The right referral for breast pain: II
Professor Ian Fentiman’s second and final article aims to help GPs make choices on referrals for breast pain, nipple problems and genetic risk
Professor Ian Fentiman's second and final article aims to help GPs make choices on referrals for breast pain, nipple problems and genetic risk
Pain is the most common breast symptom for which patients consult their GP. Often it is associated with lumpiness and although the received wisdom is that painful lumpiness is never a symptom of malignancy, the truth is not quite so simple. About 10% of cancers will present with a painful lump, the pain usually being of a burning nature. In contrast, pain in the absence of a lump is almost never caused by a breast cancer. In premenopausal women with pain and equivocal lumpiness, judicious re-examination two weeks later will often confirm that the lumpiness has resolved.
The key question to be answered is whether the pain is of mammary or extra-mammary origin. Is the pain cyclical, is it always in the same place, is it affected by exercise and from what other, if any, medical problems is the patient suffering? Cyclical pain is most likely to be of mammary origin although some rib-cage pain will be exacerbated by the luteal phase breast swelling.
Once the patient has indicated the site(s) of the pain, the breasts should be gently palpated to exclude discrete masses. Following this a more probing evaluation should be performed, focusing on the site(s) of pain. After turning the patient half on her side, so that the breast tissue falls away from the chest wall, it is often possible to identify that the pain is arising from the underlying rib. The pain can be reproduced by placing a fingertip on the affected rib and demonstrating to the patient the source of the pain. This simple test can enable the GP to reassure the patient that she has no sinister underlying pathology and avoid an unnecessary hospital referral. Often reassurance is all that is required but a few patients may benefit from a nonsteroidal anti-inflammatory drug.
If the patient is complaining of pain and possible swelling in the medial aspect of the breast, gently palpate the costochondral junctions. Many of these patients have Tietze's syndrome (osteochondritis) causing localised swelling at a costochondral junction. It is a self-limiting condition for which the mainstay of management is reassurance.
Sudden onset of a nipple discharge can be a very distressing symptom for the patient but is only rarely the first manifestation of a cancer. If however the patient has a lump and a nipple discharge, this is more likely to be a cancer and merits urgent referral. Many women have a small amount of persistent discharge following lactation. Provided that they have regular menstrual cycles, this is not going to be caused by a pituitary adenoma and it is unnecessary to check for hyperprolactinaemia.
Nipple discharge warranting hospital assessment will emerge from a single duct. If discharge can be expressed from multiple ducts it is likely to be due to duct ectasia, a benign condition and not a precursor of cancer. The most important first-line investigation is to test the discharge for the presence of haemoglobin, using a standard urine-testing stick. If no haemoglobin is present, surgical intervention is almost never necessary. If the discharge is haemoglobin-positive the patient should be referred, although even under these circumstances cancer is diagnosed in only 5% of cases. Most of these patients with Hb+ve discharge prove to have either an intraduct papilloma, duct ectasia or fibrocystic disease.
Sudden onset of unilateral nipple inversion is a cause for concern and an indication for specialist assessment. It can be difficult to determine whether there is a lump deep to the nipple since the inverted tissue may simulate this. Causes include cancer, duct ectasia and prior surgery. With equivocal clinical signs, imaging is essential to reach a correct diagnosis.
Large numbers of women are referred to specialist clinics with a non-significant family history. The situation is not helped when junior surgical staff indiscriminately urge breast cancer patients to get their sisters and daughters checked. Breast cancer affects one woman in nine so many women will have first-degree relatives with the disease, but genetic mutations are responsible for less than 10% of all breast cancers. So although a few women are at high risk as a result of being a BRCA1/BRCA2 mutation carrier, most women are not at risk of familial disease.
The criteria for referral of women with a family history are shown in the table. Using stringent selection will reduce unnecessary referral and enable the GP to reassure unnecessarily worried women.
Some practices may decide that one partner will develop a special interest in breast diseases, as has happened in dermatology. Such individuals would not be a substitute for a one-stop clinic, although they might elect to spend one session a week gaining experience at a clinic.
They would be able to conduct a more efficient triage, expediting those with potential malignancy while dealing with many women with breast pain or concerns about a family history within the health centre. These GPs with a special interest in breast diseases could hone their examination skills under the tutelage of a local breast surgeon and ensure that only appropriate cases are referred for specialist assessment. This should both improve patient care and conserve valuable primary care resources.
family history breast ca family history breast ca reassure
stringent selection will reduce unnecessary referral and enable the GP to reassure unnecessarily worried women