1. Breast disease
Meducation Course May 2014
Donna Egbeare FRCS

2. Aims and objectives
By the end of the session you should be able to:
• List common breast lumps – benign and malignant
• Describe common presentations to GP surgery or breast clinic
• Describe Triple Assessment
• Retain knowledge of Breast Cancer and Ductal Carcinoma In Situ (DCIS)
• List criteria for the national screening programme
• Give an overview of the treatment options for Breast Cancer
From the handout and references you might also have a working knowledge of
• NICE guidelines
• Genetics and family history
• New developments in the field of breast cancer

3. Why do you need to know about
breast disease?
• 25% of surgical referrals
• 1 in 4 women will be referred to breast
clinic at some point

4. Presenting complaint %
Breast lump 36
Painful lumpiness 33
Pain alone 17.5
Nipple discharge 5
Family history 3
Nipple retraction 3
Breast distortion 1
Breast swelling 1
Scaling of nipple 0.5

5. Breast lumps
Lump
Fibroadenoma <40yrs, mobile, smooth, <2cm
Cyst Sudden growth, firm, painful
Glandular tissue UOQ, no discrete edge surrounding
lump
Phyllodes Smooth, mobile, larger than FA, older
age group
Fat necrosis History of trauma, bruise, lumpiness
rather than single lump
Abscess Erythema, discharge, near to NAC,
systemic symptoms
Fibrocystic change Lumpiness, often UOQ
Skin lump Superficial, seb cysts common
Cancer Firm, woody, skin/muscle involvement,
can’t move lump in two planes

6. History
• What have they noticed?
• How long for?
• Changed?
• Menstrual cycle – LMP?
• Menarche
• Menopause
• HRT/OCP/contraception
• Breast feeding
• Family history
• Previous imaging?
• Screening mammograms?
• Other medical illnesses and medications/drug use
• Social history, dominant hand
• Job/Hobbies

7. Breast pain
• Common
• Cyclical vs Non-cyclical
• Breast or chest?
• Treatment –
• hormone control?
• Flax seeds
• Evening primrose oil
• Bra fitting
• NSAIDs

8. Triple Assessment
• Clinical (P or S)
• Look (arms up, fix muscle by pressing in on hips)
• Feel – examination of breast, systematic
• Lymph nodes – axilla, SCF
• Anything else – metastatic disease?
• Imaging (M and/or U)
• Mammogram – 2 views
• Ultrasound - targeted
• Axilla – ultrasound
• (CT/MRI)
• Histological (cytology) B (C)
• Core biopsy
• Punch biopsy
• Axilla FNA
• (FNA)

9. How would you do a breast
examination?
• Look first – patient sitting, arms up, fix muscle
• Examination with flats of fingers with patient at 45degrees
• Systematic –
• round the clock,
• quadrants and then centrally
• Doesn’t matter as long as all areas examined
• Axilla –
• relax shoulder, examine with opposite hand (i.e. right axilla with left
hand) whilst holding patients arm with same side hand
• Alternatively get patient to rest both hands on shoulders and
examine axillae
• Think about borders of axilla
• Supraclavicular fossa

10. Breast Cancer
• Broadly:
• Ductal (there are several subtypes i.e. encysted papillary,
medullary, etc. OR
• Lobular
• Invasive i.e. can metastasize
• TNM staging
• Tis = DCIS, T1 = <20mm, T2 = 21-49mm, T3 = >50mm, T4 =
involves skin or invades chest wall or is inflammatory
• N0 = no lymph node involvement, N1 = 1-3 nodes, N2 = 4-9
nodes, N3 = >10 nodes
• M0 = no distant mets, M1 = evidence of mets
• Nodal status still seen as very important to determining
systemic treatment

11. DCIS
• Non invasive i.e. can’t metastasize
• Low, intermediate or high grade
• How does it present?
• Screen detected generally
• Asymptomatic
• Controversies –
• OVERtreatment vs OVERdiagnosis
• If left alone would it turn into cancer?
• Rename it?

12. National screening programme
• Every three years
• GP registry
• 47-73 (age extension)
• Digital two view mammogram – CC (head to toe) and LMO
(oblique)
• Recall rate?

14. Treatment Options for Breast
Cancer
• ALL discussed at an MDT
• Surgery –
• WLE vs Mastectomy (oncoplastic – mammaplasty?)
• Sentinel node vs axillary clearance
• Chemotherapy – refer to oncology
• Monoclonal antibody treatment
• Traztuzamab/herceptin
• Radiotherapy – to reduce locoregional recurrence rate after WLE to
that of mastectomy
• Endocrine management
• Selective estrogen receptor modulators/SERMs (Tamoxifen)
• Aromatase Inhibitors/AI (Anastrozole, Letrozole, Exemestane)
• Estrogen Receptor Downregulators/ERDs (Faslodex)
• Metastatic disease programmes

15. NICE guidelines
• www.nice.org
• Referral guidelines
• Treatment of early breast cancer
• Treatment of advanced breast cancer
• Family history of breast cancer and management
• MRI screening
• Endocrine treatment in early breast cancer
• Osteoporosis treatment on endocrine treatments

16. Genetics and family history
• How to take a family history
• Draw it as going along
• Start with personal history – are you married, do you have any
children?
• Do any of those relatives have cancer? What type at what age? Are
they still alive?
• Then 1st degree relatives – parents, siblings
• Then go for maternal family – did mother have siblings? Then
parents, did they have any siblings, did any have cancer?
• Repeat for paternal family
• BRCA1 and BRCA2 genes linked to breast cancer. BRCA2 also linked
to ovarian cancer
• Li Fraumeni and Cowden syndromes also linked to breast cancer

17. New developments in the field of
breast cancer
• Oncotype DX – 21 gene assay, core biopsy or post surgery
• Can tell if likely to be high or low risk of recurrence
• Can tell if tumour will respond to chemotherapy
• Useful if patient unsure if wants chemo or if there is uncertainty of
there is benefit
• Not available on NHS
• Costs approx £4000
• Excision of metastatic disease
• Increasing evidence that excising metastases useful to extend
symptom free survival
• Doesn’t extend life – costs vs benefits (how do you measure this?)
• Survivorship issues –
• Should NHS pay for delayed reconstruction?
• Should there be a time limit?