Primer on the Management of Benign Breast Diseases

Jennifer L Griffin, Mark D Pearlman
US Obstetrics & Gynecology, 2011;6(2):127-34
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Abstract

Breast cancer is the highest incident non-cutaneous cancer among women and is a leading cause of cancer death worldwide. This article aims to impart a working understanding of benign breast disease as a basis for clinical management of symptoms, distinguishing benign from malignant disease and identification of high-risk lesions. High-risk lesions should be actively managed with increased surveillance and discussion of the pros and cons of risk-reduction methods. Incorporating the concepts of breast cancer risk assessment, use of algorithms for breast complaints (e.g. breast masses, nipple discharge, breast pain) and active management of high-risk lesions into day-to-day practice provides great value to patients and providers alike. This article will also review the interpretation of breast imaging with specific focus on appropriate recommendations for breast biopsy and/or breast imaging follow-up.
Keywords
Breast cancer, benign breast disease, breast cancer screening, breast diseases, breast mass, nipple discharge, mastodynia
Disclosure The authors have no conflicts of interest to declare.
Received: July 26, 2011 Accepted August 29, 2011
Correspondence: Jennifer L Griffin, MD, MPH, 983255 Nebraska Medical Center, Omaha, NE 68198-3255. E: jgriffin@unmc.edu

Obstetrician/gynaecologists encounter women almost daily in their practices with breast-related issues, including breast complaints, a need for breast cancer screening, or personal or family history of breast cancer. Breast cancer is the leading cause of cancer among women worldwide, with the highest incidence per capita in Europe and North America. Over 330,000 new cases of breast cancer are diagnosed in Europe each year.1,2 In some cases, the fear of breast cancer leads women to report breast symptoms to a healthcare provider and they rely on the provider to be able to distinguish benign from malignant conditions in an efficient manner. In other cases, the symptoms of a benign breast condition may be sufficiently bothersome to warrant evaluation and intervention.

A systematic approach to the evaluation of breast complaints is crucial to the successful resolution of the problem. When a benign diagnosis is established, the woman frequently requires no further interventions. Identification of high-risk lesions, that is, those pathologies associated with an increased future risk of breast cancer, may allow the woman an opportunity to mitigate that risk through the use of chemoprevention medications or through more intensive breast cancer surveillance. In circumstances where the symptom is due to breast cancer, timely diagnosis allows for expeditious treatment, improving the chance of a more favourable outcome.

The majority of women with breast symptoms do not have cancer; therefore, the choice of diagnostic approaches should be standardised, reserving invasive procedures, particularly excisional biopsies, for situations where they are required to establish diagnostic certainty. Decisions regarding the evaluation of breast symptoms rely on appropriate history taking and physical examination. In addition to eliciting routine historical features, such as timing, duration, severity and characteristics of the breast complaint, every woman with breast problems should be assessed for presence of breast cancer risk factors. Though the absence of high-risk factors should not preclude the thorough work-up of a breast complaint, women with elevated risk of breast cancer may warrant more aggressive evaluation or closer follow-up. Identification of high-risk women also presents an opportunity for discussion about future breast cancer screening, genetic counselling and risk reduction options.3,4

This paper will review the work-up and evaluation of women with breast problems including masses, nipple discharge, breast pain and inflammation, and the surveillance of women with an increased future risk of breast cancer based on the presence of reproductive or familial risk factors or high-risk lesions.

Breast Cancer Risk Assessment
Age is the most important predictor of breast cancer risk; breast cancer risk for all women increases continuously with age. Beyond age-based risk, breast cancer risk factors fall into three primary categories: prolonged exposure to oestrogen and progesterone (commonly referred to as reproductive risk factors), strong family history of breast cancer and personal history of high-risk breast lesions (see Table 1). Individuals may be at increased risk of breast cancer in comparison with the general population due to early age of menarche, late onset of menopause, nulliparity, later age at first birth, absence of breast feeding and long-term use of menopausal hormone therapy containing both oestrogen and progestins.5–7 The number of reproductive years increases risk in a continuous fashion; however, nulliparity or late age at first birth have a greater impact on breast cancer risk due to absent or late-onset end-differentiation of breast cells associated with pregnancy.

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