What are the recommended steps for a 57-year-old patient with tenderness in the left breast?

Evaluation and Management of Left Breast Tenderness in a 57-Year-Old Woman

For a 57-year-old woman presenting with breast tenderness, proceed directly to diagnostic mammography followed by targeted ultrasound of the tender area, regardless of whether a discrete mass is palpable, as this age group requires imaging evaluation and breast cancer can present with pain alone. 1, 2

Initial Clinical Assessment

Perform a focused clinical breast examination to determine:

• Whether the tenderness is focal (localized to a specific area) or diffuse - this fundamentally changes management, as focal tenderness requires imaging while diffuse tenderness may not 1, 2
• Presence of a palpable mass, skin changes (erythema, dimpling, retraction), nipple changes, or axillary lymphadenopathy - these findings elevate concern for malignancy 1
• Whether pain is cyclical (related to menstrual cycle) or noncyclical - though at age 57, most women are perimenopausal or postmenopausal, making cyclical patterns less common 1
• Exact location and reproducibility of tenderness - document precisely where the patient localizes the pain 1

Diagnostic Imaging Algorithm

For Age ≥40 Years (This Patient)

Obtain diagnostic mammography (with or without digital breast tomosynthesis) as the initial imaging study 1, 2, 3

• Diagnostic mammography is rated as "may be appropriate" (ACR rating 4/9) for noncyclical breast pain in women ≥40 years 1
• Follow mammography with targeted ultrasound of the tender area - ultrasound is rated as "usually appropriate" (rating 9/9) when there are palpable findings, and should be used to confirm correlation between clinical examination and imaging 2, 3

Critical Pitfall to Avoid

Never dismiss focal tenderness based solely on negative mammography - up to 10-15% of breast cancers are mammographically occult, and ultrasound may detect lesions not visible on mammography 2, 3. The combination of age 57 + focal tenderness + any palpable finding = mandatory complete imaging workup 2.

Management Based on Imaging Results

BI-RADS 1 (Negative) or BI-RADS 2 (Benign)

• Provide symptomatic management: over-the-counter NSAIDs or acetaminophen, supportive bra, ice packs or heating pads 2, 4
• If a simple cyst is identified that correlates geographically with the tender area, consider aspiration for symptom relief 1, 2
• Return to routine screening schedule 4

BI-RADS 3 (Probably Benign)

• Implement short-interval follow-up imaging every 6 months for 1-2 years (ACR rating 8/9) 1, 2
• Continue symptomatic management 2

BI-RADS 4 or 5 (Suspicious or Highly Suggestive of Malignancy)

• Perform image-guided core needle biopsy immediately (ACR rating 9/9) - this is the preferred biopsy method 1, 2
• Core needle biopsy should be performed even if the finding seems discordant with the clinical presentation 1, 2

Special Considerations for This Age Group

The risk of breast cancer presenting with pain alone is 1.2-6.7%, but this increases when focal tenderness is present 2, 4. At age 57:

• Noncyclical breast pain is more common than cyclical pain 1
• Inflammatory breast cancer can present with pain, tenderness, and skin changes 2
• Duct ectasia with periductal inflammation may cause focal burning pain, often behind the nipple, and is associated with smoking 1

When Imaging Remains Negative Despite Clinical Concern

If ultrasound and mammography are negative but clinical suspicion remains high due to persistent focal tenderness:

• Consider MRI with and without IV contrast, though this is generally rated as "usually not appropriate" (rating 2/9) in standard algorithms 2
• However, do not routinely order MRI for breast pain evaluation - there is no evidence supporting its use in this setting, and it leads to unnecessary biopsies of benign findings without improving cancer detection 4, 5

Key Clinical Pearls

• Breast pain is the most common breast symptom after palpable mass, affecting up to 70-80% of women at some time 1, 4
• Reassurance alone resolves symptoms in 52% of women with severe breast pain 2, 4
• The presence of focal tenderness in a 57-year-old woman mandates imaging evaluation - this differs fundamentally from diffuse breast pain where imaging may not be indicated 2, 4
• Timing of examination is less relevant in postmenopausal women, but if premenopausal, schedule 1-2 weeks after menses to avoid physiologic tenderness 1