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

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

3. Mammography Follow-up Guidelines Breast Exam Within Normal Limits Negative Probably Benign Suspicious or Highly Suggestive of Malignancy Schedule mammogram per risk status Repeat abnormal side(s) at 3, 6 or 12 months per Radiologist recommendation (usually 6 months). Concomitant physical exam If recommended by Radiologist No mass palpable Mass palpable Franklin Radiology referral for stereotactic or ultrasound guided biopsy. Surgery referral for needle localization biopsy as per Radiologist recommendation Surgery referral 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 Negative biopsy: Schedule mammogram per risk status or Radiology recommendation Surgery referral for positive biopsy