Primary symptoms / history
Primary symptoms
Axillary symptoms
Breast distention
Breast distortion
Breast lump
Breast pain
Nipple discharge
Node status
Chest wall pain
Skin changes
Nodularity
Axillary symptoms
The presence or absence of involved axillary lymph nodes is the single best predictor of survival of breast cancer.Both the number of nodes involved and the level of involvement predict survival.
Consequently, the examination of the axilla is very important, however, the sensitivity of the examination is in the order of 50%.
Following examination of both breasts, the axillae should be carefully assessed. Axillary node involvement occurs in up to 50% of symptomatic breast cancers and small screen detected breast cancers (<1cm) have a substantially lower incidence of metastases to nodes.
Axillary surgery can be used to stage the axilla or to treat axillary disease or both. Radiotherapy may be given to the axilla where positive nodes have been removed by an axillary sampling procedure. However, routine radiotherapy following axillary clearance may lead to unacceptable rates of lymphoedema .
Breast distension
Unilateral breast distension may occur either due to a large tumour occupying the affected breast or following conservative surgery and radiotherapy for breast cancer.
Distension may be present with or without distortion . Careful inspection and examination is required on presentation.
The commonest cause of bilateral breast distension is pregnancy.
Breast distortion
Breast distortion may occur as a consequence of the presence of a tumour, nipple retraction, skin changes or a combination of all three.Distortion due to oedema may occur after surgery and radiotherapy, causing peau d'orange changes to the skin.
Careful inspection and examination is essential on presentation. Subtle changes can be seen on close scrutiny.
Breast lump
A breast lump is probably the most common presentation of breast cancer.The lump is usually found either by self-examination or by a health professional as part of a routine examination.
Breast lumps represent a significant percentage of all symptoms in patients attending a breast clinic.
A lump can be rarely associated with pain. When a patient presents with a breast lump, it is very important that the GP carries out a careful history and examination in order to make a differential diagnosis.
The following conditions should be referred to a specialist surgeon (British Association of Surgical Oncologists (BASO) trained) for triple assessment :-
- Any new lump
- Any new lump in pre-existing nodularity
- Asymmetrical nodularity which persists after menstruation
- Any infective lesion with persistent thickening.
Breast pain
Breast pain (mastalgia) is either cyclical or non-cyclical.Cyclical mastalgia is common in pre-menopausal women. A careful history must be taken in order to assess severity and timing. Pain charts are very helpful for recording the timing of pain in relation to the menstrual cycle.
Non-cyclical pain is more common in older women (mean age 43 years). Further investigation is essential for patients in whom the pain is unilateral and persistent. Pain associated with a breast lump is uncommon but must be referred for investigation.
Cyclical mastalgia can be treated by simple measures such as reassurance, wearing a supportive bra and where the pain is interfering with daily activities, gamolenic acid .
However, if the symptom persists for longer than 6 months, danazol or bromocriptine should be considered, if the patient is not taking oral contraceptives.
If the patient is taking oral contraceptives, these should be changed to a mechanical method, and if pain continues, the patient may be started on danazol. Courses of treatment are usually for 6 months.
Non-cyclical pain may be treated with NSAIDs or simple analgesics .
Nipple discharge
The significance of a nipple discharge depends on :- Age of patient
- Presence of blood
- One or several ducts involved.
Dipstick analysis is useful to confirm the presence of blood and if positive the patient should be referred to the Breast Unit for further examination.
Physiological discharges usually occur in younger women and tend to be non-blood stained, and involve multiple ducts.
Nipple changes include retraction, alteration in skin colour and eczema. Slit-like retraction is usually seen in duct ectasia, whereas whole retraction is more indicative of malignant or inflammatory breast disease. Nipple retraction should be referred for mammography/investigation.
Node status
Breast cancer commonly metastasises to the adjacent lymph nodes in the axilla (and to a lesser extent, the internal mammary lymph nodes).The presence and extent of axillary-node metastases, grade and size of the primary tumour are the best predictors of survival and will strongly influence the choice of primary and adjuvant treatment.
Because the clinical evaluation of axillary-node involvement is subject to high false positive and negative rates pathological evaluation of the axillary specimen provides a more accurate assessment of prognosis than does clinical staging.
A recent development is Sentinel Node Biopsy , in which the lymphatic pathway from the breast cancer is tracked, using a radio-isotope label or blue lymphatic dye to allow biopsy of the first lymph node in that lymphatic pathway (sentinel node). This technique is still under evaluation.
Chest wall pain
Pain arising from the chest wall and outside the breast can be a cause of non-cyclical breast pain.The condition is usually found in older women and may be associated with heavy physical activity.
In younger patients, costochondritis or Tietze's syndrome , is a common cause of chest wall pain.
A careful history and examination is required in order to establish a clear diagnosis. NSAID s or simple analgesics are very effective.
Skin changes
In primary breast cancer, the skin is sometimes involved. There may be erythema , induration , dimpling of skin and possibly ulceration present.Occasionally, an advanced primary carcinoma will present as an ulcerating/fungating lesion, particularly if it has been concealed.
Skin changes, which may be associated with locally advanced disease, include peau d'orange , induration, and erythema.
More commonly, skin changes are associated with local recurrence after previous treatment. Again, cellulitis may be present but the skin and/or the scar may be the site of recurrent nodules . Skin changes, in the form of erythema, skin darkening, and telangiectasia , can follow radiotherapy .
Nodularity
Nodularity and aberrations of normal breast development and involution are physiological .Cyclical pain and nodularity are commonly seen in general practice.
Nodularity is ill defined, often bilateral and tends to fluctuate with the menstrual cycle. It is rarely seen in post-menopausal women or women not on hormone replacement.
Focal breast nodularity is the most common cause of a breast lump and is seen in all age groups. Any persistent nodularity should be referred for investigation (clinical examination by a breast surgeon).
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