Primary Care Guide to Managing a Breast Mass: Step-by-Step Workup

Janet Rose Osuch, MD, Vence L. Bonham, JD, Laura L. Morris, MD

What Is the Proportion of Benign Versus Malignant Breast Masses at Each Age?

To understand the composition and etiology of a breast mass, it is helpful to consider the anatomy of the normal breast. The basic elements include epithelial cells that produce milk (lobules) and ducts that carry milk from the lobules to the nipple during lactation. Connective tissue, fat, and neurovascular elements complete the breast anatomy. There are 4 common etiologies of a breast "lump": fibroadenoma, cyst, other benign fibrocystic masses, and cancer. Figure 1 shows the proportion of each type of breast mass by age.^[6]

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Figure 1.

Etiology of discrete breast lumps. Graph shows prevalence by age of fibroadenoma, cysts, other benign masses, and breast cancer in women. Reprinted with permission from Love N: Primary Care Considerations in Breast Diagnosis, Slide Lecture Program: Slide 40, Copyright © 1992, American Cancer Society, Florida Division Inc.^[6]

Fibrocystic Mass

There is a great deal of confusion about the diagnosis of a fibrocystic mass in the breast. A mass characterized by fibrocystic change is a pathological rather than a clinical diagnosis. A fibrocystic mass is diagnosed based on the presence of 2 important features: fibrous connective tissue and cysts (Fig. 2).^[7]

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Figure 2.

Fibrocystic changes noted on breast biopsy. Note characteristic presence of fibrous connective tissue (white areas) and cysts (rounded opaque areas). Image courtesy of JR Osuch, MD.

When examined microscopically, several varieties of fibrocystic change may be apparent; 2 of these types represent proliferation of the ducts and/or lobules. Referred to as epithelial hyperplasia and atypical epithelial hyperplasia,^[8] these are the only variations of fibrocystic change that elevate the risk for breast cancer. Epithelial hyperplasia doubles the relative risk of breast cancer, and atypical epithelial hyperplasia raises the risk of breast cancer 5-fold.^[8] The other types of cell changes represent proliferation of breast tissue that do not influence breast cancer risk.

Women often fear the diagnosis of any type of fibrocystic change. While physicians frequently use this diagnosis in their coding mechanisms, it must be made clear to the patient that this is an all-encompassing diagnosis that need not be feared. It is helpful to explain that when this term is used clinically rather than pathologically, reference is literally being made to a noncancerous mass or nodularity.

As seen in Figure 1, fibrocystic changes are very common in premenopausal women, primarily as a result of the influence of ovarian hormones on the physiology of breast tissue. Fibrocystic masses may also appear in some postmenopausal women being treated with HRT. Unfortunately, it is not possible for physical examination or radiological studies to definitively distinguish a fibrocystic from a malignant mass. It is especially dangerous to assign a fibrocystic origin to a change noted on breast examination of a postmenopausal woman; because ovarian function has ceased, postmenopausal women should not be undergoing dynamic breast changes.

Fibroadenoma

A fibroadenoma is a benign mass that occurs most frequently in young women, beginning in adolescence. These masses are usually quite mobile on physical examination and represent a benign proliferation of connective tissue that is encapsulated and incorporates epithelial cells (Fig. 3).^[9]

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Figure 3.

Fibroadenoma removed during breast biopsy. This type of benign mass is usually quite mobile on physical examination and represents benign proliferation of connective tissue that encapsulates epithelial cells. Reprinted with permission from Hughes LE, Mansel RE, Webster DJT: Benign Disorders and Diseases of the Breast: Concepts and Clinician Management (1989; p 63), Copyright © 1989, Bailliere Tindall.^[10]

Cyst

A breast cyst (Fig. 4),^[10] like a cyst elsewhere in the body, is a benign, fluid-filled structure. Breast cysts develop through processes of lobular involution and, as such, are found mostly in perimenopausal women. It is uncommon to find cysts in women younger than age 35. Cysts may develop in postmenopausal women, but this is distinctly uncommon unless the woman is taking HRT. Cysts are often firm, which makes them difficult to distinguish, by palpation, from solid abnormalities. Distinguishing the cyst from the solid mass is one of the most important tasks facing the clinician.

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Figure 4.

Cyst removed during a breast biopsy. Breast cysts, found most commonly in perimenopausal women, are benign, fluid-filled structures that manifest through lobular involution in perimenopausal women. Reprinted with permission from Hughes LE, Mansel RE, Webster DJT: Benign Disorders and Diseases of the Breast: Concepts and Clinician Management (1989; p 93), Copyright © 1989, Bailliere Tindall.^[10]

Cancer

Breast cancer (Fig. 5)^[11] does not always present as a mass, but when it does, it is usually firmer than the other breast mass etiologies described. In addition, breast cancer is often painless. However, exceptions to the usual firmness and painlessness of cancerous masses make reliance on such descriptors for diagnosis very hazardous.

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Figure 5.

Carcinoma removed during breast biopsy. Breast cancer, when presenting as mass, is usually firmer than breast masses of other etiologies. Reprinted with permission from Blamey R, Evans A, Ellis I, et al: Atlas of Breast Cancer (1994; p 35), Copyright © 1994, Merit Publishing International.^[11]

Postmenopausal women who present with a breast mass should be presumed to have cancer until it is proven otherwise. (As shown in Figure 1, 85% of breast masses in women 55 years and older are found to be cancerous.) HRT may mitigate the urgency of this caveat, but only to the degree that cysts are more common in postmenopausal women taking estrogen alone or in combination with progesterone. It is noteworthy, however, that each year more than 40,000 women younger than 50 years of age are diagnosed with breast cancer in the US.^[12] This makes it necessary for the clinician to pay vigilant attention to any woman who presents with a complaint of a breast mass.

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Cite this: Primary Care Guide to Managing a Breast Mass: Step-by-Step Workup - Medscape - Sep 01, 1999.

Table 1. Systematic Approach to Breast Mass Workup
Location
Ask the woman to point to the area of concern with 1 finger. Document this area on the physical examination record pictorially with an "X."
Method of Discovery
Establish how familiar the woman is with her own breast examination. How often does the woman perform breast self-examination (BSE)? Did she discover the lump during BSE or by accident? Was the lump found when the patient was in the supine position, standing in the shower, or in a different position? The evaluation may be very different if a patient rarely performs BSE and is not sure that a mass is present compared with a patient who performs BSE regularly and feels a difference on her examination compared with baseline.
Size
How big is the lump currently? Liken the size to familiar items, such as a pea, a grape, or a walnut.
Duration
When was the lump first found? Has it changed since first date of discovery?
Hormonal Influences
What is the woman's ovulatory status? When was her last menstrual period? Is she premenopausal? If so, does the mass change depend on the phase of her ovulatory cycle? Is she on hormone replacement therapy? If so, what are the drug names and dosages?
Tenderness
Is the mass tender? If the patient is premenopausal, does the tenderness change with the ovulatory cycle?

Table 2. Screening Guidelines for Women in Different Risk Categories
Risk Category	Lifetime Risk (%)	Clinical Breast Examination Schedule	Mammogram Schedule
No risk factors	11-12	Annual after age 30	1-2 years after age 40-49 Annual at and after age 50
Weak family history (2 or fewer second-degree or more distant relatives with postmenopausal breast cancer)	15-20	Annual after age 30	Annual after age 40
Strong family history (any first-degree relative with breast cancer, 3 or more relatives with breast cancer, or any second-degree relative with breast cancer before age 40)	Greater than 20	Annual after age 25; Twice yearly after age 30	Annual after age 35 or 5 years younger than youngest affected relative, whichever comes first
Carrier of known breast cancer susceptibility gene	20-85	Twice yearly after age 25	Annual after age 25
Identifiable breast cancer syndrome	20-85	Twice yearly after age 25	Annual after age 25
Very strong family history (2 or more first-degree relatives with breast or ovarian cancer, 1 or more first-degree relatives with breast cancer before age 40, or any first-degree relative with premenopausal breast)	20-85	Twice yearly after age 25	Annual after age 25
Atypical hyperplasia with a negative family history	15-20	Annual after diagnosis	Annual after diagnosis
Atypical hyperplasia with a positive family history	Greater than 20	Twice yearly	Annual after diagnosis
Lobular carcinoma in situ	20-30	Twice yearly	Annual after diagnosis

