How does breast cancer present when it manifests with a unilateral breast ache?

Presentation of Breast Cancer with Unilateral Breast Ache

Unilateral breast ache is rarely associated with breast cancer, but when it is, the pain tends to be focal, persistent, and well-localized rather than diffuse or cyclical. 1, 2

Types of Breast Pain and Cancer Association

• Breast pain is typically categorized into cyclical (70% of cases), noncyclical (25% of cases), and extramammary (10-15% of cases) 3
• Noncyclical breast pain is more commonly associated with cancer than cyclical pain and is usually unilateral, focal, and often located in the subareolar area or lower inner breast 1
• When breast cancer presents with pain, it is typically:
  • Well-localized to a specific area that the patient can precisely identify 1
  • Persistent rather than intermittent 1
  • Not related to menstrual cycle 1
  • Often accompanied by other subtle findings that may not be initially apparent 1

Specific Cancer Types Associated with Pain

• Invasive lobular carcinoma and anaplastic carcinomas are more likely to present with pain than other breast cancer types 3
• Some breast cancers with inflammatory components may cause pain due to periductal inflammation 1
• Cancers involving the chest wall or with local invasion may present with a burning, continuous pain 1

Diagnostic Approach for Unilateral Breast Ache

• For unilateral, focal breast pain without other symptoms, age-appropriate diagnostic imaging is recommended:
  • For women ≥30 years: diagnostic mammogram with ultrasound 1
  • For women <30 years: ultrasound 1
• Digital breast tomosynthesis (DBT) may be beneficial for better characterization of any suspicious findings 1
• If imaging is negative but pain persists or worsens, follow-up evaluation should be considered 1

Warning Signs That Increase Cancer Suspicion

• Pain that is:
  • Persistent and does not resolve spontaneously 1
  • Associated with skin changes, nipple retraction, or discharge 1
  • Accompanied by a palpable abnormality, even if subtle 1
  • Located in one specific area consistently 1
• Unilateral breast pain in postmenopausal women requires careful evaluation, as noncyclical mastalgia is more common in this age group 4

Important Clinical Considerations

• The overall risk of malignancy in patients presenting with isolated breast pain is low (0-3%) 1
• Noncyclical mastalgia tends to be of shorter duration than cyclical mastalgia, with spontaneous resolution occurring in up to 50% of patients 1
• Breast pain due to cancer is often accompanied by other subtle findings that may be missed on initial examination 1
• Heavy smoking is associated with duct ectasia with periductal inflammation, which can present as an exquisite continuous burning pain behind the nipple 1

Pitfalls to Avoid

• Dismissing unilateral, focal breast pain without proper evaluation 3
• Failing to perform imaging for focal breast pain, even when clinical examination is normal 1
• Not considering cancer in persistent, well-localized pain that doesn't respond to conservative measures 1
• Overlooking the need for follow-up when initial imaging is negative but pain persists 1

Remember that while most cases of unilateral breast ache are benign, persistent focal pain warrants appropriate evaluation to rule out malignancy, especially when other risk factors are present.