for other lesions that are clinically occult, but also to evaluate the mass in question. Certain mammographic features suggest malignancy:

  • Increased density
  • Irregular margins
  • Spiculation
  • Accompanying clustered irregular microcalcifications
Risk Stratification

1. Highest Risk (RR>4) Older patient born in North America.
2. Two first degree relatives with breast Ca at early age
3. History of cancer in one breast.
4. Intermediate risk (RR 2.1-4.0) Nodular densities occupying > 75% of breast volume on mammogram.
5. One first degree relative with breast cancer.
6. Atypical hyperplasia on breast biopsy.
7. High dose radiation to chest.
8. Increased risk (RR 1.1-2.0) Urban residence
9. First pregnancy after age 30
10. Menarche at age < 12 years
11. Menopause at age > 53
12. Obesity
13. Nulliparous
14. Use of hormonal contraceptives and HRT
15. History of primary endometrial ovarian and colonic cancer
16. Use of alcohol

However, mammography usually cannot determine whether a lump is benign. In addition, mammography misses 10 to 20 percent of clinically

palpable breast cancers. Thus, a negative mammogram should not stop further investigation. Mammography usually is not ordered routinely in women under age 35. The breast tissue in younger women is often too dense to evaluate the lump and breast cancer is too rare to search for it elsewhere in the breasts. Routine mammography is not cost-effective nor clinically beneficial for this younger group with breast complaints unless there is a high suspicion of cancer by clinical examination.

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