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GENERAL PRACTICE: Lucien E M Duijm, Gerard L Guit, Jan H C L Hendriks, Joost O M Zaat, and Willem P T M Mali Value of breast imaging in women with painful breasts: observational follow up study BMJ 1998; 317: 1492-1495 [Abstract] [Full text]

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Mammography for mastalgia: if it doesn't work, don't use it.

Richard Blunt   (30 November 1998)

Do better with ultrasound

Hans-Albrecht von Waldenfels   (4 December 1998)

Value of imaging in women with painful breasts

Robin Wilson   (10 December 1998)

Negative results are not reassuring

Richard Neal   (22 December 1998)

Mammography for mastalgia: if it doesn't work, don't use it. 30 November 1998
Richard Blunt, Consultant Surgeon Russells Hall Hospital, Dudley, West Midlands DY1 2HQ Send response to journal: Re: Mammography for mastalgia: if it doesn't work, don't use it.	I am concerned by the conclusion of Duijm et al that General Practitioners should have open access to mammography services for their patients with mastalgia. Their study shows no significant relationship between breast pain and breast cancer and they state that the particular value of mammography is reassurance. Surely we should strive for this outcome through an appreciation by doctors and their patients of the results of this investigation, rather than through the continued (mis)application of irradiation to the healthy breasts of young women.
Do better with ultrasound 4 December 1998
Hans-Albrecht von Waldenfels, Praxisklinik Hamburg Winterhude fuer Gynaekologie und Geburtshilfe Muehlenkamp 32, 22303 Hamburg Send response to journal: Re: Do better with ultrasound	When a painful breast has no extra risk of malignancy compared to a control group, nobody should use mamography anymore for this indication. If one needs reassurance, espacially the patient, why not to use ultrasound? You have better images of the benign lesions you are supposed to find, no radiation, and it does not hurt!
Value of imaging in women with painful breasts 10 December 1998
Robin Wilson Send response to journal: Re: Value of imaging in women with painful breasts	Editor - Duijm et al have confirmed that breast ultrasound and mammography are of little diagnostic value in women with breast pain in the absence of clinical signs(1). However we do not agree with their conclusion that breast imaging is appropriate for reassurance of women with breast pain. Mammography involves ionizing radiation and, like all x-ray procedures, should not be used unless there is a clear clinical indication to do so. Duijm et al have clearly shown that for breast pain such a clear clinical indication does not exist. There advice also ignores the possible detrimental effects of false reassurance given by "normal" mammography. Mammography has a significant false negative rate, even in women with palpable breast cancer(2). Breast pain is a very common symptom, particularly in young women, and in most cases can be managed in primary care without referral. Physical examination should be carried out. This is all that is required for the majority, who have come for reassurance. The minority, with pain severe enough to require treatment or abnormal clinical signs, should be referred to a specialist breast clinic for diagnosis and advice on treatment. The advice on the best use of imaging published by the Royal College of Radiologists (UK) in 1998 specifically states that mammography is not indicated for breast pain(3). Furthermore, in the UK direct access to breast imaging for general practitioners is not recommended for any symptomatic breast problem(3,4). Such cases should be seen in breast clinics, where appropriate imaging is carried out only if required after specialist clinical examination. Guidance on referral of patients with breast problem was published and circulated to all general practitioners in 1995 by the UK National Health Service Breast Screening Programme(5). This booklet was compiled by a multidisciplinary group and provides a concise and practical advice to general practitioners on the management of all breast problems. Advising general practitioners to referral women with breast pain to a radiologist rather than a surgeon is inappropriate and contrary to guidance on best practice. Robin Wilson Consultant Radiologist and Clinical Director Roger Blamey Professor of Surgical Science Breast Services Directorate, City Hospital, Hucknall Road, Nottingham, NG12 3RE 1.Duijm LEM, Guit GL, Hendricks JHCL, Zaat JOM, Mali WPTM. Value of breast imaging in women with painful breasts: observational follow-up study. BMJ 1998; 317: 1492-5. 2.Sibbering DM, Burrell HC, Evans AJ, Yeoman LJ, Wilson ARM, Robertson JFR, Blamey RW. Mammographic sensitivity in women under 50 presenting symptomatically with breast cancer. The Breast 1995; 4: 127- 129. 3.RCR Working Party. Making the Best Use of a Department of Clinical Radiology: Guidelines for Doctors (Fourth Edition) London:The Royal College of Radiologists, 1998. 4.Breast Surgeons Group of the British Association of Surgical Oncology. Guidelines for Surgeons in the Management of Symptomatic Breast Disease in the United Kingdom. European Journal of Surgical Oncology 1995; 21 (Suppl A): 3-13. 5.Austoker J, Mansel R, Baum M, Sainsbury R, Hobbs R. Guidelines for referral of patients with breast problems. Sheffield: NHS Breast Screening Programme, 1995. ISBN 1 871997 42 9 Dr Robin Wilson Clinical Director Nottingham Breast Service City Hospital Nottingham
Negative results are not reassuring 22 December 1998
Richard Neal Send response to journal: Re: Negative results are not reassuring	Duijm et al conclude that ‘the primary value of breast imaging in women with painful breasts seems to be that of reassurance, as no abnormalities are usually detected..' 1 Had they measured the level of reassurance that their negative results provided, it seems unlikely they would have come to this conclusion. There is increasing evidence that negative test results at best provide little reassurance, and at worst can increase anxiety levels and do considerable harm.2-4 A recent review concluded that ‘medical reassurance as currently practised is both ineffective and theoretically contraindicated'.5 The perpetuation of the myth that patients are reassured by negative test results is out-dated and potentially dangerous. Richard D Neal Lecturer in Primary Care Research Centre for Research in Primary Care Nuffield Institute for Health University of Leeds 71-75 Clarendon Road Leeds LS2 9PL Stephen Morley Professor of Clinical Psychology Division of Psychiatry and Behavioural Science in Relation to Medicine University of Leeds 15 Hyde Terrace Leeds LS2 9LT Neither author has a conflict of interest. References 1 Duijm LEM, Guit GL, Hendriks JHCL, Zaat JOM, Mali WPTM. Value of breast imaging in women with painful breasts: observational follow up study. BMJ 1998;317:1492-5. (28th November 1998) 2 McDonald IG, Daly J, Jelinek VM, Panetta F, Gutman JM. Opening Pandora's box: the unpredictability of reassurance by a normal test result. BMJ 1996; 313: 329-332 3 Fitzpatrick R. Telling patients there is nothing wrong. BMJ 1996;313:311-312. 4 Lucock MP, Morley S, White C, Peake MD. Responses of consecutive patients to reassurance after gastroscopy: results of self administered questionnaire survey. BMJ 1997;315:572-5. 5 Coia P, Morley S. Medical reassurance and patient's responses. J Psychosom Res 1998;45:377-386.