Breast Disease and Cancer: Diagnosis

Effective Date: October 1, 2013

Recommendations and Topics

• Scope
• Key Recommendations
• Screening
• Diagnosis
• Resources

Scope

This guideline provides recommendations for:

• investigation of breast complaints and/or symptoms
• diagnosis for breast disease & cancer
• management of common breast diseases in women aged ≥ 19 years.

For breast cancer management recommendations, please refer to Breast Cancer: Management and Follow-up. Refer to Appendix A (PDF, 236KB) for the algorithms associated with these guidelines.

Key Recommendations

• Screening for breast cancer in asymptomatic women as per BC Cancer Breast Screening (formerly the Screening Mammography Program).
• In order to ascertain the presence of a familial or inherited genetic risk, take a full family history and refer appropriate patients to the Hereditary Cancer Program (HCP) at BCCA.
• Core biopsy is the standard of care to establish a histological diagnosis.
• Women aged ≤ 30 years with breast complaints and/or symptoms (e.g., nipple discharge, mass) should have diagnostic ultrasound as the initial investigation.
• Women aged ≥ 30 years with breast complaints and/or symptoms should have diagnostic mammogram and ultrasound as the initial investigations.
• Pregnant and lactating women with lumps or breast complaints and/or symptoms should be investigated promptly. A diagnostic ultrasound is recommended as the initial investigation.

Screening

Screening for breast cancer in asymptomatic women should be offered as per BC Cancer's Breast Screening Program; www.screeningbc.ca/Breast.

Women with breast implants, previous history of breast cancer, and/or breast symptoms are not screened under the SMP, but should be referred for a diagnostic mammogram1 or other testing as appropriate. For women who do not meet the criteria of the SMP, refer to Appendix B: Protocol for the Use of Mammography Services at Diagnostic Facilities (PDF, 114KB).

Advise patients the risks and benefits associated with screening mammograms. Risks include:

1. the possibility of a false-negative result - a mammogram result may be normal, but that does not rule out breast cancer: About 25-30% of breast cancers will not be detected in screening mammograms in women aged 40 to 49, and about 10% of breast cancers will not show up on a mammogram in women aged > 49 years.¹
2. the possibility of a false-positive result - a screening mammogram result that is abnormal that may result in more testing though no cancer was presented. A woman who has an annual mammogram between the ages of 40 - 49 has a 30% chance of receiving at least one false-positive during this time period.^2,3
3. radiation exposure - a mammogram is about 0.7 mSv, equivalent to 3 months of background radiation.²

Diagnosis

Women with any breast symptoms should be investigated as described below with diagnostic imaging, and not at screening centres. For descriptions on these procedures, refer to Appendix C: Diagnostic Imaging Modalities and Procedures of the Breast (PDF, 105KB).

For breast lesions and/or symptoms arising during pregnancy or lactation, prompt investigation with breast imaging is recommended. Breast cancer during pregnancy is defined as breast cancer occurring during pregnancy or within the year after delivery.

Investigations

Complete history and physical examination:

1. Take full personal and family history, and ask patient about risk factors listed below.
2. Conduct a complete breast and axillary lymph node examination.

Risk Factors for Breast Cancer:¹

• early menarche (before 12 years old)
• late menopause (after 55 years old)
• nulliparity or late age at first birth
• use of hormone replacement therapy long-term
• increasing age
• breast density
• personal history of breast cancer, lobular carcinoma in situ (LCIS) or atypical ductal hyperplasia (ADH)
• family history of breast cancer and/or ovarian cancer, particularly in a patient's close relatives* on the same side of the family
• personal or family history of mutation of the BRCA1/BRCA2 genes

Anyone from a family with a confirmed mutation in a hereditary cancer gene can be referred for genetic counselling at BCCA's HCP. If the patient's family history of close relatives reveals a possible familiar or inherited mutation, consider referral for genetic counselling. For full referral criteria, refer to the Hereditary Cancer Program Referral Form.

* Close relatives include: children, brothers, sisters, parents, aunts, uncles, grandchildren and grandparents on the same side of the family. History of cancer in cousins and more distant relatives from the same side of the family may also be relevant.

Perform diagnostic imaging:⁴

• For symptomatic women aged ≤ 30 years, diagnostic ultrasound is the recommended initial investigation. Mammography may be subsequently indicated.
• For symptomatic women aged ≥ 30 years, diagnostic mammography and ultrasound are recommended for initial investigation.
• For symptomatic women of any age who are pregnant or lactating, diagnostic ultrasound is the recommended initial investigation (not mammography).

Core biopsy is the standard of care to establish a histological diagnosis. Include "request to proceed to core biopsy if indicated and feasible" on the same breast imaging requisition. Refer to the Standard Out-Patient Breast Imaging Requisition (PDF, 145KB).

Differential Diagnoses of Breast Diseases
For reference and general guidance, some common breast complaints, findings from physical exam and/or diagnostic imaging are listed below alphabetically. Clinical judgment should be applied in individual cases.

