Breast - 2WW

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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties

Top Tips for GPs holding a 2WW Conversation 

Macmillan 2WW guidance

Scope:

• the initial presentation of benign and malignant symptomatic breast diseases in adult women
• when to refer patients for exclusion of breast cancer and the process for excluding breast cancer in the specialist diagnostic breast clinic
• primary management of common benign breast diseases
• management of breast conditions that present symptomatically

Out of scope:

• any aspect of screening, either in the general population or in women at high risk due to family history or genetic susceptibility [1]

Clinical features:

• breast symptoms may be due to benign or malignant disease [2]
• benign breast conditions can have clinical features similar to cancer [2]
• both male and female patients may present with breast symptoms − breast cancer is rare in males but the possibility should not be overlooked [3]
• when assessing and managing breast conditions, the clinician should stay alert for features suspicious for malignancy, and if present, refer the patient to the diagnostic breast clinic [3]
• in the diagnostic breast clinic, the patient is assessed by a specialist multidisciplinary team on the basis of clinical features, and by imaging, core biopsy, or tissue sampling [1]
• benign breast conditions include:
  • benign breast pain [2]
  • mammary duct ectasia [2]
  • galactorrhoea [2]
  • benign intraductal papilloma (causes nipple discharge) [4]
  • benign tumours, commonly fibroadenoma [2]
  • fibrocystic nodularity [5]
  • mastitis [2]
  • benign cysts [2]
  • breast abscesses [5]
  • nipple eczema [5]
  • benign skin and nipple distortion [4]
  • haematoma [4]
  • fat necrosis [4]
  • diabetic mastopathy (rare, causes lumpiness) [4]
  • phyllodes tumour (commonly benign but can sometimes be malignant) [4]

Incidence and prevalence:

• approximately 3 in 100 females present to a GP with breast problems in the UK each year [4]
• breast pain without underlying pathology may affect approximately 70% of women in their lifetime [6] 
• prevalence of breast pain is highest in females age 30-50 years [6]

Management:

• management depends on the diagnosis [4]
• management of benign conditions falls into three categories:
  • conservative management (including symptomatic medication, advice, and 'watch and wait') in primary care, providing that there are no features that indicate investigation for malignancy − in general, if conservative management is ineffective, referral to diagnostic breast clinic is indicated [4]
  • for troublesome benign disorders that have a cyclical component, such as breast pain, hormonal therapy may be attempted if first-line management is not successful [7]
  • surgical management or radiological intervention may be appropriate for some disorders where an anatomical abnormality is present, eg:
    • ductectomy for mammary duct ectasia associated with ongoing nipple discharge and reduced quality of life [4]
    • lumpectomy for large fibroadenomas [4]
    • ultrasound-guided repeat aspiration for abscesses [1]
    • needle aspiration for symptomatic cysts [5]

 NBT Patient Information Leaflet

• Breast cancer (URL) from Macmillan Cancer Support at www.macmillan.org.uk
• Breast cancer (URL) from Cancer Research UK at www.cancerhelp.org.uk

• 'Breast lumps' (PDF) from Patient UK at http://www.patient.co.uk
• 'Breast pain' (PDF) from Patient UK at http://www.patient.co.uk

NSCCG sign off form 2017 

Updated in line with NICE Guideline NG12: Suspected cancer: recognition and referral to coincide with updated  BNSSG 2WW Referral forms

Oncology sign off form

Date of publication: 31-Jan-2014

This care map has been updated to include evidence from the following guidelines:

• [2] Institute for Clinical Systems Improvement (ICSI) . Diagnosis of breast disease. Bloomington, MN: ICSI; 2012.
• [3] Department of Health (DH), Willet AM, Michell MJ et al. Best practice diagnostic guidelines for patients presenting with breast symptoms. London: DH; 2010.
• [5] University of Michigan Health System. Common breast problems. Ann Arbor, MI: University of Michigan Health System; 2013.
• [7] Clinical Knowledge Summaries (CKS). Breast pain - cyclical. September 2012. Newcastle upon Tyne: CKS; 2012.
• [8] National Comprehensive Cancer Network (NCCN). Breast cancer screening and diagnosis. Version 2. Fort Washington, PA: NCCN; 2013.

