What is the appropriate next step for a patient with breast swelling and tenderness lasting one month?

Evaluation and Management of Breast Swelling and Tenderness Lasting One Month

Begin with a thorough clinical breast examination to identify any palpable mass, asymmetric thickening, nipple discharge, or skin changes, then proceed to age-appropriate diagnostic imaging if the pain is focal or if any abnormality is detected on examination. 1

Initial Clinical Assessment

Perform a focused clinical breast examination looking specifically for:

• Palpable masses or asymmetric thickening that would require immediate imaging workup 1
• Skin changes including erythema, peau d'orange (dermal edema), or nipple excoriation that could indicate inflammatory breast cancer or Paget's disease 1
• Nipple discharge, particularly if spontaneous, bloody, or unilateral 2
• Pain characteristics: Determine if the pain is focal (precisely localizable to one spot) versus diffuse, unilateral versus bilateral, and whether it has any relationship to the menstrual cycle 1

Imaging Decision Algorithm

If focal pain is present (even without palpable abnormality):

• For patients ≥30 years: Obtain diagnostic mammogram with or without ultrasound 1, 3
• For patients <30 years: Obtain targeted ultrasound alone 3

If pain is diffuse/nonfocal, bilateral, and clinical examination is completely normal:

• If screening mammograms are current and negative, imaging is not immediately necessary 1
• Proceed directly to reassurance and symptomatic management 1

Important caveat: While the risk of cancer presenting as breast pain alone is low (1.2-6.7%), certain aggressive cancers including invasive lobular carcinoma and anaplastic carcinoma are disproportionately associated with mastalgia, so any focal pain warrants imaging evaluation 1

Management Based on Findings

If Imaging Shows BI-RADS 4 or 5 (Suspicious or Highly Suggestive of Malignancy):

• Proceed immediately to tissue biopsy, preferably core needle biopsy 1

If Imaging Shows BI-RADS 1-3 (Negative, Benign, or Probably Benign) or Normal Clinical Exam:

First-line treatment (effective in 86% of mild cases and 52% of severe cases with reassurance alone): 3

• Provide explicit reassurance that breast pain alone rarely indicates cancer 3
• Well-fitted supportive bra, especially during exercise 1, 3
• Over-the-counter NSAIDs (ibuprofen, acetaminophen) for symptomatic relief 1, 3, 2
• Ice packs or heating pads for comfort 1, 3
• Regular physical exercise 3

Do NOT recommend caffeine elimination - there is no convincing scientific evidence that reducing caffeine intake affects breast pain 3, 4

Special Considerations:

If simple cysts are identified that correlate with focal pain:

• Consider drainage for symptom relief 3

If the patient is a smoker with periductal inflammation and burning pain behind the nipple:

• Strongly advise smoking cessation, as duct ectasia accounts for approximately 25% of noncyclical mastalgia cases and is strongly associated with smoking 5

If pain persists despite conservative measures:

• Consider acupuncture, which has demonstrated efficacy in meta-analyses for breast pain sufferers 3, 4
• Acupressure at LI4 and SP6 points can be taught for self-administration 3, 4

Critical Pitfalls to Avoid

• Never dismiss focal breast pain without imaging, even if the clinical exam is normal - some cancers present with pain as the only symptom 1, 5
• Do not order imaging for diffuse, non-focal cyclical pain when clinical exam is normal and screening is current - this increases healthcare utilization without improving cancer detection 1, 3
• Always consider extramammary causes (costochondritis, muscle strains, nerve entrapment, cardiac ischemia, gastroesophageal reflux) when breast examination and imaging are normal, as these account for 10-15% of perceived "breast pain" 1, 5, 4
• Recognize that noncyclical mastalgia resolves spontaneously in up to 50% of cases without specific treatment 5