BREAST

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Symptoms and signs

Breast symptoms are a relatively uncommon presentation in primary care. It is estimated that between 0.35% and 0.6% of all consultations in Scotland are for breast symptoms. Many of these consultations will be in young women, whereas the biggest risk factor, after gender, is increasing age. Incidence of breast cancer in women aged 30-35 is 33 per 100,000 population and approximately 81% of breast cancers occur in women over the age of 50.

Breast cancer accounts for 30% of cancers in women and around 4,400 people are diagnosed with breast cancer in Scotland each year; approximately 20 of these are men. The following recommendations seek to improve the referral and effective management of breast symptoms in women and men in primary care.

Guidance for referral to regional genetics centres for those with a family history of breast cancer is available at: Cancer Genetic Services Scotland

Breast disorder - main page

Healthcare Improvement Scotland have recently published updated guidelines and advice for breast disease and the referral of patients with suspected breast cancer to secondary care. A link to the document can be found below:

Scottish Referral Guidelines for Suspected Cancer

If you suspect that your patient has breast cancer you should make an "Urgent Suspected Cancer" referral otherwise refer “Routinely”.

It is important that you should only use the classification "Urgent Suspected Cancer" for those patients whose symptoms are highly suggestive of breast cancer as advised in the guidelines.

The Main Features of this group will be:

  • A discrete lump
  • Definite signs of cancer such as;
    • ulceration
    • skin nodule
    • skin distortion or change of contour
  • Inflamed breast in post-menopausal women
  • Eczematous nipple

Other presentations of breast cancer are much less common. Inflammatory Cancers can present with appearances mimicking a breast abscess. However, Breast Pain as a symptom is exceedingly common, but very rarely associated with a diagnosis of breast cancer in the absence of any of the features mentioned above.

Advice on the following conditions is contained in these guidelines and within the healthcare improvement Scotland national guidelines.

Breast lump
Urgent suspicion of cancer referral
Routine Referral
Primary Care Management
  • Any new discrete lump (in patients over 35 years)
  • New asymmetrical nodularity that persists at review after menstruation (in patients over 35 years)
  • Unilateral isolated axillary lymph node in women
  • Cyst persistently refilling or recurrent cyst
  • Any new discrete lump (in patients under 35 years)
  • New asymmetrical nodularity that persists at review after menstruation (in patients under 35 years)
  • Women with longstanding tender lumpy breasts and no focal lesion
  • Tender developing breasts in adolescents
GP manageable conditions

Conditions that can be initially managed in general practice:

  • Young women (<35) with tender, lumpy breasts and older women with symmetrical nodularity; provided no localised abnormality
  • Women with minor and moderate degrees of breast pain who do not have a discrete palpable lesion
  • Women with nipple discharge from more than one duct or intermittent discharge which is not bloodstained

Conditions that require referral to a breast specialist include:

  • Lump
    • any new discrete lump
    • new lump in pre-existing nodularity
    • asymmetrical nodularity persisting after menstruation
    • abscess or breast inflammation not settling after one course of antibiotics
    • cyst persistently refilling or recurrent cyst (if the patient has recurrent multiple cysts and the GP has the necessary skills, then aspiration is acceptable)
  • Pain
    • if associated with a lump
    • intractable pain that interferes with a patient's lifestyle or sleep and does not respond to reassurance, simple measures such as wearing a well-supporting bra, or common drugs
    • unilateral persistent pain in post-menopausal women
  • Nipple discharge
    • bloodstained discharge
    • persistant discharge sufficient to stain outer clothes; or persistent single duct discharge
  • Nipple retraction or distortion, nipple eczema
  • Change in skin contour
Nipple symptoms
Urgent suspicion of cancer referral
Routine Referral
Primary Care Management
  • Bloodstained discharge
  • New nipple retraction
  • Nipple eczema if unresponsive to topical steroids (such as 1% hydrocortisone) after a minimum of 2 weeks
  • Persistent discharge sufficient to stain outer clothes
  • Transient nipple discharge which is not bloodstained
  • Check prolactin levels when discharge present
  • Longstanding nipple retraction
  • Nipple eczema if eczema present elsewhere

 

Skin changes
Urgent suspicion of cancer referral
Routine Referral
Primary Care Management
  • Skin tethering
  • Fixation
  • Ulceration
  • Peau d’orange
 
  • Obvious simple skin lesions such as sebaceous cysts
Abcess / infection
Urgent suspicion of cancer referral
Routine Referral
Primary Care Management
 
  • Abscess or breast inflammation even after settled in patients over 35 years
  • Abscess or inflammation – try one course of antibiotics to cover staphylococcus and streptococcus (also consider possible anaerobic infection as per local guidelines)
Breast pain
Urgent suspicion of cancer referral
Routine Referral
Primary Care Management
 
  • Unilateral persistent pain in post menopausal women
  • Intractable pain that interferes with the patient’s lifestyle or sleep
  • Women with moderate degrees of breast pain and no discrete palpable lesion

 NOTES:

  • In the absence of a palpable abnormality this merits a routine referral.
  • Pain should have been present for at least 6 weeks despite the use of simple analgesia.
  • If the pain is clearly originating in rib or intercostal tissue, as indicated by point tenderness on the chest wall, then this should be managed in primary care as musculoskeletal pain. Referral for Patient reassurance is not required.
Gynaecomastia
Urgent suspicion of cancer referral
Routine Referral
Primary Care Management
 
  • Exceptional aesthetics referral to plastic surgery pathway if required
  • Exclude or treat any endocrine cause prior to referral
  • Examine and exclude abnormalities such as lymphadenopathy or evidence of endocrine condition
  • Review to exclude drug causes
  • Measure hormones (oestrogen, testosterone, prolactin, human chorionic gonadotropin and alpha-fetoprotein)
  • Reassure
Further information resources
Editorial Information

Last reviewed: 30 June 2017

Next review: 30 June 2017

Version: 1

Approved By: high-uhb.tam@nhs.net

Reviewer Name(s): Ian Daltrey

Document Id: TAM113