Simon Cawthorn

Breast Specialist

Breast lumps –to refer or not to refer ?

Learning objectives Know the indications to refer urgently

Who to reassure and review

How to reassure patients with non-urgent symptoms and signs

Learning Objectives 1

After completing this module you should know: How to assess a patient reporting a breast lump - Consider

what should be covered in the 10 minute consultation

The differential diagnosis of breast lumps

How to recognise ‘red flag’ symptoms and signs -Who should I be worried about?

When to refer to secondary care and the urgency of this Highlight the new NICE cancer referral guidance –

Any other referral guidance for patients not meeting NICE criteria for 2 week wait referral?

What a patient should expect to happen when referred to breast clinic

Learning Objectives 2

Understand the possible causes other than cancer which can lead patients to seek advice in primary care about a breast lump, and how to manage those in whom cancer is unlikely (in less than 3% of cases ) where urgent referral is not recommended by NICE

Managing the Breast TWW’s 1 in 7 of NHS out patient referrals are to the One-stop

Breast clinic

Increasing TWW referralsin 5 years-(NHS Eng)

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

0

50,000

100,000

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450,000

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Financial Quarter

Two Week Wait From GP Urgent Referral to First Consultant Appointment

Total Patients Seen - Quarterly Percentage of Patients Seen Within 2 weeks Operational Standard

No of cancers

94.5%

95.0%

95.5%

96.0%

96.5%

97.0%

97.5%

98.0%

98.5%

99.0%

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66,000

68,000

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One Month Wait from a Decision to Treat to a First Treatment for Cancer

Total Patients Treated - Quarterly Percentage of Patients Treated Within 31 Days Operational Standard

Breast cancer NICE Ref Guidelines 2015

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

aged 30 and over and have an unexplained breast lump with or without pain

Over 50 with nipple discharge, retraction or symptoms of concern – eczema

aged 30 and over with an unexplained lump in the axilla

Breast Cancer 2015 NICE guidance Non-urgent referral Consider non-urgent referral in people aged under 30

with an unexplained breast lump with or without pain.

(nothing about all lumps should be referred-nothing about breast pain!)

Breast Examination-what is your duty of care? In line with good practice and GMC guidance, explain to the

patient what you intend to do and why. Obtain consent for the examination and document this. Offer a

chaperone and document the discussion.

Breast inspection

Inspect with the patient sitting and then with their hands raised above head, and then pressed down on their hips producing pectoralis major muscle contraction

A lump may be visible.. This may result in indentation of the skin, or indrawing of the nipple, with muscle contraction, a sign of a probable underlying cancer/

Breast Examination-what is your duty of care? Look for: -Variations in breast size and contour. -Whether there is an inverted nipple (nipple

retraction) and, if so, is it unilateral or bilateral? -Redness associated with brawny induration of

the skin. (called peau d'orange -orange peel-caused by lymphatic invasion - inflammatory breast cancer).

-Any sign of visible ulceration is a sign of skin infiltration

-eczema of the nipple skin a sign of Paget’s disease, a form of in-situ carcinoma associated in 50% of cases with an underlying breast cancer

Breast ExaminationBreast palpation

The next next stage is palpation, and a systematic search pattern improves the rate of detection.

There is no proven "best method" Technique for palpation of the breast [13] to feel for breast lumps.

Ask the patient to lie supine with their hands above their head. Examine from the clavicle medially to the midsternum, laterally to the mid-axillary line and to the inferior portion of the breast. Remember the axillary tail of breast tissue. Examine the axilla for palpable lymphadenopathy.

Breast ExaminationBreast palpation

Examine with the hand flat to avoid pinching or probing the breast tissue.

Press the breast flat with the palmar surfaces of the second, third and fourth fingers held together.

The breast tissue is often lumpy, and the purpose of the “press test” is to identify the “lump” which persists and becomes more obvious with compression. A “lump” will have defined margins separate and distinct from the surrounding tissue.

The consistency is the most important clinical parameter in diagnosing the presence of a “lump” – hardness as the tissue is pressed – a resistance to compression –

also the contour characteristics of smoothness versus irregularity.

Breast ExaminationBreast palpation – is there a lump?

The clinical features also of importance in addition to those in the skin described above -the tethering to the underlying tissues or skin, and the mobility of the lump when palpated.

If you have difficulty finding a discrete lump, ask the patient to demonstrate it for you.

A discrete mass should be described in terms of location, size, mobility and texture.

