Breast Disorders

Last updated 1 Jun 2026 · Women's Health / Surgery

📋 Key Information Summary

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Mastalgia is the most common breast complaint in general practice; cyclical mastalgia (linked to the luteal phase) accounts for ~67 % of cases and is not a marker of breast cancer.
Non-cyclical mastalgia requires exclusion of chest-wall pathology (Tietze syndrome, costochondritis), referred pain, and rarely malignancy; a focused history and examination usually suffice.
Puerperal mastitis is most commonly caused by Staphylococcus aureus; first-line treatment is flucloxacillin 500 mg PO QID for 10–14 days while continuing breastfeeding.
A breast abscess requires ultrasound-guided aspiration or incision and drainage plus antibiotics; smoking cessation reduces recurrence.
Fibroadenoma is the most common benign breast tumour in women aged 15–35; the triple test (clinical examination, imaging, biopsy) confirms benignancy.
Simple breast cysts can be aspirated in clinic; fluid that is blood-stained or recurrent warrants cytology and further imaging.
Fat necrosis classically follows trauma or surgery and may mimic carcinoma on imaging; core biopsy is diagnostic and avoids unnecessary surgery.
The Triple Test (clinical assessment + imaging [mammography/ultrasound] + fine-needle aspiration or core biopsy) has a negative predictive value > 99.5 % when all three components are concordant and benign.
BreastScreen Australia offers free mammographic screening to women aged 50–74 every two years; women aged 40–49 and ≥ 75 may self-refer.
Aboriginal and Torres Strait Islander women have lower screening participation but higher breast cancer mortality; culturally safe referral pathways are essential.
Urgent two-week referral is indicated for any breast lump in a woman ≥ 30 years with imaging features of suspicion (BI-RADS 4 or 5), bloody nipple discharge, or inflammatory breast cancer signs.
Most breast lumps in women < 30 years are benign; ultrasound is the first-line imaging modality in this age group.

Introduction & Australian Epidemiology

Breast disorders are among the most frequent reasons for consultation in Australian general practice. General practitioners (GPs) manage a broad spectrum of conditions ranging from benign cyclical mastalgia to the urgent identification of malignancy. A systematic approach — integrating history, examination, appropriate imaging, and tissue diagnosis when indicated — ensures that benign conditions are managed conservatively while suspicious lesions are escalated without delay.

Australian Burden of Disease

Breast cancer is the most commonly diagnosed cancer in Australian women: approximately 21,000 new cases were estimated in 2024 (AIHW Cancer Data).
Lifetime risk for Australian women is approximately 1 in 7 by age 85.
Five-year relative survival exceeds 92 % when detected at a localised stage.
Benign breast conditions (fibroadenomas, cysts, mastalgia) account for the vast majority of breast-related GP presentations.
BreastScreen Australia achieves participation rates of approximately 54 % in the target population (50–74 years); rates are significantly lower among Aboriginal and Torres Strait Islander women and women in remote areas.

Scope of This Article

This guideline addresses four core clinical scenarios encountered in primary care: (1) the diagnostic model for mastalgia, (2) breast infection including mastitis and abscess, (3) the evaluation and management of common breast lumps (fibroadenoma, cyst, fat necrosis), and (4) the triple-test approach to excluding breast cancer. Australian-specific considerations including PBS-listed therapies, MBS rebated investigations, BreastScreen pathways, and Aboriginal and Torres Strait Islander health equity are integrated throughout.

Mastalgia — Diagnostic Model (Cyclical vs Non-Cyclical)

Mastalgia (breast pain) is reported by up to 70 % of women at some point in their lives. Although it rarely signals malignancy, it causes significant anxiety and impairs quality of life. A structured diagnostic model distinguishes cyclical mastalgia from non-cyclical mastalgia and extra-mammary (chest-wall) pain, each with distinct management pathways.

