Who should a patient with a breast lump be referred to?

Who to Refer for a Breast Lump

Refer all patients with a palpable breast lump to radiology for immediate imaging evaluation—never to a surgeon first—as imaging must be completed before any biopsy to avoid confusing subsequent interpretation. 1, 2, 3

Initial Referral Algorithm by Age

Women ≥40 Years

• Refer directly to radiology for diagnostic mammography as the first imaging study, which detects 86-91% of breast cancers in this age group 1, 3
• Mammography must include both breasts with a radio-opaque marker placed over the palpable finding 1
• Ultrasound must follow mammography regardless of mammography results, as ultrasound detects 93-100% of cancers that are mammographically occult 1

Women <30 Years

• Refer directly to radiology for targeted breast ultrasound as the initial study, avoiding unnecessary radiation in this low-risk population where breast cancer incidence is <1% 1, 2
• Mammography is not indicated unless ultrasound shows suspicious findings or clinical examination is highly suspicious 4, 2

Women 30-39 Years

• Either ultrasound or diagnostic mammography may be performed first, depending on clinical suspicion 3
• The American College of Radiology considers both approaches appropriate in this intermediate age group 4

When to Refer to Surgery/Breast Specialist

Only refer to a surgeon or breast specialist after imaging is complete and shows:

• Suspicious findings requiring biopsy (BI-RADS 4-5) 3
• Confirmed malignancy on core biopsy requiring definitive treatment 4
• Discordance between imaging, biopsy results, and clinical findings requiring surgical excision 3

Do not refer to surgery if imaging shows clearly benign features (simple cyst, benign lymph node, lipoma, hamartoma), as these require only clinical follow-up 4, 2

Critical Pitfalls to Avoid

• Never refer for biopsy before imaging is complete, as biopsy-related changes will confuse, alter, and obscure subsequent image interpretation 1, 2, 3
• Never assume physical examination alone is sufficient—even experienced surgeons show only 73% agreement on the need for biopsy among proven malignancies 1, 2
• Do not refer for MRI, PET, or molecular breast imaging as initial evaluation, as these have no role in the workup of a palpable mass 1, 2, 3
• Never delay imaging evaluation—only 56.9% of women with breast lumps and normal mammograms receive adequate follow-up, leading to missed cancers 5

Special Circumstances Requiring Expedited Referral

Refer urgently (within days to weeks) for imaging if:

• Clinical examination is highly suspicious for malignancy (irregular borders, fixed to chest wall, skin changes, nipple retraction) 4, 1
• Patient has high-risk factors (strong family history of breast/ovarian cancer, known BRCA mutation, prior breast cancer) 4
• Patient is pregnant or lactating with a persistent mass—mammography is not contraindicated and has 90-100% sensitivity in this population 1

Follow-Up Coordination

• Primary care physicians can coordinate follow-up for benign findings after imaging confirms benignity 4
• Oncology specialists should manage patients with confirmed breast cancer, with follow-up every 3-6 months for the first 3 years, then every 6-12 months for years 4-5, then annually 4
• The combined negative predictive value of mammography and ultrasound is >97% when both are benign, making clinical follow-up alone appropriate 1