The Incorrect Statement is C: Mammography is NOT the Examination of Choice in a 27-Year-Old Woman
In a 27-year-old woman with fibrocystic breast disease, ultrasound—not mammography—is the appropriate initial imaging modality. Statement C is incorrect because mammography is less accurate in young women due to increased breast density, and current guidelines clearly recommend ultrasound as the primary imaging tool for women under 30 years of age.
Why Mammography is Inappropriate in This Age Group
The ACR Appropriateness Criteria explicitly state that mammography is known to be less accurate than ultrasound in evaluating symptomatic women less than 30 years of age due to greater breast density 1. For women younger than 30 with palpable breast masses, the guidelines recommend:
- Ultrasound receives a rating of 9 (usually appropriate) as the initial imaging examination 2
- Mammography receives a rating of 1 (usually not appropriate) for this age group 2
This represents a fundamental principle in breast imaging: dense breast tissue in young women obscures mammographic findings, making ultrasound far superior for detecting and characterizing breast lesions.
Why the Other Statements Are Correct
Statement A: One or More Painful Breast Masses
This is accurate. Fibrocystic disease presents with palpable masses, nodularity, and fibrocystic plaques that cause discomfort 3. The condition affects at least 50% of women of childbearing age 4.
Statement B: Symptoms Worsen Before Menstruation
This is correct and reflects the hormonal pathophysiology. Fibrocystic disease is determined by estrogen predominance and progesterone deficiency, with symptoms progressing cyclically and being most pronounced during the premenopausal years 3. Cyclical breast pain is a hallmark feature, with studies showing no malignancy in patients presenting with cyclical breast pain alone 1.
Statement D: Suspicious Lesions Are Biopsied
This is appropriate management. When ultrasound findings are suspicious for malignancy in women under 30, image-guided core biopsy receives a rating of 9 (usually appropriate) 2. Even in fibrocystic disease, appropriate follow-up is necessary after assessing breast cancer risk 5, as certain histologic subtypes (particularly atypical epithelial hyperplasia) carry increased cancer risk 3, 6.
Clinical Pitfalls to Avoid
- Do not order screening mammography in women under 30 unless there are highly suspicious clinical findings or strong family history requiring diagnostic evaluation
- Do not dismiss all fibrocystic findings as benign without proper ultrasound characterization—complex cysts and solid masses require tissue diagnosis 7
- Recognize that fibrocystic disease is not entirely benign—it carries a 1.5-3.0 relative risk for breast cancer, with higher risks in certain histologic subtypes 3, 6
The answer is C.