Breast Symptoms + Mastalgia

Question 1

When do you refer

Answer 1

Suspected cancer / FH
30+ unexplained lump in breast or axilla
Skin or nipple changes associated with cancer e.g. Paget’s
Unilateral bloody nipple discharge
Previous cancer with new suspicious symptoms

Question 2

How long for referral

Answer 2

Suspected cancer

Within 2 weeks

Question 3

When do you consider referral

Answer 3

Skin changes

30+ lump in axilla

Question 4

What is non-urgent referral

Answer 4

<30 with lump

Question 5

What are symptoms of breast disease

Answer 5

Breast Lump
Nipple retraction 
Mastalgia
Axillary lump 
Gynaecomastia 
Discharge
Bleeding
Skin dimpling 
Distortion
Nipple inversion 
Skin changes 
Go down = more malignancy

Question 6

What does nipple inversion suggest

Answer 6

CARCINOMA

INFLAMMATORY

Question 7

What should you never forget about

Answer 7

Skin changes around breast

Question 8

Difference between retraction and inversion

Answer 8

Retraction = flat and broad

Likely benign

Question 9

What can discharge be

Answer 9

Blood - 10% malignant

Milk - physiological if breast feeding

Question 10

What causes discharge

Answer 10

Intraductal papilloma
Duct ectasia
Breast abscess 
Adenoma
Carcinoma
Hormonal 
Physiological

Question 11

What does discharge from malignancy ten to be

Answer 11

Bloody

Single duct

Question 12

How do you investigate

Answer 12

Examine breast

Triple assessment if mass

Question 13

What do you do if non-malignant

Answer 13

Exclude endocrine disorder - prolactin
Smoking cessation if duct ectasia
Cytology

Question 14

What is more worrying if discharge

Answer 14

Unilateral

One duct

Question 15

What causes enlarged LN

Answer 15

Skin inflammation - cellulitis 
Granulomas in breast - TB
Sarcoidosis
Viral infection 
Accessory breast
Breast cancer

Question 16

What are different types of skin changes

Answer 16

DImpling - skin mobile 
Indrawing - skin fixed 
Lymphoedema
Peau d'orange
Eczema
Ulceration 
Erythema

Question 17

If you have an axillary lump

Answer 17

Full breast exam
Mammogram
USS of axilla

Question 18

What do you need to do with mastalgia

Answer 18

Differentiate between chest wall vs true breast

Question 19

What causes mastalgia

Answer 19

Increased oestrogen
Increased prolactin
Decreased prolactin

Question 20

What are other causes of non breast ben

Answer 20

MSK
CArdiac
Gall stone
HRT 
Lung disease 
Inflammation around ribs

Question 21

What is more likely to be cancer

Answer 21

Constant

Still unusual to present

Question 22

What is common

Answer 22

Cyclical breast pain

Common to have nodules

Question 23

What is important in HX

Answer 23

Rule out cardiac

Trauma

Question 24

How do you investigate

Answer 24

HE

Mammogram / USS

Question 25

When do you do imaging

Answer 25

If unilateral persistent

Question 26

When do you do USS > mammogram

Answer 26

If focal pain = USS

If >40 = mammogram

Question 27

What do you do for true breast

Answer 27

Reassure
Support
NSAID and primrose oil = 1st line
Hormonal has high SE

Question 28

What do you do for chest wall pain

Answer 28

Reassure
NSAID
Steroid

Question 29

What do you ask in Hx of breast lump

Answer 29

Location, onset, size 
Pain - SOCRATES
Any nipple changes or skin 
Menstrual cycle and Hx 
- First period = exposed hormones for longer 
Personal hx of cancer 
FH inc cancer
RF

Question 30

What are modifiable RF to ask

Answer 30

Contraception
HRT
Alcohl 
Smoking 
Weight 
Activity
Breast feeding