🩺 Breast Lump

A breast lump is a common presentation in primary care and a source of significant patient anxiety. While the majority of lumps are benign, particularly in younger women, breast cancer is the most common malignancy in UK women. Effective management relies on the 'triple assessment' protocol to ensure no malignancy is missed. Diagnostic urgency is dictated by age and the physical characteristics of the lump as outlined in national referral guidelines.

Ask about the duration of the lump and any changes in size, particularly in relation to the menstrual cycle. Inquire about pain (mastalgia), nipple discharge, or skin changes. Screen for risk factors: age, family history of breast/ovarian cancer (BRCA status), age of menarche/menopause, parity, breastfeeding history, and use of HRT or the OCP. Alcohol consumption and obesity are also relevant. Ask about systemic 'Red Flags' like weight loss or bone pain.

Perform a systematic breast examination including both breasts and the axillary tail. Use the 'triple assessment' mindset. Inspect for asymmetry, skin dimpling, nipple inversion, or rashes/eczema (Paget's disease). Palpate the lump to assess its size, shape, consistency, and whether it is tethered to the underlying muscle or overlying skin. Ensure the axillary and supraclavicular lymph nodes are palpated. Document the position of the lump using the 'clock face' method and its distance from the nipple.

Breast Cancer (Invasive Ductal/Lobular), Fibroadenoma, Breast Cyst, Fat Necrosis (post-trauma), Breast Abscess/Mastitis, and Periductal Mastitis.

A lump that is hard/irregular/fixed, new nipple inversion, blood-stained nipple discharge, skin dimpling (tethering), 'peau d’orange' (skin oedema), and axillary lymphadenopathy.

The cornerstone of management is 'Triple Assessment': 1. Clinical examination, 2. Imaging (Ultrasound if <40, Mammography if >40), and 3. Biopsy (Fine Needle Aspiration for cytology or Core Biopsy for histology). MRI is reserved for specific cases like BRCA carriers or lobular carcinoma. Bloods are generally not useful for the primary diagnosis of breast cancer but may include LFTs or Calcium if metastasis is suspected. Breast cysts can be aspirated and sent for cytology if the fluid is blood-stained.

Most breast lumps are benign (e.g., fibroadenomas or cysts), but any new lump must be treated as cancer until proven otherwise. Lumps that change with the menstrual cycle are more likely to be benign. Skin tethering or 'peau d’orange' are late signs of malignancy. In younger women (<30), fibroadenomas are common ('breast mice'), whereas in perimenopausal women, cysts are more frequent. Always ask about nipple discharge—bloody discharge is more concerning for intraductal papilloma or cancer.

Understand the 2-week wait referral criteria for breast cancer (e.g., any woman >30 with an unexplained mass). Recognise the components of triple assessment. Be familiar with the screening programme in the UK (mammogram every 3 years for women aged 50-70). Distinguish between the presentation of a fibroadenoma and a malignant mass.