What is the management of a 31-year-old woman with a family history of breast cancer (in her aunt) who presents with a tender breast nodule?

From the Guidelines

For a 31-year-old woman with a family history of breast cancer (aunt) who has discovered a tender breast nodule, I recommend a prompt clinical breast examination by a healthcare provider, followed by a breast ultrasound as the initial imaging modality, given her young age and the potential for dense breast tissue, as suggested by 1. This approach is based on the most recent and highest quality guidelines for breast cancer screening and diagnosis. The clinical breast examination should include a thorough assessment of the patient's personal and family health history, as outlined in 1, to identify any potential risk factors for breast cancer. Key points to consider during the clinical history include:

• Screening practices for breast health
• Any breast changes and how they were identified
• Risk assessment, including age, personal history, and family history
• Health promotion habits Given the patient's age and family history, a breast ultrasound is the preferred initial imaging modality, as mammography may be less sensitive in dense breast tissue common in younger women, as noted in 1 and 1. If the ultrasound findings are concerning, a mammogram may be added to further evaluate the nodule. Based on imaging results, a biopsy may be necessary if suspicious features are identified, following the guidelines outlined in 1 and 1. While waiting for the appointment, the patient should track any changes in the nodule, particularly noting if it fluctuates with her menstrual cycle, which would suggest a benign fibrocystic change. The family history of breast cancer in an aunt slightly increases her risk but doesn't necessarily indicate high genetic risk unless there are multiple affected relatives, especially first-degree relatives or early-onset cases, as discussed in 1. For ongoing care, she should establish regular clinical breast exams, consider baseline mammography between ages 35-40, and discuss whether genetic counseling is appropriate based on a more detailed family history assessment. Breast pain or tenderness often suggests a benign condition, but proper evaluation is essential for definitive diagnosis and peace of mind, as emphasized in the guidelines 1 and 1.

From the Research

Management of a 31-year-old Woman with a Family History of Breast Cancer

The patient is a 31-year-old woman with a tender nodule and a family history of breast cancer, specifically an aunt who has been diagnosed with the disease.

• The patient's age and family history are important factors to consider in determining her risk of developing breast cancer. According to 2, breast cancer is the most common nonskin cancer in women, and numerous risk factors are associated with its development.
• A risk assessment tool can be used to determine the patient's individual risk and help guide screening decisions. However, the USPSTF and AAFP recommend against teaching average-risk women to perform breast self-examinations.
• For women at high risk of breast cancer, mammography starting at 30 years of age or earlier, with supplemental screening such as magnetic resonance imaging, may be beneficial 2.
• Chemoprevention with agents such as tamoxifen or raloxifene may also be considered for high-risk women. Studies have shown that these agents can reduce the risk of invasive breast cancer in postmenopausal women 3, 4, 5.
• When discussing management options with the patient, it is essential to incorporate shared decision-making principles, including evaluating the prognosis and treatment options, understanding the patient's priorities, and basing recommendations on these priorities 6.

Screening and Chemoprevention Options

• The patient's tender nodule should be evaluated further, and screening options such as mammography or ultrasound should be considered.
• If the patient is found to be at high risk of breast cancer, chemoprevention with tamoxifen or raloxifene may be discussed as an option.
• The benefits and risks of these agents should be carefully weighed, and the patient's individual priorities and values should be taken into account when making a decision.