A common theme during these meetings has been a focus on the referral of breast pain to secondary care services. A consensus was formed around two principles that:

1. There has been an increasing medicalisation of the symptom of breast pain, despite this being usually an entirely normal physiological process. Breast pain is the main factor in around 15% of all symptomatic breast clinic referrals leading to over investigation.
2. Almost all people who are referred with breast/axillary pain have chest wall pain unrelated to the breast itself.

The Modernising Patient Pathway Programme Symptomatic Breast Group was tasked to discuss current and proposed practice and to develop recommendations for the management of people with breast pain. It is important to note that these recommendations are for patients with breast pain only and with no other worrying symptoms or signs on presentation (details of such signs and symptoms are provided in the NICE CKS).^1,2

The recommendations fall into three groups:

1.   Imaging for breast pain

1. Currently there is a widespread difference between, and within, Scottish breast units with regard to imaging patients with breast pain; with some imaging no patients, some all patients and some using it as an opportunity for screening.

We suggest that:

1. There is no indication for imaging patients with breast pain in the absence of any other symptoms or signs
2. If patients have missed screening appointments they should be directed to the appropriate screening pathway to be included within a fully quality-assured programme, and opportunistic screening within symptomatic practice is not recommended
3. If units wish to image patients with breast pain it may be worth auditing this pathway to see if the incidence of cancers differs from an age-matched screening population.

2.  Referral to secondary care

We suggest that patients with symptoms of breast pain, whether pre- or postmenopausal, can be reassured that this a normal process, usually settles of its own accord and are directed to symptomatic relief advice. Ideally, this reassurance would be provided through public messaging on NHS and third-sector platforms without necessitating a need to be seen in primary care.³

Patients who are referred to secondary care should:

• have intractable severe unifocal postmenopausal breast (not chest wall or axillary) pain
• have had 3 months’ trial of conservative advice management
• appreciate that further management options, apart from analgesia, are very limited.

The very small number of patients with breast pain requiring referrals to secondary care do not necessarily need to be managed in rapid access clinics but instead could be given:

• written advice which is also shared with their GP
• a telephone/Near me appointment with specialist nurses
• an appointment in a low risk/benign clinic.

3.   Management of patients with breast pain within primary care practice

1. Patients experiencing breast or chest wall pain can be strongly reassured that in the absence of any other symptoms or findings that this is normal, usually self limiting and not linked with malignancy.
2. Most postmenopausal breast pain is actually chest wall in origin and patients can be reassured accordingly.
3. Conservative management advice should include a well-fitted supportive bra and regular use of topical NSAIDs massaged into the symptomatic area on the chest wall.