Breast Lumps and Breast Examination

When a woman presents with a lump in the breast she is anxious because she fears that it is cancer. Over the age of 50 she may well be right. The younger the woman, the less likely is malignancy but it can occur, even in quite young women. Rather than immediately referring any such patient to a breast clinic, history and examination should be performed to stratify the level of risk. Careful and meticulous examination will increase the chance of correct diagnosis.¹

Breast cancer is the commonest cancer in women with 35,000 new cases in the UK each year. It represents 1 in 4 of all malignancies in women. Most patients are over 50 years old. In 2001, deaths from breast cancer in England and Wales were 11,574 women and 80 men.² Incidence rises with age and over half of deaths are in women over 70 but it can strike much younger.

In the UK in 2002, 12,840 women died of breast cancer and 13,380 died of lung cancer making 17 and 18% respectively of cancer deaths in women.³ Lung cancer is less common but has a poorer prognosis.
The death rate from breast cancer is falling. This is probably due to better treatment but mammography may also be detecting cases earlier.
In less than 1% of cases there is simultaneous bilateral breast cancer.
The average GP will see one new case of breast cancer per year but probably many more lumps.

• 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 ⁴
• Age - 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 duration⁵
• Radiation to chest, even quite small doses
• High alcohol intake may increase risk in a dose related manner⁶
• Silicone breast implants do not increase the risk of developing breast cancer nor the risk of late presentation⁷

90% of breast cancer present with a lump, 20% as a painful lump, 10% with nipple changes, 3% with nipple discharge, 5% with skin contour changes. Breast pain/mastalgia alone is a very uncommon presentation of breast cancer. Intraduct carcinoma may present as a bloody discharge from the nipple.

• How long has she had the lump? Sometimes old women present with a lump that they claim to have just noticed and produce a fungating and ulcerating growth but most women are much more rational and present early rather than going into denial.
• Where is it?
• Has there been any change? This includes a nipple becoming inverted.
• If she is pre-menopausal, when was her LMP?
• Is there any pain?
• 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 and even some that it may do harm.⁸As always, the first part of examination is to look. Look with her arms at her sides and with her arms above her head.

• Is a lump visible?
• Do the breasts look symmetrical? Slight asymmetry is quite normal.
• Is there an inverted nipple and if so is it unilateral or bilateral?
• Is there puckering of the skin or peau d'orange?

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:
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.
Using the second, third and fourth fingers held together moved in small circles is the most sensitive technique. Begin with light pressure and then repeat the same area using medium and deep pressure before moving to 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.
If she has not complained of any discharge from the nipple it is not worth trying to produce any. If she has complained then it is often easier to get the patient to demonstrate it than for the doctor to do so.
A discrete mass should be described in terms of location, size, mobility and texture. Mobility includes whether attached to skin or underlying tissue. Note presence or absence of palpable regional nodes.
Diagram of frequency of malignancy by site in the breast:

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 she thinks there was something there, do give her 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 them referral is required.

If the lump is thought to be a cyst it may be safely aspirated as described in the article on benign breast disease.

If the doctor cannot be sure that there is no malignancy then referral to a breast clinic is required. 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

• 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.⁹
• 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
• with nipple distortion of recent onset
• with spontaneous unilateral bloody nipple discharge
• 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

Consider in:

• 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 possible reflect the age of patients.¹⁰ 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.¹¹

• Stage 0 is carcinoma in situ and is not invasive
• Stage I has a tumour up to 2cms in diameter and no lymph node involvement
• Stage II has a tumour between 2 and 5cms in diameter or there is spread to the axillary lymph nodes on the same side and the nodes are not adherent
• Stage IIIA is when the tumour is over 5cms in diameter or the nodes are adherent
• Stage IIIB is invasive breast cancer in which a tumour of any size has spread to the breast skin, chest wall, or internal mammary lymph nodes and includes inflammatory breast cancer with peau d'orange.
• Stage IV is spread beyond the breast, axilla and internal mammary nodes. It may have spread to supraclavicular nodes, bone, liver, lung or brain.

Management of carcinoma of breast is described elsewhere, as is benign breast disease, galactorrhoea and mammography.