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Breast problems are a common reason for women to attend their general practitioner. These problems can cause significant anxiety, primarily because breast cancer is the most common malignancy in the population, affecting nearly one in eight women. Some of the most common presentations are breast lumps, mastalgia (pain in the breast), nipple problems and skin changes.

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Management of breast problems begins with a thorough clinical history, including when the problem first arose, its evolution over time, and other potentially associated or contributory factors such as smoking and family history of breast conditions. A good history should also include a reproductive, surgical and drug history.

Clinical examination is essential in women presenting with breast problems. The breasts should be examined systematically, including visual inspection in several positions and detailed palpation of the entirety of both breasts, including the axillary tail. The nearby lymph nodes should also be examined.

Any masses should be documented in terms of their location, size, borders, consistency, pain, mobility and associated skin changes. Most women with a breast mass will require further clinical evaluation in the form of imaging, with ultrasound and mammography being the most common preliminary imaging modalities.

Secondary care breast clinics can also perform tissue sampling of any suspicious lesions via a fine needle aspirate or core biopsy. Any new mass should be referred for investigation via the breast clinic for potential malignancy.

Mastalgia describes any type of breast pain, with the most common causes being cyclical breast pain and mastitis. Mastalgia is rarely associated with malignancy. Cyclical breast pain is related to hormonal changes during the menstrual cycle, and is typically described as a dull, non-specific discomfort that occurs prior to menstruation. Mastitis typically presents with a hot, red or swollen breast, and may be accompanied by fever or general malaise. Mastitis may be inflammatory or infectious in origin, and is more common in breastfeeding women. Women with dense or large breasts may also complain of discomfort in the breasts, which may be relieved with supportive underwear.

Nipple problems are another common breast-related presentation. Nipple discharge is a common and often benign presentation. It is important to note if the discharge is bilateral or unilateral, its association with the menstrual cycle, and any relevant examination findings. Changes to the nipple such as a new inversion should be investigated for potential malignancy.

Skin changes are common; of course, the breast can be affected by skin conditions such as eczema and dermatitis. New skin changes that do not respond to topical therapy or are associated with any suspicious examination findings should be referred to secondary care

Encouraging patients to be “breast aware” is one of the most effective ways of identifying breast problems, including malignancy, in the early stages.

Women should be encouraged to perform routine self-examinations to become familiar with the natural feel of their breasts and the overlying skin, and to present promptly where any changes are noted. In addition, it is important to ensure women are aware of screening programs and the importance of attending these.

Dr Samantha Miller, MBChB

Read another article like this one: Managing pregnancy complications in primary care

References

1. Australian Government: Department of Health and Aged Care. BreastScreen Australia Programme. https://www.health.gov.au/initiatives-and-programs/breastscreen-australia-program
2. Department of Health, State Government of Victoria, Australia. Better Health Channel: Breast conditions other than breast cancer. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/breast-conditions-other-than-breast-cancer
3. BMJ Best Practice (2022). Assessment of breast mass. https://bestpractice.bmj.com/topics/en-gb/1179
4. Klassen CL et al. (2019). Common benign breast concerns for the primary care physician. Cleveland Clinic Journal of Medicine 86 (1) 57-65; DOI: 10.3949/ccjm.86a.17100 https://www.ccjm.org/content/86/1/57
5. Salzman et al. (2019). Common breast problems. The American Family Physician. https://www.aafp.org/pubs/afp/issues/2019/0415/p505.html
6. National Institute for Health and Care Excellence. Clinical Knowledge Summary: Cyclical breast pain. https://cks.nice.org.uk/topics/breast-pain-cyclical/
7. Cunliffe, A & Simcock, R (2016). Breast cancer in primary care. British Journal of Family Medicine. https://www.bjfm.co.uk/breast-cancer-in-primary-care