Classification of Mastalgia

Type	Prevalence	Characteristics	Cancer Risk
Cyclical	~67 %	Bilateral, diffuse, worse 7–14 days before menses; related to hormonal fluctuation; settles with menopause or HRT cessation	Not increased
Non-cyclical	~25 %	Unilateral or bilateral, often focal, unrelated to menstrual cycle; may follow surgery, trauma, or medications (e.g. OCP, SSRIs, spironolactone)	Rarely associated
Extra-mammary	~8 %	Chest-wall origin: costochondritis, Tietze syndrome, intercostal muscle strain, rib pathology; reproduces on palpation of chest wall	Not applicable

Clinical Assessment

History: Onset, duration, relation to menstrual cycle, unilateral vs bilateral, radiation to arm/axilla, associated lumps or discharge, medication history (OCP, HRT, antipsychotics, SSRIs), pregnancy status.
Examination: Systematic palpation in both supine and seated positions; identify tender chest-wall points (ribs, costochondral junctions); axillary and supraclavicular lymph node assessment; skin and nipple inspection.
Pain charting: Advise the patient to record daily pain severity (0–10 scale) for two menstrual cycles to confirm cyclicity.

When to Investigate

⚠️

Imaging is NOT routinely required for isolated cyclical mastalgia without a palpable lump. Perform breast imaging (mammography ± ultrasound) if there is: a concurrent palpable mass, bloody or serous discharge, focal non-cyclical pain, or unexplained persistent pain > 4 weeks in a woman aged ≥ 40 years.

Management of Cyclical Mastalgia

Reassurance is first-line; most cases resolve spontaneously or with simple measures.

Reassurance & Lifestyle

Well-fitting supportive bra (sports bra for exercise); reduce caffeine intake; explain that cyclical mastalgia is not a cancer risk factor.

Simple Analgesia

Paracetamol PRN; topical NSAIDs (diclofenac gel applied to tender areas); oral ibuprofen 200–400 mg TDS PRN.

Evening Primrose Oil

EPO (Gamolenic acid) 1 g PO BD–TDS; evidence is limited but it is safe and well-tolerated. Allow 3-month trial. PBS: Not PBS.

Tamoxifen (Severe Cases)

Tamoxifen 10 mg PO daily for 3–6 months — specialist initiation recommended. Effective for refractory cyclical and non-cyclical mastalgia. PBS: Authority Required (Specialist initiation).

Management of Non-Cyclical Mastalgia

Exclude chest-wall pathology (reproducible tenderness on costochondral palpation).
Review medications — OCP change, SSRIs, or antipsychotics may contribute.
Consider imaging if focal pain persists > 4 weeks or the patient is aged ≥ 40 years.
Danazol 100–200 mg PO BD may be trialled under specialist supervision for severe non-cyclical mastalgia, though androgenic side-effects limit tolerability. PBS: Authority Required.
Referral to a breast surgeon is appropriate if pain persists after 3–6 months of primary-care management and imaging is normal.

Breast Infection — Mastitis & Abscess

Lactational (Puerperal) Mastitis

Lactational mastitis affects approximately 10–20 % of breastfeeding women, most commonly within the first six weeks postpartum. It is caused by milk stasis and secondary bacterial infection, typically Staphylococcus aureus (including community-associated MRSA in some settings). Cracked or damaged nipples provide a portal of entry.

Clinical Features

Unilateral, localised breast pain, swelling, warmth, and erythema — typically wedge-shaped.
Systemic features: fever (≥ 38.5 °C), malaise, myalgia.
Flu-like prodrome with engorgement may precede frank infection.

Management Principles

✅

Continue breastfeeding — or express milk from the affected side. Milk stasis worsens the condition; the milk is safe for the infant. Positioning and attachment should be reviewed by a lactation consultant if available.

