A Breast Pain Protocol for Women Can Reduce Overall Specialist Visits, Thereby Reducing Health Care Expenditure and Maintaining Quality Care

Edirisinghe, E., Callahan, C., Brown, M., Quijano, M., Nath, R., Brophy, P., Cornell, K Winchester Hospital Breast Care Center, Woburn, MA

Breast pain is a common, distressing problem among women. Many of them seek medical attention because they are concerned about the possibility of breast cancer. (Howard, Battaglia, Prout, Freund, 2012).  After significant disease is ruled out, most patients respond to simple reassurance. Others, however, require treatment because symptoms interfere with their lives.

Breast pain is a common complaint heard by primary care physicians and breast specialists, who often recommend breast imaging to provide reassurance of benign etiology.  (Howard, Battaglia, Prout, Freund, 2012). Nurses can serve an important role in providing that reassurance and the education that is essential in treating these women (Chase, Wells, Eley, 2011).

Breast pain (mastalgia) is a general term used to describe pain in one or both breasts. It occurs in up to 70% of the female population. When breast cancer has been ruled out, 15% of breast pain requires drug treatment. (Gately, Mansel, 1990)

Breast pain can be cyclical, usually affecting both breasts and is related to a woman’s menstrual cycle, occurring in pre-menopausal women commonly in their 20s.  Cyclical breast pain commonly occurs in women in their 20s 30s and 40s. Patients describe it as sharp, burning, achy and/or sore. (Chase & Wells, 2011 and Norlock 2002). Non-cyclical breast pain may occur in post-menopausal women frequently in a localized area of the breast. (Steinbrunn, Zera, Rodriguez, 1997)

When no breast abnormality is seen on breast imaging, a clinician can offer suggestions on how to ease the discomfort. These may include hot or cold compresses and a supportive bra (without an under-wire), which may be worn at night, if it is comfortable, as well as during the day. Non-prescription anti-inflammatory pain relievers, vitamin E, and evening primrose oil (EPO) may all provide symptom relief. Research at Mayo Clinic on breast pain led to a recommendation of acupuncture and topical anti-inflammatory over-the-counter (OTC) medications, such as ibuprophen. (Mayo Foundation for Medical Education, 2008).

The etiology of breast pain is difficult to determine and may never be identified. Causes may include breast tissue nodularity, hormonal changes, decreased essential fatty acids, and methylxanthines derivatives that are found in caffeine and theophylline. Many OTC dietary supplements such as ephedra, ginseng, and don quai can have effects similar to caffeine (Berry, 2010). It is possible that the pain is not breast-related and the patient may instead be experiencing chest wall pain, an inflammation of the chostochondral junction or other medical conditions requiring further work up by the referring physician.

A current accepted theory blames a hypersensitive state at hormone receptor sites that may cause a decrease in essential fatty acids. This decrease could affect the sensitive cell membrane receptors, resulting in breast pain. In the Cardiff Breast Clinic, 45% of women complained of breast pain as one of the presenting symptoms. Most of them feared that because they had breast pain they had breast cancer, but it is rare without an associated lump or mammographic abnormality. Clinical examination and mammography followed by an explanation and reassurance is the most effective treatment for breast pain in 85% of cases. (Gately & Mansel, 1990).

Studies on dietary recommendations are limited. Several options for treatment are available with some benefit to patients including EPO, Vitamin E, and Vitamin B6. Medications include nonsteroidal anti-inflammatory drugs (NSAIDs), danazol, bromocriptine, tamoxifen, diuretics and luteinizing hormone-releasing hormone (LH-RH). In severe cases, narcotics are used.

EPO is a rich source of gamma linoleic acid (GLA) and is often used as a first-line dietary supplement in the treatment of mild breast pain. A dose of 3 gms per day has produced a useful response in 44% of patients with cyclical breast pain and 27% in non-cyclical breast pain.(Gately & Mansel, 1990; Steinbrunn, Zera, Rodriquez, 1997; Berry, 2010). The theory is that GLA reduces the pain by increasing the ratio of essential to saturated fatty acids. (Norlock, 2002). EPO can be used without adverse side effects in patients who want to get pregnant. Besides oral NSAIDs, EPO is the only recommended treatment that does not interfere with the effectiveness of birth control and hormone replacement therapy (Norlock, 2002; Berry, 2010).

