Healthcare Improvement Scotland have recently published updated guidelines and advice for breast disease and the referral of patients with suspected breast cancer to secondary care. A link to the document can be found below:
Scottish Referral Guidelines for Suspected Cancer
If you suspect that your patient has breast cancer you should make an "Urgent Suspected Cancer" referral otherwise refer “Routinely”.
It is important that you should only use the classification "Urgent Suspected Cancer" for those patients whose symptoms are highly suggestive of breast cancer as advised in the guidelines.
The Main Features of this group will be:
- A discrete lump
- Definite signs of cancer such as;
- ulceration
- skin nodule
- skin distortion or change of contour
- Inflamed breast in post-menopausal women
- Eczematous nipple
Other presentations of breast cancer are much less common. Inflammatory Cancers can present with appearances mimicking a breast abscess. However, Non cyclical Breast Pain is an exceedingly common symptom, often musculo-skeletal and referred to the breast rather than due to breast disease and does not confer any increased risk of or is it associated with a diagnosis of breast cancer in the absence of any of the features mentioned above.
Advice on the following conditions is contained in these guidelines and within the healthcare improvement Scotland national guidelines.
| Condition |
Urgent suspicion of cancer referral |
Routine referral |
Primary care management |
| Breast lump |
- Any new discrete lump (in patients over 30 years)
- New asymmetrical nodularity that persists at review after two to three weeks (in patients over 35 years)
- Unilateral isolated axillary lymph node in women persisting at review after two to three weeks
- Recurrent lump at the site of a previously aspirated cyst
|
- Any new discrete lump in patients under 30 years with no other suspicious features
- New asymmetrical nodularity that persists at review after two to three weeks (in patients under 35 years)
|
- Women with longstanding tender lumpy breasts and no focal lesion
- Tender developing breasts in adolescents
|
| Nipple symptoms |
- Bloodstained discharge
- New nipple retraction
- Nipple eczema if unresponsive to topical steroids (such as 1% hydrocortisone) after a minimum of 2 weeks
|
- Persistent discharge sufficient to stain outer clothes
|
- Transient nipple discharge which is not bloodstained
- Only check prolactin levels when copious white discharge present
- Longstanding nipple retraction
- Nipple eczema if eczema present elsewhere
|
| Skin changes |
- Skin tethering
- Fixation
- Ulceration
- Peau d’orange
|
|
- Obvious simple skin lesions such as sebaceous cysts
|
| Abscess / infection |
- Abscess or breast inflammation which does not settle or recurs after one course of antibiotics
|
|
|
|
Breast pain
- Pain should have been present for at least 3 months despite the use of simple analgesia.
- If the pain is clearly originating in rib or intercostal tissue, as indicated by point tenderness on the chest wall, then this should be managed in primary care as musculoskeletal pain.
Referral for Patient reassurance is not required.
|
|
- Examine and exclude abnormalities such as lymphadenopathy or evidence of endocrine condition
- Review to exclude drug causes
- Reassure
|
- Women with moderate degrees of breast pain and no discrete palpable lesion. (Tenderness is not an indication of a palpable lump or reason for referral)
|
| Gynaecomastia |
|
- Exceptional aesthetics referral to plastic surgery pathway if appropriate (i.e. NOT to the breast service)
- Exclude or treat any endocrine cause prior to referral
|
- Examine and exclude abnormalities such as lymphadenopathy or evidence of endocrine condition
- Review to exclude drug causes
- Measure hormones (oestrogen, testosterone, prolactin, human chorionic gonadotropin and alpha-fetoprotein)
- Reassure
|
TAM (Treatments and Medicines) NHS Highland