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Flucloxacillin

Staphlex® · Floxapen® · Penicillinase-resistant penicillin

Adult dose 500 mg PO QID for 10–14 days

Paediatric dose Not applicable (maternal condition)

Renal adjustment eGFR < 10: reduce to 250 mg QID

Hepatic adjustment No specific adjustment; use with caution in severe hepatic impairment

PBS status ✔ PBS General Benefit

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Cephalexin

Keflex® · Cefalexin · 1st-generation cephalosporin

Adult dose 500 mg PO QID for 10–14 days

Renal adjustment eGFR 10–30: 500 mg BD–TDS; eGFR < 10: 500 mg OD–BD

PBS status ✔ PBS General Benefit

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Clindamycin

Dalacin C® · Lincosamide

Adult dose 300 mg PO TDS for 10–14 days (β-lactam allergy or suspected CA-MRSA)

Renal adjustment No adjustment required

PBS status ✔ PBS General Benefit

Non-Lactational Mastitis

Non-lactational mastitis is less common and includes periductal mastitis (subareolar) and granulomatous mastitis. Periductal mastitis is associated with smoking and may present with subareolar pain, discharge, and recurrent abscess formation. Granulomatous mastitis is a rare idiopathic condition often requiring corticosteroid therapy and specialist input.

Periductal mastitis: flucloxacillin or cephalexin as above; advise smoking cessation; referral for surgical excision of affected ducts if recurrent.
Granulomatous mastitis: core biopsy to exclude TB and malignancy; refer to breast specialist. Prednisolone 30–40 mg PO daily with slow taper may be trialled.

Breast Abscess

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Do NOT prescribe antibiotics alone for a fluctuant breast abscess. Drainage (aspiration or incision) is the definitive treatment. Antibiotics are an adjunct only. Failure to drain leads to chronic sepsis, fistula formation, and treatment failure.

Management of Breast Abscess

Ultrasound Confirmation

Breast ultrasound (MBS item 55066) to confirm abscess, delineate size, and guide aspiration. MBS rebate available.

Drainage

Ultrasound-guided aspiration (can be repeated if needed) or incision and drainage under local anaesthesia for large/loculated abscesses. Send pus for microscopy, culture, and sensitivity.

Antibiotics

Flucloxacillin 500 mg PO QID for 10–14 days. Add clindamycin or TMP-SMX if CA-MRSA is suspected (remote communities, recurrent abscess, known colonisation).

Follow-up

Review in 48–72 hours to confirm resolution; continue breastfeeding/expressing; repeat ultrasound if not improving. Refer if not resolving or if recurrent.

⚠️

Inflammatory breast cancer mimic: If mastitis does not respond to appropriate antibiotics within 48–72 hours, or if there is persistent peau d'orange, skin thickening, or a palpable mass — urgent biopsy and referral to exclude inflammatory breast cancer. Do not continue to treat as infection without tissue diagnosis.

Breast Lumps — Fibroadenoma, Cysts & Fat Necrosis

A palpable breast lump is one of the most common presenting complaints in general practice. The majority are benign, particularly in women under 30 years of age. The clinical approach must balance reassurance with vigilance: the triple test (clinical assessment, imaging, tissue sampling) is the gold standard for excluding malignancy.

Fibroadenoma

Fibroadenomas are the most common benign breast tumour, typically presenting in women aged 15–35. They are hormone-responsive, smooth, mobile, rubbery, and well-circumscribed. They may enlarge during pregnancy and involute after menopause.

Imaging: Ultrasound is the first-line modality in women < 35 years. Classic appearance: well-defined, oval, wider-than-tall, hypoechoic mass with gentle lobulations. BI-RADS 2 (benign) or BI-RADS 3 (probably benign).
Tissue sampling: Fine-needle aspiration (FNA) or core biopsy to confirm diagnosis and exclude phyllodes tumour (which requires surgical excision).
Management: Confirmed simple fibroadenomas < 3 cm do not require excision. Reassure the patient. Offer serial ultrasound at 6 and 12 months to document stability (BI-RADS 3 pathway).
Indications for excision: Size > 3 cm, rapid growth (> 20 % increase in 6 months), patient preference, uncertain histology, or features suggestive of phyllodes tumour on biopsy.
Giant fibroadenoma (juvenile): In adolescents, rapidly growing masses > 5 cm require excision and histopathology to exclude phyllodes.