The disadvantage is that it may take up to 4 months for a patient to see the benefits. (Berry, 2010;Gately & Mansel,1990).

Vitamin E has been used by clinicians for more than 35 years in the medical management of benign breast disease. It seems to relieve symptoms that are caused by excessive estrogen levels and provides an anti-inflammatory effect, giving some women relief. The recommended dose is 400-800 IU daily. Other than providing a placebo effect, the exact mechanism of Vitamin E action is unclear (Berry, 2010).

Caffeine reduction has been recommended for many years without real determination of its effectiveness. Reducing the ingestion of methylxanthines has been a strong recommendation by clinicians for many years. Because pain is subjective to each individual, many researchers have studied the relationship between caffeine and breast pain. Xanthine is a purine nitrogenous-based substance found in nature. Methylxanthines are Xanthine derivatives found in cocoa, black tea and chocolate. Caffeine, theophylline and aminophylline are methylxanthines (Chase, Wells, Elley, 2011).

Restricted intake of dairy products and foods high in saturated fats can relieve breast pain when it is mild to moderate, but not when it is severe. Salt restriction, diuretics and medroxyprogesterone have been found to be ineffective (Berry, 2010). Diuretics can often be used as first line drug therapy for cyclical breast pain but no theoretical basis has been shown to suggest that they are effective. Measurement of total body water, early and late in the menstrual cycles of 39 women with breast pain showed no correlation (BeLieu,1994).

BACKGROUND

Baseline data show that 210 patients (100%) in 2009 were seen in the Breast Care Center [BCC] for consultation visits with breast specialists for breast pain. In January, 2010 the BCC surgeons identified a subgroup of patients referred to the BCC breast pain that had a diagnostic mammogram and breast ultrasound with negative breast imaging results and no other breast symptoms.

The Breast Pain Protocol was developed to meet the needs of these patients. The BCC Nurse Coordinator developed this protocol in collaboration with the BCC surgeons and nurses. The nurse coordinator, with editing and final approval by the BCC surgeons, developed a breast pain education sheet that identified 10 common triggers for pain. It recommended the elimination and/or modifications of these triggers, along with dietary supplements to aid in the relief of pain. The education sheet encourages monitoring of menstrual cycle to determine its correlation to cyclical or non-cyclical pain. Specific triggers for breast pain are identified and recommendations are made.

The project involved 255 patients referred to the BCC with breast pain from March 1, 2010 through February 28, 2011. Negative breast imaging was defined as a negative bilateral diagnostic mammogram and a focused breast ultrasound in the area of pain. Any patient identified during nursing assessment as having non-breast related symptoms was sent back to her referring physician.  The protocol also required that a BCC nurse provide a 6-8 week follow-up phone call to the patient to assess the patient’s pain relief.

METHODOLOGY

Patient diagnostic breast imaging is reviewed by the radiologist and the findings are provided to the BCC nurse. The BCC nurse navigator reviews results of the breast imaging findings, and meets with all patients who have breast pain, negative breast imaging and no other breast related symptoms. The nurse reviews the breast pain education sheet with the patient to help identify possible triggers and recommends a plan of care that is specifically for the patient. Dietary and lifestyle changes such as reducing caffeine, limiting sodium, reducing high fat and sugar intake and maintaining a low-fat healthy diet rich in fruits, vegetables and grains is recommended. Dietary supplements are recommended if not contraindicated. Patients are encouraged to try one supplement at a time consistently for 4-6 weeks, to see if it relieves the breast pain. The supplements are Vitamin E 400 IU-800 IU per day not to exceed 800 IU, EPO 3-4 grams per day or Omega 3 fish oil 1000 mg per day.

Triage assessments also identify pain that is non-breast related and the patient is sent for further evaluation by the referring physician. Following review and discussion of the education sheet, the patient provides a phone number where she can be reached for follow-up, and the patient signs the education sheet acknowledging education was received and that breast pain questions were addressed and answered.

