Breast cancer

The detection of a lump in the breast causes understandable fear of a cancer diagnosis. Careful examination will increase the chance of correct diagnosis. It is important that referrals are appropriate and that information and discussion accompany this assessment.

Prevalence

Breast cancer is by far the most common cancer in women. Sometimes there are cases found in men too, the male female ratio being 1:144

Liable aspects for malignancy

• Previous history of breast cancer.
• Family history of breast cancer in a first-degree relative.
• A number of genetic mutations are implicated. The BRCA1, BRCA2 and TP53 mutations carry very high risk but only around 5% of women diagnosed with breast cancer carry a relevant genetic mutation on their chromosomes.
• Between 6% and 19% of women will have a family history but this may be due to chance, shared environmental or lifestyle risk factors, or increased genetic susceptibility.
• Risk increases with age. I≤5% of cases present before age the age of 35, ≤25% before the age of 50
• Never having borne a child or first child after the age of 30.
• Not having breast-fed (breast-feeding is protective).
• Early menarche and late menopause.
• Continuous combined HRT increases risk.
• Radiation to chest (even quite small doses).
• Being overweight after the menopause.
• High alcohol intake – may increase risk in a dose-related manner.
• Breast-feeding and physical activity may reduce risk.
• Breast augmentation is not generally associated with increased risk. Type of implant used may be important. There are also concerns that implants may slow detection and therefore adversely affect survival; however, research has been inconclusive

Appearance

Presenting symptoms of breast cancer:

Breast lump. Most patients present having felt a lump – usually painless but may be painful in some.

Nipple change – eg, inversion, change in shape or a scaling rash.

Nipple discharge.

Bloodstained discharge from nipple – intraduct carcinoma may present in this way.

Skin contour changes.

Axillary lumps – lymph nodes.

Breast pain/mastalgia. Alone this is an uncommon presentation.

Symptoms of metastatic disease – bone pains/fractures, symptoms of lung, liver or brain metastases. (Unusual at presentation.)

Asymptomatic but picked up at routine mammography screen.

History

Organised screening, education programmes and improved consciousness of the female population have substantially changed the type of patients seen nowadays compared with a few decades ago and the neglected tumour is much rarer than it was. Occasionally, patients (usually elderly but not always) will still present with a fungating mass that has obviously been neglected for a long time.

Patients presenting with a lump in the breast will be aware of the possible diagnosis and will be very anxious. This should be taken into account when taking the history and discussing management.

Direct questions should include the following:

When was the lump first noticed?

Has it changed in size or in any other way? This includes a nipple becoming inverted.

Is there any discharge from the nipple?

Menstrual history. If she is premenopausal, when was her last menstrual period?

Any changes noted through the menstrual cycle?

Family history (including breast cancer, other cancers and other conditions).

Investigation

In the past, advice has been to use the examination to teach the patient self-examination. It is logical that regular self-examination should be beneficial. Most authorities now suggest women should be “breast-aware” and report any change promptly.

Breast inspection

Inspect with the patient sitting and then with their hands raised above head. A lump may be visible.

Doctor needs to look for:

Variations in breast size and contour.

Whether there is an inverted nipple (nipple retraction) and, if so, is it unilateral or bilateral?

Any oedema (may be slight).

Redness or retraction of the skin.

Dimpling of the skin (called peau d’orange and is like orange peel because of oedema of the skin. This has sinister significance as it is caused by lymphatic invasion, and therefore is due to an invasive underlying tumour, or an inflammatory breast cancer).

The next stage is palpation, and a systematic search pattern improves the rate of detection.

Clinical features of palpable breast masses

Malignant breast masses

Consistency: hard

Painless (90%)

Irregular margins

Fixation to skin or chest wall

Skin dimpling may occur

Discharge: bloody, unilateral

Nipple retraction may be present

Benign breast masses

Consistency: firm or rubbery

Often painful (consistent with benign breast conditions)

Regular or smooth margins

Mobile and not fixed

Skin dimpling unlikely

Discharge: no blood and bilateral discharge. Green or yellow colour

No nipple retraction