Note from the National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline. Refer to the full text for additional information, including detailed information on evaluation and imaging techniques, specific breast signs and symptoms, assessment and management of women of high risk women, and the anxious patient. Definitions for the levels of evidence (A, B, C, D) are provided at the end of the "Major Recommendations" field.

Palpable Mass or Asymmetry (See Figure 1 in the original guideline document)

• Discrete solid masses have a medium to high index of suspicion because physical exam cannot be a reliable tool to rule out malignancy.
  • Breast imaging is the best diagnostic approach.
  • Fine needle aspiration (FNA) by a qualified practitioner is an acceptable diagnostic tool, though if it precedes imaging it may disrupt tissue and affect mammography sensitivity. If aspiration reveals cyst, send fluid for cytology if it is bloody, if mass does not resolve completely with aspiration, or if cyst is recurrent in same location. A definitive report of fibroadenoma by fine needle aspiration requires no further workup. Masses not reported as definitive fibroadenomas or cysts should be evaluated by a breast specialist.

  Follow up physical exam after imaging or FNA is important. Cysts that recur are more likely to be malignant, and any nondiagnosed mass that persists should be evaluated by a specialist whether imaging has detected it or not.

• A non-discrete possible mass or thickening has a lower index of suspicion and should be reexamined in 1-2 months, preferably the week after menses in premenopausal woman. If a localized area remains abnormal on repeat exam then workup for possible malignancy is indicated, with diagnostic imaging and referral to a breast specialist. Persistent asymmetry, especially in postmenopausal women, is more suspicious than asymmetry that varies with the menstrual cycle [D].
• Referral to breast care specialist is recommended for: (a) any suspicious mass, (b) any mass that is undiagnosed after diagnostic imaging, or (c) any woman at very high risk for breast cancer [D].

Breast Pain - Negative Exam (See Figure 2 in the original guideline document)

• If physical exam and appropriate breast imaging are negative, the likely diagnosis is benign cyclic or noncyclic mastalgia: reassure patient. Trial of evening primrose oil (1000 mg twice a day [bid] for 3-6 months (or its active ingredient, gamma linoleic acid 160 mg bid) is reasonable [A]. Topical diclofenac gel is also promising for mastalgia [A]. Recommendation for a well-fitted bra is often helpful [C].
• If persistent or localized pain not responsive after 2 to 3 months of conservative treatment, refer to breast specialist [C].

Nipple Discharge Without Abnormal Exam Findings (See Figure 3 in the original guideline document)

• If discharge is serous or sanguinous, or if other risk factors are present (spontaneous discharge, single duct discharge), refer to breast specialist [C].
• If discharge is not suspicious. If clearly galactorrhea, pursue medical workup and do not refer to breast specialist [D]. If discharge is from multiple ducts and gray to green in color do not refer to a breast specialist unless patient requests referral for symptomatic relief.

Assessment and Management of Women at High Risk for Breast Cancer

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