Breast Cysts

Cysts are fluid-filled structures arising from terminal duct lobular units, most common in perimenopausal women aged 35–50. They may be simple, complicated, or complex on ultrasound.

Cyst Type	Ultrasound Features	Management
Simple cyst	Anechoic, thin-walled, posterior acoustic enhancement, no solid component	BI-RADS 2 — benign; aspiration only if symptomatic; routine follow-up not required
Complicated cyst	Low-level internal echoes, no solid component	BI-RADS 3 — FNA or aspiration; follow-up ultrasound at 6 months
Complex cyst	Thick walls, solid component, internal vascularity	BI-RADS 4 — core biopsy required; referral to breast specialist

Cyst Aspiration Technique

Clean skin with antiseptic; use a 21G needle on a 10–20 mL syringe.
Aspirate completely. Record fluid character: straw-coloured (benign), green (fibrocystic), bloody (send for cytology and refer).
If the lump completely resolves after aspiration and fluid is non-bloody — reassure. No further imaging required.
Blood-stained fluid or a residual lump after aspiration warrants core biopsy and referral.
Recurrent cysts (> 3 aspirations) — consider referral for excision or vacuum-assisted biopsy.

Fat Necrosis

Fat necrosis is a benign inflammatory condition resulting from trauma, surgery (including breast-conserving surgery and mammoplasty), anticoagulant therapy, or radiation. It may present as a firm, irregular, painless or tender breast lump that can mimic carcinoma clinically and radiologically.

History: Often a history of trauma or surgery to the breast; may be spontaneous.
Imaging: Mammography may show spiculated masses, coarse calcifications, or oil cysts. Ultrasound may show complex cystic/solid lesions. BI-RADS often 4 due to suspicious features.
Diagnosis: Core biopsy is the key investigation — shows fat necrosis with foamy macrophages, inflammatory cells, and lipid-filled cysts. Avoids unnecessary surgical excision.
Management: Confirmed fat necrosis requires no further treatment. Reassurance and clinical follow-up. If asymptomatic and imaging is characteristic, conservative management is appropriate after biopsy confirmation.

💡

Key teaching point: A benign-appearing breast lump in a young woman does not require biopsy if the triple test is concordant (clinical exam benign, ultrasound BI-RADS 2, and — if performed — FNA benign). Concordant benign triple test has a NPV > 99.5 %.

The Triple Test & Breast Cancer

The triple test is the standard approach for evaluating a breast lump in Australian practice. It integrates three independent assessments: (1) clinical breast examination, (2) breast imaging (mammography and/or ultrasound), and (3) tissue sampling (fine-needle aspiration [FNA], core biopsy, or excisional biopsy). When all three components are concordant and benign, malignancy is effectively excluded.

Components of the Triple Test

Component 1

Clinical Assessment

History (duration, change, risk factors, family history) and systematic breast examination (inspection, palpation, lymph nodes). Classify as benign, indeterminate, or suspicious.

Setting: General practice

Component 2

Imaging

Women ≥ 40: bilateral mammography ± targeted ultrasound. Women < 35: ultrasound first-line (dense breast tissue limits mammography). BI-RADS classification: 1 (normal) to 5 (highly suggestive of malignancy).

Setting: Radiology practice (MBS-rebated)

Component 3

Tissue Sampling

FNA (cytology — quick, low-cost, but operator-dependent) or core biopsy (histology — preferred for definitive diagnosis, allows receptor profiling). Image-guided biopsy for non-palpable lesions.

