Ten Top Tips on referring breast problems

Surgeon and breast cancer researcher Mr Mike Dixon explains which cases should set alarm bells ringing 1. Be aware of any recent change in contour. About a third or more of patients with breast cancer have dimpling or a change in breast contour. Most patients with dimpling will have cancer. It is important to look for it and patients need to be inspected in good light with both their arms above their head and their hands on their hips. 2. Any new, discrete, easily palpable lump that is obvious should be referred. But it's important to realise that cancer in young women often does not present with a discrete lump, it often presents with a localised area of nodularity. If a patient has one area of the breast which feels different from the identical area in the opposite breast then that may be significant. At the very least, review them, or alternatively, if the nodularity is clearly different, refer them then and there. Make sure patients are examined lying down with their hands under their head. This gives you the best chance of finding any abnormality. 3. A number of patients present with an enlarged axillary node in the absence of an obvious breast mass. Patients who present with axillary lymph node masses are best referred to a breast surgeon rather than a general surgeon. Even if it turns out to be lymphoma then the breast surgeon will be able to establish that diagnosis quickly. 4. Look out for unilateral, spontaneous, persistent or bloodstained nipple discharge. Patients with significant pathology affecting the breast ducts have persistent discharge, which is defined as discharge more than twice a week that continues for a number of weeks. Patients who have one episode of discharge that then stops are unlikely to have any significant abnormality, even if the single episode of discharge is bloodstained. The majority of bloodstained discharges are benign. Discharge that only comes out when the patient squeezes the nipple, that is multiduct and bilateral, is unlikely to be significant. Remember two-thirds of women can be made to produce fluid from the nipple by cleaning the nipple and squeezing. This is physiological discharge and usually multicoloured. 5. Few patients with breast pain have breast cancer. Most patients with ‘breast pain' do not actually have breast pain. They have chest-wall pain and GPs can diagnose this by lying the patient on their side, allowing the breast to fall away and examining the underlying chest wall. If the tenderness is in the chest wall and not in the breast, then the patient does not need to be referred to a breast clinic at all. 6. Nipple retraction associated with breast cancer is not symmetrical, with the nipple pulled in one direction or the other. A number of benign conditions cause nipple retraction and the retraction in these patients is slit-like and usually involves the central part of the nipple being pulled in. The nipple lies at the same level as the other nipple and is not pulled in a particular direction, unlike with breast cancer. 7. Look for discharge from the surface of the nipple. There may be concern in patients with a rash on the nipple or areola as to whether it is Paget's disease or eczema. There is a very easy way to discriminate between the two conditions: Paget's disease always affects the nipple first and only spreads on to the areola later, whereas eczema almost always affects the areola first and only rarely spreads to the nipple. 8. Be suspicious of breast inflammation that does not settle after one course of antibiotics. It is surprising how many patients with inflammatory cancer and some patients with breast abscesses are treated with repeated courses of antibiotics before they are referred to hospital. If the patient's symptoms do not settle within two to three days of starting a course of appropriate antibiotics then refer urgently because they may have an abscess or an inflammatory cancer. 9. Some patients with inflammatory cancer do not present with a discrete mass, they just present with an oedematous swollen breast. If the two breasts look different and there is clearly a large area of oedema on one breast, the patient should be referred urgently. In inflammatory cancers, the oedematous breast will usually be red and inflamed but this is not always the case. Some older patients with heart failure get oedematous swollen breasts and some patients in pregnancy get bilateral oedematous breasts. If in doubt, refer. 10. Always be aware of the importance of a strong family history of breast cancer. There are clear guidelines from NICE as to which women should be screened based on their family history. Breast examination Breast examination

Ten Top Tips on referring breast problems

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Ten Top Tips on referring breast problems

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