Breast Pain

Breast pain is a very common symptom that most women will experience at some point during their lifetime. However, in the absence of other symptoms, breast pain alone is not a cause or symptom of breast cancer.

The healthcare system in current use has propogated the idea that breast pain might have an association with breast cancer, by use of pathways that refer patients with breast pain alone into cancer diagnostic clinics. There they will undoubtedly come into contact with women with red flag symptoms for breast cancer (eg, a lump) and undergo potentially uneccessary investigations that will likely heighten their anxiety.

The evidence base to support the statement that 'Breast pain is not a symptom of breast cancer' is summarised here, together with the current national guidance endorsing this.

The Evidence:

Low Incidence of breast cancer associated with breast pain only

Published literature review* (2022) of 5,100 patients with ‘breast pain only’ (BPO) (11 publications post-2020) - breast cancer (BC) incidence of 3.7 per 1,000

• Largest prospective UK cohort study** (2022) of 10 830 symptomatic women presenting to a BC diagnostic clinic reported 1972 (18%) with BPO - BC incidence of 4 per 1,000
• Combined dataset of 7,408 patients presenting with BPO (post-2000 publications) – BC incidence 4 per 1,000
• 3,819 patients- BPO & 12 months follow up*** - 14 sites in 8 Cancer Alliances which implemented East Midlands Breast Pain Pathway– incidence 3.7 per 1,000 (CI: 2.2-6.2)
• Total dataset of >11,000 patients with BC incidence between 3.7–4 per 1,000

Breast Cancer concordance (where reported) with site/side of breast pain only

• Published review* (2022) of 5,100 patients: concordant in 7 out of 12
• Largest prospective cohort** (2022) of 1972 (18%) with BPO: concordant in 4 out of 8
• Approximately half of BCs are contralateral/non-concordant with breast pain

References:

* Jahan BMJ OQ paper

** No association between breast pain and breast cancer study

*** (Personal Communication – East Midlands BPP Implementation Team)

Breast Pain Only Guidance

• Suspected cancer: recognition and referral NICE guideline [NG12] – “Based on NG12, in the absence of associated red flag symptoms, ie lump or skin changes, breast pain alone is not a symptom of cancer and should not be automatically referred on an urgent cancer pathway.” Published: 23 June 2015 Last updated: 29 January 2021 NHS Publications approval reference: 001559 (NHS England)
• BSBR has clarified its recommendations for the management of breast pain stated in the 4th edition of the RCR Symptomatic & Screening Breast Imaging Guidelines 2019 - 'Breast pain is not an indication for breast imaging' and therefore patients presenting with breast pain (general or focal) ONLY should not be offered imaging.” 7 February 2023
• NHS England published guidance (4 March 2024) on the implementation of ‘Best practice timed diagnostic pathways’ - It [breast pain alone] is not a sign of cancer but can take many months to resolve.”