oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
The detection of a lump in the breast causes understandable fear of a cancer diagnosis. Careful examination will increase the chance of correct diagnosis. It is important that referrals are appropriate and that information and discussion accompany this assessment.
Breast cancer is by far the most common cancer in women. In 2009 there were 48,788 new cases in the UK and, of those, 371 cases were in men. Within the UK, rates are broadly similar for all countries except Northern Ireland which has a slightly lower rate (and has done for a period of two decades). The lifetime risk of (females) developing breast cancer in the UK is 1 in 8. The European age-standardised incidence rate is approximately 120 per 100,000 women.
Risk factors for malignancy
- Previous history of breast cancer.
- Family history of breast cancer in a first-degree relative. The BRCA1, BRCA2 and TP53 mutations carry very high risk but only 3-5% of women are likely to carry them on their chromosomes. Between 6% and 19% of women will have a family history but this may be due to chance, shared environmental or lifestyle risk factors, or increased genetic susceptibility.
- Risk increases with age; ≤5% of cases present before age 35, ≤25% before 50 years.
- Never having borne a child, or first child after age 30.
- Not having breast-fed (breast-feeding is protective).
- Early menarche and late menopause.
- Continuous combined HRT increases risk.
- Radiation to chest (even quite small doses).
- High alcohol intake may increase risk in a dose-related manner.
- Breast augmentation is not generally associated with increased risk. Type of implant used may be important.
In breast cancer:
- Most patients present having felt a lump (20% as a painful lump).
- 10% of patients present with nipple change.
- 3% of patients present with nipple discharge.
- 5% of patients present with skin contour changes.
- Breast pain/mastalgia alone is a very uncommon presentation.
- Intraduct carcinoma may present as a bloody discharge from the nipple.
Organised screening, education programmes and improved consciousness of the female population have substantially changed the type of patients seen nowadays compared with a few decades ago and the neglected tumour is much rarer than it was.
Patients presenting with a lump in the breast will be aware of the possible diagnosis and will be very anxious. This should be taken into account when taking the history and discussing management.
- Most patients present having found a painless lump in the breast.
- Other symptoms include a lump under the arm, lump in other regional lymph nodes and with retraction or inversion of the nipple.
- A suspicious mass may have been found at routine mammography.
- Metastases may cause pain in bones or even pathological fractures.
- Metastases at other sites - for example, the liver, lung or brain - may cause symptoms.
- Intraduct carcinoma may present as a bloody discharge from the nipple.
- The lump of breast cancer is usually painless.
- Occasionally, patients (usually elderly, but not always) will still present with a fungating mass that has obviously been neglected for a long time.
- Direct questions should include the following:
- When was the lump first noticed?
- Has it changed in size or in any other way? This includes a nipple becoming inverted.
- Menstrual history. If she is premenopausal, when was her last menstrual period?
- Any changes noted through the menstrual cycle?
- Family history (including breast cancer, other cancers and other conditions).
- Is there any discharge from the nipple?
- Go through the risk factors listed above.
In line with good practice, explain to the patient what you intend to do and why, and consider using a chaperone.
Some people advocate using the examination to teach the patient self-examination. It may seem logical that self-awareness should be beneficial but there is remarkably little evidence that self-examination is beneficial.
- Inspect the breasts:
- Inspect with the patient sitting and then with hands raised above head.
- A lump may be visible.
- Look for:
- Variations in breast size and contour.
- Whether there is an inverted nipple (nipple retraction) and, if so, is it unilateral or bilateral?
- Any oedema (may be slight).
- Redness or retraction of the skin.
- Dimpling of the skin (called peau d'orange and is like orange peel because of an inflamed tumour under the skin).
- The next stage is palpation, and a systematic search pattern improves the rate of detection.
Technique for palpation of the breastDifferent people have different techniques and, whilst the following is recommended here, it is by no means the only acceptable technique.
Ask the patient to lie supine with their hands above their head. Examine from the clavicle medially to the mid-sternum, 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. Be aware that 50% of breast tissue is found in the upper outer quadrant and 20% under the nipple.
- Examine with the flat of the hand to avoid pinching up tissue. Use the second, third and fourth fingers held together and moved in small circles (the most sensitive technique).
- Begin with light pressure and then repeat the same area using medium and deep pressure before moving to the next area.
- Three search patterns are generally used:
- Radial spoke method (wedges of tissue examined starting at the periphery and working in towards the nipple in a radial pattern).
- Concentric circle method, examining in expanding or contracting concentric circles.
- Vertical strip method, which examines the breast in overlapping vertical strips moving across the chest. The vertical strip method has been shown to be more sensitive because the entire nipple-areolar complex is included and the examiner is able to keep track better.
- If you have difficulty finding a discrete lump, ask the patient to demonstrate it for you.
- Do not take the breast tissue between index finger and thumb, as this way it is very easy to pinch up spurious lumps. Also, teach the patient to self-examine with flat fingers rather than pinching.
- A discrete mass should be described in terms of location, size, mobility and texture. Mobility includes whether attached to skin or underlying tissue.
