Symptomatic Breast
Overview
The Modernising Patient Pathway Programme (MPPP) Symptomatic Breast Specialty Delivery Group (SDG) has been established to support and explore innovative approaches to the delivery of symptomatic breast services across NHS Scotland.
Through the development of Once for Scotland approaches to delivery of patient care, there is a strong focus on identifying opportunities to further develop clinical pathways. This aims to reduce unwarranted variation in the quality of care and to improve waiting times for non-urgent breast services. Specialty Delivery Groups play a key role in this work by engaging clinical leadership and fully utilising their roles across NHS Scotland.
The development of a Gynaecomastia Pathway has been progressed through the MPPP SDG, reflecting a common theme identified during engagement with colleagues across NHS Scotland.
The recommendations outlined have not followed the standard SIGN development process and are instead based on available guidance and expert consensus. Peer review has also been undertaken to provide appropriate quality assurance.
This guidance will be reviewed and updated as new evidence emerges.
Consensus
A common theme during the Breast Speciality Delivery group meetings has focused on the referral of men with breast issues to secondary care services.
A consensus was formed around the principles that:
- Gynaecomastia is a breast manifestation of a systemic problem. Secondary care referral and investigation is not necessary in the vast majority of cases and variation in practice and over investigation are common.
- Breast lumps in men (rather than generalised swelling of the breast tissue) require specific investigation.
Patient Guidance
The Breast Services pathways for Scotland seek to promote equitable, safe, and timely access to assessment and care for all patients presenting with breast related symptoms, including breast pain, nipple discharge, axillary or skin lumps, and gynaecomastia. Pathway access and clinical decision‑making should be based on the presenting symptom, underlying breast tissue, and individual clinical risk, ensuring that no patient is unintentionally disadvantaged.
These symptomatic pathways apply to all patients, including trans and gender‑diverse individuals. Referral, investigation, and management should be guided by the nature of the presenting symptom, relevant anatomy, prior medical or surgical history (including any gender-affirming treatment), and clinical risk factors, rather than gender identity alone. The aim is to ensure that patients with breast symptoms are directed to the most appropriate diagnostic pathway without delay.
Patients who have residual breast tissue, regardless of gender identity, should be referred through standard symptomatic breast pathways when they present with breast symptoms. Those who have had chest or breast surgery may still require referral if symptoms arise in remaining breast tissue, the chest wall, axilla, or skin.
In light of the Supreme Court ruling on the definition of biological sex within the Equality Act 2010, services should recognise that biological sex may remain a relevant determinant for certain aspects of investigation, clinical management, or accommodation within breast services. Where this is the case, any alternative arrangements should be proportionate, clinically justified, and handled sensitively, ensuring patient dignity while maintaining safety and pathway clarity.
@NHSScotCfSD
Centre for Sustainable Delivery
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