“thickening” if localised and is asymetric = LUMP- avoid words like “fibro-adenosis”

Examine both breasts, the axillae, the infra-clavicular and supra-clavicularareas

if there is no lump, state this- no lump found- normal breasts

Breast Examination If there is a history of discharge from the nipple, with

permission apply gentle pressure to the areolar skin pressing with the index finger tip over the 4 quadrants. This is to distinguish the presence of single or multi-duct discharge, and the type of fluid seen, of note clear or blood-stained.

If there is no such history, it is inappropriate to attempt to demonstrate a discharge.

Breast examination should be thorough and take about three minutes each side.

Answer – NO this is a reason for an urgent 2WW referral

Question A woman aged 31 complains of a lump in her breast,

without any other symptoms other than discomfort. On both visual examination and palpation you cannot confirm the presence of a lump in the left breast in the area where the patient had felt a lump and no skin changes are seen. The opposite breast and both axillaeare also normal.

Q. Do you reassure her but ask her to return after her next period?

Answer – Yes – if the GP is unable to find a discrete lump

(including localised thickening not present in the opposite breast) the duty of care has been undertaken, and no action is needed –you don’t need to see her after the next period – her breast was normal

But does that work? How often does the patient come back still worried

with the same feeling that there is a lump?

But would they if in addition you gave them the offer of a full explanation about why women’s breasts get painful and lumpy, and that this is not a sign of cancer in 99%

Plus show them how to do BSE? All that in 10 mins (inc finding a chaperone!)

Same patient ? Lump age 31 You are unable to confirm the presence of a lump. The

breast examination as described above is normal- The breast is generally tender and lumpy. It is day 20 of her menstrual cycle, and this is irregular. She is very anxious as her mother had breast cancer at the age of 64, and is the only relative with the disease. The patient has no other risk factors. What should you do?

Answers? Tell the patient you are pretty sure it’s OK but refer her

as a non-urgent referral to the breast clinic

2. Tell her you are not an expert, and refer her as an urgent 2ww

3. Ask her to come back after her next period explaining you are confident it’s nothing to worry about

4. Inform the patient there is no lump, and that the area she is worried about is swollen but normal tissue.

5. offer to refer the patient over 40 years of age for a mammogram or if under 40 for an U/S scan

Tests

Where patients have symptoms suggestive of breast cancer, NICE recommends that tests should not be carried out before referral to a specialist.

So ask her to come back after her next period explaining you are confident it’s nothing to worry about

Imaging - Ultrasound Sensitivity high - may be the only modality to

show a cancer

Specificity fairly high

Quick, Cheap, Safe

Particularly safe in young women, pregnant women and lactating women

Can be used for guided needle biopsy of impalpable lesions

Frenchay Breast Care Centre 2002

Mammography Sensitivity fairly high - about 10-20% of cancers not

seen on mammogram

Specificity high

Quick but more expensive, dose of radiation, and can be uncomfortable

Not useful in young women - dense breasts and increased sensitivity to radiation

Frenchay Breast Care Centre 2002

Breast Cancer 2015 NICE guidance Non-urgent referral Consider non-urgent referral in people aged under 30

with an unexplained breast lump with or without pain.

(nothing about all lumps should be referred-nothing about breast pain!)

Same patient Q. The same patient aged 31 in whom no lump was

detected did however have a localised area of tenderness in the site where she had felt the lump.

Do you refer her for a focal Breast U/S scan?

Answer Yes – Best practice diagnostic guidelines for patients

presenting with breast symptoms Editors Alexis M Willett, Michael J Michell, Martin J R Lee November 2010

Patients in a one stop clinic with no lump, but an area of localised tenderness should have a breast U/S

A 20 year old woman presents with a painless lump in her breast.

Breast examination reveals a tender well defined firm smooth mobile mass 2 cms in diameter with no skin or other worrying signs. She is taking microgynon. Do you

1.refer as urgent 2ww referral? 2. Refer as a non-urgent referral? 3. Refer her for an U/S scan 4. Reassure her it is harmless and review after the next

period 5. Switch her to a progesterone only pill 6. Inform her it is a fibro-adenoma and it is harmless

Ans – no 6 is correct

This is likely to be a fibro-adenoma –BUT reassurance without imaging is unlikey to be effective in allaying her anxieties – in which case a non-urgent referral to a breast clinic is appropriate. Biopsy is not indicated unless the U/S has specific worrying features under 25 –less than 3 cms (Best Practice guidelines)

Smith et al. Bradford Royal Infirmary “a palpable lump with ultrasound characteristics

consistent with a fibroadenoma need not be biopsied unless there is overriding clinical concern”. They suggested the patients to be reassured, discharged and advised them to return for further evaluation only if they detected a change in the palpable abnormality

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Fibroadenomas

True Benign tumour

Commonest age 16-25

Common and multiple in Africans

Most remain unchanged

Some, particularly in very young grow rapidly – giant fibroadenomas

A 27 year old woman presents with a painless lump in her breast. She is 20 weeks pregnant

Breast examination reveals a tender well defined firm smooth mobile mass 2 cms in diameter with no skin or other worrying signs.

