Breast pain is a common complaint among patients and accounts for anywhere from 45 to 70 percent of breast-related complaints in the primary care setting. While imaging may seem to provide reassurance to patients concerned about the possibility of cancer, initial imaging increases the odds of subsequent clinical services utilization that provides no benefit, according to a study published online Jan. 31 in the Journal of General Internal Medicine.
The presence of breast pain by itself has a low risk of breast cancer (3 percent or less), but guidelines recommend imaging if pain is in conjunction with a palpable mass, according to Karen Freund, MD, MPH, of the Boston University School of Medicine (BUSM), and colleagues. They also pointed out that previous research has recommended imaging for patients who need reassurance and that no further studies would be necessary if initial imaging findings are normal. However, no study has examined the effect initial imaging has on subsequent clinical management in women with breast pain.
“While some have suggested that doing further testing in women with breast pain will help to reassure the patient, we did not find this to be the case,” explained Mary Beth Howard, MS, an MD candidate at BUSM, in a statement.
The researchers analyzed a group of 916 women referred to Boston Medical Center for breast pain from 2006 to 2009. Clinical management of women who received imaging to evaluate breast pain was compared to management of women who did not receive imaging.
Six cancers were identified and all of these women either had a lump on exam or had a routine screening mammogram find a cancer in the other breast. Twenty-five percent of all patients had imaging ordered at the initial visit; 75 percent of this group had normal radiographic findings. Despite the majority of initial imaging exams being normal, 98 percent returned for additional evaluation, meaning initial imaging exhibited increased odds for subsequent clinical services utilization (odds ratio: 25.4). For women with a completely normal breast exam, the addition of an ultrasound, MRI or mammogram did not help the patient or the doctor in their decisions.
“While initial imaging in women with breast pain has been recommended for reassurance purposes, there is significant increased subsequent utilization in women who receive initial imaging, without increased diagnostic yield,” wrote the authors, who pointed out that overutilization of diagnostic imaging is a concern.
“More tests are not always a good thing,” said Howard. “They can lead to still further tests or even biopsies which themselves have some risk. They can sometimes increase anxiety without providing any benefit to the patient.”
The authors recommended that further studies assess anxiety and reasoning for subsequent imaging. They also said the results of the study stress the critical role of the clinical breast exam in the evaluation of breast pain.