A 48-year-old woman comes to see you complaining of a “swelling” in her breast, which is uncomfortable.

What issues you should cover

  • The concern is whether there is an abnormality requiring referral for specialist assessment, to exclude malignancy. Ask about the duration and nature of symptoms. Is there nipple discharge and if so, volume and nature. Blood-stained or clear discharge should be referred for further assessment. Breast pain alone is an uncommon presentation of breast cancer, but examination is essential to exclude an underlying breast lump. Does the lump fluctuate with the menstrual cycle and is she pre-, peri-, or post-menopausal? The use of oral contraceptive pill or hormone replacement therapy should be documented. Other symptoms, such as significant weight loss, or severe skeletal pain, may indicate advanced cancer, but is uncommon at presentation.
  • Is there a past history of benign breast disease or previous investigations for breast abnormality? There may be a particular anxiety regarding the diagnosis breast cancer precipitating the referral. Is there a family history of breast cancer and if so, how old were the relatives at time of diagnosis: 5 – 10% of breast cancer cases have an underlying identifiable genetic abnormality. Patients with a strong family history according to local guidelines, should be referred for specialist genetic counselling, once significant underlying pathology has been excluded.

What should you do?

  • On breast examination, look for change in breast contour, puckering or dimpling of the skin, cutaneous oedema (peau d’orange), and nipple changes. If nipple inversion present, is it of recent onset? Skin involvement or nipple changes are strong indicators of malignancy and urgent referral is recommended.
  • Clinically determine if there is a discrete, definable lump, or an area of nodularity. If an abnormality is found, does it appear to be within the breast substance or related to the chest wall? If within the breast, clarify clinically whether this is a smooth, rounded mobile mass or irregular and fixed within the breast substance. Irregular lumps are highly suspicious and urgent referral should be arranged. If there is a possible lump or nodularity, it is helpful to ask the women to attend again after her next period for repeat examination and if abnormality persists, referral is recommended.
  • Benign causes of breast lumps include cysts or fibroadenomas. Breast cysts are most common in the 40 – 50 years age group, and are frequently multiple. Cysts constitute 17% of all discrete breast masses, and referral should be made to establish the diagnosis. They are readily diagnosed at ultrasonography and typically resolve following fine-needle aspiration. Fibroadenomas are typically mobile, smooth, and well defined, but an unlikely cause of this woman’s symptoms, as they occur most commonly in the 15 – 30 years age group. Breast nodularity is ill defined, may be bilateral, and tends to fluctuate with the menstrual cycle. Again, it can be helpful to re-examine following menstruation, when nodularity typically decreases.
  • Also check for axillary and supraclavicular fossa lymphadenopathy. Palpable lymph nodes may be found in up to 30% of patients who, with further assessment, have no evidence of malignancy. But if present, urgent referral is indicated.
  • Specialist assessment is likely to induce anxiety, although most women will be relieved by the act of referral. Explain to the woman the reasons for the referral and the likely diagnostic tests that will be undertaken. Diagnosis will be achieved by the triple assessment of clinical assessment, imaging (mammography and ultrasound), and cytology (fine-needle aspirate or core biopsy).
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