Red flag symptoms
- Hard, irregularly shaped lump
- Fixity of lump to skin or chest wall +/skin tethering
- Fixed axillary lymphadenopathy
- Bloody nipple discharge
Breast lumps are usually found by the patient, incidentally or through self-examination. The lump may be painless or painful and may be associated with nipple and/or skin changes.
It is important to rule out malignancy, but most breast lumps are benign and are caused by fibrocystic changes and fibroadenomas.
Fibrocystic changes may manifest as breast pain and cysts. They are more commonly seen in nulliparous women and in those who had an early menarche.
Non-tender breast lumps, which are smooth and mobile, in women of reproductive age are likely to be fibroadenomas.
Fibroadenomas usually decrease in size over time, in contrast to juvenile fibroadenomas, which may increase in size. Mastitis may result in abscess formation, which can occur postpartum or in relation to trauma. A galactocele may present several months after lactation.
Clinical evaluation involves taking a history of how long the lump has been present and whether it is painful. It may fluctuate in size or there may have been a change in the shape of the breast. There may be a relationship between the size or presence of the lump and menstruation. A history of previous breast lumps should be sought.
It is relevant to assess whether there are any associated nipple or skin changes. Assessing nipple changes includes asking about the presence of any discharge and if present, whether it is bloody, milky or clear.
There may be a history of nipple inversion. Skin changes include dimpling, rashes and ulceration.
It is helpful as part of the clinical evaluation to assess for risk factors for breast cancer; for example, there may be a history of breast and/or ovarian cancer in a first-degree relative, and a history of HRT.
Age is an important consideration because breast carcinoma is more likely to present in a postmenopausal woman, in contrast to fibroadenomas, which are more common in younger women. It may be relevant to ask about breastfeeding.
Further evaluation involves examining the breasts and assessing for cervical and axillary lymphadenopathy.
There may be skin changes present on inspection, for example, an eczematous rash, erythema, skin dimpling and peau d'orange changes.
It is helpful to ask the patient where the lump is located. It should be examined for tenderness, size, consistency and fixity. Fixity with or without skin tethering, irregular shape, hardness in consistency, fixed lymphadenopathy and bloody nipple discharge may be associated with malignancy. Tender, rubbery lumps may be more suggestive of fibrocystic changes.
- Fibrocystic changes
- Trauma - fat necrosis
NICE recommends1 that a suspected cancer pathway referral (for an appointment within two weeks) is appropriate if the patient is:
Aged 30 or over, with an unexplained breast lump (whether painful or not), or
Aged 50 or over with discharge, retraction or other changes of concern in one nipple
Referral using the same pathway should be considered if the patient has skin changes that suggest breast cancer, or is aged 30 or over with an unexplained lump in the axilla. Non-urgent referral should be considered in people aged under 30 with an unexplained breast lump.
In any woman with a prior history of breast cancer presenting with a lump or suggestive symptoms, urgent referral should be considered, regardless of the woman's age.
Women who are referred undergo triple assessment, comprising clinical examination, mammography or ultrasonography followed by pathological assessment, which may be cytological or from a biopsy specimen.
- Dr Suneeta Kochhar is a GP in Bexhill, East Sussex
- NICE. Suspected cancer: recognition and referral. NG12. London, NICE, June 2015.