A      Evidence based guidelines - the evidence base for mammography in generalised lumpiness, breast pain or tenderness of longstanding nipple retraction

Evidence Table J9

Generalised lumpiness, pain or tenderness, longstanding nipple retraction

A

  

Clinical Problem

Generalised lumpiness, tenderness, longstanding nipple retraction

A1

  

Ref No. in MBUR4 (if any)

J9

A2

  

Section in MBUR4

Breast disease

B

  

Search strategy: databases used; period; MeSH headings; other key words.

Medline 1966-2001, EMBASE 1988-2001, hand search relevant journals, diagnostic imaging, and breast, pain or nodularity or lumpiness or tenderness or nipple inversion or nipple retraction.

C

  

Search results: no. found;

no. used.

13 found, 2 used

D

  

Reference numbers of cited references in attached master list.

J9 1,2

E

  

Summarised results from each of the cited references

Kerin et al (J9 1) assessed the value of mammography in 585 symptomatic patients with non suspicious clinical and cytological findings. 8 with nodularity alone had cancer shown on mammography. Overall 3% of these women had breast cancer. Sweeney and Wylie (J9 2) report the mammographic features of duct ectasia including long standing nipple retraction.

F

  

Statement (= the conclusion drawn from E)

When women over 40 present with non suspicious symptoms the rate of cancer shown on mammography is low at 3% but higher than in an asymptomatic screening population. Mammography is recommended before discharge from the breast clinic.

G

  

Evidence level of F classified I - IV

3

H

  

Investigation

Mammography

I

  

Recommendation *

2 Not indicated initially

J

  

Grade of Recommendation

A - C

B

K

  

Comment (if any) to go in booklet version of MBUR5

 May be worthwhile in women over 40 with persisting non suspicious breast symptoms

L

  

Any other comments on this problem (e.g. caveats; suggestions for research or systematic review; cost or opportunity cost; users' views.

Ros Given-Wilson

Comments: Imaging in these circumstances has little part to play in women <40 years

References: -

Ref ID Author; Year; Country; Grade (I-IV). Aims Patient population Study design* Results
J8 1 Dennis MA 2001 USA 3 Review of women with a breast lump and normal imaging 486 women presenting with breast lumps Retrospective series No cancers if mammo and US showed no focal abnormality
J8 2 Roche NA 1998 UK 3 Assess standardised imaging reporting as part of triple test 400 women with symptomatic breast lumps Prospective series All lesions reported as C4/5 and I 4/5 proved malignant. All palpable cancers showed an US abnormality
J8 3 Duijm LE 1997 Netherlands 3 Assess combined use of US and Mammo in symptomatic women 3014 consecutive,mainly symptomatic women Observational follow-up After ave 30 months follow up sens for breast cancer was 92% and spec 97.7%
J8 4 Steinberg JL 1996 Canada 3 Assess triple test in the diagnosis of BC 290 patients with palpable breast lumps Retrospective series Where all 3 - mammo, clinical and FNA agreed on malig or benign, sens 95.5% and Spec100%
J8 5 Kaufman Z 1994 Israel 3 Assess triple test for breast lumps 234 patients with palpable breast lumps Prospective series For combined mammo, clin and FNA sens 100% (all cancers positive in 1 or more components) and NPV 100% (if all 3 indicated benign= no cancers)
J8 6 Butler JA 1990 USA 3 Assess triple test for breast lumps 113 women with lumps Prospective series For combined mammo, clin and FNA 1 or more positive in every cancer.
J8 7 Johnstone PA 2001 USA 3 Assess mammo in women age 30 or less with breast symptoms 142 symptomatic young women <=30 Retrospective series No cancers found
J8 8 Brand IR 1993 UK 3 Assess utility of mammo in symptomatic women age < 35 159 symptomatic women <35 74% without and 24% with lumps Retrospective series Mammography did not help clinical management
J8 9 Shaw de Paredes E 1991 USA 3 Assess utility of mammo in diagnosis of BC <=35 66 women age<=35 with BC Retrospective series Despite 52% having dense breasts mammo showed 89% cancers and may be useful when the suspicion of BC is high
J8 10 Bassett LW 1991 USA 3 Assess utility of mammo and US in women <35 1016 women <35 having mammo Retrospective series 6 had cancers, mammo positive in 1, benign in 3 and negative in 2
J8 11 Yelland A 1991 UK 3 Assess triple test in women<36 with BC 81 consecutive women age < 36 with BC Retrospective series Mammo sens low at 45%. In 16% of women all 3 aspects of triple test negative
* e.g. RCT Comparison (pro/retro-spective)
Series (pro/retro-spective)
Audit