Breast lumps – when to refer

Facts and figures

In 2014, in the UK there were 55,222 new cases of invasive breast cancer and 11,433 deaths reported; 78% of new diagnoses are expected to live for 10 years and longer, following diagnosis, and most cases being diagnosed are in the 50-69 age group.

Family history and BRCA

Concerns around inheriting breast cancer are very common for women who have a family history of breast cancer. According to NICE there are three different risk groups:

1. Near population risk –10-year risk less than 3% between age 40 and 50 years, and a lifetime risk of less than 17%; cared for in primary care
2. Moderate risk – 10-year risk 3-8% between age 40 and 50 years, and a lifetime risk of between 17% and 30%; cared for in secondary care
3. High risk – 10-year risk >8% between age 40 and 50 years, and a lifetime risk of >30%; assessed in tertiary care

A woman’s lifetime risk of developing breast and ovarian cancer is greatly increased if she inherits a harmful mutation in the BRCA gene – BRCA1 and BRCA2 are human genes that produce tumour suppressor proteins.

For those who have inherited the BRCA1 gene, there is a 50-85% risk of developing breast cancer by age 70, and 40-60% risk of developing ovarian cancer by age 85.

For those who have inherited the BRCA2 gene, there is a 50-85% risk of developing breast cancer by age 70.

Screening, prophylactic surgery and chemoprevention are preventative mechanisms commonly used to lower the risk or to prevent cancer from developing.

Referral, assessment and diagnosis

According to NICE guidelines (2015), a suspected cancer pathway referral for breast cancer should be considered for people who are:

• aged 30 and over and have an unexplained breast lump with or without pain, or
• aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction, other changes of concern.

Similarly, a suspected cancer pathway referral for breast cancer should be considered in people:

• with skin changes that suggest breast cancer, or
• aged 30 and over with an unexplained lump in the axilla.

A patient may present the following after examination:

• Discharge
• Benign nipple discharge
• Nipple inversion
• Nipple retraction

Similarly, a patient may present with breast pain. According to recent figures, one in five women are seen in breast clinics for reporting breast pain. Although it must be communicated that in the absence of any other symptoms or signs, breast pain is not a sign of cancer, patients should be encouraged to see a GP about breast pain, if:

• the pain is not improving or painkillers aren't helping
• a very high temperature or a feeling of being hot and shivery is present
• any part of the breast is red, hot or swollen
• there's a history of breast cancer in the family.

If examination is normal, no further investigation is required in women under 40. Those who are over 40 should be offered an opportunistic mammogram.

For symptomatic patients, The Royal Marsden offer a triple assessment for cancer out of the Rapid Diagnostic and Assessment Centre (RDAC), including,

1. History and Clinical Examination
2. Imaging (Mammogram / ultrasound)
3. Pathology (Core biopsy / FNA)

Treatment

The main stay of standard treatment for breast cancer is still surgery, which has become less aggressive over the last 30 years. However, survival rates have been improving mostly due to adjuvant systematic treatment. Neoadjuvant treatment can be used to down stage disease in the breast and axilla. Primary endocrine treatment or radiotherapy can also be given for patients considered not fit for surgery.