Chapter 09 — Benign Breast Disease

Most people who come to a breast clinic do not have cancer, but almost all of them fear that they do. The surgeon’s task is to reach a reliable diagnosis quickly, to explain it in a way that removes unnecessary fear without offering false reassurance, and to avoid operations that are not needed. Many benign conditions need no surgery at all, and some, such as breast infection during breastfeeding, are made worse by the wrong advice. This chapter covers the breast consultation and the common benign conditions; breast cancer is covered in Chapter 10.

Table 9.1. Common benign breast conditions at a glance.

STEP 1 Explaining the diagnosis and the plan

9.1 The breast consultation

Examine every patient with a chaperone, and offer a female clinician where possible; many patients will not mention a breast symptom at all unless they know this is available. Ask about the symptom, its relation to the menstrual cycle, breastfeeding, medicines, and family history. Women aged 30 and over with an unexplained breast lump, and those aged 50 and over with discharge, retraction, or other changes in one nipple, meet criteria for an urgent suspected-cancer referral [1].

Diagnosis rests on triple assessment: clinical examination, imaging, and, for any solid or uncertain lesion, core needle biopsy (Figure 9.1). Ultrasound is the main test in younger women, with mammography added in older women according to local protocol. When all three components agree that a lesion is benign, the patient can be reassured with confidence; when they disagree, further sampling or excision is needed even if the biopsy was benign. A lesion classified as probably benign on imaging (BI-RADS 3) carries a risk of cancer of 2 in 100 or less, and is usually followed with short-interval imaging rather than biopsy [2].

[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]

Figure 9.1. Triple assessment of a new breast symptom.

Waiting for results is often the hardest part. Give a date, say how the results will be given, and ask whether the patient wants a family member present. If a cancer is diagnosed, use the approach in Section 1.7 and the pathway in Chapter 10. Figure 9.2 summarizes the usual plan for the six most common benign problems, described in the sections that follow.

[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]

Figure 9.2. Six common benign breast problems and the usual plan.

9.2 Cysts and fibroadenomas

Cysts are fluid-filled sacs, common in the decade before menopause. A simple cyst seen on ultrasound needs no treatment; aspiration relieves a painful or large cyst. Bloody fluid, a lump that remains after aspiration, or a cyst that keeps returning needs further assessment.

A fibroadenoma is a benign solid lump of breast tissue, most common in young women. Recent guidelines from the American Society of Breast Surgeons and the Society of Breast Imaging advise that a fibroadenoma proven on core biopsy, and concordant with imaging, needs removal only if it causes symptoms, reaches a large size, grows substantially, or the patient prefers it removed; no imaging follow-up is needed, and the patient returns to routine screening [3]. Lesions suspicious for a phyllodes tumor need complete surgical excision [3]. Vacuum-assisted excision under local anesthetic is an alternative to open surgery for suitable lesions.

9.3 Breast pain

Breast pain is common and is usually hormonal, varying with the menstrual cycle. Pain alone, without a lump or other change, is rarely a sign of cancer. Examine the patient; image a focal, persistent area of pain according to local protocol. Most patients need reassurance, a well-fitting supportive bra, and simple pain relief, such as a topical anti-inflammatory gel. A pain diary helps to show whether pain is cyclical. Many supplements are promoted for breast pain, but few have been shown to work in trials.

9.4 Nipple discharge

Discharge that appears only when squeezed, comes from several ducts in both breasts, and is milky, green, or clear is usually physiological and needs reassurance, with advice to stop squeezing. Discharge that is spontaneous, from a single duct, or bloody or watery needs imaging. The most common cause is a benign intraductal papilloma. Persistent pathological discharge is treated by removing the affected duct (microdochectomy), or the major ducts (total duct excision) in women who do not plan to breastfeed.

9.5 Breast infection

Mastitis during breastfeeding is best understood as a spectrum that starts with inflammation and swelling, not infection. Current guidance advises continuing to breastfeed directly from the affected breast, avoiding excessive pumping and deep massage, using ice and anti-inflammatory medicines, and giving antibiotics when bacterial mastitis is suspected [4]. An abscess is usually treated by ultrasound-guided needle aspiration, which can be repeated, rather than by incision [4].

Infection outside breastfeeding is often periductal mastitis, which is strongly linked to smoking and tends to recur; stopping smoking is part of treatment, and recurrent disease may need duct excision. Idiopathic granulomatous mastitis, seen relatively often in women of Middle Eastern and South Asian origin, can mimic both abscess and cancer. It is diagnosed by core biopsy and is usually managed medically; repeated incisions should be avoided.

9.6 Gynecomastia

Gynecomastia is enlargement of breast tissue in men. It is common at puberty and in older age, and can be caused by medicines, anabolic steroids, liver or kidney disease, or hormonal conditions. Assessment includes a medicine review, examination of the testes, and blood tests where indicated; a hard, eccentric, or fixed lump needs triple assessment. Most pubertal gynecomastia settles. Surgery, by liposuction, excision, or both, is offered for persistent enlargement that troubles the patient. Many men find the subject embarrassing; acknowledge its effect on confidence and body image.

