Finding the balance between detecting cancer and avoiding over-investigation…

While breast lumps are common, deciding what to do when someone presents with one can be tricky. “There’s a spectrum between what clearly doesn’t need an investigation or follow up and what clearly does, with a lot of grey zone in between,” says Dr Melissa Bochner, Head of the Breast Endocrine Unit at Royal Adelaide Hospital.

One challenge is that breasts vary with age, the menstrual cycle, and life stages such as pregnancy and menopause. “So it is very difficult for women to be aware of whether there is a significant change in their breasts—and equally difficult for the doctor,” she says.

There is also the need to strike a balance between detecting cancer and avoiding over- investigation and unnecessary patient concern.

So, how can GPs distinguish between normal, benign changes and those that are significant and need to be investigated?

Follow a framework for investigation

Dr Bochner suggests Cancer Australia’s guide for investigating a new breast symptom is a good starting point.

“That’s actually very helpful because it allows the GP to work to a guideline rather than having to fret about it themselves.”

You need to arrange investigations after doing a history and examination, and this is where confusion can sometimes occur, Dr Bochner says.

The guideline provides specific recommendations to help with this. It notes that ultrasound is more sensitive than mammography for detecting cancers in younger women and is therefore recommended as the first imaging modality for those under 35.

Mammography should be added for women in this age group if:

• clinical findings are suspicious or malignant, or
• ultrasound findings are suspicious, indeterminate, or malignant, or
• ultrasound findings are inconsistent with clinical findings.

For women aged 35 years and over with breast symptoms, both mammography and ultrasound should be performed.

Core biopsy is the standard of care for all solid breast lesions, Dr Bochner adds. She suggests letting your patient know this may be needed and that you’ll request for the radiologist to conduct a biopsy if indicated.

She also advises requesting all necessary investigations on the one form to avoid dragging out the diagnostic process, which can lead to fatigue and additional expense for patients.

What if imaging is clear?

Although contemporary imaging is better than it used to be, a normal ultrasound or mammogram may not be reassuring in the presence of a symptom, Dr Bochner says.

“If you order a test and it’s negative, and you’re still concerned, then you have to do something about it.”

In this case, she recommends referring the patient for a specialised breast assessment.

She also stresses the importance of personally following up any tests you order, noting normal results are sometimes signed off by someone else at the practice and the patient may therefore not get the follow up they need.

Managing benign breast disease

Dr Bochner notes that GPs see a lot of benign breast problems, including cysts, hormonal lumpiness, and benign nipple discharge from duct ectasia.

It’s important to give the condition a name and reassure the person appropriately “so that they don’t repeatedly come back with the same symptom or sit at home worrying about it,” she says.

“Physiological breast changes such as cysts can be really confusing for women. Even if a symptom is benign, you still have to be able to explain to them what it is, why they’ve got it, will it go away, and what they should look out for.”

In the case of fibroadenomas, Dr Bochner recommends a no-nonsense approach.

“You can spend a lot of time fussing with something like a fibroadenoma,” she says. “You don’t want to do a biopsy because it’s probably benign. But every now and again, a very aggressive breast cancer will look like a fibroadenoma.

“And if that’s in the back of your mind, you won’t be able to discharge that person, because you’ll think, ‘what if it changes, what if it grows?’ It’s a little bit counterintuitive, but the easiest thing to do is fully investigate upfront, tell them it’s a fibroadenoma, and then you can tell them they do not need to see you again unless it gets bigger. And if they’ve come with a palpable one, they’ll know that.”

Key takeaways:

• Normal breast changes and the need to balance cancer detection against over-investigation can make managing breast lumps tricky.
• Cancer Australia’s guide for investigating a new breast symptom provides clear advice.
• Ultrasound is the first imaging modality for women aged under 35 with a breast symptom.
• Mammography and ultrasound should both be conducted in women aged 35 and over with a breast symptom.
• Refer for a specialised breast assessment if investigations are clear but you still have concerns.
• Manage benign breast disease by giving it a name, providing reassurance, and explaining what changes to look out for.