BMJ 2014;349:g5275 doi: 10.1136/bmj.g5275 (Published 5 September 2014)
Page 1 of 3
Practice
PRACTICE 10-MINUTE CONSULTATION
Breast lumps 1
1
M Twoon medical student , N Y B Ng medical student , S E Thomson specialist training year 4, 2 plastic and reconstructive surgery University of Aberdeen, Aberdeen, Scotland; 2Plastic and Reconstructive Surgery Unit, Aberdeen Royal Infirmary, Aberdeen, Scotland
1
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
A 35 year old woman presents with a 1 cm hard lump in the upper outer quadrant of her right breast. She first noticed this when she was in the shower three months ago. She is worried that the lump might be malignant.
What you should cover
Breast lumps are common and have a variety of causes. Although most lumps are not malignant, any abnormal changes to the breasts need to be reviewed as soon as possible. Refer patients to a breast clinic where triple assessment can be performed and the lump fully investigated. It is often difficult to make a definitive diagnosis on clinical history and examination alone. Many patients who are referred for specialist assessment will be found not to have cancer.
Examination Undertake a clinical breast examination, with consent and chaperone. People have different techniques and, although the following technique is recommended, it is by no means the only acceptable one. • Compare both sides, and include all four quadrants, the retro-areolar area, and axillary tail. Examine the axilla and supraclavicular areas for lymphadenopathy.
• Note the location of lump; its consistency; tethering to overlying or underlying structures; and associated features of lymphadenopathy, skin changes (such as peau d’orange—skin with an “orange peel” appearance owing to invasion of the lymphatics by tumour cells, which causes obstruction and oedema), or nipple discharge. • If nipple discharge is clearly evident send a sample for microbiology and cytology.
• An eczematous rash might represent Paget’s disease of the nipple and underlying cancer. Compare both nipples for evidence of eczema or Paget’s disease. Eczema tends to be bilateral with marked itching. Furthermore, there tends
to be a history of atopy and areas of eczema on multiple sites of the body. Paget’s disease tends to be unilateral with associated bleeding and nipple erosion.
• Advanced cutaneous spread might cause ulceration of the skin and is occasionally seen in a late presentation. • In patients with a history of cancer or those presenting with advanced disease, look for hepatomegaly or vertebral tenderness, which would indicate possible metastatic disease.
Breast cancer cannot be ruled in or out solely by taking a history or profiling of risk factors. Similarly, clinical breast examination can confirm breast masses but cannot definitively distinguish the cause.
History • Age—Although incidence in younger women is increasing, the probability of a lump being associated with cancer increases with age. Benign lumps are common in women under 30 years.1 2 However, a discrete lump, persisting after the next period, warrants urgent referral, irrespective of age.
• Characteristics of lump (site, size, consistency, and duration)—Malignant lesions are more likely to enlarge over time without periods of resolution. Lumps persisting after a woman’s next period or in postmenopausal women require referral for further assessment. Progressive enlargement of a discrete lump or breast size merits referral to a breast clinic. • Associated features warranting referral—Peau d’orange, skin tethering, nipple inversion, spontaneous unilateral nipple discharge (associated with breast cancer or ductal papilloma), and unilateral eczema not responding to topical therapies require referral. General features such as malaise or weight loss also warrant referral. • Breast pain and tenderness—Benign conditions, such as fibroadenosis and fibroadenomas, might present with
Correspondence to: [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;349:g5275 doi: 10.1136/bmj.g5275 (Published 5 September 2014)
Page 2 of 3
PRACTICE
cyclical breast pain and diffuse changes in the breast parenchyma rather than a discrete lump. This pain is also likely to be bilateral. Non-cyclical unilateral breast pain is usually caused by a problem outside the breast—for example, muscle or connective tissue strain, or skin injury. It might be associated with a lump but is rarely caused by breast cancer. If the pain is an isolated symptom of short duration, it might be managed initially in a primary care setting. If other focal clinical findings are present, however, referral for triple assessment is required. Non-urgent referral might be considered if isolated breast pain persists despite initial measures.
malignancy urgently (within two weeks) to a breast clinic for triple assessment (table).⇓
Red flags The red flags in the list below are all from the National Institute for Health and Care Excellence. Referral guidelines for suspected cancer.9 • All patients presenting with a discrete, hard lump with fixation—with or without skin tethering. • Women aged 30 years or more who have a discrete lump that persists after the next period, or those who present after menopause.
