Audience

  • HHSCP only
  • Primary Care
  • Adults

 

Symptoms and signs

Breast symptoms are a relatively uncommon presentation in primary care. It is estimated that between 0.35% and 0.6% of all consultations in Scotland are for breast symptoms. Many of these consultations will be in young women, whereas the biggest risk factor, after gender, is increasing age. Incidence of breast cancer in women aged 30-35 is 33 per 100,000 population and approximately 81% of breast cancers occur in women over the age of 50.

Breast cancer accounts for 30% of cancers in women and around 4,400 people are diagnosed with breast cancer in Scotland each year; approximately 20 of these are men. The following recommendations seek to improve the referral and effective management of breast symptoms in women and men in primary care.

Guidance for referral to regional genetics centres for those with a family history of breast cancer is available at: Cancer Genetic Services Scotland

GP manageable conditions

Conditions that can be managed in general practice:

  • Young women (under 35) with tender, lumpy breasts and older women with symmetrical nodularity; provided no localised abnormality
  • Women with breast pain who do not have a discrete palpable lesion
  • Women with transient nipple discharge which is not bloodstained
  • Obvious simple skin lesions such as epidermoid (sebaceous) cysts

Conditions that require referral to a breast specialist include:

  • Lump
    • any new discrete lump
    • new lump in pre-existing nodularity
    • asymmetrical nodularity persisting after review in primary care 3 weeks apart
    • abscess or breast inflammation not settling after one course of antibiotics
    • cyst persistently refilling or recurrent cyst (if the patient has recurrent multiple cysts and the GP has the necessary skills, then aspiration is acceptable)
  • Pain
    • unilateral pain persisting over three months in post-menopausal women
  • Nipple discharge
    • visibly bloodstained discharge
    • persistant discharge sufficient to stain outer clothes; or persistent single duct discharge
  • New nipple retraction or distortion, nipple eczema if unresponsive to moderately potent topical steroids after a minimum of two weeks
  • Skin changes such as skin tethering, fixation, Ulceration, Peau d'orange or change in skin contour

When to refer

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

Editorial Information

Last reviewed: 27/04/2022

Next review date: 30/04/2025

Author(s): General Surgery.

Version: 2

Approved By: TAMSG of ADTC

Reviewer name(s): Mr Ian Daltrey, Consultant Breast Surgeon.

Document Id: TAM113

References

Further information for patients: