What is the next best step for a 64-year-old female patient presenting with breast pain?

Management of Breast Pain in a 64-Year-Old Female

For a 64-year-old female with breast pain, the next best plan is to determine if the pain is focal/noncyclical or diffuse/cyclical, and proceed with diagnostic mammography with complementary ultrasound if the pain is focal and noncyclical. 1

Initial Assessment

• Determine if the pain is focal (limited to one quadrant) or diffuse/noncyclical (affecting more than one quadrant) 1
• Assess if the pain is cyclical (related to menstrual cycle) or noncyclical (constant or intermittent without relation to menstrual cycle) 2
• Evaluate for associated symptoms such as palpable masses, skin changes, or nipple discharge 2
• Note that breast pain alone rarely indicates cancer, with risk of malignancy being extremely low when pain is the only symptom 3

Diagnostic Algorithm Based on Pain Characteristics

For Diffuse/Cyclical Pain:

• No imaging beyond usual screening recommendations is indicated if clinical examination is normal 1, 2
• Reassurance and symptomatic management are appropriate first steps 2

For Focal/Noncyclical Pain (Most Relevant for This Patient):

• For women 40 years and older with focal, noncyclical breast pain:
  • Diagnostic mammography and digital breast tomosynthesis (DBT) are appropriate and equivalent alternatives 1
  • Ultrasound is complementary to mammography/DBT in this age group 1

Imaging Recommendations

• Mammography with DBT: Rated as appropriate (rating of 7-9) for women 40 years and older with focal, noncyclical breast pain 1
• Ultrasound: Complementary to mammography in women 40 years and older 1
• If mammogram has been obtained within the last 3-6 months, the patient may proceed directly to ultrasound 1
• MRI, PEM, and MBI are not indicated for evaluation of breast pain without other suspicious findings 1

Management Based on Imaging Results

• For BI-RADS 1 (negative) findings: Provide reassurance and symptomatic management 2
• For BI-RADS 2 (benign) findings: Consider drainage if a cyst correlates with pain location 2
• For BI-RADS 3 (probably benign) findings: Short-interval follow-up is appropriate 1
• For BI-RADS 4-5 (suspicious or highly suggestive of malignancy): Perform tissue biopsy 1, 2

Symptomatic Management

• Reassurance that breast pain alone rarely indicates cancer 2, 3
• Over-the-counter pain medications as needed 2, 4
• Supportive bra and application of ice packs or heating pads for comfort 2
• Topical NSAIDs (e.g., diclofenac) as first-line pharmacological treatment 4
• For severe pain affecting quality of life, consider pharmacological options after appropriate counseling about side effects 5

Important Considerations

• Breast pain is common, affecting up to 70-80% of women during their lifetime 2, 6
• Noncyclical breast pain tends to be more common in postmenopausal women 3
• Consider non-breast causes of pain (musculoskeletal, chest wall conditions) if breast exam and imaging are normal 2, 7
• Avoid unnecessary imaging for diffuse, non-focal breast pain as it may lead to additional clinical visits without increasing cancer detection 2