Breast symptoms in general practice — KFP-style written assessment

KFP 1 (10 marks)

A 29-year-old woman presents with a three-month history of right-sided breast pain, worse before her period, bilateral but worse on the right. Examination reveals generalised nodularity, no discrete lump, no skin or nipple change, no axillary nodes. She is terrified she has cancer — her aunt died of it at 55. ^{[5] [10]}

1. What is the likely diagnosis and what is her cancer risk with pain alone? (3) ^[5]
2. Outline your evidence-based management ladder. (4) ^{[10] [4]}
3. She asks whether evening primrose oil would help. What does the evidence say? (3) ^[10]

Model answers

1. Cyclical mastalgia (worse premenstrually, bilateral, hormonal pattern). Cancer risk with pain as the only symptom is low — 1.24% in a series of 447 women, and all four cancers had an abnormality on clinical examination. Her family history raises her baseline risk and justifies formal risk assessment, but the pain itself is not the cancer presentation. ^[5]
2. Ladder: (1) reassurance after proper examination — the majority need nothing more once cancer is excluded; (2) well-fitting supportive bra plus topical NSAID gel massage — usually effective as a combination; (3) second-line for severe refractory cyclical pain: anti-oestrogen therapy (tamoxifen or centchroman) for 3–6 months — topical 4-hydroxytamoxifen gel reduced pain significantly versus placebo (−12.71 mm VAS) with excellent tolerability; (4) danazol for resistant cases. Set expectations: cyclical pain resolves spontaneously in 20–30% but recurs in 60%. ^{[10] [4]}
3. It does not work. Systematic review evidence states gamma-linolenic acid/evening primrose oil, though commonly prescribed, is not effective for mastalgia. Chamomile extract showed benefit over placebo for mild-to-moderate cyclical mastalgia in a double-blind RCT if she wants a low-risk adjunct. ^{[10] [12]}