What is the management approach for focal breast pain with normal mammograms?

From the Guidelines

The management of focal breast pain with normal mammograms primarily involves reassurance and symptomatic treatment, with a focus on wearing a well-fitted supportive bra, applying local heat or cold, and using over-the-counter NSAIDs like ibuprofen or naproxen for pain relief, as recommended by the NCCN Panel 1. The initial approach to managing focal breast pain includes a comprehensive history, type of pain, relationship to menses, duration, location, impact on activities of daily living, factors that aggravate or alleviate pain, and a thorough clinical breast exam (CBE) 1. If the CBE fails to identify any physical abnormality and screening mammograms are current and negative, the NCCN Panel recommends providing reassurance to the patient and treating the pain with symptomatic management, such as over-the-counter pain medications, use of a good support bra, ice packs or heating pads 1. For those with focal breast pain, age-appropriate diagnostic imaging, such as diagnostic mammogram with or without ultrasound for those ≥30 years of age, and ultrasound for those <30 years of age, may be considered 1. Key points to consider in the management of focal breast pain include:

• Reassurance that breast pain with normal imaging rarely indicates cancer
• Symptomatic treatment with over-the-counter NSAIDs, topical NSAIDs, or evening primrose oil
• Lifestyle modifications, such as reducing caffeine intake, maintaining a low-fat diet, and vitamin E supplementation
• Referral to a breast specialist if pain persists beyond 6 months despite these interventions It is essential to note that the risk of cancer in a woman presenting with breast pain as the only symptom is low, between 1.2% and 6.7% 1, and that reassurance alone has shown to help resolve the symptom in a significant proportion of women 1. The American College of Radiology Appropriateness Criteria also support the use of imaging evaluation for focal, noncyclic pain, mainly for reassurance and to identify treatable causes, with ultrasound as the initial examination for women under 30 and diagnostic mammography, digital breast tomosynthesis, and ultrasound for women 30 and older 1.

From the Research

Management Approach for Focal Breast Pain with Normal Mammograms

• The management of focal breast pain with normal mammograms typically involves a thorough clinical evaluation to determine the cause of the pain 2, 3.
• The risk of cancer in women presenting with breast pain as their only symptom is extremely low, and most patients respond favorably to reassurance and nonpharmacological measures 2, 4.
• For women with focal breast pain, imaging evaluation may include ultrasound, mammography, or both, depending on the patient's age and clinical presentation 4, 5.
• Targeted ultrasound may be deferred in women 40 and older with focal breast pain, no other clinical findings, and a negative mammogram 5.
• Management of breast pain is often supportive, as most breast pain resolves spontaneously, but if pain persists, imaging and management should follow a step-wise approach 3, 4.
• Conservative measures such as nonpharmacologic strategies should be tried first, and if these fail, second-line therapy with topical nonsteroidal anti-inflammatory drugs may be considered 4.
• For severe and resistant cases, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications 4.

Classification of Breast Pain

• Breast pain can be classified as cyclic mastalgia, noncyclic mastalgia, or extramammary pain, and management approaches may vary depending on the type of pain 2, 6.
• Cyclic mastalgia is breast pain that has a clear relationship to the menstrual cycle, while noncyclic mastalgia is constant or intermittent and not associated with the menstrual cycle 2, 6.
• Extramammary pain arises from the chest wall or other sources and is interpreted as having a cause within the breast 2.

Treatment Options

• Medications such as danazol, tamoxifen, and bromocriptine are effective for breast pain, but their use is limited due to potentially serious adverse effects 2, 6.
• Other therapeutic strategies, including antibiotics, combined oral contraceptive pill, diuretics, evening primrose oil, and vitamin E, have been studied, but their effectiveness and safety vary 6.