• Axillary swelling—Persistent unexplained axillary swelling might represent breast tail pathology and should be referred for assessment.
• Women under 30 years with an enlarging lump or a fixed, hard, or tethered lump, or a worrying family history.
• History—Note any history of breast conditions. New symptoms on a background history of cancer require urgent referral.
• All patients who have previously had histologically confirmed breast cancer, who present with a further lump or suspicious symptoms.
• Drugs—Use of the oral contraceptive pill or hormone replacement therapy in women who have reached menopause confers an increased risk of some breast cancer subtypes.3 Note the duration and frequency of drug use. • History of trauma—History of trauma might be associated with fat necrosis or haematoma.
• Family history—It is important to ask about family history, including all first and second degree relatives, of breast or ovarian cancer. Practitioners should also inform the patient that most women with breast cancer do not have a family history. Having one or more first degree relative who developed breast cancer under the age of 50 years substantially increases the patient’s risk. BRCA1, BRCA2, and TP53 mutations carry high risk, but only 3-5% of women with a family history of breast cancer in a first degree relative carry these mutations.4 Between 6% and 19% of women will have a family history, but this might be caused by chance, shared environmental or lifestyle risk factors, or increased genetic susceptibility.5 • History of malignancy—A history of malignancy, especially lung adenocarcinoma and skin cancer6 7 or radiotherapy can confer increased risk.
• Breast lumps in men—Although breast cancer in men is rare, any firm, unilateral breast lump requires urgent referral. Marginal risk factors that provide more information but rarely alter decision making include: • Late age at first full term pregnancy, low number of pregnancies (lower parity), early age at menarche, and late age at menopause. • History of high alcohol consumption. High alcohol consumption is increasingly linked to an increase in the incidence of breast cancer.8
What you should do The differential diagnoses include carcinoma, fibroadenoma, fat necrosis, and fibrocystic changes.
Refer patients with red flags (recommended by the National Institute for Health and Care Excellence9), which might indicate
For personal use only: See rights and reprints http://www.bmj.com/permissions
• Unilateral eczematous skin that does not respond to topical treatment. • Nipple distortion or dimpling of the skin (peau d’orange). • Unilateral bloody nipple discharge.
Despite her young age, this patient with a well defined persistent unilateral breast lump should be referred for triple assessment. Advise the patient that it is difficult to make a diagnosis on the basis of history and clinical findings alone, and that many women referred for triple assessment will have a benign condition. Should this turn out to be the rarer diagnosis of a breast cancer, however, early diagnosis is associated with a better prognosis, and the option for breast conserving oncoplastic procedures or reconstructive surgery is available.9 Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none. Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent: patient is hypothetical. 1 2 3 4 5 6 7 8 9 10
Hussein AA, Katia EK, Haifa D, Lana EK, Tarek HM, Nagi SES. Epidemiology and prognosis of breast cancer in young women. J Thorac Dis 2013;5:S2-S8. Bouchardy C, Fioretta G, Verkooijen HM, Vlastos G, Schaefer P, Delaloye JF, et al. Recent increase of breast cancer incidence among women under the age of forty. Br J Cancer 2007;96:1743-6. Elebro K, Butt S, Dorkhan M, Jernström H, Borgquist S. Age at first childbirth and oral contraceptive use are associated with risk of androgen receptor-negative breast cancer: the Malmö Diet and Cancer Cohort. Cancer Causes Control 2014;25:945-57. National Institute for Health and Care Excellence. Breast cancer—managing FH. Clinical Knowledge Summary. 2013. http://cks.nice.org.uk/breast-cancer-managing-fh. McPherson K, Steel CM, Dixon JM. Breast cancer—epidemiology, risk factors, and genetics. BMJ 2000;321:624-8. Chuang SC, Scelo G, Lee YCA, Friis S, Pukkala E, Brewster DH, et al. Risks of second primary cancer among patients with major histological types of lung cancers in both men and women. Br J Cancer 2010;102:1190-95. Chaturvedi AK, Kleinerman RA, Hildesheim A, Gilbert ES, Storm H, Lynch CF, et al. Second cancers after squamous cell carcinoma and adenocarcinoma of the cervix. J Clin Oncol 2009;27:967-73. McDonald JA, Goyal A, Terry MB. Alcohol intake and breast cancer risk: weighing the overall evidence. Curr Breast Cancer Rep 2013;5. National Institute for Health and Care Excellence. Referral guidelines for suspected cancer. 2009. www.nice.org.uk/nicemedia/pdf/cg027niceguideline.pdf. Mark K, Temkin SM, Terplan M. Breast self-awareness: the evidence behind the euphemism. Obstet Gynecol 2014;123:734-6.