1. refer as urgent 2ww referral?

2. Refer as a non-urgent referral?

3. Refer her for an U/S scan

Reassure her it is harmless

Refer her to the antenatal clinic

Answer –1. –Urgent 2WW

A 48 year old woman presents with a vague history of a lumpy tender right breast for several months

Her periods are irregular, she is nulliparous, and her mother had breast Cancer at the same age.

Breast examination reveals both breast have a normal appearance. The right breast is different to the left in that there is thickening in the upper outer quadrant which although not a discrete lump feels firmer than the left breast which is soft and normal.

Do you 1 .refer as urgent 2ww referral? 2. Refer as a non-urgent referral? 3. Refer her for an mammogram 4. Reassure her it is harmless and review after the next period 5. Refer her for an U/S scan

Answer . 1 urgent 2ww

Same patient but history of cystsexamination smooth tender lump Do you

1. refer as urgent 2ww

2.Refer as non-urgent probable cyst

3. Reassure her it feels like another cyst – stop worrying and come back after next period

4.Refer for an U/S

5. refer for a mammogram

Answer Ask her to come back after her next period explaining

you are confident it’s nothing to worry about

Cysts Common in 40-50 year olds

Stop after menopause unless taking HRT

Appears quickly, painful at first

Gets smaller and less painful over a week

Degenerative ?glandular tissue degenerates before the ducts

Breast Pain A forty 43 year old woman presents with 6 months of

breast pain in the right breast, which is non-cyclical. She has no other symptoms, and breast examination bilaterally is normal. (no focal tenderness)

Do you

1. refer an non-urgent 2ww

2.Reassure and offer to see her after her next period or refer to the well-woman Practice Nurse who has been trained to talk to women about breast pain, lumps and how to perform breast examination

Answer 5 – if you have a practice nurse who has been trained

to talk to women about breast pain, lumps and how to perform breast examination – if not 2.

Same patient Q. The same patient aged 31 in whom no lump was

detected did however have a localised area of tenderness in the site where she had felt the lump.

Do you refer her for a non-urgent breast Clinic appointment?

Answer Yes – Best practice diagnostic guidelines for patients

presenting with breast symptoms Editors Alexis M Willett, Michael J Michell, Martin J R Lee November 2010

Patients in a one stop clinic with no lump, but an area of localised tenderness should have a breast U/S

Breast Pain – in the absence of a lump

Pre-menopausal

Commom

Not linked to breast cancer

risk

Duct hypertension

milk leaking into breast

Caused by oestrogen

•Made worse by stress

•Stress increases prolactin

•Prolactin up-reg ER

•Usually worse in one

breast

•It become a viscious

cycle

Premenopausal Breast Pain (no lump)– how to manage?

Explain

Reassure

Identify factors ie irregular period

Stress

Don’t offer treatment

Refer if fails to settle

Post-menopausal Breast Pain (no lump)– how to manage?

Refer (even if on HRT)

Abscesses Common in early lactation

Uncommon in other women except periductal mastitis (usually young smokers)

Refer urgently by phone, fax, e-mail for an urgent scan that day - Southmead Hospital ext 47035

Multi-duct Discharge

Non Suspicious Discharge Multi-duct, Not Spontaneous, Not Bloodstained

No Treatment unless troublesome

Causes of Nipple Discharge Physiological

Duct Papilloma

Duct Ectasia Older women - dilated ducts

Periductal Mastitis Younger women

Cancer Invasive or DCIS

Galactorrhoea Raised Prolactin levels

Decreasing

Frequency

Other Benign Conditions-Periductal Mastitis Peri-areolar inflammation

Young women

Smokers

Nipple discharge, nipple inversion

Recurrent infections

Suspicious Discharge Single Duct, Bloodstained, Spontaneous

Needs further investigation

Usual Investigation is ultra-sound and mammography

Diagnosis and treatment of discharge can also be achieved by mammotome

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Investigations Physical Examination

Ultrasound

Mammography (if over age 35)

Single duct profuse or blood-stained discharge do a mammotome excision biopsy

questions?