Borders Ref Help Toolkit
Breast Cancer: Urgent Suspicion of Cancer Referral Criteria:
Patients presenting with symptoms below should be referred to the Breast service urgently as a Suspicion of Cancer:
Lump:
- New breast lump in a person aged 30 years or over
- New breast lump in a person aged under 30 who also has other suspicious features such as an axillary lump, nipple or skin changes (as below) or a significant family history of breast cancer (see Regional Genetics Centres)
- New, unexplained axillary lump (2cm or more in size, persisting for 6 weeks or more, or increasing in size)
Nipple changes:
- Nipple discharge that is serosanguinous (clear yellow liquid with or without red blood staining)
- New, unilateral, and non-reversible nipple retraction
- Unilateral nipple eczema that is unresponsive to a two-week treatment with moderately potent topical steroids
Skin changes:
- Skin tethering
- Peau d’orange
- Unexplained, new breast ulceration
Inflammation:
- Mastitis or breast inflammation that does not settle or recurs after one course of antibiotics
Assessment of suspected breast cancer
Breast cancer is characterised by a narrow symptom signature, meaning that most people present with only a few specific symptoms such as a breast lump and typically have short diagnostic intervals.
Assessment of a person presenting with breast symptoms or signs should include examination to determine if any lump (discrete, palpable abnormality) or lesion (any abnormal tissue change) is within the breast tissue, or related to the skin and if there are any associated axillary lumps. If there is an axillary lump without other breast findings, examination for other lymphadenopathy should be performed.
It is helpful to document if any nipple discharge is spontaneous or expressed, is from a single duct, multiple ducts or bilateral and if there is any blood staining. It is also helpful to note if any nipple inversion is fixed or reversible.
Any pain should be assessed to determine if it is coming from the breast or the chest wall.
Ask about any family history of breast cancer or other cancers related to inherited genetic alterations (e.g. ovarian cancer). Also ask about past medical history including menopausal status, previous chest radiotherapy, and mammography or breast screening results, as patients with false-positive results have a higher risk of developing breast cancer.
Routine Referral Criteria: The undernoted symptoms are not suggestive of cancer, patients presenting with these should be referred as routine:
Breast lump:
Consider a non-USC referral for a person with:
- New asymmetrical breast nodularity (generalised unevenness or thickened areas rather than a discrete lump) that persists for three weeks or more
- A new breast lump under 30 years of age but with no other suspicious features (described above under USC referral)
Infection:
- An acute breast abscess requires immediate discussion with the breast team or on-call surgical team for management.
Male breast cancer:
- Breast cancer is much less common in men than women. Most men are diagnosed over the age of 60. It can be confused with gynaecomastia. Gynaecomastia is a benign enlargement of the male breast with firm tissue extending concentrically beyond the nipple. It may present as unilateral, bilateral, painful, or asymptomatic. If a man presents with a new breast lump (not generalised breast tissue swelling or a skin lesion close to the breast) or other suspicious features as described above, they should be referred as a USC.
Breast pain:
- Breast pain alone (no associated suspicious features described above under USC referral), is not associated with breast cancer – see CfSD pathway.
Skin and nipple changes:
- Skin and nipple changes are common breast symptoms. Suspicious changes described above should be referred as a USC. Available guidelines on Right Decision Service (RDS) should be followed for other skin or nipple changes.
Axillary lumps:
- Breast cancer rarely presents with axillary nodes alone. Consider other malignant or non-cancer causes of lymphadenopathy such as, connective tissue disease, eczema and HIV infection. Consider other causes of axillary lumps, for example, skin lesions or accessory breast tissue.
- If axillary lymph node(s) are persisting with no obvious cause, the patient should be referred to secondary care. Further guidance on assessment of lymphadenopathy can be found in the Haematological cancer referral guideline.
Breast implants:
- In the context of breast implants, it is important to determine if the issue being described relates to the implant or the overlying breast tissue. If there is an implant issue rather than a breast issue, then please refer to the service that first inserted the implant (usually plastic surgery) or follow your local pathway.
Family history:
- A family history of breast cancer increases the risk of developing breast cancer, however most women diagnosed will not have a family history. See Regional Genetics Centres for advice on referral.
Recurrence of primary breast cancer:
- Recurrence is when breast cancer has come back, it is not a new breast cancer. If a patient has been discharged from follow-up they may present in primary care. For recurrence symptoms see the Breast clinical management pathway.
Metastatic breast cancer:
- Metastatic or secondary breast cancer is when breast cancer spreads to other parts of the body, such as the bones, liver, lungs or brain. For metastatic breast cancer symptoms please see the Breast clinical management pathway and refer to the Non-Specific Cancer Referral Guideline.
Access CfSD clinical management guidelines for a range of breast symptoms, including breast pain.