Accepted: 25 July 2014 Cite this as: BMJ 2014;349:g5275 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;349:g5275 doi: 10.1136/bmj.g5275 (Published 5 September 2014)
Page 3 of 3
PRACTICE
Useful reading for patients NHS Choices. Breast lump. www.nhs.uk/Conditions/Breast-lump/Pages/Introduction.aspx National Institute for Health and Care Excellence. Improving outcomes in breast cancer. http://guidance.nice.org.uk/CSGBC/Guidance/ pdf/English
Table Table 1| Patients who do not warrant immediate referral Patients who don’t warrant immediate referral No discrete lump
How to manage Manage anxiety while encouraging self awareness10 and lifestyle advice
Young patients under the age of 30, with no family history, Ask patient to keep a diary of symptoms and re-examine if the lump persists after next menstruation. bilateral diffusely lumpy breast tissue, and cyclical pain If symptoms persist then non-urgent referral Isolated, unilateral breast pain
Breast pain of any kind in the absence of a red flag symptom does not warrant urgent referral because it is rarely associated with cancer. If the pain is an isolated feature manage initially with reassurance and simple analgesia, and a follow-up review
Superficial abscess without nipple changes or sebaceous Short history of breast lump and pain, with evidence of infection. Breast abscesses are most common cyst postpartum. An overlying punctum suggests a sebaceous cyst. If the cyst does not respond to oral antibiotics, it might require incision and drainage or referral for ultrasound guided drainage. Be cautious about missing an inflammatory breast cancer, particularly if symptoms persist despite treatment. Early re-evaluation and urgent referral are indicated if clinical suspicion arises
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Practice
PRACTICE 10-MINUTE CONSULTATION
Breast lumps 1
1
M Twoon medical student , N Y B Ng medical student , S E Thomson specialist training year 4, 2 plastic and reconstructive surgery University of Aberdeen, Aberdeen, Scotland; 2Plastic and Reconstructive Surgery Unit, Aberdeen Royal Infirmary, Aberdeen, Scotland
1
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
A 35 year old woman presents with a 1 cm hard lump in the upper outer quadrant of her right breast. She first noticed this when she was in the shower three months ago. She is worried that the lump might be malignant.
What you should cover
Breast lumps are common and have a variety of causes. Although most lumps are not malignant, any abnormal changes to the breasts need to be reviewed as soon as possible. Refer patients to a breast clinic where triple assessment can be performed and the lump fully investigated. It is often difficult to make a definitive diagnosis on clinical history and examination alone. Many patients who are referred for specialist assessment will be found not to have cancer.
Examination Undertake a clinical breast examination, with consent and chaperone. People have different techniques and, although the following technique is recommended, it is by no means the only acceptable one. • Compare both sides, and include all four quadrants, the retro-areolar area, and axillary tail. Examine the axilla and supraclavicular areas for lymphadenopathy.
• Note the location of lump; its consistency; tethering to overlying or underlying structures; and associated features of lymphadenopathy, skin changes (such as peau d’orange—skin with an “orange peel” appearance owing to invasion of the lymphatics by tumour cells, which causes obstruction and oedema), or nipple discharge. • If nipple discharge is clearly evident send a sample for microbiology and cytology.
• An eczematous rash might represent Paget’s disease of the nipple and underlying cancer. Compare both nipples for evidence of eczema or Paget’s disease. Eczema tends to be bilateral with marked itching. Furthermore, there tends
to be a history of atopy and areas of eczema on multiple sites of the body. Paget’s disease tends to be unilateral with associated bleeding and nipple erosion.
• Advanced cutaneous spread might cause ulceration of the skin and is occasionally seen in a late presentation. • In patients with a history of cancer or those presenting with advanced disease, look for hepatomegaly or vertebral tenderness, which would indicate possible metastatic disease.
