What is the treatment algorithm for a breast mass?

From the Guidelines

The treatment algorithm for a breast mass should begin with a thorough clinical breast examination, followed by diagnostic mammography and targeted-breast ultrasound, as these are the recommended imaging options according to the American College of Radiology Appropriateness Criteria 1. When evaluating a palpable breast mass, it is essential to consider the patient's age and degree of radiologic suspicion to determine the most appropriate imaging approach.

• For most women, diagnostic mammography and targeted-breast ultrasound are the primary imaging modalities used to characterize the palpable lesion.
• Advanced technologies such as MRI, positron emission mammography, or molecular breast imaging have little role in the evaluation of a palpable mass, unless otherwise indicated by specific clinical scenarios.
• If a suspicious finding is identified, biopsy is indicated to determine the nature of the lesion, and treatment depends on the pathology results, taking into account factors such as tumor stage, grade, hormone receptor status, and HER2 status 1. Key considerations in the treatment algorithm include:
• Clinical follow-up for benign lesions (BI-RADS 1-3)
• Tissue sampling for suspicious findings (BI-RADS 4-5)
• Treatment options for malignant lesions, including breast-conserving surgery, mastectomy, and systemic therapy decisions based on tumor characteristics
• A multidisciplinary approach involving surgeons, radiologists, pathologists, and oncologists to optimize outcomes and consider patient preferences and quality of life.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Algorithm for a Breast Mass

The treatment algorithm for a breast mass involves a step-by-step approach to evaluate and manage the condition. The following steps are recommended:

• Initial evaluation: A detailed clinical history and physical examination are essential in the initial evaluation of a breast mass 2, 3, 4, 5.
• Imaging: Diagnostic mammography is the initial imaging modality of choice for women aged ≥ 40 years, while ultrasound is typically necessary unless a definitively benign mass is identified 2. For women aged <30 years and women who are pregnant or lactating, ultrasound is used for initial evaluation 2.
• Biopsy: Biopsy is indicated for masses with suspicious features 2, 3, 6. A core needle biopsy should be performed with imaging guidance for evaluation of a suspicious mass 5.
• Short-term follow-up: Short-term follow-up is a reasonable alternative to biopsy for solid masses with probably benign features suggesting fibroadenoma 2.
• Correlation between imaging and clinical findings: Correlation between imaging and the clinical finding is essential to ensure accurate diagnosis and management 2.

Special Considerations

• Women with a palpable breast mass should have a diagnostic mammogram (DM) during workup, rather than a screening mammogram (SM) 4.
• Clinical breast examination (CBE) should be performed prior to ordering a mammogram, as recommended by the American Cancer Society and National Comprehensive Cancer Network 4.
• The type of mammogram ordered and the performance of CBE may vary depending on the primary care physician's specialty 4.

Diagnostic Evaluation

• The diagnostic evaluation of a breast mass should include a detailed clinical history, physical examination, and imaging studies 2, 3, 5.
• Any suspicious mass detected on physical examination, mammography, or ultrasonography should undergo biopsy 5.
• The triple-diagnosis method, which includes clinical breast examination, radiography, and fine-needle aspiration biopsy (FNAB), can lower the risk of missing cancer to only 1% 3.