Further information was provided by the following references, including practice-based knowledge:

• [1] Practice-informed recommendations. London; 2014.
• [6] Goyal A. Breast pain. Clin Evid 2011; pii: 0812.
• [11] National Cancer Action Team, Breakthrough Breast Cancer, NHS Improvement. Going further on cancer waits: the symptomatic breast two week wait standard. Leicester: NHS Improvement; 2009.
• [17] Department of Health (DH). Improving outcomes: a strategy for cancer. London: DH; 2011.

Tumour

Malignancy

2 week wait

Cancer

Oncology

breast lump

breast pain

nipple discharge

Patients with breast disease may present with one or more of the following:

• a discrete breast lump, with or without breast tenderness [3]
• diffuse unilateral or bilateral lumpiness (nodularity), with or without breast tenderness [3]
• unilateral or bilateral, cyclic or non-cyclic breast pain [2]
• nipple discharge − may be bloody, clear, yellow, white, dark green or milky
• sore, eczematous, cracked, or ulcerated nipple [3]
• nipple distortion or retraction [3]
• change in breast size, with signs of oedema [3]
• skin distortion [3]
• symptoms of inflammation, such as erythema, swelling, pain, and fever [2]
• changes in appearance of the skin of the breast, eg retraction [4], peau d'orange [8]

Clinical presentation for breast lump:

• is a localised swelling distinct from the surrounding breast tissue [2]
• approximately 50% are located in the upper outer quadrant [4]
• may be single or multiple [4]
• may be unilateral or bilateral, regardless of whether they are benign or malignant [4]
• may be tethered to superficial or deep structures by inflammation or malignancy [4]

Nipple discharge:

• is usually of benign origin [5]
• fluid may be bloody, clear, yellow, white, dark green, or milky [5]
• is more likely to be associated with malignancy if it is:
  • spontaneous [3]
  • unilateral and confined to one duct [3]
  • bloody, clear, or serous colour [3]
  • associated with a mass or inflammation [3]
  • present in patient age 50 years or older [2]
• is more likely to be of benign origin if it is [5]:
  • characterised by discharge only with compression or squeezing
  • bilateral and involves multiple ducts
  • is most commonly caused by nipple stimulation by frequent squeezing of nipples [4]

Possible causes of nipple eczema or ulceration:

• atopic or irritant dermatitis [4] 
  • mainly affects the areola and is often bilateral
  • responds well to standard treatments for eczema − see 'Eczema' pathway
• Paget's disease of the nipple: 
  • is a presentation of breast cancer [8]
  • commonly presents with eczema of the areola, bleeding, ulceration, and itching of the nipple [8]
  • usually unilateral and spreads from the nipple in an eccentric pattern [4]
  • palpable breast mass is present in approximately 50% of cases − if present, the mass is usually located more than 2cm from the nipple areolar complex [4]
  • may be associated with occult ductal carcinoma (ie that is neither palpable nor mammographically visible) [4]

Other rare causes include [4]:

• erosive dermatoses 
• Bowen's disease 
• basal cell carcinoma 
• superficial spreading malignant melanoma
• nipple adenoma 
• pemphigus vulgaris 

Possible causes of nipple distortion or retraction [1]:

• may be a normal variant, commencing when the breast is maturing during puberty and tends to remain retracted
• nipple retraction may also be congenital
• fibrosis surrounding a benign or malignant process can cause flattening or withdrawal of the nipple
• benign causes include duct ectasia and acute mastitis  
• recent nipple retraction or distortion should raise suspicion of an underlying cancer

Inflammatory symptoms that are not responding to antibiotic treatment could be a sign of:

• an abscess that may be developing
• inflammatory carcinoma
• granulomatous mastitis

Breast pain:

• may co-exist with other features, which should take priority if present [4]
• breast pain alone (ie with normal examination) is seldom due to malignancy [2]
• may be unilateral or bilateral [2] (unilateral is more suspicious for malignancy than bilateral) [4]
• may be diffuse or focal [2] (focal is more suspicious for malignancy) [4]
• may be cyclic (ie vary with the menstrual period) or non-cyclic [2] (non-cyclic breast pain is more suspicious for malignancy) [4]

 Possible differential diagnoses may include:

• pregnancy
• infection
• herpes zoster (shingles)
• spinal and paraspinal disorders
• post-thoracotomy syndrome
• chest wall muscle pain
• costochondritis - Tietze's syndrome
• angina pectoris (consider if pain is unilateral)