Breast cancer cannot be ruled in or out solely by taking a history or profiling of risk factors. Similarly, clinical breast examination can confirm breast masses but cannot definitively distinguish the cause.
History • Age—Although incidence in younger women is increasing, the probability of a lump being associated with cancer increases with age. Benign lumps are common in women under 30 years.1 2 However, a discrete lump, persisting after the next period, warrants urgent referral, irrespective of age.
• Characteristics of lump (site, size, consistency, and duration)—Malignant lesions are more likely to enlarge over time without periods of resolution. Lumps persisting after a woman’s next period or in postmenopausal women require referral for further assessment. Progressive enlargement of a discrete lump or breast size merits referral to a breast clinic. • Associated features warranting referral—Peau d’orange, skin tethering, nipple inversion, spontaneous unilateral nipple discharge (associated with breast cancer or ductal papilloma), and unilateral eczema not responding to topical therapies require referral. General features such as malaise or weight loss also warrant referral. • Breast pain and tenderness—Benign conditions, such as fibroadenosis and fibroadenomas, might present with
Correspondence to: [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;349:g5275 doi: 10.1136/bmj.g5275 (Published 5 September 2014)
Page 2 of 3
PRACTICE
cyclical breast pain and diffuse changes in the breast parenchyma rather than a discrete lump. This pain is also likely to be bilateral. Non-cyclical unilateral breast pain is usually caused by a problem outside the breast—for example, muscle or connective tissue strain, or skin injury. It might be associated with a lump but is rarely caused by breast cancer. If the pain is an isolated symptom of short duration, it might be managed initially in a primary care setting. If other focal clinical findings are present, however, referral for triple assessment is required. Non-urgent referral might be considered if isolated breast pain persists despite initial measures.
malignancy urgently (within two weeks) to a breast clinic for triple assessment (table).⇓
Red flags The red flags in the list below are all from the National Institute for Health and Care Excellence. Referral guidelines for suspected cancer.9 • All patients presenting with a discrete, hard lump with fixation—with or without skin tethering. • Women aged 30 years or more who have a discrete lump that persists after the next period, or those who present after menopause.
• Axillary swelling—Persistent unexplained axillary swelling might represent breast tail pathology and should be referred for assessment.
• Women under 30 years with an enlarging lump or a fixed, hard, or tethered lump, or a worrying family history.
• History—Note any history of breast conditions. New symptoms on a background history of cancer require urgent referral.
• All patients who have previously had histologically confirmed breast cancer, who present with a further lump or suspicious symptoms.
• Drugs—Use of the oral contraceptive pill or hormone replacement therapy in women who have reached menopause confers an increased risk of some breast cancer subtypes.3 Note the duration and frequency of drug use. • History of trauma—History of trauma might be associated with fat necrosis or haematoma.
• Family history—It is important to ask about family history, including all first and second degree relatives, of breast or ovarian cancer. Practitioners should also inform the patient that most women with breast cancer do not have a family history. Having one or more first degree relative who developed breast cancer under the age of 50 years substantially increases the patient’s risk. BRCA1, BRCA2, and TP53 mutations carry high risk, but only 3-5% of women with a family history of breast cancer in a first degree relative carry these mutations.4 Between 6% and 19% of women will have a family history, but this might be caused by chance, shared environmental or lifestyle risk factors, or increased genetic susceptibility.5 • History of malignancy—A history of malignancy, especially lung adenocarcinoma and skin cancer6 7 or radiotherapy can confer increased risk.
• Breast lumps in men—Although breast cancer in men is rare, any firm, unilateral breast lump requires urgent referral. Marginal risk factors that provide more information but rarely alter decision making include: • Late age at first full term pregnancy, low number of pregnancies (lower parity), early age at menarche, and late age at menopause. • History of high alcohol consumption. High alcohol consumption is increasingly linked to an increase in the incidence of breast cancer.8
What you should do The differential diagnoses include carcinoma, fibroadenoma, fat necrosis, and fibrocystic changes.
Refer patients with red flags (recommended by the National Institute for Health and Care Excellence9), which might indicate
For personal use only: See rights and reprints http://www.bmj.com/permissions
• Unilateral eczematous skin that does not respond to topical treatment. • Nipple distortion or dimpling of the skin (peau d’orange). • Unilateral bloody nipple discharge.
