Breast Cancer

It is estimated that between 0.35% and 0.6% of all GP consultations in Scotland are for breast symptoms. Many of these will be for young women, whereas the biggest risk factor, after gender, is increasing age, with more than 80% of breast cancers occurring in women over the age of 50.

Breast cancer accounts for 30% of cancers in women and around 4,500 people are diagnosed with breast cancer in Scotland each year; approximately 25 of these are men. In cases of gender reassignment, care must be taken to provide sensitive and clinically appropriate care depending on individual circumstances and taking into account any hormone therapy involved.

Guidance about referral to regional genetics centres  (see Appendix 5) for those with a family history of breast cancer is available.

 Urgent suspicion of cancer referralRoutine referralPrimary care management
 - issue relevant advice leaflet (if available)
Lump
  • Any new discrete lump (in patients 30 years and over)
  • 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 35 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 breast and no focal lesion
  • Tender developing breasts in adolescents
Nipple Symptoms
  • Visibly bloodstained discharge
  • New unilateral nipple retraction
  • Nipple eczema if unresponsive to moderately potent topical steroids after a minimum of two weeks
  • Persistent unilateral spontaneous  discharge sufficient to stain outer clothes
  • Transient nipple discharge which is not bloodstained
  • Check prolactin levels in persistent bilateral discharge
  • Longstanding nipple retraction
  • Nipple eczema if eczema present elsewhere
Skin changes
  • Skin tethering
  • Fixation
  • Ulceration
  • Peau d’orange
  
  • Obvious simple skin lesions such as epidermoid (sebaceous) cysts
Abscess/ infection
  • Mastitis or breast inflammation which does not settle or recurs after one course of antibiotics
  
  • Abscess or inflammation - try one course of antibiotics as per local guidelines
  • Any acute abscess requires immediate discussion with secondary care
Pain  
  • Unilateral pain persisting over three months in post-menopausal women
  • Intractable pain that interferes with the person’s lifestyle or sleep
  • Women with moderate degrees of breast pain and no discrete palpable lesion
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 with blood tests as per local guidelines
  • Review to exclude drug causes
Breast implants  
  • If appropriate, refer to the service that first inserted the implant (usually plastic surgery)
  • Reassurance is often appropriate if symptoms relate to the implant alone and not to underlying breast tissue
Quick Reference Guideline