13.5 Breast Disease, Cancer Screening & Suspected Cancer Referral
Key Takeaways
NICE NG12 refers women aged 30 or over with an unexplained breast lump on the suspected cancer pathway, and people aged 50 or over with unilateral nipple discharge, retraction or other concerning nipple change.
Breast lumps are assessed by triple assessment: clinical examination, imaging (ultrasound under 40, mammography plus ultrasound from 40) and core biopsy.
The NHS Breast Screening Programme invites women aged 50 to their 71st birthday for mammography every 3 years.
Tamoxifen increases the risk of VTE and endometrial cancer, whereas aromatase inhibitors cause bone loss and need bone density monitoring.
Lactational mastitis is managed by continuing to breastfeed or express, with flucloxacillin if infection is likely; a breast abscess needs ultrasound-guided drainage.
Breast Disease, Cancer Screening & Suspected Cancer Referral
Assessing a Breast Symptom
NICE NG12 Referral Criteria
- Suspected cancer pathway referral:
- aged 30 or over with an unexplained breast lump (with or without pain)
- aged 50 or over with discharge, retraction or other concerning change of one nipple only
- Consider a suspected cancer pathway referral: skin changes suggestive of breast cancer (peau d'orange, tethering, ulceration), or aged 30 or over with an unexplained axillary lump.
- Consider a non-urgent referral: under 30 with an unexplained breast lump.
Triple Assessment (in the breast clinic)
- Clinical history and examination (both breasts and axillae).
- Imaging: ultrasound under 40 (dense breast tissue); mammography plus ultrasound from 40.
- Tissue sampling: core needle biopsy (or fine-needle aspiration of cysts and axillary nodes).
Benign Breast Conditions
| Condition | Typical Patient | Features | Management |
|---|---|---|---|
| Fibroadenoma | Under 30 | Smooth, firm, highly mobile ("breast mouse"), painless | Reassure after triple assessment; excise if large or growing |
| Breast cyst | 35–55, perimenopausal | Smooth, fluctuant, may be tender | Ultrasound and aspiration; investigate if blood-stained or recurs |
| Fibrocystic change | Premenopausal | Cyclical lumpiness and pain | Supportive bra, analgesia |
| Lactational mastitis | Breastfeeding | Painful, red, wedge-shaped area, fever | Continue breastfeeding or expressing; flucloxacillin if infection is likely (erythromycin or clarithromycin if allergic) |
| Breast abscess | Lactating or smokers (non-lactational) | Fluctuant, tender mass, systemic upset | Ultrasound-guided aspiration or drainage plus antibiotics |
| Duct ectasia | Perimenopausal, smokers | Thick, coloured nipple discharge, nipple retraction | Exclude cancer; reassure |
| Intraductal papilloma | 35–55 | Blood-stained discharge from a single duct | Imaging and excision |
| Fat necrosis | After trauma or surgery | Firm, irregular lump that can mimic cancer | Triple assessment |
| Gynaecomastia | Males (puberty, older men) | Rubbery subareolar tissue | Review drugs (spironolactone, digoxin, anti-androgens, cannabis), liver disease, hypogonadism and testicular tumours (hCG); men 50 or over with a unilateral firm subareolar mass need a suspected cancer referral |
Breast Cancer
The most common cancer in UK women (about 1 in 7 lifetime risk).
- Risk factors: age, BRCA1/BRCA2 and other inherited variants, strong family history, previous breast cancer or atypical hyperplasia, early menarche, late menopause, nulliparity or late first pregnancy, combined HRT, alcohol, obesity after menopause and chest radiotherapy.
- Family history (NICE CG164): refer to a family history or genetics service if criteria are met (for example several affected relatives, young age at diagnosis, male breast cancer, or ovarian cancer in the family); higher-risk women receive earlier or enhanced surveillance (including annual MRI for BRCA carriers in their 30s and 40s) and may consider risk-reducing medication or surgery.
- Presentation: a painless hard irregular lump, skin tethering, peau d'orange, nipple retraction or eczema-like change (Paget's disease of the nipple), axillary nodes.
- Treatment principles:
- Surgery: wide local excision with radiotherapy, or mastectomy; sentinel lymph node biopsy to stage the axilla.
- Hormone therapy for oestrogen receptor-positive tumours: tamoxifen (mainly premenopausal; risks VTE, endometrial cancer and hot flushes) or an aromatase inhibitor such as letrozole or anastrozole (postmenopausal; causes bone loss, so check bone density and consider bisphosphonates).
- HER2-targeted therapy (trastuzumab) for HER2-positive tumours; it can cause cardiotoxicity, so cardiac function is monitored.
- Chemotherapy according to risk.
UK Cancer Screening Programmes
| Programme | Who | Test & Interval |
|---|---|---|
| Breast | Women aged 50 to 71st birthday (older women can self-refer) | Mammography every 3 years |
| Cervical | People with a cervix aged 25–64 | HPV testing, every 5 years if HPV-negative (section 9.3) |
| Bowel (England) | Aged 50–74 | Home FIT every 2 years; colonoscopy if abnormal |
| Lung | Aged about 55–74 with a smoking history | Risk assessment and low-dose CT (being rolled out nationally) |
| AAA | Men in the year they turn 65 | One-off abdominal ultrasound (section 2.6) |
Screening tests aim to find disease before symptoms. Symptomatic patients should never be told to wait for screening; they need diagnostic assessment. There is no national prostate or ovarian screening programme; PSA and CA125 are used for symptomatic assessment, not population screening.
Suspected Cancer Referral Principles
- The suspected cancer pathway (formerly the "2-week wait") aims for a diagnosis or ruling out of cancer within 28 days (the Faster Diagnosis Standard).
- Non-specific symptoms pathways (rapid diagnostic centres) accept patients with vague but concerning features such as unexplained weight loss, fatigue or abdominal pain.
- Safety-netting: explain the referral and why it matters, give clear advice about when to return, and check that appointments and results are followed up; record discussions in the notes.
- Tumour markers (CA125, PSA, AFP, CEA) have specific roles in symptomatic assessment or monitoring but are not general screening tests.
- Breaking bad news uses a structured approach (such as SPIKES): set up a private setting, explore what the patient knows and wants to know, give a warning shot, deliver information clearly without jargon, respond to emotions, and agree a plan with follow-up.
A 34-year-old woman has a 2 cm painless lump in her left breast that she noticed 3 weeks ago. It is firm and irregular. There is no family history of breast cancer. What is the most appropriate action?
Start antibiotics for a possible abscess
Reassure and review after her next period
Refer on the suspected cancer pathway to a breast clinic
Arrange a routine mammogram through the screening programme
A 62-year-old woman with oestrogen receptor-positive breast cancer is starting adjuvant letrozole. Which monitoring is most important to arrange?
Baseline and follow-up bone density assessment
Monthly full blood count
Annual transvaginal ultrasound for endometrial thickness
Regular echocardiography
A 28-year-old woman who is breastfeeding her 5-week-old baby has a painful, red, wedge-shaped area in her right breast and a temperature of 38.4°C for 36 hours. There is no fluctuant mass. What is the most appropriate management?
Stop breastfeeding from the right breast and start cabergoline
Continue breastfeeding or expressing, and start oral flucloxacillin
Refer for urgent surgical incision and drainage
Refer on the suspected cancer pathway
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