Diagnosis

Screening

• NHS screening is offered to all women in the UK from ages 50-70
• Women at an increased risk of breast cancer (such as with a strong family history of breast cancer) may be eligible for breast screening before 47 years of age. Women who may be at increased risk can be referred to have their risk formally assessed and their management options, which include screening, discussed.
• In the UK the NHS breast screening programmes detect most cases of breast cancer.
• Women diagnosed via the screening programme are generally asymptomatic and cancers detected are at an early stage, making them easier to treat.
• Current evidence suggests that breast screening reduces the number of deaths from breast cancer by about 1,300 a year in the UK.
• There is a risk of over diagnosis and over treatment. Currently there is no way of knowing whether a small breast cancer or carcinoma in situ will grow or not.

Referral for genetic testing

NICE Guideline: Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

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

People without a personal history of breast cancer can be cared for in primary care if they have only one first-degree or second-degree relative diagnosed with breast cancer when over 40 years of age, provided that none of the following are present in the family history:

• Bilateral breast cancer.
• Male breast cancer.
• Ovarian cancer.
• Jewish ancestry.
• Sarcoma in a relative younger than 45 years of age.
• Glioma or childhood adrenal cortical carcinomas.
• Complicated patterns of multiple cancers at a young age.
• Two or more relatives with breast cancer on the father's side of the family.

Refer people to secondary care who have:

• One first-degree female relative diagnosed with breast cancer under the age of 40 years.
• One first-degree male relative diagnosed with breast cancer at any age.
• One first-degree relative with bilateral breast cancer where the first primary was diagnosed under the age of 50 years.
• Two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age.
• One first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative).
• Three first-degree or second-degree relatives diagnosed with breast cancer at any age.

The most common presentation of breast cancer in women is a lump in their breast. It is important to note however that 90% of breast lumps are benign. Other causes of breast lumps include fibroadenoma, cyst and injury or trauma. If the cause of the breast lump is uncertain then an urgent two week wait referral to a specialist is indicated.

Caution should be exercis if a woman reports a change in the shape, feel or look of a breast. It is important to rule out changes in the breast due to the natural changes in the hormonal cycle as many women experience changes in their breasts (such as lumpiness or tenderness) immediately before their period. However changes in look and feel which are persistent could indicate breast cancer and you should consider an urgent referral..

Nipple changes could include:

• Unilateral and spontaneous blood stained discharge inwomen who aren’t pregnant or breast feeding. Malignant nipple discharge is usually single duct, and can be blood stained or translucent. Benign nipple discharge is often multiduct, often creamy, but can be green/yellow/brown.
• A change in position of the nipple – it might retract into the breast or turn. Be alert to women saying that it looks or feels different, especially when compared to the other nipple
• Eczema on the nipple that doesn’t respond to topical treatment.

It is important to note that breast pain alone is very rarely a symptom of breast cancer and should not prompt a two week wait referral unless there are other symptoms present.

NICE Guideline: Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:

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

Miss Katherine Krupa, Oncoplastic Breast Surgeon says:

"Skin changes that indicate a possible breast cancer include a rash, redness, puckering or dimpling of the breast. Some patients present with skin that looks like orange peel or with a texture to the skin that is different to rest of the breast skin. A rare cause of skin changes in the breast is Paget’s disease. This presents with a scaly, red, and sometimes itchy rash which looks like eczema. Paget’s disease can be a sign of underlying breast cancer and warrants further investigation.

Swelling around the collarbone or armpit could be an indication of breast cancer that has spread to the lymph nodes. This can present even before there is a palpable mass in the breast tissue."

NICE Guideline: Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.

Miss Katherine Krupa, Oncoplastic Breast Surgeon says:

"Breast cancer is very rare in women under 30. Consider referring women under 30 if they have a palpable breast lump that has been present for more than one menstrual cycle.

If the patient has other concerning symptoms as well as the mass, such as nipple discharge or retraction, skin changes or unexplained axillary swelling they should be referred immediately."