Journal of General Internal Medicine

, Volume 27, Issue 7, pp 817–824

The Effect of Imaging on the Clinical Management of Breast Pain

  • Mary Beth Howard
  • Tracy Battaglia
  • Marianne Prout
  • Karen Freund
Original Research

Abstract

BACKGROUND

Breast pain is a common complaint to primary care and breast specialists. Literature recommends imaging to provide reassurance of benign etiology. The effect of imaging on reassurance and subsequent healthcare utilization has not been described.

OBJECTIVE

To determine if initial imaging for breast pain reduces subsequent utilization.

DESIGN

Retrospective cohort study at a hospital-based breast health practice.

PATIENTS

Women referred for breast pain from 2006–2009.

MAIN MEASURES

Imaging ordered at initial provider visit; clinical utilization, defined as the number of follow-up visits, diagnostic imaging studies, and biopsies completed within 12 months following initial visit.

KEY RESULTS

Sixty-percent of women were age 40 or younger, 87% were from racial/ethnic minority groups. Twenty-five percent had imaging ordered at initial visit. Of those who received initial imaging, 75% had normal radiographic findings, yet 98% returned for additional evaluation. In adjusted analyses, women with initial imaging had increased clinical services utilization (OR 25.4, 95% CI: 16.7, 38.6). Women with normal clinical breast exams who received initial imaging exhibited increased odds for subsequent clinical services utilization (OR 23.8, 95% CI: 12.9, 44.0). Six cancers were diagnosed; imaging in the absence of clinical breast exam abnormalities did not result in any cancer identification.

CONCLUSIONS

Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy.