Despite her young age, this patient with a well defined persistent unilateral breast lump should be referred for triple assessment. Advise the patient that it is difficult to make a diagnosis on the basis of history and clinical findings alone, and that many women referred for triple assessment will have a benign condition. Should this turn out to be the rarer diagnosis of a breast cancer, however, early diagnosis is associated with a better prognosis, and the option for breast conserving oncoplastic procedures or reconstructive surgery is available.9 Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none. Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent: patient is hypothetical. 1 2 3 4 5 6 7 8 9 10
Hussein AA, Katia EK, Haifa D, Lana EK, Tarek HM, Nagi SES. Epidemiology and prognosis of breast cancer in young women. J Thorac Dis 2013;5:S2-S8. Bouchardy C, Fioretta G, Verkooijen HM, Vlastos G, Schaefer P, Delaloye JF, et al. Recent increase of breast cancer incidence among women under the age of forty. Br J Cancer 2007;96:1743-6. Elebro K, Butt S, Dorkhan M, Jernström H, Borgquist S. Age at first childbirth and oral contraceptive use are associated with risk of androgen receptor-negative breast cancer: the Malmö Diet and Cancer Cohort. Cancer Causes Control 2014;25:945-57. National Institute for Health and Care Excellence. Breast cancer—managing FH. Clinical Knowledge Summary. 2013. http://cks.nice.org.uk/breast-cancer-managing-fh. McPherson K, Steel CM, Dixon JM. Breast cancer—epidemiology, risk factors, and genetics. BMJ 2000;321:624-8. Chuang SC, Scelo G, Lee YCA, Friis S, Pukkala E, Brewster DH, et al. Risks of second primary cancer among patients with major histological types of lung cancers in both men and women. Br J Cancer 2010;102:1190-95. Chaturvedi AK, Kleinerman RA, Hildesheim A, Gilbert ES, Storm H, Lynch CF, et al. Second cancers after squamous cell carcinoma and adenocarcinoma of the cervix. J Clin Oncol 2009;27:967-73. McDonald JA, Goyal A, Terry MB. Alcohol intake and breast cancer risk: weighing the overall evidence. Curr Breast Cancer Rep 2013;5. National Institute for Health and Care Excellence. Referral guidelines for suspected cancer. 2009. www.nice.org.uk/nicemedia/pdf/cg027niceguideline.pdf. Mark K, Temkin SM, Terplan M. Breast self-awareness: the evidence behind the euphemism. Obstet Gynecol 2014;123:734-6.
Accepted: 25 July 2014 Cite this as: BMJ 2014;349:g5275 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;349:g5275 doi: 10.1136/bmj.g5275 (Published 5 September 2014)
Page 3 of 3
PRACTICE
Useful reading for patients NHS Choices. Breast lump. www.nhs.uk/Conditions/Breast-lump/Pages/Introduction.aspx National Institute for Health and Care Excellence. Improving outcomes in breast cancer. http://guidance.nice.org.uk/CSGBC/Guidance/ pdf/English
Table Table 1| Patients who do not warrant immediate referral Patients who don’t warrant immediate referral No discrete lump
How to manage Manage anxiety while encouraging self awareness10 and lifestyle advice
Young patients under the age of 30, with no family history, Ask patient to keep a diary of symptoms and re-examine if the lump persists after next menstruation. bilateral diffusely lumpy breast tissue, and cyclical pain If symptoms persist then non-urgent referral Isolated, unilateral breast pain
Breast pain of any kind in the absence of a red flag symptom does not warrant urgent referral because it is rarely associated with cancer. If the pain is an isolated feature manage initially with reassurance and simple analgesia, and a follow-up review
Superficial abscess without nipple changes or sebaceous Short history of breast lump and pain, with evidence of infection. Breast abscesses are most common cyst postpartum. An overlying punctum suggests a sebaceous cyst. If the cyst does not respond to oral antibiotics, it might require incision and drainage or referral for ultrasound guided drainage. Be cautious about missing an inflammatory breast cancer, particularly if symptoms persist despite treatment. Early re-evaluation and urgent referral are indicated if clinical suspicion arises
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