Table 2. Screening Guidelines for Women in Different Risk Categories
Risk Category	Lifetime Risk (%)	Clinical Breast Examination Schedule	Mammogram Schedule
No risk factors	11-12	Annual after age 30	1-2 years after age 40-49 Annual at and after age 50
Weak family history (2 or fewer second-degree or more distant relatives with postmenopausal breast cancer)	15-20	Annual after age 30	Annual after age 40
Strong family history (any first-degree relative with breast cancer, 3 or more relatives with breast cancer, or any second-degree relative with breast cancer before age 40)	Greater than 20	Annual after age 25; Twice yearly after age 30	Annual after age 35 or 5 years younger than youngest affected relative, whichever comes first
Carrier of known breast cancer susceptibility gene	20-85	Twice yearly after age 25	Annual after age 25
Identifiable breast cancer syndrome	20-85	Twice yearly after age 25	Annual after age 25
Very strong family history (2 or more first-degree relatives with breast or ovarian cancer, 1 or more first-degree relatives with breast cancer before age 40, or any first-degree relative with premenopausal breast)	20-85	Twice yearly after age 25	Annual after age 25
Atypical hyperplasia with a negative family history	15-20	Annual after diagnosis	Annual after diagnosis
Atypical hyperplasia with a positive family history	Greater than 20	Twice yearly	Annual after diagnosis
Lobular carcinoma in situ	20-30	Twice yearly	Annual after diagnosis

Sidebar: Risk Factor Interpretation

A risk factor represents an association and does not necessarily infer a cause-and-effect relationship. Its presence does not guarantee the development of a disease, nor does its absence confer absolute protection. However, risk factors are important to consider when assessing an individual woman. The 4 terms most important to consider are odds ratio, relative risk, confidence interval, and absolute risk.

The odds ratio is a risk calculation based on retrospective studies, representing expression of the chance of having a disease in a population with a given characteristic, as compared with a population without the characteristic.

When studied prospectively, the odds ratio is expressed as relative risk.^[1] In other words, relative risk (RR) is a ratio of an outcome disease in a group exposed to a risk compared with the outcome in a group not exposed to a risk.
For both odds ratio and RR, an expression of 1.0 represents the baseline risk of disease in the population without the characteristic.
Any number less than 1.0 in the study group represents a lack of association, whereas any number over 1.0 represents an association of the trait with the disease.

The statistical expression of significance for odds ratio or RR is the confidence interval.
If a range of numbers overlaps 1.0, the trait in question has not achieved significance.

An RR of 2.0 means that a person who possesses the characteristic is twice as likely to get the disease over a given number of years as is someone without the characteristic. This also can be expressed as conferring a 100% increase in risk: A patient with an RR of 2.0 is 100% more likely to get the disease than someone without the characteristic, who has an RR of 1.0.

A 100% increase in risk can be very startling, but what does this number really mean? To answer this question, consider the following example in a population of 500 people age 50 to 60 studied over 10 years:

Variable X	Cases Breast Cancer	Relative Risk and Confidence Intervals *
Absent	20	1.0
Present	40	2.0 (1.14-1.54)

* Of the people with variable X, 40 of a total population of 500 developed breast cancer (RR of 2.0) compared with people without variable X, in which 20 of a total population of 500 developed the disease (RR = 1.0). This illustrates the reality of an expression of "a 100% increase in risk" for the clinician. Notice in this example that the confidence interval is above 1.0 and is relatively narrow, adding validity to the interpretation.

Absolute risk (AR) is the actual number of people, exposed and unexposed to the risk, who acquired the disease.
AR represents the chance of developing a disease over a given time interval. For breast cancer, the best known statistic is the 12.5% (or 1 in 8) risk over a lifetime.

Vogel VG: Assessing women's potential risk of developing breast cancer. Oncology 10:1451-1458, 1996.

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Primary Care Guide to Managing a Breast Mass: Step-by-Step Workup

What Is the Proportion of Benign Versus Malignant Breast Masses at Each Age?

Fibrocystic Mass

Fibroadenoma

Cyst

Cancer

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

Sidebar

Sidebar: Risk Factor Interpretation

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Figure 3.

Figure 3.

Figure 4.

Figure 4.

Figure 5.

Figure 5.

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