ABC of Breast Diseases

J. Michael Dixon

• Publisher: BMJ Books
• Year: 2012
• Print ISBN: 9781444337969
• eBook ISBN: 9781118471869
• Edition: 4
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

The ABC of Breast Diseases provides comprehensive guidance to the assessment of symptoms, and how to manage all common breast conditions and provides guidelines on referral. It covers congenital problems, breast infection and mastalgia, before addressing the epidemiology, prevention, screening and diagnosis of breast cancer. It outlines the treatment and management options for breast cancer within different groups and includes new chapters on the genetics, prevention, management of high risk women and the psychological aspects of breast diseases.

Edited and written by internationally renowned experts in the field and highly illustrated in full colour, this fourth edition remains a practical guide for general practitioners, family physicians, practice nurses and breast care nurses as well as for surgeons and oncologists both in training and recently qualified as well as medical students.

Chapter 1

Symptoms, Assessment and Guidelines for Referral

J Michael Dixon¹ and Jeremy Thomas²

¹Edinburgh Breast Unit, Western General Hospital, Edinburgh, UK
²Pathology Department, Western General Hospital, Edinburgh, UK

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Overview

• Breast conditions account for approximately 25% of all surgical referrals
• Guidelines for referral exist to ensure that patients with breast cancer do not suffer delays in referral
• Cancer can present as localised nodularity, particularly in young women
• All discrete masses and the majority of localised asymmetric nodularities require triple assessment
• Delay in diagnosis of breast cancer is the single largest cause for medicolegal complaints

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One woman in four is referred to a breast clinic at some time in her life. A breast lump, which may be painful, and breast pain constitute over 80% of the breast problems referred to hospital and breast problems constitute up to a quarter of all female surgical referrals (Table 1.1).

Table 1.1 Prevalence of presenting symptoms in patients attending a breast clinic.

When a patient presents with a breast problem the question for the general practitioner is: ‘Is there a chance that cancer is present and, if not, can I manage these symptoms myself?’ (Figure 1.1; Tables 1.2 and 1.3).

Figure 1.1 Bathsheba by Rembrandt. Much discussion surrounds the shadowing and possible distortion of the left breast and whether this represents an underlying malignancy. Such findings would be an indication for hospital referral.

Table 1.2 Conditions that require hospital referral.

Lump

Any new discrete lump New lump in pre-existing nodularity Asymmetrical nodularity in a woman over the age of 35 Asymmetric nodularity in a younger woman that persists at review after menstruation Abscess or breast inflammation that does not settle rapidly after one course of antibiotics Palpable axillary mass including an enlarged axillary lymph node

Pain

If associated with a lump Intractable pain that interferes with a patient's lifestyle or sleep and that has failed to respond to reassurance, simple measures such as wearing a well-supporting bra or anti-inflammatory drugs Unilateral persistent pain in postmenopausal women that is in the breast rather than in the chest wall (see Chapter 3)

Nipple discharge

All women aged >50 Women aged ≤ 50 with either bloodstained discharge spontaneous single duct discharge bilateral discharge sufficient to stain clothes

Nipple retraction or distortion

Nipple eczema

Change in skin contour

Family history

Request for assessment of a woman with a strong family history of breast cancer should be to a family cancer genetics clinic.

Table 1.3 Patients who can be managed, at least initially, by their GP.

Women with bilateral tender, nodular breasts provided that they have no localised abnormality on examination Young women ( ≤ 35 years) with asymmetrical localised nodularity; these women require assessment after their next menstrual cycle, and if nodularity persists hospital referral is then indicated Women with minor and moderate degrees of breast pain who do not have a discrete palpable lesion Women aged <50 who have nipple discharge that is small in amount and is from more than one duct and is intermittent (occurs less than twice per week) and is not bloodstained. These patients should be reviewed in 2–3 weeks and if symptom persists hospital referral is indicated

For patients presenting with a breast lump, the general practitioner should determine whether the lump is discrete or there is nodularity, as well as whether any nodularity is asymmetrical or is part of generalised nodularity (Figure 1.2). A discrete lump stands out from the adjoining breast tissue, has definable borders and is measurable. Localised nodularity is more ill defined, is often bilateral and tends to fluctuate with the menstrual cycle. About 10% of all breast cancers present as asymmetrical nodularity rather than a discrete mass. When the patient is sure that there is a localised lump or lumpiness, a single normal clinical examination by a general practitioner is not enough to exclude underlying disease (Tables 1.2 and 1.3). Reassessment after menstruation or hospital referral is indicated in such women.

Figure 1.2 Management of patient presenting in primary care with a breast lump or localised lumpy area or nodularity.

Assessment of Symptoms

Patient's History

Details of risk factors, including family history and current medication, should be obtained and recorded. Knowing the duration of a symptom can be helpful, as cancers usually grow slowly but cysts may appear overnight.

Inspection should take place in a good light with the patient's arms by her side, above her head, then pressing on her hips (Figure 1.3). Skin dimpling or a change in contour is present in up to a quarter of symptomatic patients with breast cancer (Figure 1.4). Although usually associated with an underlying malignancy, skin dimpling can follow surgery or trauma, and can be associated with benign conditions or occur as part of breast involution (Figures 1.5–1.7).

Figure 1.3 Position for breast inspection. Skin dimpling in lower part of breast evident only when arms are elevated or pectoral muscles contracted.

Figure 1.4 Skin dimpling (left) and change in breast contour (right) associated with underlying breast carcinoma.

Figure 1.5 Skin dimpling visible in both breasts due to breast involution.

Figure 1.6 Skin dimpling after previous breast surgery.

Figure 1.7 Skin dimpling associated with breast infection.

Breast Palpation

Breast palpation is performed with the patient lying flat with her arm...

Table of contents

• Cover
• Title Page
• Copyright
• Contributors
• Preface
• Chapter 1: Symptoms, Assessment and Guidelines for Referral
• Chapter 2: Congenital Problems and Aberrations of Normal Development and Involution
• Chapter 3: Mastalgia
• Chapter 4: Breast Infection
• Chapter 5: Breast Cancer: Epidemiology, Risk Factors and Genetics
• Chapter 6: Prevention of Breast Cancer
• Chapter 7: Screening for Breast Cancer
• Chapter 8: Breast Cancer
• Chapter 9: Management of Regional Nodes in Breast Cancer
• Chapter 10: Breast Cancer: Treatment of Elderly Patients and Uncommon Conditions
• Chapter 11: Role of Systemic Treatment of Primary Operable Breast Cancer
• Chapter 12: Locally Advanced Breast Cancer
• Chapter 13: Metastatic Breast Cancer
• Chapter 14: Prognostic Factors
• Chapter 15: Psychological Impact of Breast Cancer
• Chapter 16: Carcinoma in situ
• Chapter 17: Breast Reconstruction
• Index