Management of Proliferative Breast Lesions Without Atypia
Women with proliferative breast lesions without atypia should undergo routine annual screening mammography starting at age 40, with no need for short-interval follow-up imaging, as 6-month surveillance does not improve cancer detection rates or outcomes compared to standard annual screening. 1, 2
Understanding the Lesion Category
Proliferative lesions without atypia include usual ductal hyperplasia, sclerosing adenosis, complex fibroadenomas, radial scars/complex sclerosing lesions, papillomas, and papillomatosis. 1 These lesions carry approximately 1.5-1.9 times the baseline risk of developing breast cancer compared to nonproliferative lesions—a modest elevation that does not warrant intensive surveillance. 3, 4
Imaging Surveillance Strategy
For Women Age 40 and Older
Annual screening mammography is the appropriate surveillance modality, following standard ACR and Society of Breast Imaging recommendations for all women starting at age 40. 1
Digital breast tomosynthesis (DBT) is preferred over standard mammography as it increases cancer detection rates and decreases false-positive recalls. 5
No short-interval follow-up (such as 6-month imaging) is indicated, as studies demonstrate that 6-month intervals compared to routine annual screening did not improve cancer detection rates or change invasive cancer rates, stage, tumor size, or nodal status. 1, 2
For Women Under Age 40
Women under 40 with proliferative lesions without atypia should undergo age- and risk-appropriate screening per standard guidelines. 1
Screening mammography before age 40 is generally not indicated unless additional risk factors elevate overall risk to higher-than-average. 1
What NOT to Do
Avoid these unnecessary interventions:
Diagnostic mammography is not routinely indicated for asymptomatic women with this diagnosis. 1
Breast MRI is not warranted for average-risk patients with proliferative lesions without atypia, as this modality is reserved for high-risk patients (such as those with atypical hyperplasia or lobular neoplasia). 1
FDG-PET breast imaging has no role in this clinical scenario. 1
Molecular breast imaging (MBI) is not supported by evidence for this indication. 1
Important Clinical Considerations
Expected Mammographic Performance
Women with a history of benign breast biopsies show no difference in mammographic sensitivity but may have decreased specificity compared to women without prior biopsies—this is attributed to tissue characteristics rather than the biopsy itself. 1, 2 This means you should expect slightly more callbacks, but cancer detection remains effective.
Risk Context
Almost 30% of women with breast cancer have a history of benign breast disease, making this a relevant but not alarming risk factor. 1, 2 The key distinction is that proliferative lesions without atypia carry substantially lower risk than those with atypia (1.5-1.9x vs 4.5-5.3x baseline risk). 3, 4
Family History Interaction
Unlike atypical hyperplasia where family history dramatically amplifies risk (to 8-11x baseline), family history has minimal effect on risk in women with nonproliferative or proliferative lesions without atypia. 4
Critical Pitfall to Avoid
Do not confuse proliferative lesions without atypia with atypical hyperplasia. The management differs substantially:
- Atypical ductal hyperplasia on core biopsy typically warrants surgical excision. 1
- Proliferative lesions without atypia require only routine screening. 1, 2
- Management of atypical lobular hyperplasia, LCIS, and flat epithelial atypia remains more varied and controversial. 1
Practical Algorithm
- Confirm pathology shows proliferative lesion without atypia (not atypical hyperplasia)
- If patient ≥40 years: Begin annual screening mammography (preferably DBT)
- If patient <40 years: Follow age-appropriate screening unless additional risk factors present
- Continue annual screening as long as patient has good health and life expectancy ≥5-7 years 5
- No short-interval imaging unless new symptoms or findings develop