- Examine both breasts.
- Support the patient's arm to palpate axillary nodes and then feel for supraclavicular and cervical nodes. Note the presence or absence of palpable regional nodes.
- If there is a history of discharge from the nipple it is often easier to get the patient to demonstrate the discharge (rather than the doctor attempting to do so). 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.
- It can be taught using silicone models.
- Remember that the breast has an axillary tail.
- The diagram of frequency of malignancy by site in the breast:
- If a lump is found, note size, consistency and whether is attached to skin or underlying tissue.
Clinical features of palpable breast massesMalignant breast massesBenign breast masses Consistency: hard Consistency: firm or rubbery Painless (90%) Often painful (consistent with benign breast conditions) Irregular margins Regular or smooth margins Fixation to skin or chest wall Mobile and not fixed Skin dimpling may occur Skin dimpling unlikely Discharge: bloody, unilateral Discharge: no blood and bilateral discharge. Green or yellow colour Nipple retraction may be present No nipple retraction
- Breast cancer in men:
- Is rare (especially under 50 years old).
- Can present as a unilateral mass (subareolar, with or without nipple distortion or associated skin changes).
- Urgent referral is required.
The importance of minimising delay is consistently reported by patients in surveys to be very important and is recognised by professional consensus. Short delays are unlikely to affect the clinical course of a breast cancer. Longer delays are usually either due to patient delay or to the GP's failure to refer. Whilst there is evidence that delays of at least six months may reduce survival, there is debate about the effects of shorter delays.
Is any referral necessary?
This will depend upon what you find. Sometimes there is not really any discrete lump but general nodularity. If you have failed to find a true discrete lump, then agree with the patient on your findings. If you really cannot find anything but the patient thinks there was something there, do give them the invitation to return again and see if you both can find it.
In a woman who is before the menopause and has only just found a lump, it is worth asking her to return in the early part of her next menstrual cycle to see if it has disappeared. A woman who has had a hysterectomy may still be having cyclical hormonal changes only without menstruation. If she has already observed it for a few months and it is constant, then referral is required.
If the lump is thought to be a cyst, it may be safely aspirated. It should disappear beneath the fingers as the fluid is withdrawn. If the fluid is frankly bloody it should be submitted for cytology. Otherwise, that is unnecessary. See separate article Benign breast disease.
If the doctor cannot be sure that there is no malignancy, then referral to a breast clinic is required. The referral should be made to a team specialising in breast cancer. It is generally important to be optimistic about treatment and outcome. Results are much better than they used to be.
The National Institute for Health and Clinical Excellence (NICE) recommends that the following patients should be seen within two weeks:
- Patients of any age with a discrete, hard lump with fixation, with or without skin tethering, or who are female, aged 30 years and older with a discrete lump that persists after their next period, or presents after menopause.
- Patients who are female, aged younger than 30 years:
- With a lump that enlarges.
- With a lump that is fixed and hard.
- In whom there are other reasons for concern, such as family history.
- Patients of any age, with previous breast cancer, who present with a further lump or suspicious symptoms.
- Patients with unilateral eczematous skin or nipple change that does not respond to topical treatment.
- Patients with nipple distortion of recent onset.
- Patients with spontaneous unilateral bloody nipple discharge.
- Patients who are male, aged 50 years and older with a unilateral, firm subareolar mass, with or without nipple distortion, or associated skin changes.
The following patients should be seen within four weeks:
- Women aged younger than 30 years with a lump.
- Patients with breast pain and no palpable abnormality, when initial treatment fails and/or with unexplained persistent symptoms.
These may vary locally, but usually involve mammography ± ultrasound, with biopsy if appropriate. For further details of investigation and diagnostic procedures, see separate article Breast cancer.
Further reading & references
- Breast cancer - suspected; NICE CKS, July 2005
- Vaidyanathan L, Barnard K, Elniki DM; Benign breast disease: When to treat, when to reassure, when to refer - Review, Cleveland Clinic Journal of Medicine, May 2002
- Breast cancer - UK incidence statistics; Cancer Research UK.
- Breast cancer - managing FH; NICE CKS, November 2009
- Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up; European Society for Medical Oncology (2011)
- Farquhar C, Marjoribanks J, Lethaby A, et al; Long term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD004143.
- Kent A; Alcohol and breast cancer. Rev Obstet Gynecol. 2012;5(1):57.
- Pan SY, Lavigne E, Holowaty EJ, et al; Canadian breast implant cohort: Extended follow-up of cancer incidence. Int J Cancer. 2012 Apr 19. doi: 10.1002/ijc.27603.
- Improving outcomes in breast cancer, NICE Clinical Guideline (2002)
- Vogel VG, Breast Lumps, Merck Manual, Nov 2008
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
|Original Author: Dr Richard Draper||Current Version: Dr Hayley Willacy||Peer Reviewer: Prof Cathy Jackson|
|Last Checked: 13/06/2012||Document ID: 641 Version: 26||© EMIS|