Education And Debate

ABC of Breast Diseases : Symptoms Assessment and Guidelines for Referral

BMJ 1994; 309 doi: (Published 17 September 1994) Cite this as: BMJ 1994;309:722
  1. J M Dixon,
  2. R E Mansel

    “Bathsheba bathing” by Rembrandt. The model was Rembrandt's mistress, and much discussion has surrounded the shadowing in her left breast and whether this represents an underlying malignancy.

    A breast lump, which may be painful, and breast pain constitute over 80% of the breast problems that require hospital referral, and breast problems constitute up to a quarter of the general surgical workload.

    View this table:

    Prevalence of presenting symptoms in patients attending a breast clinic

    Guidelines for referral to hospital

    Conditions that require hospital referral

    • All patients with a discrete mass (aspiration of masses by general practitioners is not encouraged because bruising can follow aspiration of a solid mass, making subsequent assessment difficult)

    • Nipple discharge in patients aged over 50, and bloodstained, persistent, or troublesome nipple discharge in younger patients

    • Mastalgia that interferes with patient's lifestyle or sleep and which has failed to respond to reassurance, simple measures such as wearing a well supporting bra, and common drugs

    • Nipple retraction or distortion, change in skin contour, or nipple eczema

    • Request for assessment by a patient with a strong family history of breast cancer

    • Asymmetrical nodularity that persists at review after menstruation

    Patients who can be managed at least initially by their general practitioner

    • Young patients with tender, lumpy breasts and older patients with symmetrical nodularity, provided that they have no localised abnormality

    • Patients with minor and moderate degrees of breast pain who do not have a discrete palpable lesion

    • Patients aged under 50 who have nipple discharge that is from more than one duct or is intermittent and is neither bloodstained nor troublesome

    When a patients presents with a breast problem the basic question for the general practitioner is, “Is there a chance that cancer is present, and, if not, can I manage these symptoms myself?”

    For patients presenting with a breast lump, the general practitioner should determine whether the lump is discrete or is an area of lumpiness or nodularity. A discrete lump stands out …

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