672

be acted upon. Dying may be obvious in acute illness but in NATURAL HISTORY OF BREAST PAIN
many patients admitted to hospital, and particularly in the
elderly, the process of dying is imperceptibly gradual, and it JOHN R. WISBEY* SANDEEP KUMAR
can be difficult to know when dying should become the ROBERT E. MANSEL PAUL E. PEECE†
diagnosis. This difficulty can be aggravated by adverse JONATHAN K. PYE LESLIE E. HUGHES
attitudes and impaired perceptions of staff as well as by
Department of Surgery, Welsh National School of Medicine, Cardiff
problems of communication between the patient and staff.
Dysphasia, deafness, and mental confusion create obvious
difficulties, but covert depression can hinder communication Summary 258 patients with breast pain were restudied
in 45% of dying patients.3Under all these circumstances 2 to 7 years after initial assessment in a

(especially if staff have their own difficulties in confronting special mastalgia clinic. Pain persisted at follow-up in 65% of
the subject) medical and nursing staff may be unaware that patients. Mastalgia was cyclical in two-thirds. Mean duration
dying is occurring or that death is inevitable. of pain in patients experiencing complete relief before follow-
up examination 6·8 years, while duration of pain
was
Only 18% of our respondents discussed the diagnosis with from 2 to 30 years. In patients
the patients and only J4°7o discussed the possibility of death. persisting follow-up at ranged
This low level of communication was compensated for by who had relief or substantial improvement in pain, the
27% and 29% of respondents concluding from other improvement was spontaneous in 22% and resulted from a
information that patients were aware of their diagnosis and of hormonally related event—menopause, pregnancy, or use of
their impending death. oral contraceptives—in the remainder. Onset of cyclical pain
There are several possible explanations for the before the age of 20 years was followed by a prolonged course.
A quarter of the patients had non-cyclical pain. There were
’disagreement between respondents about whether patients two populations of patients in this group. One experienced
were distressed while dying and which symptoms caused the
distress. First, there had been failure to pool perceptions at relief after a mean of 3 years, and in the other pain still
weekly multidisciplinary case conferences. Secondly, the persisted after 2-22 years. Relief was spontaneous in one
traditional weekly ward rounds interspersed with junior staff half, and rarely followed a hormonally related event. About
rounds may have predisposed the staff to "snapshot" 70% of the patients, with both cyclical and non-cyclical pain,
assessments of patients’ symptoms and needs, reducing considered that their pain had warranted active treatment.
awareness of changing patterns of distress and of patients
This study indicates that the type of pain and age at onset may
allow some prediction of the course of the disease and may aid
beginning to die. In these ways multidisciplinary
the choice of therapy.
management may actually hinder rather than enhance the
delivery of effective care for dying patients. Thirdly, staff
INTRODUCTION
may not appreciate that care standards need to be improved,
because responses given by patients’ relatives may reinforce MASTALGIA has remained a controversial subject since the
with gratitude what has been done. The dying patient does early work of Atkins. It is a common presenting symptom in
not remain to complain.
general practice and in surgical clinics. Several pain patterns
Edwards5 has described the likelihood of student nurses have been distinguished but the natural history ofthe disease
being faced with not only probing questions from patients but in these subgroups is unknown. The present study was
also their own feelings of inadequacy and failure because of undertaken to provide these data and was helped by the
inability to handle these threatening situations. Although establishment and continuation over the past 10 years of a
student nurses are the youngest and least experienced, they special mastalgia clinic within the department of surgery of
spend more time at the bedside and have more opportunity to the Welsh National School of Medicine.
become involved with patients who may be dying. As the Because many clinicians believe that breast pain has a
moment of death is unpredictable and nurse reactions are
psychological basis, treatment of mastalgia has often been
variable, counselling is more timely and appropriate if it is perfunctory. However, the lack of psychological abnormality
initiated by the ward sister or staff nurse. They were most in most of these patients3 and the response of many to
likely to be aware of each patient’s concern about clinical appropriate hormonal manipulation4,5 means that active
diagnosis and impending death. treatment should be considered in patients with severe pain.
Our results suggest that improved communication between A knowledge ofthe natural history of untreated mastalgia will
medical and nursing staff would increase the general allow more rational treatment.
understanding of individual patient’s needs and enable more
appropriate treatment to be given. Improved understanding PATIENTS AND METHODS
could also help resolve an ethical dilemma which increasingly
Initial Assessment
faces medical staff-whether patients should be resuscitated
or allowed to die. Patients with breast disease were first seen in the breast clinic of
the department of surgery, where a detailed proforma-directed
We thank the ward staff and Mrs J. Mills for their help with the
questionnaires, Mrs M. McGann for secretarial assistance, and Dr W. F. history was taken and a thorough physical examination was carried
Whimster for constructive criticism of the manuscript. out. This clinic sees more than a 1000 new patients each year.
Mammograms are performed routinely in all patients over the age of
Correspondence should be addressed to B. L., St Francis’ Hospital, St 25 years.
Francis’ Road, London SE22 8DF.
Patients with pain as a primary symptom are reassured after full
REFERENCES assessment, and most require no further treatment. Patients with
1. Office of Population Censuses and Surveys. Hospital in-patient enquiry 1979. London:
severe pain are asked to fill in a specially designed breast pain chart6
HM Stationery Office, MB4 No. 12. over a 4-week period. If on the subsequent visit the patient still
2. Exton-Smith AN. Terminal illness in the aged. Lancet 1961; ii: 305-08
3. Hinton JM. The physical and mental distress of the dying. Quart Med J 1963; 1: 1-21.
4. Witzel L. Behaviour of the dying patient. Br MedJ 1975, ii: 81-82.
Present address: *Department of Surgery, Hammersmith Hospital, London.
5. Edwards P. Am I going to die, nurse? Nurs Times 1983; 79, 10: 27-28.
†Departmentof Surgery, Ninewells Hospital, Dundee.
 673

