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.
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
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.
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.
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).
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.
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
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