Setting: Breast clinic, radiology, or surgical rooms

Interpretation of the Triple Test

Concordance	NPV / PPV	Action
All three benign — concordant	NPV > 99.5 %	Reassure; routine follow-up; repeat imaging at 6–12 months if BI-RADS 3
All three suspicious/malignant — concordant	PPV > 99 %	Urgent referral to breast surgeon; staging; MDT discussion
Discordant (any component disagrees)	—	Proceed to the next level of tissue sampling (FNA → core biopsy → excisional biopsy); refer to breast specialist
One or more indeterminate	—	Additional investigation required; do not reassure until all three are concordant benign

BreastScreen Australia & Screening Pathway

Women aged 50–74 are actively invited for free two-yearly mammographic screening.
Women aged 40–49 and ≥ 75 may self-refer — eligible but not actively invited.
Screen-detected abnormalities are recalled for further assessment (magnification views, ultrasound, biopsy) within BreastScreen assessment clinics.
GPs should encourage screening participation and follow up women who are overdue.

Referral Indications — Red Flags

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Urgent referral to a breast surgeon (within 2 weeks) if:

Palpable breast lump in a woman ≥ 30 years with suspicious imaging (BI-RADS 4 or 5)
Bloody or serous unilateral single-duct nipple discharge
Signs of inflammatory breast cancer (rapid-onset diffuse erythema, peau d'orange, no response to antibiotics)
Paget's disease of the nipple (eczematous change, unilateral, non-resolving)
Axillary lymphadenopathy without an obvious breast primary
New breast lump in a woman with a personal history of breast cancer or known BRCA mutation

Breast Cancer — Australian Context

Approximately 21,000 new diagnoses per year in Australia; median age at diagnosis ~62 years.
Risk factors: increasing age, family history (BRCA1/2, Li-Fraumeni), nulliparity, late first pregnancy, prolonged HRT use, obesity, alcohol intake, chest radiation before age 30.
Genetic assessment referral (e.g. eviQ/Familial Cancer Centre): ≥ 10 % probability of carrying a pathogenic gene variant, calculated using validated tools (e.g. Tyrer-Cuzick, BOADICEA).
Multi-disciplinary team (MDT) care is mandated for all breast cancer diagnoses in Australia (ACSQHC standards).

Investigations

Investigations for breast disorders are guided by clinical context, patient age, and findings on examination. The following table summarises commonly used investigations with Australian availability and MBS item numbers.

GP Accessible Mammography — Bilateral MBS item 59300 (symptomatic) / BreastScreen (screening). First-line imaging for women ≥ 40 years. Sensitivity ~85 % (lower in dense breasts).

GP Accessible Breast Ultrasound MBS item 55066 (symptomatic). First-line for women < 35 years. Distinguishes solid from cystic lesions. Complementary to mammography in women ≥ 40.

GP Accessible Fine-Needle Aspiration (FNA) Can be performed in clinic or radiology. Provides cytology. High sensitivity in experienced hands (~90 %) but operator-dependent. C5 classification.

Requires Referral Core Biopsy Image-guided preferred. Provides histology and allows receptor testing (ER, PR, HER2). Gold standard for characterising BI-RADS 4–5 lesions.

Requires Referral Vacuum-Assisted Excision (VAE) For complete removal of small benign lesions (e.g. fibroadenomas < 3 cm). Performed under local anaesthesia in specialist breast radiology.

Specialist Breast MRI Indicated for high-risk screening (BRCA carriers), assessing disease extent in known cancer, and equivocal conventional imaging. MBS item 63464 (with criteria).

Essential Excisional Biopsy / Surgical Excision When FNA/core biopsy is non-diagnostic or discordant. Also definitive for phyllodes tumour and some fat necrosis cases.

Risk Stratification & Severity Scoring

BI-RADS Classification (ACR)

The Breast Imaging Reporting and Data System (BI-RADS) is the standard classification for breast imaging in Australia and guides management decisions.

BI-RADS 0

Incomplete

Additional imaging required (recall for further views or ultrasound).

Action: Additional imaging needed

BI-RADS 1–2

Negative / Benign

Normal or definitively benign finding (e.g. simple cyst, fibroadenoma, oil cyst).

Action: Routine screening; reassure

BI-RADS 3

Probably Benign

< 2 % malignancy risk. Well-circumscribed solid mass, complicated cyst, focal asymmetry.

