Breast Lumps and Breast Examination

The detection of a lump in the breast causes understandable fear of a cancer diagnosis. It is important in responding to this symptom and the inevitable underlying fear that a careful assessment is undertaken so that appropriate management can be organised in a timely and efficient way. Careful and meticulous examination will increase the chance of correct diagnosis.¹ It is important that referrals are appropriate and that information and discussion accompany this assessment.

The detection of a breast lump is a relatively common problem in general practice. Each year the average GP, with a patient list of 2,000 will see one or two new cases of breast cancer.² The same GP will see many more patients with benign breast problems. An average breast unit serving a population of 300,000 will receive about 40 referrals from GPs and 2 from screening centres per week. On average 4 cases of breast cancer will be diagnosed from these referrals per week.²

Risk factors for malignancy

• Previous history of breast cancer.
• Family history of breast cancer in first-degree relative. The BRCA1 and BRCA2 genes carry very high risk but represent under 5% of cases. The importance of family history is often exaggerated and 8 of every 9 women who develop the disease do not have a mother, sister or daughter so affected. ³
• Risk increases with age with 5% of cases presenting before age 40 and 2% before age 35.
• Never having borne a child or first child after age 30.
• Not having breast-fed (breast-feeding is protective).
• Early menarche and late menopause.
• Oestrogens and HRT. Risk with HRT starts after 5 years' duration but is significant if more than 10 years' duration.⁴
• Radiation to chest, even quite small doses.
• High alcohol intake may increase risk in a dose-related manner.⁵
• Silicone breast implants neither increase the risk of developing breast cancer nor the risk of late presentation.⁶

In breast cancer:

• About 90% of patients still 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.

History

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 lump in the breast. A third of all women attending a breast unit outpatients will have a painless breast lump - of whom 1 in 8 or 9 will have a breast cancer.
• 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 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, still patients (usually elderly, but not always) will 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 pre-menopausal, when was her LMP?
  • 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.

Examination

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
    • Is there 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 inflamed tumour under the skin)
    The peau d'orange appearance is of serious significance. The underlying tumour is likely to be aggressive and classified as stage IIIB.
• The next stage is palpation, and a systematic search pattern improves the rate of detection. Different people have different techniques and whilst the following is recommended here, it is by no means the only acceptable technique:
  

  Technique for palpation of the breast: Ask the patient to lie supine with her hands above her 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 (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 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 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 examine herself 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 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.

  
  It is also worth noting:
  • Breast examination should be thorough and take about 3 minutes each side
  • It can be taught using silicone models¹
  • 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 masses
    Malignant breast masses:	Benign 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
    Note: there are no reliable features to distinguish cysts from solid masses

• 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.² Whilst there is evidence that delays of at least six months may reduce survival, there is debate about the effects of shorter delays.²

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.⁷ See the separate Benign Breast Disease record.

If the doctor cannot be sure that there is no malignancy, then referral to a breast clinic is required.
Remember that referral should be made to a team specialising in breast cancer, as they get the best results.²
It is generally important to be optimistic about treatment and outcome. Results are much better than they used to be.
The following is the recommendation from NICE with regard to urgency of referral - it is unsurprising that it is very similar to the Clinical Knowledge Summaries guidance:

Urgent referral

The following patients should be seen within 2 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.⁸
• 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.

Routine referral

The following patients should be seen within 4 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.

If cancer is suspected, time should not be spent on investigation but referral should be made to a breast clinic and the woman should be seen within 2 weeks. The standard investigation is mammography - that is the basis for the national screening programme. It probably detects around 90% of cancers and is quite good at differentiating malignant from benign tumours. The exact figures vary between studies and possibly reflect the age of patients.⁹ Mammography is less useful in younger women with denser breasts where ultrasound may be preferable.
Neither mammography nor clinical examination will detect all cancers but the two together will detect most. Computer-aided detection may increase sensitivity.¹⁰For further details of investigation and diagnostic procedures, see separate article Breast Cancer.