Ask the patient about:

• the predominant problem (lump, nodularity, pain, discharge, or nipple changes) [2]
• the location and severity of symptoms [2]
• the duration of symptoms, and whether or how they are changing over time [4]
• whether symptoms are unilateral or bilateral, symmetrical, or asymmetrical [4]
• whether symptoms vary with the menstrual cycle or physical activity [2]
• whether other features are present, even if they are not predominant [4]
• breastfeeding history [4]

Ask about aetiological factors for breast disease, including:

• history of trauma to chest area [2]
• history of enlarged lymph nodes [4]
• personal history of breast cancer [3]
• number of previous benign breast biopsies [8] and personal history of breast biopsy or surgery [1]
• history of risk factors for breast cancer, including:
  • age (risk increases with age) [8]
  • personal history of ductal hyperplasia on previous biopsies [2]
  • prior radiation before age 30 years [2] (US guidelines specify between age 10−30 years [8])
  • family history of:
    • breast cancer in first-degree relatives [2]
    • breast and/or ovarian cancer (particularly in a first-degree relative who developed the disease before age 50 years − this is an extremely high-risk group who should be referred for genetic testing and counselling [2])
  • genetic predisposition [8] (carrier of mutated breast cancer genes [1])
  • race [8], eg Jewish ancestry (increased risk of hereditary breast cancer in Ashkenazi Jews) [4]
  • age of menarche [8] (risk increases with earlier menarche [4])
  • obstetric history [8] (nulliparity and first live birth after age 30 years are risk factors [4])
  • menopausal status [4]:
    • ask if the patient is pre-, post-, or peri-menopausal
    • note age of menopause if the patient is postmenopausal (postmenopausal females are at higher risk and late menopause is a risk factor)
  • alcohol intake [4]
  • hormone replacement therapy (HRT) or oral contraceptive use [2,3]
  • obesity and weight gain[4]
• current medications [2]
• date of last mammogram, if any [3]
• establish whether the patient is currently, or has recently stopped, breastfeeding:
  • nipple discharge [5], mastitis [9], and breast abscesses [9] are common in lactating women
  • conversely, these conditions should increase suspicion of malignancy in women who are not lactating [4]

Lumps and nodularity:

• establish how any lumpiness was first noted, either [4]:
  • accidentally
  • by self-examination
  • during a screening clinical breast examination or mammogram

Ask about nipple changes or discharge, including:

• duration, frequency, and volume of nipple discharge [3]
• if present, note the colour of any nipple discharge [3]
• whether the discharge is:
  • spontaneous or stimulated [3]
  • bilateral or unilateral [3]
  • single or multiduct [3]
  • persistent or intermittent [4]
  • sufficient to stain clothing [4]
  • red colour or blood/bloodstained discharge [3]
  • containing pus [4]

Before the examination [4]:

• document the current phase of the menstrual cycle
• consider whether a chaperone should be present (seek patient’s consent before asking a chaperone to attend the examination)

As part of the physical examination:

• perform a bilateral examination, even if symptoms are unilateral [3]
• inspect and palpate the patient’s breasts, neck, chest wall, and arms [2] whilst the patient is positioned in an upright position, and again with the patient supine [2]
• include examination of the lymph node basins [8]
• examine the breasts with the flat part of the fingers; gently but firmly examine each quadrant and the nipple and areolar complex with regard to shape, size, texture, position within breast, mobility, and tenderness [4]
• delineate and document any breast masses with regard to shape, size, texture, position within breast, mobility, tenderness, and whether mass is attached to skin or underlying structures [4]
• compare the breasts and take note of any asymmetry [4]
• look for the following:
  • masses [2]
  • nodules [2]
  • skin retraction (may be revealed by asking the patient to place her arms on her hips, contract her pectoral muscles, and then raise her arms) [4]
  • peau d'orange [8]
  • swelling [2]
  • redness or inflammation of the skin [2]
  • nipple discharge [2]
  • nipple erythema, eczema-like changes, or excoriation/ulceration [8]
  • nipple retraction or distortion
  • fungation [4]
• examine the axillae by holding the patient's arm and opening up the axilla [4]
• examine the supraclavicular fossae for thickening or lymphadenopathy − if lymphadenopathy is noted, a full examination of the cervical nodes should be performed [4]
• examine the skin covering the breast for lesions that may be staining the patient's clothes and mimicking nipple discharge, such as:
  • Paget's disease [2]
  • insect bites [4]
  • local infections [5]
  • eczema [5]

