Breast cancer

Access CfSD clinical management guidelines for a range of breast symptoms, including breast pain.

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.

 

Breast cancer is the most common (non-skin) cancer in women in Scotland, with around 5,140 new cases each year¹. Breast cancer is much less likely in men, with approximately 40 cases per year in Scotland. Incidence rises from age 30 in women (more than 99.5% of new cases are aged 30 years or over) and from age 45 in men (more than 90% of new cases are aged 45 or over)¹.

Most breast cancers are diagnosed at an early stage (1 or 2). In 2022, 38.0% of cases were diagnosed at stage 1, 46.5% at stage 2, 8.4% at stage 3, 4.8% at stage 4, and 2.2% were diagnosed at an unknown stage in Scotland⁵. Women diagnosed at an earlier stage may have an improved chance of survival²⁴. Stage distribution differs by deprivation, with women living in more deprived areas being more likely to experience an advanced stage breast cancer diagnosis⁴.

There are several risk factors for breast cancer, including²⁵:

• Significant family history of breast cancer (see good practice section) or an inherited genetic alteration
• A previous diagnosis of breast cancer
• Early menarche (before age 11)
• Oral contraceptive use or hormone replacement therapy
• Older age at first giving birth (35 years or over)
• Nulliparity
• Not breastfeeding
• Older age at menopause (50 years or over)

The risk of breast cancer is also two to four times higher in women with previous false positive breast screening results²⁶.

Published data has shown that transgender women have a higher risk of breast cancer compared to men, and transgender men have a lower risk of breast cancer compared to women. In transgender women the risk of breast cancer is associated with hormone treatment²⁷. In cases of gender reassignment, it is important to provide sensitive and clinically appropriate care depending on individual circumstances and considering any hormone therapy involved.

Help-seeking behaviours and awareness of symptoms varies by demographic. There is evidence suggesting that first-generation Black African and Black Caribbean women in the UK who were diagnosed with symptomatic breast cancer had lower symptom awareness and faced barriers which resulted in delayed help-seeking²⁸.