Assessing a woman with a breast lump

Women with a lump or discharge need prompt evaluation.

Breast cysts may be benign
Breast cysts may be benign

There are between 350,000 and 500,000 referrals to breast clinics a year. Approximately 125,000 GP referrals are marked 'urgent'.

At present, GPs see virtually all patients with breast symptoms and usually manage or refer according to local guidelines devised by the breast unit.

Any patient presenting with a palpable lump requires a thorough evaluation to determine whether the lump is discrete or an area of nodularity.

Clinical assessment should include a comprehensive history, using a model such as the Calgary model,1 and an examination that includes palpation and assessment of axillary nodes and skin changes, all of which should be documented.

History-taking and examination of the breast and axillae are fundamental to assessment of patients with breast disease and a key component of the triple assessment of all patients presenting with breast symptoms.2

Research has shown that nurse practitioners can become highly competent in breast and axillary node examination following adequate training.3

Examination
Breast inspection should be undertaken in good light, with the patient in different positions, holding their arms by their side, above their head and pressing on their hips (see figure).

Skin dimpling or a change in contour is revealed in a high percentage of patients who have breast cancer.

Breast palpation should be performed with the patient lying flat with their arms above their head; all breast tissue is examined with the hand held flat. Any abnormality should be further examined with the fingertips and assessed for dip fixation by tensing the pectoralis major.

Once both breasts have been palpated, the patient's nodal areas should be checked. Clinical assessment of the axillary nodes is often inaccurate - palpable nodes can be identified in up to 30 per cent of patients who have no clinically significant breast or other disease, while up to 40 per cent of patients with breast cancer who have clinically normal axillary nodes have axillary nodal metastases.3

Some conditions may be managed initially by the GP or nurse practitioner, while other presentations will require urgent referral to a breast clinic (see boxes below).

Reasons to make a referral
For patients presenting with a breast lump, the practitioner should determine whether it is discrete or an area of lumpiness or nodularity.

A discrete lump stands out from the adjoining breast tissue, has definable borders and is measurable. In contrast, nodularity has ill-defined borders, is often bilateral and tends to fluctuate with the menstrual cycle.

Those with a discrete lump should be referred to a breast unit, although if a patient has previously had cysts aspirated and the lump is likely to be a further cyst, it is reasonable for the GP to aspirate the cyst if both patient and GP agree.

Although recent nipple inversion may be caused by benign duct fibrosis, an underlying breast carcinoma is also possible; therefore inversion should be referred to a breast unit.

It should be noted that an inverted nipple that can be manually everted is unlikely to be associated with malignancy.

Long-term nipple inversion is common, frequently bilateral and of no clinical consequence; it does not require referral.

TREATING BREAST INFECTIONS

Four guiding principles

  • Give appropriate antibiotics at an early stage to reduce abscess formation.
  • Refer to secondary care if the infection does not settle with appropriate antibiotics.
  • Carry out an ultrasound scan to evaluate whether aspiration is viable.
  • Further assess any inflammatory lesion to exclude breast cancer and keep the patient under surveillance.

Breast infection
Inflammatory breast cancer and breast abscess/mastitis can be difficult to differentiate because symptoms appear similar in both conditions.

Breast infection is less common than it used to be. It is seen occasionally in neonates, but most often affects women aged 18-50 years; in this group it can be divided into lactational and non-lactational infection.

The infection can affect the skin, when it can be either a primary event or secondary to a skin lesion, such as a sebaceous cyst. The four guiding principles (see box above right) include referral if the infection does not settle with antibiotics.

Common skin conditions, such as unilateral nipple eczema, may incidentally affect the nipple, which may be treated with a course of standard topical therapy. Patients whose conditions fail to resolve should be referred to a breast unit, where a punch biopsy may be performed. Reddening, thickening and scaling of the nipple may indicate malignancy (Paget's disease).

Conclusion
A multidisciplinary approach is key to the management of breast disease in secondary or primary care.

With increasing pressure on breast units to achieve the two-week waiting time for urgent referrals and the move to shift patterns for surgical trainees, it is essential that breast clinics are staffed with clinicians who have appropriate training in breast and loco-regional node examination. Nurse practitioners are in an ideal position to fulfil this role by developing their technical and specialist skills, underpinned by academic knowledge.

  • Ms Chapman is a nurse consultant in breast disease and Ms Rowley is a nurse practitioner at the Cambridge Breast Unit, Addenbrooke's NHS Trust, Cambridge.
PRIMARY CARE OPTIONS

These cases may initially be managed by nurse practitioner or GP

  • Young patients with tender, lumpy breasts and older patients with symmetrical nodularity (if no localised nodularity).
  • Patients with minor to moderate breast pain who do not have a discrete palpable lesion.
  • Patients aged under 50 years who have nipple discharge from more than one duct or intermittent discharge that is not watery/bloodstained or troublesome.

 

WHEN URGENT REFERRAL IS NEEDED

Patients presenting with the following require urgent referral:

  • A new, discrete lump (at any age).
  • Bloodstained, persistent or troublesome nipple discharge.
  • Recent nipple retraction or distortion.
  • Altered breast contour or dimpling.
  • Suspected Paget's disease of the breast.
  • Persistent asymmetrical nodularity.
  • Mastalgia that interferes with the patient's lifestyle.
  • Moderate to high familial risk of breast cancer - may be referred directly to clinical genetics.

 

REFERENCES

1. Silverman J, Kurtz S, Draper J. Skills for communicating with patients. Radcliffe Publishing, Oxford, 2005.

2. Dixon M, Sainsbury R. Handbook of diseases of the breast. Churchill Livingstone, London, 1998.

3. Chapman D, Purushotham A, Wishart G. Nurse practitioner training in breast examination. Nurs Stand 2002; 17(2): 33-6.

Dawn Chapman and Joanna Rowley recommends

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