Breast lumps
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5275 (Published 05 September 2014) Cite this as: BMJ 2014;349:g5275
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Two medical students and a plastic surgeon offer phenomenally useful and extensive advice on the management of a breast lump.
Breast Clinic specialists have responded to point out that not all breast lumps need triple assessment, and some patient can be reassured on clinical assessment by confident experience doctors. GPs have all been medical students, yet many would lack the confidence NOT to refer. Long ago our local clinic had strict guidelines for breats lump referral, and age < 35 was a criterion not to refer - excluding the possibility of early diagnosis of young women with a cancer. All that changed with litigation, and now I am fairly sure every patient with lump is referred. What discussion takes place about the risks and benefits of referral ? And what of the increasinglycommon scenario of the returning patient, with another lump , referred last year ?
The cardinally lacking element in this 10-minute consultation is the patient !
How do you deal with her ideas, concerns, expectations ? How much informagtion regarding cancer risk can be put to shared decision-making ? Are we heading for an automated signpost in the GP waiting-room , pointing to hospital ?
Competing interests: No competing interests
We thank Dr Twoon et al for their article on management of a breast lump in general practice.
However, we would like to clarify their advice to refer patients with red flag breast symptoms or abnormal changes to a breast clinic "for triple assessment". Referral to a breast clinic is for a specialist opinion, which may or may not include triple assessment. As Mr Barber acknowledges in his response, triple assessment is simple in the case of a discrete breast lump. The spectrum of breast symptoms including 'abnormal changes' and 'red flag' symptoms is a wide one, and clinical examination at the breast clinic may be all that is indicated, without need for imaging or biopsy.
Referral of patients with breast symptoms other than a discrete lump may well be entirely appropriate, but it is important not to give patients the expectation of triple assessment in every case.
Competing interests: No competing interests
The issue determining if a patient should be referred to a specialist breast clinic is whether the general practitioner can adequately reassure the patient that they do not have a remediable breast problem, notably a breast cancer. With a lump this is simple. Such reassurance requires triple assessment (clinical, imaging and biopsy) and the patient should be referred. Features from the history such as character of lump, family history or endocrine exposure may be epidemiologically interesting but are of no use in determining the cause of a lump. Information on comorbidity, drug and social history are of more practical value.
The wider problem is a combination of 1)the apparent lack of confidence in breast assessment by GPs (who receive 2 days of undergraduate breast teaching locally) and 2) patient anxiety, in part driven by charity, media and government-sponsored awareness campaigns (which have yet to have been shown to produce an increase in breast cancer diagnosis). This has contributed to an increase in referrals to the specialist breast clinic in Edinburgh of around 4% per year while symptomatic cancer diagnosis has increased by about 2% per year. Currently about 1 in 19 patients referred to our specialist breast clinic has breast cancer. Most patients with breast pain and skin lesions should not need to be seen at a specialist breast clinic but again, this requires the GP to be confident to adequately assess and reassure the patient who is often programmed to seek specialist referral.
General practitioners lacking confidence in clinical assessment of the breast are encouraged to get in touch with their local breast unit and arrange to join us for a few clinics.
Competing interests: No competing interests
Re: Breast lumps
This article has conveyed a confusing message about the lumps discovered in patients under 30.
Discrete breast lump in younger patients less than 30 years old with no worrying features i:e texture/ fixation/ skin changes and no family history of early age breast cancer do not require urgent referrals.
We may inundate the urgent clinic with such referrals which could have detrimental effect on actual suspicious lumps assessment.
Competing interests: No competing interests