Revisiting the Need for Breast Imaging in Young Women with Clinically Significant Breast Pain and a Normal Physical Breast Examination.

Abstract

Introduction: Although breast pain as a sole symptom is very rarely associated with cancer, national guidelines recommend that all women with a complaint of breast pain have to be referred for ultrasound evaluation. This study sought to investigate the necessity of this practice.

Methods: A retrospective study was conducted in consecutive women aged between 17 and 39 years, at average risk of breast cancer who presented at a major tertiary breast clinic with clinically significant breast pain (unilateral, unifocal, and noncyclic) in 2017-2023. Data on background, physical examination, imaging, and pathology were collected from the electronic medical records and analyzed by outcome.

Results: The cohort included 814 women. Among the 574 women (70%) with a normal physical breast examination, ultrasound revealed normal findings or BI-RADS 1-2 lesions in 499 (87%), BI-RADS 3 lesions in 59 (10%), and BI-RADS 4 lesions in 16 (3%). Biopsies, performed in 30 BI-RADS 3 lesions and all BI-RADS 4 lesions, were benign. Half of the 337 patients with available follow-up data continued to attend the breast clinic (mean 3.5 ± 2.2 years). Among the 240 women (30%) with a palpable abnormality on breast examination, ultrasound revealed normal or benign BI-RADS 2 findings in 112 (47%), BI-RADS 3 lesions in 69 (29%), and BI-RADS 4-5 lesions in 59 (25%). Biopsies performed in BI-RADS 3 lesions (12%) were all benign. Biopsies, performed in all BI-RADS 4-5 lesions, yielded malignant pathology in 16 lesions (7%) (including IDC, DCIS, or angiosarcoma). The overall breast cancer risk was 2%. Ultrasound sensitivity was 94%, specificity 85%, and negative predictive value 99%. The negative predictive value for dedicated physical examination without imaging was 100%. The biopsy-proven positive predictive value was 0 in patients with a normal breast examination compared to 18% in patients with a palpable finding on breast examination (p = 0.0017).

Conclusion: A subset of women <40 years old with average breast cancer risk and breast pain, who would normally be referred for imaging, can be triaged by a dedicated physical examination. Limiting ultrasound evaluation to those with palpable findings will spare patients and the healthcare system unnecessary radiology and biopsy studies.