considers her pain to be severe and this is corroborated by her pain TABLE I-DISTRIBUTION OF PATIENTS BY SUBGROUP WITH
chart, sheis referred to the special mastalgia clinic. Here a further THEIR MEAN AGE AT PRESENTATION
detailed questionnaire related specifically to pain is completed.
Psychiatric assessment is performed by means of the Middlesex
7
Hospital questionnaire.
An assessment of patients studied in this way led to a clinical
classification.2The three main subgroups of idiopathic mastalgia
were designated cyclical, non-cyclical, and Tietze’s disease. All

patients are now put into the appropriate subgroup. The cyclical
group consists of those patients whose symptoms are predominantly
premenstrual and cyclical. Non-cyclical breast pain is experienced
either continuously throughout the month or is intermittent with
0 cyclical
irregular exacerbations. Classification of post-hysterectomy or . nan-cyclical
other atypical patients is made by reference to the pain charts
II1II Tietze’s disease
recorded over 3 months. A third distinct group, those with Tietze’s
disease, can be differentiated by the clinical finding of tender
costochondral junctions with a non-cyclical, continuous pain
pattern.
Thus, the study group comprised a heterogeneous group of
patients whose primary presenting feature was breast pain, in whom
malignancy was excluded, and who did not have a discrete lump
requiring biopsy. These patients did not receive any medication
other than self administered analgesics and in some cases, an oral
contraceptive, although several patients with non-cyclical pain had Age-groups at onset of mastalgia
surgery at some stage for removal ofa painful lump or excision of the Fig I-Age at onset for each type of mastalgia.
duct system for periductal mastitis.

