Breast

Breast cancer is the commonest malignant condition to affect women, with a 1:10 lifetime risk of developing the disease. However, survival rate has improved over the last 20 years in Scotland, with the 5 year all-cause mortality for those with treated invasive breast cancer now well above 70% (73.2%, 2012, ISD).

A woman presenting with breast problems is a common occurrence in general practice. General practitioners can expect to see up to 30 new presentations per 1000 women per year, with problems ranging from mild breast pain to frank malignancy.

There is an increased awareness of breast disease in the population due to a combination of education, breast screening and media coverage. This has led to an increased presentation of all breast symptoms to the GP and a corresponding increase in referrals, placing pressure on specialist breast clinics, resulting in delayed patient appointments.

Referral guidelines are an attempt to help with this problem. Referral Guidelines are based on the 2019 Scottish Cancer Referral Guidelines and the 2023 Modernising Patient Pathways Programme.

Our diagnostic clinics:

Improving patient access to better and more rapid cancer diagnostics is a priority at NHS Borders. We provide consultant-led diagnostic services for patients with suspected cancer. Patients referred for diagnostic services have immediate access to a multidisciplinary team of experts including a consultant surgeon, consultant radiologist, consultant pathologist and clinical nurse specialist. Several of our clinics are one-stop, meaning all investigations can be conducted during just one visit – a tremendous benefit to patients.

Breast clinic:

The one-stop breast diagnostic clinic features the gold-standard triple assessment process which involves three diagnostic measures – clinical examination, imaging and biopsy. Most patients receive their diagnosis on the same day as their assessments.

Who to refer, who not to refer, how to refer

We accept referrals from GPs and ANPs for the diagnosis and treatment of breast disease.

URGENT referrals

Breast lumps:

Any new palpable breast lump which is suspicious of breast cancer

Any lump associated with nipple or skin changes

Any new skin dimple

Skin changes characteristic of peau d’orange

Mammographic abnormality suspicious of cancer.

Inflammation:

Suspicion of inflammatory breast cancer or persistent mastitis / abscess.

Nipple changes / discharge:

Blood-stained nipple discharge

Persistent, spontaneous, single duct, nipple discharge

Nipple eczema suspicious of Paget’s disease

Permanent nipple retraction or distortion of recent onset.

Suspected male breast cancer:

Non-tender breast lump in a male (male breast cancer does occur: 0.2% of all breast cancers).

ROUTINE referrals

Symptoms:

Recurrent breast cysts in a patient with history of benign cysts

Persistent breast nodularity

Persistent breast pain not responding to evening primrose oil (/)

Lactational mastitis

Periductal mastitis

Non-blood-stained, non-spontaneous, nipple discharge

Areola, nipple-sparing, rash

Tender gynaecomastia in a male.

Strong family history of breast cancer:

One first-degree relative* diagnosed with breast cancer under 40 (or under 45 for chemoprevention studies)

Two or more first- or second-degree relatives

One or more first-degree relatives with bilateral breast cancer.

(* a first-degree relative can be a mother, father, sister or daughter, and a second degree relative can be an aunt, grandmother or granddaughter)

If there is uncertainty about their family history, we will write to the patient for more details prior to their clinic appointment. Patients may be sent postal questionnaires to help estimate their risk before being sent an appointment. Some patients may be reassured by post.

Primary care management

Please refer to specific pages within RefHelp for more information on individual conditions.

Gynaecomastia – please differentiate ‘generalised breast plate swelling and discomfort’ from, ‘localised lump and/or skin involvement’; the latter indicates urgent referral whereas the former is either physiological or iatrogenic and necessitating reassurance or routine referral if no cause for symptom.

Inflammation – please differentiate superficial ‘dermatological’ infection from, benign/painful generalised ‘mastitis’ with/without localised swelling of ‘abscess’ and ‘suspicious inflammation’ of skin thickening without common benign causes of lactation and smoking; mastitic inflammation not responding to a course of antibiotics and signs of dermal lymphatic obstruction indicates urgent referral.

Skin lesions – please differentiate benign dermatological lesions including cysts with/without punctum (sebaceous, inclusion), warts, seborrhoeic keratosis, hydradenitis suppuritiva and skin tag from, suspicious skin ‘dimpling or tethering’; the latter skin signs indicate urgent referral and whereas the former only require routine referral if symptomatic and request for minor intervention.

Nipple symptoms – please differentiate benign ‘nipple-sparing’ areola skin rash from, suspicious nipple-specific signs of inflammation, erosion and retraction.

Resources and links

Sexual Health – HRT Further Info Incr Risk Breast Cancer MHRA

Breast Cancer at MacMillanorg.uk

Breast Cancer at Cancer Research Uk

Breast Cancer at Breast Cancer Now

Breast Cancer section of Scottish Referral Guidelines for Suspected Cancer

Local service contact details

Borders Breast Unit

Borders General Hospital, Huntlyburn, Melrose TD6 9BS

An on call surgeon will always be available to discuss referral or general management issues with GPs. During office hours (8.30am-5.00pm), call the numbers below. Out of hours call via the BGH switchboard (01896 826000).
Bleep: 6008

Consultants:

Miss D Twelves

Mr Al-Sabounchi

Single Point of Contact

Patients with Breast Cancer are provided with the number for the Single Point of Contact. Calls can be directed to the most appropriate care team including the Breast Cancer Nurses. Single Point of Contact can be accessed by calling 01896 826811 (Monday to Friday 9am to 4;30pm, excluding most public holidays).

Email: BOR.spoc@borders.scot.nhs.uk

Last reviewed: 15/08/2024

Next review date: 15/08/2025

Author(s): Dominique Twelves.

Author email(s): dominique.twelves@borders.scot.nhs.uk.