Approach to Breast Lumps

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Recommendations

  • A complaint of a breast lump must be taken seriously and the clinician should follow the patient closely
    until satisfactory resolution.
  • Breast lumps cause anxiety in most patients. Support and careful communication are essential. An expedient evaluation is important to relieve anxiety.
  • In general,
    the older the woman, the more aggressive the evaluation since breast cancer incidence increases with age. Furthermore, older women are more likely than younger women to delay presenting with a breast complaint.

Nevertheless, younger women with breast lumps are still at far greater risk for cancer than asymptomatic women in the same age group.

Women younger than age 35

Mammography is not helpful in women under age 35 because the breast tissue is too dense for the mammographer to read clearly. In a young woman with no physical findings indicating malignancy, it is reasonable to ask that the patient return 3 to 10 days after the next menstruation begins to determine if the lump regresses.

  • FNA can be performed if the lump remains easily palpable and feels cystic (round, smooth, and not hard) and the patient wants quick resolution of the issue. FNAs are usually performed by surgeons but family physicians with appropriate training can perform this procedure competently. If fluid is obtained and is not bloody, the patient can be reassured and followed in 4 to 6 weeks to check for recurrence; a recurrence suggests the need for surgical referral. If bloody fluid is obtained it should be sent for cytology.
  • If the lump does not feel cystic, the patient should be referred for ultrasound. If ultrasound shows a solid mass, the patient should undergo either FNAB, core needle biopsy, or excisional biopsy, depending upon local expertise. Some experts suggest that if a solid lump is small (<1 cm in size) and is not clinically suspicious (eg, is soft, not fixed, not new, and not changing) the lump is likely to be a fibroadenoma and the patient can be followed with physical examination every 3 to 6 months.
  • Sometimes, general lumpiness rather than a distinct lump is felt. A second opinion should be sought in such a situation
  • Women who have had breast cysts are at higher than expected risk for the later development of breast cancer However, because the absolute risk remains small, increased breast cancer surveillance for young women who have had documented breast cysts is not recommended at this time.

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