ACR Appropriateness Criteria® Breast Pain

Abstract

Breast pain is a common complaint. However, in the absence any accompanying suspicious clinical finding (eg, lump or nipple discharge), the association with malignancy is very low (0%-3.0%). When malignancy-related, breast pain tends to be focal (less than one quadrant) and persistent. Pain that is clinically insignificant (nonfocal [greater than one quadrant], diffuse, or cyclical) requires no imaging beyond what is recommended for screening. In cases of pain that is clinically significant (focal and noncyclical), imaging with mammography, digital breast tomosynthesis (DBT), and ultrasound are appropriate, depending on the patient's age.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Best Practice Guidelines for Breast Imaging, Breast Imaging Society, India: Part-1

“…Breast pain that needs investigation such as focal persistent noncyclical pain is often a nonspecific breast symptom. In symptomatic women younger than 30 years, ultrasound is more accurate in making a diagnosis than mammography, 11 and hence ultrasound is recommended as the first investigation. In the 30 to 39 years age group, adding mammography is advised.…”

“…In the 30 to 39 years age group, adding mammography is advised. 11 Mammography may also be indicated in patients under the age of 30 years if a suspicious lesion is found on the initial ultrasound examination, or if clinical signs justify the radiation exposure. Above the age of 40 years, mammography is recommended as the first investigation.…”

Diagnostic Imaging for Breast Pain

“…Breast pain occurs in 70% to 80% of women during their lifetime and accounts for 45% to 70% of breast-related complaints in a primary care setting. [1][2][3][4] Although breast cancer rarely presents with breast pain, diagnostic imaging for patients with breast pain is common, purportedly to evaluate for possible breast cancer and to provide reassurance for both the patient and physician. 4 In a study of 3 community hospitals, 799 women with a billing code diagnosis of breast pain over a 1-year period underwent breast imaging.…”

“…[1][2][3][4] Although breast cancer rarely presents with breast pain, diagnostic imaging for patients with breast pain is common, purportedly to evaluate for possible breast cancer and to provide reassurance for both the patient and physician. 4 In a study of 3 community hospitals, 799 women with a billing code diagnosis of breast pain over a 1-year period underwent breast imaging. No cancers or high-risk lesions were identified in the area where breast pain occurred.…”

Invasive lobular carcinoma mammographic findings: correlation with age, breast composition, and tumour size

“…Mammography is still considered the first-line imaging modality of choice in women aged 40 years or over, and it should be performed in patients under 40 years old with clinically suspicious findings and/or ultrasonically suspicious findings [ 7 - 9 ]. Even in women with clinically significant focal and noncyclical breast pain or with pathologic nipple discharge aged greater than or equal to 30 years, mammography is usually considered appropriate as an initial imaging modality [ 10 , 11 ].…”