CPD: Key questions on breast problems

Key Learning Points

Patients of any age with a definite breast lump should be referred
Re-examine those with nodularity or lumpiness after a short interval, especially premenopausal patients age <40
A two-week referral is needed if nipple discharge is unilateral, from a single duct, spontaneous and bloody
Check serum prolactin in patients with profuse galactorrhoea who are not pregnant or lactating
Mastalgia in isolation is very rarely a sign of underlying malignancy
There is no evidence that mastalgia is helped by stopping or changing the pill, or taking evening primrose oil, antibiotics or diuretics

Q. Traditionally, in premenopausal women, GPs would re-examine a breast lump after the patient’s next period (unless it had malignant features), as some resolve. But NICE suggests we refer all unexplained lumps in women aged 30 or over. What is the best approach?

A. This depends on the confidence of the assessing clinician. Is there a lump present or not? Is this just a lumpy breast, or cyclical nodularity?

Referral patterns have changed. There may not be capacity for a GP to review a patient after their next period. Also, the threshold for referral has decreased.1 Best Practice Diagnostic Guidelines for patients with breast symptoms2 suggest fast-track referral for these patients (irrespective of age):

A discrete hard lump with fixation with or without skin tethering, dimpling or altered contour.
A lump that enlarges.
A persistent focal area of lumpiness or focal change in breast texture.
Progressive change in breast size with signs of oedema.
Skin distortion.

Patients of any age with a definite lump should be referred to secondary care but not necessarily fast tracked. The lump is unlikely to disappear following a period. In patients where examination does not reveal a focal lump, especially those under 30, it is reasonable to assess again following their next period as referral may not be necessary.

Q. Women with a history of breast cancer sometimes attend with concerns about new swellings or other changes in their breast or chest wall. Examination can be very difficult because of scar tissue or post-radiotherapy changes. How can GPs properly assess these women?