OUTCOMES

Implementing this protocol resulted in a 94% reduction (238 patients) in consultation visits with specialists.

  • 103 patients (41%) on the protocol had resolution of breast pain symptoms without any intervention.
  • 31 patients (12%) utilized dietary supplements such as fish oil, Vitamin E, and EPO that relieved breast pain symptoms.
  • 16 patients (6%) had breast pain symptom resolution after reducing caffeine intake.
  • 15 patients (6%) reported their breast pain symptoms were cyclical and
  • 10 patients (4%) noted other hormonal causes.
  • 2 patients (1%) felt their breast pain was lifestyle related and stress induced – returned to referring physician for subsequent care.
  • 4 patients (2%) did not have relief of breast pain symptoms – did surveillance with breast imaging follow-up
  • 42 patients (16%) were lost to BCC follow-up. Collected patient information was faxed to referring physician at the end of eight weeks and patient returned to the referring physician for their subsequent care.
  • 15 patients (6%) had non-breast related conditions and returned to their primary care physician.
  • 17 patients (6%) were scheduled for a consultation visit with BCC specialist.

CONCLUSION

The Breast Pain Protocol was developed in an attempt to find a more efficient way to evaluate women with breast pain and avoid unnecessary consultation visits with BCC specialists. With our protocol, the nurse navigator meets with a woman who has had breast pain with negative breast imaging and no other associated breast symptoms such as lump, redness, swelling or nipple discharge. There is a triage conversation to identify possible triggers and the patient receives recommendations for lifestyle changes and dietary supplements. The whole process is then summarized for the patient on the education sheet. The protocol does not include prescription medications.

As noted by Chase Wells, Eley, 2011, women very often seek medical attention for breast pain due to concerns about breast cancer. Allowing the patients the opportunity to speak to a nurse immediately after diagnostic breast imaging alleviates their fears. The nurse helps a woman take part in her own care by providing education based on her personal history and lifestyle. Together they identify contributing factors for the breast pain and the nurse makes recommendations to lessen or alleviate it.  This process decreases patient anxiety and empowers a woman with the knowledge needed to be engaged in her own care.

The nursing implications of the Breast Pain Protocol is that it gives insight, awareness, education and reassurance to patients. Eliminating fear and providing relief is the cornerstone of nursing care.

This breast pain protocol abstract was presented at the 13th annual meeting of the American Society of Breast Surgeons, May 2-6, 2012 in Phoenix, AZ. The supplemental narrative is an expanded discussion of the many aspects of breast pain management and can be used as a guide for the NCBC patient navigators.  A copy of the patient breast pain education form is included, for reference.

REFERENCES

Berry, J. (2010). Benign breast pain, new approaches to manage common conditions more effectively. ADVANCE for Nurse Practitioners 9(10)  33-37.

Chase, C. & Wells, J. & Eley, S. (2011).  Caffeine and breast pain - revisiting the connection. Nursing for Women’s Health, 15(4) 284-289.

BeLieu, R.M. (1994). Mastodynia. Obstetrics and Gynecology of North America 21(3) 474-475.

Gately, C.A. & Mansel, R.E. (1990). Management of clinical breast pain.  British Journal of Hospital Medicine. 43(5) 330-332.

Howard, M.B., Battaglia,T., Prout, M & Fruend, K. (2012) The effects of imaging on the clinical management of breast pain. J. Gen Intern Med. 27(7)   817-824.

Mayo Clinic Women’s Healthsource (2008). Worrisome Breast Pain. 12 (2) 8.

Norlock, F. (2002). Benign breast pain in women, a practical approach to evaluation and treatment. JAMWA 57 (2) 85-89.

Schmidt-Steinbrunn, B., Zera, R.T. & Rodriquez, JL (1997). Monitoring treatment to type of breast pain/ Mastalgia. Post Graduate Medicine. 102 (5) 183-9, 193-4.

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BREAST PAIN PROTOCOL for NCBC dec 2014

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