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Breast Symptoms

  

Guide to breast symptom management and referral


All advice based upon the pan-collegiate approved Best Practice Diagnostic Guidelines for Patients Presenting with Breast Symptoms (Willett et al 2010) – see link

Breast lump

Refer Two Week Wait

Nipple discharge

Refer Two Week Wait

Nipple discharge is a common symptom.

More than 80% of nipple discharge is benign. Can be associated with an underlying malignancy in up to 20% of cases.

  • Establish the duration, frequency, volume and colour of nipple discharge, whether it is bilateral or unilateral, and particularly whether it occurs spontaneously or only on squeezing.
  • Other breast symptoms, such as a lump, nipple inversion, skin changes / ulceration / eczema etc.?
  • Medication producing nipple discharge eg antipsychotics.
  • If profuse milky discharge is present in non-pregnant patients, measure the prolactin level.
  • The risk of an underlying malignancy is increased if the nipple discharge is spontaneous, single duct, persistent (occurs more than twice per week), bloody, patient age >50years, or if associated with a palpable abnormality.
Nipple inversion

Refer Two Week Wait

Nipple eczema

In absence of any other clinical signs, reasonable to initially try 1% hydrocortisone topically to see if resolves.

If persists, or reoccurs, or any other clinical signs, refer Two Week Wait.

If in doubt, refer.

Paget’s disease of the nipple (rare < 5% of breast malignancies) can be misdiagnosed as eczema therefore, refer to breast clinic if does not resolve with initial trial of hydrocortisone.

Breast Pain

Breast pain is a common symptom.

When of minor or moderate degree, and short duration with no other clinical concern or clinical signs, it is reasonable to manage this initially in Primary Care

If persists or worsens refer Two Week Wait.

Breast lumps in men & Gynaecomastia

Male breast cancer is rare (approx. 390 cases diagnosed each year in the UK, compared to approx. 54,800 cases in women)

Gynaecomastia (benign enlargement of male breast tissue) is very common.

Breast cancer is only diagnosed in about 1% of cases of male breast enlargement.

If gynaecomastia suspected ask about:

  • Alcohol intake
  • Recreational drug use (especially cannabis)
  • Anabolic steroid use
  • Testicular lumps
  • Obesity (measure BMI)
  • Medication
  • Liver disease or testicular tumour

Consider blood tests:

  • FBC, U+Es, LFTs, prolactin, testosterone, oestradiol, sex hormone binding globulin, luteinising hormone, LDH, alphafetoprotein, beta HCG, and TSH.
  • However, these blood tests are not routinely indicated in those with fatty breast enlargement, physiological pubertal or senile changes, identified drug cause, or clinically obvious cancer.

Refer Two Week Wait if:

  • Clinical suspicion of malignancy
  • Men over 50 with unilateral breast symptoms
  • Unilateral breast lumps
  • Persistent pain and swelling
  • Increased risk of breast cancer (eg: family history)
  • Clinical uncertainty regarding diagnosis

Please refer to CCG policy on aesthetic treatment for gynaecomastia

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