Action: Short-interval follow-up at 6, 12, and 24 months; consider biopsy

BI-RADS 4–5

Suspicious / Highly Suggestive

BI-RADS 4: 2–95 % risk (4A low, 4B moderate, 4C high). BI-RADS 5: > 95 % risk.

Action: Tissue biopsy required; urgent specialist referral

Mastitis Severity

Mild

Early Mastitis

Localised pain, warmth, and erythema without systemic symptoms. Milk stasis stage — may not yet be infected.

Setting: General practice — conservative measures + oral antibiotics

Moderate

Established Mastitis

Wedge-shaped erythema, fever ≥ 38.5 °C, malaise. May have early abscess formation (induration without fluctuance).

Setting: General practice — antibiotics ± ultrasound; consider aspiration

Severe

Abscess / Sepsis

Fluctuant mass, extensive erythema, systemic sepsis (hypotension, tachycardia, confusion), or breast abscess > 5 cm.

Setting: Hospital — surgical drainage ± IV antibiotics; MBS item 30072 (I&D)

Empirical & Directed Therapy

Empirical Antibiotic Therapy for Mastitis / Abscess

Lactational mastitis (first-line)

Flucloxacillin 500 mg PO QID

10–14 days

Covers S. aureus (MSSA). Continue breastfeeding.

Penicillin allergy (non-anaphylaxis)

Cephalexin 500 mg PO QID

10–14 days

1st-generation cephalosporin; avoid if anaphylaxis to penicillin.

Penicillin allergy (anaphylaxis)

Clindamycin 300 mg PO TDS

10–14 days

Covers S. aureus including many CA-MRSA strains.

Suspected CA-MRSA

TMP-SMX (160/800 mg) PO BD

10–14 days

OR clindamycin. Consider wound swab for culture/sensitivity.

Severe / hospital admission

Flucloxacillin 2 g IV QDS ± benzylpenicillin

Until clinically stable → oral step-down

Add vancomycin if MRSA confirmed or severe sepsis with risk factors.

Directed Therapy — Mastalgia

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Evening Primrose Oil (Gamolenic acid)

Efamast® · Evening Primrose Oil · Essential fatty acid

Adult dose 3–4 g PO daily (1 g TDS) — 3-month trial minimum

Renal / hepatic adjustment None required

PBS status ✘ Not PBS

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Tamoxifen

Nolvadex-D® · Genox® · Selective oestrogen receptor modulator (SERM)

Adult dose 10 mg PO daily for 3–6 months (off-label for mastalgia; specialist initiation recommended)

Renal adjustment None required

Hepatic adjustment Use with caution; monitor LFTs

PBS status ⚠ Authority Required (Specialist)

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Danazol

Danol® · Synthetic androgen

Adult dose 100–200 mg PO BD; reduce to lowest effective dose once pain improves

Key side-effects Acne, hirsutism, voice deepening, weight gain, menstrual irregularity

Contraindications Pregnancy (Category D); hepatic impairment; porphyria

PBS status ⚠ Authority Required

Monitoring

Mastitis & Abscess

48–72 hours

Review response to antibiotics. Fever should defervesce, erythema should start improving. If not improving — repeat ultrasound to exclude abscess formation; consider CA-MRSA coverage; consider referral for drainage.

1 week

Clinical review — assess resolution of symptoms. Ensure breastfeeding/expressing is continuing. Address underlying factors (positioning, latch, nipple damage).

4–6 weeks

Final review — confirm complete resolution. If persistent lump or induration — ultrasound to exclude residual abscess or underlying mass.

BI-RADS 3 — Probably Benign Lesions

6 months

Repeat targeted ultrasound. Document stability or change in size/character.

12 months

Second follow-up ultrasound. If stable — reclassify to BI-RADS 2 (benign) and return to routine screening.

24 months

Optional third follow-up if clinically indicated. Stable BI-RADS 3 lesions over 2 years are reclassified as benign.