To examine for nipple discharge:

• squeeze the nipple gently yourself; or [4]
• ask the patient to squeeze the nipple [4]
• note accompanying changes in appearance of the breast, such as dimpling of the skin, nipple soreness, itch or redness, nipple inversion, or change in shape [4]

2WW Breast services are available at Southmead (NBT)

Suspected Cancer Referral - refer via 2WW

• Age 30 and over with an unexplained breast lump with or without pain
• Age 30 and over with an unexplained lump in the axilla
• Have skin changes which suggest cancer

• Age 50 and over with any of the following symptoms in one nipple only:
  • discharge - clear or blood
  • retraction - new onset and sustained (nipple distortion may be a consequence of mastitis, and should resolve)
  • Other changes of concern

• Males aged 50 and over with unilateral firm sub areolar mass with/without nipple distortion and skin changes

Symptomatic Breast Referral (non-suspected cancer referral via referral service but can use 2WW form)

• Aged under 30 with an unexplained breast lump with or without pain
• Other (please detail)

All breast referrals are seen within two weeks

2WW Breast services are available at Southmead (NBT)

Suspected Cancer referral - via 2WW

• Age 30 and over with an unexplained breast lump with or without pain
• Age 30 and over with an unexplained lump in the axilla
• Have skin changes which suggest cancer

• Age 50 and over with any of the following symptoms in one nipple only:
  • discharge - clear or blood
  • retraction - new onset and sustained (nipple distortion may be a consequence of mastitis, and should resolve)
  • Other changes of concern

• Males aged 50 and over with unilateral firm sub areolar mass with/without nipple distortion and skin changes

Symptomatic Breast Referral (non-suspected cancer referral via referral service but can use 2WW form)

• Aged under 30 with an unexplained breast lump with or without pain
• Other (please detail)

All breast referrals are seen within two weeks

Consider recommending:

• oral paracetamol and/or ibuprofen
• topical non-steroidal anti-inflammatory drugs (NSAIDs) e.g. Ibuprofen 5% gel or Piroxicam 0.5% (benefits are thought to outweigh the risk of adverse effects)

In general, continue first -line treatment for 6 months before considering second-line treatment or referral.

Department of Health (DH) guidelines state that the patient should be referred if presenting with minor/moderate degree of breast pain with no discrete palpable abnormality, when initial treatment fails and/or with unexplained persistent symptoms [3].

Urgency of referral depends on the clinical circumstances – the following features favour more urgent referral [4]:

• older age (especially postmenopausal)
• unilateral pain [2]
• focal (rather than diffuse) pain
• non-cyclical pain
• severe pain

Expert opinion states that some patients may benefit from the reassurance of a non-urgent referral for an examination by a breast specialist and a normal mammography result [1]. 

All breast referrals are seen within two weeks

Breast services are available at Southmead (NBT)

Refer patients presenting with the following non-urgent symptoms [3]:

• unexplained breast lump in a patient age under 30 years with or without pain
• patient age under 50 years with nipple discharge that is from multiple ducts or is intermittent and is neither bloodstained nor troublesome
• patient with minor/moderate degree of breast pain with no discrete palpable abnormality, when initial treatment fails and/or with unexplained persistent symptoms

All breast referrals are seen within two weeks

Breast services are available at Southmead (NBT)

Women should be provided with information about [8]:

• the screening test:
  • use of compression
  • mammography views
  • examination times
• how they will receive their results
• organisation of the screening programme
• harms and benefits of screening
• possibility of missing cancer in women with dense breasts and the increased likelihood of needing further investigations [9]
• the importance of breast awareness

Mammography screening:

• should be performed every 3 years in women age 50-70 years (part of the NHS breast screening programme) [2]:
  • the breast screening interval is being expanded to women age 47-73 years, with full implementation of this by 2016 [2]
• there are individualised strategies for women at moderate and high risk of breast cancer, including known or likely BRCA1, BRCA2, or TP53 carriers [9]
• NB: the National Screening programme for breast cancer is specific for England – refer to your own programme regarding screening, where appropriate [8]

  Bristol Regional Genetics Service Referral Guidelines Breast/Ovarian Cancer Family History