What should I do if I find a lump in my breast?

What to Do If You Find a Lump in Your Breast

If you find a breast lump, seek medical evaluation promptly and start with ultrasound imaging if you're under 30 years old, or both diagnostic mammography and ultrasound if you're 30 or older—never assume a lump is benign based on how it feels, as physical examination alone is unreliable. 1, 2

Immediate Steps

• Do not delay seeking medical evaluation, as imaging is necessary in almost all cases to characterize palpable breast lesions, regardless of how the lump feels 2, 3
• Physical examination alone cannot reliably distinguish benign from malignant masses—studies show experienced surgeons agreed on the need for biopsy in only 73% of proven cancers 1, 2
• Even lumps that feel soft, mobile, or well-defined require imaging evaluation, as benign and malignant masses often have overlapping physical characteristics 1

Age-Based Imaging Algorithm

If You Are Under 30 Years Old

• Start with targeted breast ultrasound as your first imaging test—this is the American College of Radiology's recommended initial approach for women under 30 1, 2
• Ultrasound avoids unnecessary radiation exposure in this low-risk age group where breast cancer incidence is very low (only 0.3% of probably benign masses in women under 25 turn out to be cancer) 1
• Mammography is not recommended initially in women under 30 unless ultrasound findings are highly suspicious 1

If You Are 30 Years or Older

• Begin with both diagnostic mammography and targeted ultrasound of the affected breast 1, 3
• Mammography provides sensitivity of 86-91% for detecting breast cancer and screens the remainder of both breasts for occult lesions 1
• Ultrasound complements mammography by characterizing whether masses are solid or cystic and can detect 93-100% of cancers that are occult on mammography 3

Management Based on Imaging Results

If Imaging Shows Clearly Benign Findings

• Return to routine clinical follow-up only—no further imaging or short-interval monitoring is needed if ultrasound shows a simple cyst, benign lymph node, hamartoma, or other definitively benign entity 1, 2
• No biopsy is indicated for clearly benign findings 2

If Imaging Shows Probably Benign Features (BI-RADS 3)

• Perform short-interval ultrasound follow-up at 6 months, then every 6-12 months for 1-2 years 2, 3
• The cancer risk for probably benign masses is extremely low, particularly in young women (0.3% in women under 25) 1
• Consider immediate biopsy instead of surveillance if you have high anxiety, are at high risk for breast cancer, have other known cancers, are awaiting organ transplant, or are planning pregnancy 1

If Imaging Shows Suspicious Features (BI-RADS 4-5)

• Proceed directly to image-guided core needle biopsy—this is the preferred method of tissue sampling 1, 3
• Core biopsy provides higher sensitivity and specificity than fine needle aspiration, allows correct histological grading, and enables hormone receptor testing 3
• Ultrasound-guided biopsy is preferred when the lesion is visible on ultrasound, as it provides real-time visualization, requires no breast compression, and involves no radiation 3

If Imaging Is Negative But Physical Exam Is Highly Suspicious

• Do not let negative imaging overrule a strongly suspicious clinical finding—proceed to tissue sampling with core biopsy or surgical biopsy 1
• The negative predictive value of combined mammography and ultrasound ranges from 97.4% to 100%, but this is not absolute 1

Critical Pitfalls to Avoid

• Never undergo biopsy before imaging, as biopsy-related changes (bleeding, hematoma, architectural distortion) will confuse and limit subsequent image interpretation 1, 2
• Do not order MRI, PET, or molecular breast imaging as initial evaluation—these advanced technologies have no role in the routine workup of a palpable breast mass 1, 2
• Do not assume benignity based on clinical features alone—cysts cannot be reliably distinguished from solid masses by palpation (only 58% accuracy in one study) 1
• Ensure concordance between pathology results, imaging findings, and clinical examination if biopsy is performed—discordance requires additional tissue sampling or surgical excision 3

Special Considerations

If You Are Pregnant or Breastfeeding

• Start with ultrasound as the initial imaging modality 4
• Mammography can be performed safely if needed (it incurs no risk to the embryo or fetus) and should be done for lesions classified as BI-RADS 4a or higher 4
• Most breast lumps during pregnancy are benign (fibroadenoma, lactating adenoma, cysts, galactocele), but breast cancer must still be considered to avoid diagnostic delays 4, 5

If Changes Correlate with Your Menstrual Cycle

• Cyclical breast changes that wax and wane with menstruation are not associated with malignancy 6
• However, if a dominant mass persists through a complete menstrual cycle, proceed with imaging evaluation as outlined above 6
• Reassurance alone resolves symptoms in 86% of women with mild cyclical pain and 52% with severe pain 6