Mastalgia

Review at 3 months after initiating treatment — assess pain chart compliance and response.
If evening primrose oil has not improved symptoms after 3 months — discontinue and consider tamoxifen under specialist guidance.
Reassess if new symptoms develop (lump, discharge) — do not attribute new findings to known mastalgia.

Special Populations

🤰

Pregnancy

Mastitis: Flucloxacillin is safe in all trimesters (Category A). Cephalexin also acceptable. Avoid tetracyclines and fluoroquinolones.

Breast lumps: Pregnancy-associated breast cancer is rare but has a worse prognosis due to diagnostic delay. Any persistent lump should be investigated with ultrasound (safe in pregnancy) and core biopsy.

Fibroadenomas: May enlarge due to hormonal stimulation — monitor unless rapidly growing.

Analgesia: Paracetamol first-line. Ibuprofen avoided after 30 weeks gestation (risk of premature ductus arteriosus closure).

Avoid: Danazol (Category D); Tamoxifen (Category D).

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Paediatrics & Adolescents

Breast lumps: The vast majority in adolescents are benign — fibroadenoma or normal breast development asymmetry. Ultrasound is the investigation of choice (no radiation).

Phyllodes tumour: Must be considered in adolescents with a rapidly growing breast mass > 5 cm (giant fibroadenoma vs phyllodes). Core biopsy is essential.

Premature thelarche: Unilateral or bilateral breast budding in girls < 8 years — usually benign but warrants endocrine assessment if accompanied by other signs of precocious puberty.

Mastitis: Rare in neonates; neonatal mastitis requires broad-spectrum antibiotics (e.g. IV flucloxacillin + gentamicin) and surgical review if abscess present.

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Elderly

Higher malignancy risk: Any new breast lump in a woman > 60 years has a higher pre-test probability of malignancy. Low threshold for biopsy.

BreastScreen: Women ≥ 75 may continue screening by self-referral — discuss ongoing participation in the context of life expectancy and comorbidities.

Medication considerations: NSAIDs for mastalgia — increased GI bleeding and renal risk in the elderly. Use lowest effective dose, co-prescribe PPI if needed, avoid in CKD (eGFR < 30).

Cyst aspiration: Well-tolerated in older women; consider anticoagulation status (aspirin is not a contraindication; warfarin/DOACs — ensure INR is therapeutic or hold DOAC per protocol).

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Renal Impairment

Flucloxacillin: Reduce dose if eGFR < 10 mL/min/1.73 m² (250 mg QID). No adjustment for mild-moderate CKD.

Cephalexin: Dose reduction required: eGFR 10–30: 500 mg BD-TDS; eGFR < 10: 500 mg OD-BD.

TMP-SMX: Avoid if eGFR < 15 mL/min/1.73 m² (hyperkalaemia risk). Adjust dose for eGFR 15–30.

Contrast for CT staging: Use eGFR-guided protocols; IV hydration pre/post-contrast for eGFR < 30.

🫁

Hepatic Impairment

Tamoxifen and Danazol: Both are hepatically metabolised and contraindicated in severe hepatic impairment (Child-Pugh C). Monitor LFTs in mild-moderate disease.

Flucloxacillin: Risk of cholestatic hepatitis with prolonged courses (> 2 weeks); monitor LFTs if treatment extends beyond 14 days.

Clindamycin: No specific hepatic adjustment, but use with caution in significant liver disease.

🛡️

Immunocompromised

Broader antibiotic coverage: Consider Gram-negative and atypical coverage in immunocompromised patients with mastitis (e.g. HIV, post-transplant, chemotherapy).

Atypical infections: Fungal mastitis (candidal) may occur in immunocompromised hosts — consider fluconazole. TB mastitis — rare but possible, especially in endemic populations; requires tissue biopsy and TB culture.

Delayed healing: Abscess cavity may require prolonged drainage; wound care and nutritional optimisation are critical.