Duration of Pain
Follow-up
’

In many patients cyclical pain persisted for a long time; this

From 1973 to 1977, 417 patients with severe mastalgia were persistence was common when pain started in the second
identified. A follow-up arranged during
was 1979-80 either by decade (fig 2). Often relief came only with the onset of the
personal interview of attenders (65%), or a postal
current menopause.
questionnaire (25%) was sent to discharged patients or their general Patients with non-cyclical pain tended to fall into two
practitioners. Those who did not respond to the postal populations, with pain of relatively short duration (2-4
one
questionnaire (10%) were visited at home. Follow-up was achieved years) and a second with a much longer duration continuing
in 258 (62%) of the 417 patients, with a mean follow-up time of 4
to the time of follow-up (fig 3). Some patients in the first
years (range 2 to 7 years). Most patients were lost to follow-up
because of a change of address. Few of those traced declined to population had achieved relief by surgery.
cooperate.
At follow-up details of the following were requested-the type of
pain; any changes in the type, character, and site of pain; changes in .
/’0//! stopped at follow-up
the hormonal status (ie, pregnancy, contraceptive pill usage,
A
pain continued at fallaw-up
- t- mean <t/f<7 f/ 0/) m years=1Sf
menopause); and any breast, ovarian, or uterine operation occurring
during the intervening period. Patients were asked if they thought
in retrospect that active treatment had been necessary in their case.
Pain at follow-up was classified by clinicians who were unaware of
the classification at initial presentation. The duration of pain was
taken from the time of onset to its spontaneous disappearance or
when pain was still present as the interval between onset and follow-
up. When the follow-up survey was completed the 2 proformas for
each patient were correlated and information on the natural history
of breast pain was recorded on cards and subsequently transferred to
the departmental computer for analysis.

RESULTS
II GV &1..,.., oJl TV -1 - UV -:::AJ
Two-thirds of the patients had cyclical pain and one quarter
had non-cyclical pain (table i).
Age-groups at onset of cyclical mastalgia
Fig 2-Duration of cyclical breast pain related to age at onset.

Age at Onset
In more than half the patients in the cyclical group Patients with Tietze’s disease generally did not have pain of
symptoms began before the age of 30 years and in most pain long duration, only one patient had had symptoms for more
started in the third decade (fig 1). Only 3 patients had cyclical than 10 years.
pain developing after the age of 50 years. In the non-cyclical Analysis of the duration of symptoms in those women in
group the most common age of onset was in the fourth decade whom pain had completely stopped at follow-up showed a
of life and in about 12% cases pain developed after the age of mean duration of about 6 - 8 years for the cyclical group, 3
50 years. Onset of Tietze’s disease was more evenly years for the non-cyclical group, and 3-55 years for the
distributed throughout the age-groups. Tietze’s group.
674

the naturalhistory of benign breast disease has been largely

.
pain stopped at follow-up
*
pain conttnuerJ at follow-up ignored simply reported in anecdotal fashion.8 The details
or

