1. Breast Lump Bilateral Breast Exam No Palpable MassPalpable Mass Age < 35Age > 35 Diagnostic Mammogram -- unless negative mammogram within the past 6 months Aspiration in Primary Care or OB/GYN Cystic (Fluid) Solid (No Fluid ) Age > 35Age < 35 AbnormalNormal Recheck Exam 1 Month Surgery Referral Patient Complaint Resolved Unresolved Refer to Surgery for Persistent Concern of Patient or Provider Screening Mammogram per Guidelines for Age/Risk No Residual Mass Fluid not Bloody Residual Mass Bloody Fluid Diagnostic Mammogram -- Unless negative mammogram within past 6 months Surgery Referral Recheck 1 Month No Recurrent Mass Diagnostic Mammogram -- Unless negative mammogram within past 6 months Surgery Referral Recurrent Mass Age < 40Age > 40 Screening Mammogram per Routine Guidelines AbnormalNormal Follow Radiology Recommendation re: Stereo vs. bx vs. follow - up Screening Mammogram per Guidelines for Age/Risk * Note: Do not aspirate if patient has breast implants: To Surgery Diagnostic Mammogram -- Unless negative mammogram within past 6 months Encourage: Reduction in Caffeine, Vitamin E 800 u daily

2. Breast Implants Breast Lump Question of Implant Integrity Possible Infection/Mastitis Assessment may include the following: localized redness, warmth, pain, swelling; generalized redness, warmth, pain, swelling; nipple discharge with pus, draining wound, fever Treat with antibiotics per Infection/Mastitis Guideline with a recheck within 10 days Note: Inflammatory carcinoma should be considered Assessment may include any of the following: change of breast contour, shape or softness, patient concerns regarding possible leakage Surgical referral NO ASPIRATIONS WILL BE ATTEMPTED Refer to Plastic Surgery* Symptoms resolved Symptoms continue Refer to Plastic Surgery* Follow-up PRN *Patient to be instructed to obtain a copy of the medical record pertaining to implant placement for the KP medical record if done outside KP Treat implant patients as per guidelines for: Mammography Follow-up/Breast Exam WNL; Breast pain; Nipple Discharge Bilateral Breast Exam Age < 35Age > 35 Diagnostic Mammogram --Unless negative mammogram within past 6 months.

3. Mammography Follow-up Guidelines Breast Exam Within Normal Limits Negative Schedule mammogram per risk status Probably Benign Repeat abnormal side(s) at 3, 6 or 12 months per Radiologist recommendation (usually 6 months). Concomitant physical exam If recommended by Radiologist Stable Schedule mammogram per recommendation usually 6 months Stable mammogram findings are followed up at the Radiologist recommended intervals, usually annually for a total follow-up period of 3 years. Findings that are found to be negative or suspicious during follow-up will be managed per Radiologist recommendation and guideline Suspicious or Highly Suggestive of Malignancy No mass palpable Mass palpable Surgery referral Franklin Radiology referral for stereotactic or ultrasound guided biopsy. Surgery referral for needle localization biopsy as per Radiologist recommendation Negative biopsy: Schedule mammogram per risk status or Radiology recommendation Surgery referral for positive biopsy