STEP 2 Procedures, preparation, and recovery

9.7 What to expect from each procedure

Table 9.2. Benign breast procedures: what patients should expect.

9.8 Preparation and recovery

• Blood thinners. Core biopsy can usually proceed on aspirin; anticoagulants and other antiplatelet medicines need an individual plan (Chapter 22).

• Breastfeeding. Tell the team if the patient is breastfeeding; most procedures can be done without stopping.

• Support. A firm, supportive bra worn day and night for the first days reduces pain and bruising.

• Activity. Normal daily activity resumes within a day or two after biopsy and small excisions; avoid strenuous exercise for about a week after surgery.

• Prayer and washing. Patients can pray normally; keep the dressing dry or use a waterproof dressing for ablution.

STEP 3 Questions patients ask

“Is it cancer?”

Most breast lumps are not cancer. We will know for certain when all three tests agree, and I will tell you the results myself on [day].

“Can a fibroadenoma turn into cancer?”

No. A fibroadenoma is harmless and does not turn into cancer. You do not need extra scans for it [3].

“Does it have to be removed?”

Not usually. We remove it if it bothers you, grows, becomes large, or if you would prefer it gone [3].

“Does breast pain mean cancer?”

Pain on its own is very rarely a sign of cancer. It is usually linked to hormones. We have examined you carefully, and a good supportive bra and simple pain relief usually help.

“Should I stop breastfeeding because of the infection?”

No. Keep feeding from both breasts, including the sore one. It is safe for your baby and helps you recover [4].

“Will I be able to breastfeed after duct surgery?”

If only one duct is removed, usually yes. If all the main ducts are removed, breastfeeding from that breast is not possible, so tell us if you plan to have children.

“Can I see a female doctor?”

Yes. We will arrange a female doctor where possible, and a female nurse will always be present.

“Will the needle test hurt?”

We numb the area first. Most people feel pressure and a clicking sound, not sharp pain. A bruise afterward is normal.

“Do I need mammograms more often now?”

For most benign conditions, no. You go back to the screening that is normal for your age.

“Men get breast swelling too? Is it serious?”

It is common and usually harmless, often due to hormones or medicines. We will check the cause, and most cases settle on their own.

STEP 4 Risks, warning signs, and consent

9.9 Material risks

Table 9.3. Material risks of benign breast procedures. Square brackets mark figures to replace with unit data.

9.10 Consent checklist

9.11 Warning signs

Table 9.4. Green, amber, and red warning signs after benign breast procedures.

STEP 5 Patient education guide

The following pages may be photocopied and given to patients. Tick the test or treatment the patient had, and add your unit’s name, phone numbers, and review date before use.

Most breast problems are not cancer

We check breast problems in three ways: an examination, a scan, and sometimes a small needle sample. When all three agree, we can be very sure of the answer. Most breast lumps and changes turn out to be harmless.

The test or treatment you had

☐ Needle sample (core biopsy)

☐ Fluid removed from a cyst or abscess

☐ Lump removed with a needle device (vacuum-assisted excision)

☐ Lump removed by an operation

☐ Operation on a nipple duct

☐ Operation for male breast swelling (gynecomastia)

Your results

• Your results will be ready on: ______________________

• We will give you the results by: ☐ clinic visit ☐ phone call

• You are welcome to bring a family member.

1. Pain and pain medicines

• The area may ache for a few days. Take simple pain medicine, such as paracetamol, as we advised.

• Wear a firm, supportive bra day and night for the first few days.

2. Your wound

• Bruising is common and fades in 1 to 2 weeks.

• Keep the dressing dry for 1 to 2 days, then shower normally. Use a waterproof dressing for washing before prayer if needed.

• A small firm area under the scar is normal while it heals.

3. Breastfeeding

• If you are breastfeeding, you can usually keep feeding from both breasts.

• If you have mastitis, keep feeding from the sore breast. Use cold packs and anti-inflammatory medicine as advised. Do not pump extra or massage hard.

4. Rest and activity

• You can do normal daily activities the next day after a needle test.

• After an operation, avoid hard exercise and heavy lifting for about a week.

• You can pray as usual.

5. Getting back to normal

6. Follow-up

• Your follow-up appointment is on your card.

• For most harmless conditions, you do not need extra scans. Go back to the screening that is normal for your age.

• Always tell us about a new lump or change.

7. Warning signs: when to get help

References

1. National Institute for Health and Care Excellence. Suspected cancer: recognition and referral (NG12). London: NICE; 2015, updated.

2. D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. 5th ed. Reston, VA: American College of Radiology; 2013.

3. Rosenberger LH, et al. American Society of Breast Surgeons and Society of Breast Imaging 2025 guidelines for the management of benign breast fibroepithelial lesions. JAMA Surg. 2025. doi:10.1001/jamasurg.2025.4392

4. Mitchell KB, Johnson HM, Rodríguez JM, et al. Academy of Breastfeeding Medicine Clinical Protocol #36: the mastitis spectrum, revised 2022. Breastfeed Med. 2022;17(5):360-376.

Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.