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A 40-year-old woman sees you for "lumps" in her breasts. She describes a history of fibrocystic disease and lumpy breasts but thinks that her lumps are becoming more noticeable. She is worried because her maternal aunt was recently diagnosed with breast cancer at age 68.

  • What additional questions would you ask regarding her breast lumps?
  • What are the historical risk factors for breast cancer?
  • How can the patient history distinguish between benign breast disease and breast cancer?

The 3 most common breast complaints are breast lumps, breast pain, and nipple discharge.1–3 Although most of these concerns prove to be due to a benign cause, the greatest fear among patients is the diagnosis of breast cancer. A delay in the diagnosis of breast cancer remains a leading cause of medical malpractice suits.4 Therefore, it is important to elicit features of the history that suggest a malignant process. The purpose of the physician evaluation is to rule out breast cancer and to address the underlying cause of the breast complaint.

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Breast cancerCancerous growth beginning in the ductal/lobular unit of the breast. If the cancer is confined to the ductal/lobular unit, it is referred to as ductal carcinoma in situ. If the cancer disrupts the basement membrane, it is referred to as invasive or infiltrating carcinoma.
Duct ectasiaThe benign distention of subareolar ducts associated with breast discharge.
FibroadenomaA benign solid tumor with glandular and fibrous tissue, which is well defined and mobile.
Fibrocystic changesAn increased number of cysts or fibrous tissue in an otherwise normal breast. When these changes are accompanied by symptoms such as pain, nipple discharge, or lump(s), the condition is referred to as fibrocystic disease.
MastalgiaBreast pain.
PapillomaThe growth of papillary cells from the wall of a duct or cyst into the lumen. This lesion is usually benign.
Proliferative breast diseasePremalignant changes in the breast including ductal hyperplasia, atypical ductal hyperplasia, and atypical lobular hyperplasia.

Most breast complaints prove to be due to a benign condition. However, the cause varies based on the particular symptom, the patient's age, and menopausal status. For example, fibroadenoma is more common in younger, premenopausal women. In contrast, the incidence of breast cancer increases with age.

Differential Diagnosis

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CommentsPrevalencea
Fibrocystic diseaseThe most common cause of breast lumpiness and painAccounts for 20% of breast complaints in primary care clinic1
FibroadenomaThe cause in 7%–13% of breast lumps in a specialty clinic
Mastitis/breast abscessOccurs in up to 13% of lactating postpartum women5
Stretching of Cooper ligamentsCyclical breast pain in women with large, pendulous breasts
PapillomaThe most common cause of a bloody nipple discharge50% of patients have nipple discharge without a palpable mass6
Breast cancerThe risk ...

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