New Palpable Mass

Management of the patient with a breast mass varies according to age, history and clinical findings. Detection of a breast mass often creates anxiety for the woman and her family, requiring sensitive provider/patient communication. Important questions to consider when assessing the index of suspicion of a breast mass (lesion) detected on CBE include:

* Is it an asymmetrical finding in both breasts?
* Is it a three dimensional discrete palpable mass?
* What is the location and depth?
* Is it mobile or fixed?
* What is the size and shape?
* What is the consistency?
* Is it tender or non-tender?

Normal glandular tissue is generally mirrored in the contralateral breast. A discrete palpable mass is three-dimensional, different from surrounding tissues and usually asymmetric. Clinical signs that are suggestive of benignity, but are not diagnostic, include a mass that is soft, rubbery and mobile. Features suggestive of malignancy include a mass that feels firm or hard, is fixed, has an irregular shape, is solitary, and feels much different from the surrounding breast tissue (Barton, 1999; Goodson, 1996).

CBE is a screening method, not a diagnostic test. Regardless of age, every clinically suspicious lesion requires further evaluation. CBE finds 4% to 7% of cancers that are normal or benign on mammography (Green 2003, Bobo 2000, Beyer 2003, Georgian-Smith 2000). Thus, an abnormal CBE in the presence of a negative mammogram requires further follow-up. The leading cause of physician delay in the diagnosis of breast cancer continues to be inappropriate judgment that a mass is benign without performing a biopsy. Reducing delay in diagnosis requires less reliance on CBE to determine the benignity of a mass as well as less reliance on benign mammographic reports in deciding not to biopsy a mass (Goodson, 2002). Physical exam alone is approximately 70% accurate; mammography alone is approximately 85% accurate; minimally invasive tissue diagnosis alone is approximately 95% accurate. While physical exam and mammogram alone can detect many cancers, no single test by itself allows for detection of all breast cancers. The best clinical approach to the diagnosis and management of patients with a palpable mass is the combination of all three tests – physical exam, radiographic imaging and pathology (biopsy or FNA). This diagnostic triad is known as the "triple test." The diagnostic accuracy of these three tests taken together approaches 100% (Morris, 2002; Vetto, 2003). Clinicians should select the "triple test" method as it helps make an evidence-based decision about clinical management. If one of the "triple test" components is discordant, the entire diagnosis is uncertain and each of the "triple test" findings will need to be reviewed before proceeding.

Pre-menopausal Women
In patients younger than 30 years of age, or patients who are pregnant, ultrasound may be the first or sole breast imaging modality performed (Mehta, 2003 and Baker, 2000). For patients 30-49 years of age with a new palpable mass, a cyst is the most likely diagnosis and can be confirmed or ruled-out by fine needle aspiration (FNA) or ultrasound (a diagnostic imaging modality). If the degree of suspicion is very low (the palpable mass is a "ridge" and is two-dimensional, rather than three-dimensional), it is acceptable to repeat the screening CBE at a more optimal time of the menstrual cycle. Any palpable mass that persists and has not been proven to be a simple cyst, must receive additional diagnostic work-up until a final diagnostic status is determined.

Post-menopausal Women
Since the risk of breast cancer increases with age, clinicians need to be more suspicious of a dominant mass or asymmetric thickening in the breasts of postmenopausal women. Cystic findings decrease after menopause, although cysts, pain, and discharge can be found in women taking hormone replacement therapy. Diagnostic imaging evaluation is usually the first-line investigation of a palpable breast mass in postmenopausal women.

Regardless of age, it is important to request a diagnostic imaging evaluation for a palpable mass, and NOT a screening mammogram.