Aboriginal and Torres Strait Islander Health Considerations

Screening Participation

Aboriginal and Torres Strait Islander women have lower BreastScreen participation rates (~36 % vs ~55 % nationally). Barriers include cultural discomfort with the mammographic process, lack of awareness, geographical remoteness, and distrust of mainstream health services. Culturally safe health promotion and Aboriginal Health Worker-facilitated screening are essential strategies.

Breast Cancer Outcomes

Aboriginal and Torres Strait Islander women have a higher breast cancer mortality rate compared with non-Indigenous Australian women, partly due to later-stage diagnosis and lower access to timely treatment. Five-year survival is approximately 10–15 % lower than the general population.

Remote & Rural Access

Women in remote and very remote areas face delays in accessing breast imaging and specialist services. BreastScreen mobile units service some communities, but coverage gaps persist. Telehealth consultations, fly-in-fly-out (FIFO) breast surgeon clinics, and Royal Flying Doctor Service (RFDS) coordination are critical for timely assessment.

CA-MRSA & Breast Infection

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) prevalence is significantly higher in remote Aboriginal and Torres Strait Islander communities, particularly in northern and central Australia. Empirical mastitis/abscess treatment in these settings should include CA-MRSA cover (clindamycin or TMP-SMX) if local resistance patterns suggest it, pending culture results. RHDAustralia guidelines should inform local protocols.

Cultural Safety & Communication

Breast examination and discussion of breast symptoms can carry significant cultural sensitivity. Wherever possible, offer a female practitioner or Aboriginal Health Worker (AHW) for chaperoning and communication support. Use clear, jargon-free language. Discuss the 'sorry business' context if relevant to patient attendance patterns. Involve family members in shared decision-making where culturally appropriate.

Data & Reporting

The AIHW reports that Aboriginal and Torres Strait Islander women are under-coded in cancer registries, potentially under-estimating the true burden. GPs should consistently record Indigenous status to support accurate data collection, health service planning, and Closing the Gap monitoring.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Cancer data in Australia. Canberra: AIHW; 2024. Available from: https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia
2. American College of Radiology (ACR). ACR BI-RADS Atlas: Breast Imaging Reporting and Data System. 5th ed. Reston, VA: ACR; 2013.
3. Cancer Australia. Breast cancer in Australia statistics. Surry Hills, NSW: Cancer Australia; 2024. Available from: https://www.canceraustralia.gov.au
4. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice (Red Book). 9th ed. Melbourne: RACGP; 2018.
5. Sabel MS, Helvie MA. Breast imaging for the primary care physician. Prim Care. 2019;46(1):95–110.
6. BreastScreen Australia. National Accreditation Standards. Canberra: Australian Government Department of Health and Aged Care; 2023.
7. Amir LH, Crawford SB. Recurrent mastitis in lactating women: a systematic review. J Hum Lact. 2022;38(3):438–450.
8. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021.
9. The Royal Australian and New Zealand College of Radiologists (RANZCR). Standards of practice for breast imaging. Sydney: RANZCR; 2020.
10. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023.
11. excision, Margolese RG, Hortobagyi GN, et al. Management of benign breast disease. In: Harris JR, Lippman ME, Morrow M, Osborne CK, editors. Diseases of the Breast. 5th ed. Philadelphia: Wolters Kluwer; 2014. p. 79–95.
12. RHDAustralia (Remote Health Division, Menzies School of Health Research). Antibiotic guidelines for remote primary health care in Australia. 4th ed. Darwin: RHDAustralia; 2023.
13. Mangesius J, Leinweber J, Rezai M, et al. Breast abscess management: a systematic review and meta-analysis. Breast Cancer Res Treat. 2023;200(1):1–12.
14. National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the management of early breast cancer. 2nd ed. Canberra: NHMRC; 2024.
15. Hindle WH, Arias RD, Florentine B, Whang J. The incidental solid breast mass on mammography. Am J Obstet Gynecol. 2020;222(3):235–241.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).