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Breast symptoms, including palpable mass, breast pain, and nipple discharge, are common. While most breast symptoms are due to a benign cause, breast cancer is one of the most common malignancies worldwide. It is the most common cancer in women (excluding nonmelanoma skin cancer) and the second most common cause of cancer death. 1 in 8 women in the United States will develop breast cancer in their lifetime. Evaluation should include a thorough medical and family history to assess risk and a clinical breast examination and breast imaging.
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Most breast cancers are diagnosed by mammography, but approximately 25% of breast cancers are initially identified as a self-palpated mass. Less-frequent symptoms are breast pain; nipple discharge; erosion, retraction, enlargement, or itching of the nipple; and redness, generalized hardness, enlargement, or retraction of the breast. The breast-related history should include the following:
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When the mass or abnormality was first noticed
Changes in size over time
Associated pain and symptoms such as skin changes or nipple discharge
Risk factors for breast cancer: age, deleterious BRCA1/BRCA2 genes, history of chest radiation, history of atypical hyperplasia on biopsy, mother or sister with breast cancer, nulliparity, first-term pregnancy at or after age 30 years, menarche before age 12, menopause after age 55, dense breast, history of benign breast biopsy, alcohol use (>2 drinks per day), and postmenopausal combination hormonal therapy
Ancestry: 1 in 40 people of Ashkenazi Jewish ancestry may carry a germline BRCA pathogenic mutation
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Self-examination is not recommended for average-risk women by the American Cancer Society (ACS), American College of Obstetricians and Gynecologists (ACOG), or U.S. Preventive Services Task Force (USPSTF) due to lack of efficacy in the literature. ACOG recommends breast self-awareness for average-risk women, emphasizing patient education about breast changes.
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INDICATIONS FOR PERFORMING THE BREAST EXAM
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In the Asymptomatic Patient
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The current guidelines for asymptomatic clinical breast examinations (CBEs) are controversial. Some guidelines (ACS and USPSTF) do not recommend CBEs for average-risk women because of conflicting efficacy in the literature. No studies demonstrate that it improves clinical outcomes (ie, detects cancer at an earlier stage, demonstrating positive impact on cancer-related morbidity or mortality) when performed as a stand-alone examination. Other guidelines (ACOG) advise CBEs may be offered to women at average risk with shared decision making.
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In the Symptomatic Patient
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The goal of the examination in the setting of symptoms is to better characterize the abnormality, identify underlying etiology, and direct additional evaluation and treatment. Breast symptoms in any patient merit careful history taking and, if indicated, evaluation of other organ systems. Breast symptoms may be caused by diseases elsewhere in the body. For example, inappropriate milk production may be due to a prolactin-secreting pituitary tumor, or breast enlargement in men may signify underlying liver disease.
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Breast-related symptoms may include ...