Breast cancer - recognition and referral
Exam Tips
- Know referral thresholds exactly: unexplained breast lump at age >=30 years is suspected cancer pathway referral, regardless of pain.
- Unilateral nipple change of concern (discharge/retraction/other worrying change) at age >=50 years triggers suspected cancer pathway referral.
- Skin changes suggestive of breast cancer or unexplained axillary lump at age >=30 years should prompt consideration of suspected cancer pathway referral.
- Under age 30 with unexplained breast lump is usually non-urgent referral unless other red flags are present.
- Diagnosis is usually confirmed in secondary care by imaging plus core biopsy (triple assessment concept is a common OSCE viva point).
- Use safety-netting language in stations: explain urgency, likely timelines, and that many urgent referrals do not end in a cancer diagnosis.
- If DVT is unexplained, consider occult malignancy (including breast) and assess for additional cancer features.
- Image cue for revision: review standard clinical images of peau d'orange, skin tethering, and nipple retraction in your breast examination atlas (for example Macleod's breast chapter figures).
Definition
Breast cancer is a malignant epithelial tumour of the breast (most commonly ductal, less often lobular) that may present in primary care with a new breast lump, unilateral nipple change, axillary lump, or suspicious skin change. In UK practice, this topic focuses on early recognition and correct referral timing so that people with possible cancer enter the suspected cancer pathway promptly for diagnosis (typically by imaging and core biopsy in secondary care).
Pathophysiology
Most breast cancers arise from terminal duct-lobular units after stepwise genetic and epigenetic change (for example involving BRCA pathways, hormone-receptor signalling, and growth-factor pathways). Disease may begin as in-situ neoplasia (DCIS/LCIS) and progress to invasive carcinoma, with stromal invasion enabling lymphatic spread (often to axillary nodes) and haematogenous metastasis (for example bone, liver, lung, brain). Tumour biology (ER/PR/HER2 status, grade, proliferative activity) strongly influences progression risk and treatment selection.
Risk Factors
- Increasing age (incidence highest in older adults)
- Female sex (male breast cancer is rare but important)
- Family history of breast/ovarian cancer, especially first-degree relatives
- Pathogenic variants (for example BRCA1, BRCA2, PALB2)
- Prolonged oestrogen exposure (early menarche, late menopause, nulliparity, later first pregnancy)
- Current or recent menopausal hormone therapy (risk varies by regimen/duration)
- Previous chest radiotherapy at a young age
- Obesity (especially postmenopausal), alcohol use, and physical inactivity
- Personal history of atypical hyperplasia, LCIS, or prior breast cancer
Clinical Features
Symptoms
- Unexplained breast lump (with or without pain); malignant lumps are often painless
- Unilateral nipple discharge (especially blood-stained) or new nipple retraction
- New unilateral nipple shape change or other concerning unilateral nipple change
- Awareness of breast skin change (for example dimpling/tethering or peau d'orange appearance)
- Unexplained axillary lump
- Occasionally breast pain as a presenting complaint
Signs
- Irregular, hard, less mobile breast mass
- Skin tethering, dimpling, ulceration, or peau d'orange
- Nipple inversion/retraction that is new and unilateral
- Eczematous nipple-areolar change suspicious for Paget disease
- Ipsilateral axillary lymphadenopathy or discrete axillary mass
- Advanced disease signs (for example fixed chest wall mass, supraclavicular nodes)
Investigations
Management
Lifestyle Modifications
- Explain clearly why urgent referral is being made; reassure that many urgent referrals are not cancer
- Provide safety-netting: seek review for progression/new red-flag symptoms and ensure attendance at booked appointments
- Encourage breast awareness and prompt reporting of new unilateral breast/nipple/axillary changes
- Address modifiable long-term risk factors (weight, alcohol reduction, physical activity) without delaying referral
Pharmacological Treatment
Primary-care symptom relief while awaiting assessment (does not treat cancer)
- Paracetamol 1 g orally every 4-6 hours when required (max 4 g/day)
- Ibuprofen 400 mg orally up to three times daily with food (max OTC-style regimen unless specialist advice)
Use only for short-term discomfort; do not delay referral. Avoid/limit NSAIDs in peptic ulcer disease, severe renal impairment, heart failure, anticoagulation, or NSAID-sensitive asthma.
Adjuvant endocrine therapy (oncology initiation after diagnosis)
- Tamoxifen 20 mg orally once daily
- Anastrozole 1 mg orally once daily
- Letrozole 2.5 mg orally once daily
Choice depends on menopausal status and tumour biology. Tamoxifen: VTE and endometrial cancer risk; caution with prior thrombosis and CYP2D6-interacting drugs. Aromatase inhibitors: bone loss/arthralgia risk; assess fracture risk and bone protection.
Systemic anti-cancer therapy (specialist only)
- Trastuzumab (dose per protocol: typically 8 mg/kg loading then 6 mg/kg every 3 weeks IV, or SC fixed-dose regimens)
- Common chemotherapy regimens include anthracycline/taxane-based protocols (cycle dosing protocol-specific)
Not initiated in primary care. Key safety warnings: cardiotoxicity (trastuzumab/anthracyclines), neutropenic sepsis risk with cytotoxics; urgent same-day assessment required for fever during chemotherapy.
Surgical / Interventional
- Breast-conserving surgery (wide local excision/lumpectomy) when suitable, usually with adjuvant radiotherapy
- Mastectomy when tumour factors or patient preference indicate
- Sentinel lymph node biopsy for nodal staging; axillary clearance in selected node-positive disease
- Oncoplastic and reconstructive options discussed as part of shared decision-making
Complications
- Local progression with skin/chest wall involvement
- Nodal spread causing axillary disease and potential arm lymphoedema
- Distant metastases (bone, liver, lung, brain)
- Cancer-associated thrombosis (including DVT/PE)
- Treatment-related complications (for example neutropenic sepsis, cardiotoxicity, endocrine adverse effects)
- Psychological morbidity (anxiety, depression, body-image disturbance)
Prognosis
UK 5-year survival is around 85% overall (including screen-detected and symptomatic cases), but prognosis varies markedly by stage at diagnosis and tumour biology. Earlier-stage, node-negative, receptor-guided disease has substantially better outcomes than metastatic presentation.
Sources & References
✅NICE Guidelines(1)
- Breast cancer - recognition and referral[overview]
📖Textbook References(4)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 115)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1013)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 718)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 276)[context]