KEY WORDS

breast pain mammography breast cancer 

References

  1. 1.
    Millet AV, Dirbas FM. Clinical Management of Breast Pain: A Review. Obstet Gynecol Surv. 2002;57(7):451–61.PubMedCrossRefGoogle Scholar
  2. 2.
    Ganschow P, Norlock F, Jacobs E, Marcus E. Breast health and vommon nreast problems: a practical approach. Philadelphia: American College of Physicians; 2004.Google Scholar
  3. 3.
    BeLieu R. Mastodynia. Obstetrics and gynecology clinics of North America. 1994;21(3):461–77.PubMedGoogle Scholar
  4. 4.
    Ader D, Browne M. Prevalence and impact of cyclic mastalgia in a United States clinic-based sample. Am J Obstet Gynecol. 1997;177:126–32.PubMedCrossRefGoogle Scholar
  5. 5.
    Leinster SJ, Whitehouse GH, Walsh PV. Cyclical mastalgia: Clinical and mammographic observations in a screened population. Br J Surg. 1987;74(3):220–2.PubMedCrossRefGoogle Scholar
  6. 6.
    Barton MB, Elmore JG, Fletcher SW. Breast Symptoms among Women Enrolled in a Health Maintenance Organization: Frequency, Evaluation, and Outcome. Ann Intern Med. 1999;130(8):651–7.PubMedGoogle Scholar
  7. 7.
    Lumachi F, Ermani M, Brandes AA, et al. Breast complaints and risk of breast cancer. Population-based study of 2,879 self-selected women and long-term follow-up. Biomed Pharmacother. 2002;56(2):88–92.PubMedCrossRefGoogle Scholar
  8. 8.
    Smith RL, Pruthi S, Fitzpatrick LA. Evaluation and Management of Breast Pain. Mayo Clin Proc. 2004;79(3):353–72.PubMedCrossRefGoogle Scholar
  9. 9.
    Duijm LEM, Guit GL, Hendriks JHCL, Zaat JOM, Mali WPTM. Value of breast imaging in women with painful breasts: observational follow up study. Br Med J. 1998;317(7171):1492–5.CrossRefGoogle Scholar
  10. 10.
    Preece P, Baum M, Mansel R, et al. Importance of mastalgia in operable breast cancer. Br Med J (Clinical Research Edition). 1982;284(6325):1299–300.CrossRefGoogle Scholar
  11. 11.
    Tumyan L, Hoyt AC, Bassett LW. Negative predictive value of sonography and mammography in patients with focal breast pain. Breast J. 2005;11(5):333–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Morrow M. The evaluation of common breast problems. Am Fam Physician. 2000;61(8):2371–8.PubMedGoogle Scholar
  13. 13.
    Ader DN, Shriver CD. Cyclical mastalgia: prevalence and impact in an outpatient breast clinic sample. J Am Coll Surg. 1997;185(5):466–70.PubMedGoogle Scholar
  14. 14.
    Brand IR, Sapherson DA, Brown TS. Breast imaging in women under 35 with symptomatic breast disease. The British Journal of Radiology. 1993;66(785):394–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Klimberg V. Etiology and management of breast pain. In: Harris J, Lippman M, Morrow M, Hellman S, eds. Diseases of the Breast, vol. 99-106. Philadelphia: Lippincott-Raven; 1996.Google Scholar
  16. 16.
    Stone MD, Norton S, Mendez JE, Hirsch E. Positive impact of a breast-health triaging system on breast-care access and physician satisfaction. Am J Surg. 2007;194(4):482–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Swan J, Breen N, Coates RJ, Rimer BK, Lee NC. Progress in cancer screening practices in the United States. Cancer. 2003;97(6):1528–40.PubMedCrossRefGoogle Scholar
  18. 18.
    Chang S, Kerlikowske K, Napoles-Springer A, Posner S, Sickles E, PerezStable E. Racial differences in timeliness of follow-up after abnormal screening mammography. Cancer. 1996;78(7):1395–402.PubMedCrossRefGoogle Scholar
  19. 19.
    Gwyn K, Bondy ML, Cohen DS, Lund MJ, Liff JM, Flagg EW, et al. Racial differences in diagnosis, treatment, and clinical delays in a population-based study of patients with newly diagnosed breast carcinoma. Cancer. 2004;100(8):1595–604.PubMedCrossRefGoogle Scholar
  20. 20.
    Gross CP, Smith BD, Wolf E, Andersen M. Racial disparities in cancer therapy. Cancer. 2008;112(4):900–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Shavers VL, Brown ML. Racial and ethnic disparities in the receipt of cancer treatment. J Natl Canc Inst J Natl Canc Inst. 2002;94(5):334–57.Google Scholar
  22. 22.
    Kerin M, O'Hanlon D, Khalid A, Kent P, McCarthy P, Given H. Mammographic assessment of the symptomatic nonsuspicious breast. Am J Surg. 1997;173(3):181–4.PubMedCrossRefGoogle Scholar
  23. 23.
    Hendee WR, Becker GJ, Borgstede JP, et al. Addressing overutilization in medical imaging. Radiology. 2010;257(1):240–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Levin DC, Rao VM. Turf wars in radiology: Other causes of overutilization and what can be done about it. J Am Coll Radiol. 2004;1(5):317–21.PubMedCrossRefGoogle Scholar
  25. 25.
    McDonald IG, Daly J, Jelinek VM, Panetta F, Gutman JM. Opening Pandora's box: the unpredictability of reassurance by a normal test result. Br Med J. 1996;313(7053):329–32.CrossRefGoogle Scholar
  26. 26.
    Fitzpatrick R. Telling patients there is nothing wrong. Br Med J. 1996;313(7053):311–2.CrossRefGoogle Scholar
  27. 27.
    Screening for breast cancer: U.S. Preventive Services Task Force Recommendations. Ann Intern Med. 2009;151(10):I–44.Google Scholar
  28. 28.
    Lutfey KE, Link CL, Marceau LD, et al. Diagnostic certainty as a source of medical practice variation in coronary heart disease: results from a cross-national experiment of clinical decision making. Med Decis Making. 2009;29(5):606–18.PubMedCrossRefGoogle Scholar
  29. 29.
    Balsa AI, Seiler N, McGuire TG, Bloche MG. Clinical uncertainty and healthcare disparities. Am J Law Med. 2003;29(207).Google Scholar
  30. 30.
    Lutfey KE, Link CL, Grant RW, Marceau LD, McKinlay JB. Is certainty more important than diagnosis for understanding race and gender disparities?: An experiment using coronary heart disease and depression case vignettes. Health policy (Amsterdam, Netherlands). 2009;89(3):279–87.CrossRefGoogle Scholar
  31. 31.
    Gail MH, Brinton LA, Byar DP, et al. Projecting individualized probabilities of developing breast cancer for white females who are being examined annually. J Natl Canc Inst J Natl Canc Inst. 1989;81(24):1879–86.Google Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Mary Beth Howard
    • 1
  • Tracy Battaglia
    • 1
    • 2
  • Marianne Prout
    • 2
  • Karen Freund
    • 1
    • 2
  1. 1.Women’s Health Unit, Section of General Internal Medicine, Department of Medicine, and Women’s Health Interdisciplinary Research CenterBoston University School of MedicineBostonUSA
  2. 2.Department of EpidemiologyBoston University School of Public HealthBostonUSA

Personalised recommendations