Cases corner – 34 years old with a breast lump

21st February 2019

Jane, a 34 year old women, presents with a 2 week history of a right sided breast lump she found incidentally in the shower. The lump is non-tender and mobile. She reports regular menses and is due her next period in 4 days. There is no relevant past medical history or family history of breast cancer. She reports she commonly experiences bilateral mastalgia before her period. On examination you confirm the presence of a 2x2cm mobile lump on the right upper quadrant of her right breast. There is no associated lymphadenopathy.

What should you do next?

  1. Safety net the patient and ask her to come back in two weeks
  2. Reassure the patient and advise her that the if the lump remains after her period to come back for review
  3. Refer the patient for a non-urgent breast referral
  4. Refer the patient along an urgent 2-week-wait breast referral

The majority of breast lumps are fibroadenomas or breast cysts. However, it is not possible to reliably distinguish between a benign or malignant lump from clinical examination alone. All breast lumps should be investigated further with imaging +/- fine needle aspiration. Had this patient been under 30 years of age, a non-urgent referral would have been appropriate due to the lowered risk of breast cancer.

There is no guidance that suggests waiting or reviewing breast lumps for resolution. Rather, due to the relatively low cost of these tests and investigations, with many clinics offering one stop shops, it is a cost-effective route to identify those patients with malignant lumps.

The NICE guidance is as follows:

  • Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if:
    • They are aged 30 and over and have an unexplained breast lump with or without pain or
    • They are aged 50 and over with any of the following symptoms in one nipple only:
      • Discharge
      • Retraction
      • Other changes of concern (new NICE recommendation for 2015)
  • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) people:
    • With skin changes that suggest breast cancer or
    • Aged 30 and over with an unexplained lump in the axilla (new NICE recommendation for 2015).
  • Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain (new NICE recommendation for 2015).