- i. mean duration in years f / f of natural history derived from this study allow some
prediction of the likely course. Women in whom cyclical
mastalgia develops in middle life can look forward to relief
with the menopause, but younger patients with severe
symptoms may expect many years of symptoms. These are
likely to be particularly troublesome when mastalgia has its
onset in the second decade. Persistent severe symptoms
should prompt consideration of specific therapeutic
measures, especially now that new drugs of proven efficacy
such as bromocriptine and danazol are available.4,5 However,
there are few data available on whether these hormones alter
the long-term behaviour of the condition, or whether they
will prove to have undesirable side-effects with prolonged
administration. Fortunately many milder cases are more
II. w -, w v.....,..- ....,... oJV mv
evanescent, but such cases were excluded by the nature of this
Age-groups at onset of non-cyclical mostotgia study.
Fig 3-Duration ofnon-cyclical breast pain related to age at onset. The pattern seen with non-cyclical pain is rather different,
since there seem to be two populations. In the first, pain lasts
Events Related Relief of Symptoms
to
2-3 years, but in the second group pain persists, and
About 60% of patients in the cyclical group had complete or improvement at the menopause cannot be guaranteed. We
substantial relief of their symptoms during follow-up, and in have no effective treatment for this group, and management
most cases this was related to some "hormonal" event (table will remain unsatisfactory until more is known about the
II). Symptoms improved in less than half the patients in the underlying pathology. Patients with very local pain may be
non-cyclical group. Half the patients with Tietze’s disease considered for excision biopsy, and those with retroareolar
had relief from symptoms and in all these cases the relief was pain associated with signs of periductal mastitis may be
spontaneous. No therapy was associated with complete treated by duct excision. However, a satisfactory result
resolution of pain. cannot be guaranteed.
About 70% of patients with severe breast pain-ie, Mastalgia may be the sole presenting symptom of breast
approximately 5% of all mastalgia patients-in retrospect cancer.9 In this follow-up study 3 patients had to be referred
thought that their pain should have been treated. The type of back to the main breast clinic with frank malignancy after
pain changed in only 3% of the patients and most patients they had presented with persistent localised pain (unlike that
were consistent in their description of the pain between the seen with the commoner cyclical mastalgia). Such persistent
initial and follow-up proformas. localised pain warrants careful follow up.
At presentation 17% of patients with
cyclical pain and The higher rate of hysterectomy in the group with non-
Tietze’s disease and 33% in the non-cyclical group had cyclical pain probably reflects the higher mean age of this
already had a hysterectomy (table III). group, since older women have more years "at risk" of
having the operation and gynaecologists are more likely to
TABLE II-PATIENTS IN WHOM PAIN WAS RELIEVED AND EVENTS
RELATED TO THIS RELIEF
perform the procedure in women who are past childbearing
age. The incidence of hysterectomy does not seem to be
increased in the cyclical group, although this group is often
postulated to be more likely to have a central hormonal
"imbalance" leading to irregularities of menstruation.
This has confirmed that symptoms may persist for
study
many years in patients with severe mastalgia. The type of
pain and age of onset may allow some prediction of its long-
term behaviour.

Correspondence should be addressed to L. E. H., Department of Surgery,

5 cases; Hadfield’s Welsh National School of Medicine, Cardiff CF4 4XN.
*Excision biopsy, operation for duct ectasia, 3 cases.

REFERENCES
TABLE III-PATIENTS WHO AT PRESENTATION WITH MASTALGIA
1. Atkins HJB. Treatment of chronic mastitis. Lancet 1938; i 707-12.
HAD ALREADY HAD HYSTERECTOMY 2. Preece PE, Hughes LE, Mansel RE, Baum M, Bolton PM, Gravelle IH. Clinical
syndromes of mastalgia. Lancet 1976; ii: 670-73.
3. Preece PE, Mansel RE, Hughes LE. Mastalgia: psychoneurosis or organic disease? Br
Med J 1976, 1: 29-30.
4. Mansel RE, Preece PE, Hughes LE. A double blind trial of the prolactin inhibitor
bromocriptine in painful nodular benign breast disease. Br J Surg 1978; 65: 724&mdash;27
5. Mansel RE, Wisbey JR, Hughes LE. Controlled trial ofthe antigonadotropin danazol
in painful nodular benign breast disease. Lancet 1982; ii: 928-31.
6. Hughes LE, Mansel RE. Benign breast disease. In: Russel RCG, ed. Recent advances
in surgery No 11. Edinburgh. Churchill Livingstone, 1982: 114.
7. Crown S, Crisp AH. Manual of Middlesex Hospital Questionnaire. Barnstaple

DISCUSSION Psychological Test Publications, 1970.

8. Geschickter CF. Diseases of the breast 2nd ed. Philadelphia: JB Lipincott and Co
1945. 183-99
The pathology of benign breast disease and its relation to 9. Preece PE, Baum M, Mansel RE, Webster DJT, Fortt RW, Gravelle IH, Hughes LE
the development of cancer has received much attention, but Importance of mastalgia in operable breast cancer. Br Med J 1982; 284: 1299-1300