American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Standard 2.19: Evaluation and Management of Non-Malignant Breast Disease

Evaluation and management of non-malignant breast disease follows nationally recognized guidelines.

Definition and Requirements

Non-malignant breast disease is a spectrum of breast physiologic, physical and imaging abnormalities that can cause the patient or treating physician concern but do not result in a diagnosis of breast cancer. Non-malignant breast conditions range from inconsequential imaging abnormalities (such as a resolved density) or minor clinical finding (lipoma of the breast) to severe atypia.

A process is in place to ensure evaluation with the intent to rule out a malignancy, determine the patient’s risk status and subsequently initiate appropriate surveillance and management.

Non-malignant breast conditions include, but are not limited to the following clinical presentations:

  • Mastodynia / pain
  • Skin changes such as thickening, rashes, indentations and other lesions.
  • Masses
  • Nipple discharge
  • Inflammatory changes
  • Imaging abnormalities
  • Skin thickening
  • Densities: BIRADS category 3, 4 or 5

Process Requirements

The Breast Program Leadership Committee (BPLC) determines the nationally recognized guidelines that will be used to evaluate and manage patients with non-malignant breast disease at the center.

Appropriate evaluation and management of non-malignant breast disease is documented in the medical record.

The center will select five (5) high-risk patient (atypical hyperplasia, lobular carcinoma in situ) medical records for the medical record review portion of the site visit.

Documentation

Complete all required standard fields in the Survey Application Record (SAR).

Upload/describe your center's process for management of patients with high risk lesions.

Documentation of good clinical practice in the care of these patients will be determined by the chart review.

Evaluation

The surveyor will review the high-risk patient charts during the medical records review portion of the site visit to evaluate adherence to national guidelines for the evaluation and management of non-malignant breast disease.

Rating Compliance

Compliance

Evaluation and management of non-malignant breast disease follows nationally recognized guidelines.

Noncompliance

The center does not fulfill one or more of the compliance criteria.

Resources

National Comprehensive Cancer Network (NCCN)