About 50% of women in the UK experience symptoms of benign breast disease during their reproductive years. Compared with breast cancer there has been relatively little work on the epidemiology of benign breast disease. While hormonal imbalances are thought to contribute to its development, oral contraceptive use decreases the risk of fibrocystic breast changes, presumably by providing a balanced source of oestrogen and progesterone.
The four major symptoms
The four major symptoms with which women present are:
- nipple discharge
- nipple retraction
General principles of management and referral
Having taken a history and examined the patient, the key issue is whether a breast mass is indeed present. Lumps may be within the skin (for example, sebaceous cysts or lipomas), or deep to the breast (for example, costochondral junctions). Some women experience a lump or lumpiness as part of the menstrual cycle or in association with pregnancy. If on examination there is no discrete lump present, or the symptoms can be explained by a history of trauma or hormonal fluctuations, reassurance should suffice, even if no clear diagnosis has been made.
It is important to elicit particular fears of breast cancer, either due to family history or personal exposure. The patient may be reassured by counselling, but specialist referral may be indicated, even if there is no significant abnormality, in order to alleviate her concerns. Advice should always be given about breast awareness, and the woman should be invited to re-consult should there be further problems or persisting symptoms. For many women complaining of lumpy breasts, particularly in their thirties and forties, it can be very difficult to make a definite diagnosis. It can be helpful to ask a woman to return for repeat examination at a different time in the menstrual cycle, especially after a period. If at presentation or at second examination there is some abnormality, nodularity, or thickening, then referral to a specialist is the safest course of action. The act of referral induces anxiety and so the general practitioner (general practitioner) should advise her about what is likely to happen when she attends hospital.
Summary of conditions requiring referral to a surgeon with a special interest in breast disease
- Any new discrete lump
- New lump in pre-existing nodularity
- Asymmetrical nodularity that persists at review after menstruation
- Cyst persistently refilling or recurrent
- If associated with a lump
- Intractable pain, not responding to reassurance, simple measures such as wearing well-supporting bra and simple analgesics
- Unilateral pain in postmenopausal women
- All women over the age of 50 years
- Women under 50 with:
bilateral discharge sufficient to stain clothes
persistent single duct
Nipple retraction or distortion, nipple eczema
Change in skin contour
- Request for assessment by a woman with a strong family history of breast cancer (refer to a family cancer genetics clinic if possible) – see “genetic testing” for further discussion
There is evidence that delay of over 3 months in breast cancer diagnosis has a significant impact on overall survival from breast cancer. Clearly, total delay in the diagnostic pathway should be kept to a minimum, and has medicolegal implications. Referral without delay for specialist assessment should be made as clinically indicated. Conditions requiring referral to a specialist for further assessment are summarized in Summary of conditions requiring referral to a surgeon with a special interest in breast disease. Conditions that initially can be managed by the general practitioner are shown in Women who can initially be managed by their general practitioner. There is clear evidence that the outcome for women with breast cancer is improved if they are treated in specialist centres in a multidisciplinary team setting, and by surgeons with a special interest in breast disease.
Women who can initially be managed by their general practitioner
- Young women with tender lumpy breast and older women with symmetrical nodularity, provided that they have no localized abnormality
- Women with minor and moderate degrees of breast pain who do not have a discrete palpable lesion
- Women aged under 50 who have nipple discharge that is from more than one duct or is intermittent and is neither blood-stained nor troublesome
Infection of the breast
The commonest cause of breast abscess is infection associated with lactation, although the incidence of this problem appears to be decreasing. The commonest infectious agent is Staphylococcus aureus. The early symptoms of non-infectious mastitis may be identical to an infectious cause: namely, a painful, red, and swollen breast often with some constitutional upset. It is extremely important to empty the breast, either by continuing suckling or expression. An antipyretic/anti-inflammatory drug is recommended. In non-infective mastitis, symptoms will resolve quickly. If the cause is infective, treatment with flucloxacillin is usually adequate to resolve the infection. However, a small number of women (5 – 10%) go on to develop an abscess requiring surgical drainage. In older women, periductal mastitis and duct ectasia, sometimes associated with inverted nipples and a chronic nipple discharge, is the commonest cause of infection. The causative organism in this scenario is more likely to be anaerobic.