For atypical proliferative lesions, ductal carcinoma in situ (DCIS) and invasive disease, refer to Breast Cancer: Management & Follow-up.

ABNORMALITY CHARACTERISTICS	MANAGEMENT
Breast Abscess and Infection
Lactational Infections
Present as mastitis or an abscess caused by the entry of bacteria (often S. aureus) through the nipple into the duct system.5,6	Treatment includes frequent breast emptying, antibiotics and drainage of abscess. If erythema and edema persist, inflammatory breast cancer must be ruled out.
Periductal Mastitis
Occurs in non-lactating women and is associated with smoking, diabetes,6,7 poor hygiene, rheumatoid arthritis, chronic steroid use, and trauma6. Often chronic, relapsing infections, the inflammatory changes can lead to nipple retraction, subareolar masses and fistula formation.	At the early stage, warm compresses and antibiotics covering aerobic and anaerobic bacteria may be adequate. If an abscess forms, incision and drainage along with antibiotics is required. Excision of the nipple areolar complex is rarely indicated.6
Sebaceous Cysts and Hidradenitis Suppurativa
Can occur on the breast.6	Manage clinically.
Candidal infections
Common in women with large, pendulous breasts,8 often in the area of the inframammary fold or lower breast.	Advise patient to keep the area clean and dry; use topical antifungal treatments.6,8
Cysts
Fluid-filled, epithelial lined cavities which vary in size and can be influenced by ovarian hormones. The incidence is greatest in women aged > 35 and declines after menopause.6	If a cyst is suspect, ultrasound is helpful in confirming diagnosis. If aspirated, send BLOODY fluid for cytology. If the cyst recurs more than twice, order ultrasound guided core biopsy of the solid component. Refer for excision if abnormal pathology/cytology, repeated recurrences or patient wishes excision.9
Fibroadenoma
Benign solid tumor that arises in the late teens and early reproductive years; rarely seen as a new mass in women aged > 40 years.6	Confirm diagnosis with ultrasound guided core biopsy. Surgical excision is not required unless symptomatic/request excision or the pathology is not consistent with a fibroadenoma.10
Fibrocystic Change
Characterized by "lumpy" breasts with ridges of tissue felt on palpation6 and can be tender. Common in women between ages 30 and 50.11	If there is a dominant mass, diagnostic imaging and potentially a core biopsy may be required to rule out a malignancy. Symptoms improve with menopause or oral contraceptive use.
Mastalgia
Often benign.5 1. Cyclical breast pain: occurs due to premenstrual changes in the breast. 2. Non-cyclical pain: tends to occur in older women and may be associated to medications listed in Table 1 in Appendix D (PDF, 97KB).	Rule out infection and carcinoma with diagnostic imaging. Management suggestions include: reducing caffeine intake, a supportive bra, non-steroidal anti-inflammatory drugs (NSAIDs), evening primrose oil and flaxseed; (refer to Table 2 in Appendix D [PDF, 97KB]).5 There is no surgical management for mastalgia. Women may require reassurance.
Nipple Discharge
Milky discharge
Milky discharge is considered to be galactorrhea until proven otherwise. Medications associated with galactorrhea are listed in Table 3 in Appendix D (PDF, 97KB).	If the discharge is milky, work-up for galactorrhea. Consider ordering prolactin and thyroid-stimulating hormone (TSH) levels.5 Discourage self-induced discharge.
Dark brown, green nipple or bloody discharge
Dark brown or green nipple discharge is often associated with duct ectasia but can also occur with papillomas and ductal carcinoma in situ (DCIS).6 Bloody nipple discharge is pathologic, most commonly with a solitary intraductal papilloma but DCIS and invasive carcinoma are in the differential.6	The work-up includes diagnostic imaging, cytology of nipple discharge, request core biopsy if a solid lesion is identified. A referral to a surgeon † is recommended.6
Nipple Inversion/Retraction
Congenital nipple inversion occurs in one or both breasts in 10% of women. Acquired nipple inversion is due to duct ectasia, abscess and cancer. Benign causes yield a central, symmetric transverse slit in the nipple with a normal areola. Malignancy causes asymmetrical changes, changes to the areola, a possible palpable mass or flattening of the nipple and the retraction may vary with position of the breast.	Image new nipple changes with diagnostic imaging.
Paget's Disease
Associated with a form of breast cancer and must be differentiated from eczema and dermatitis. Paget’s presents as erythema, change in pigmentation, flaking or a non-healing sore on the nipple-areolar complex.9	Does not respond to steroid treatment.5 Diagnostic imaging is required to assess for an underlying lesion. Refer to a surgeon† for a possible biopsy.9 Skin punch biopsy can be done by GP to expedite diagnosis.
Papillomas
Solitary papillomas are most often close to the areola. Peripheral papillomas should be excised to differentiate from invasive papillary carcinoma.	Treatment involves diagnostic imaging, core biopsy, and excision to rule out any associated cancer.
Phyllodes Tumour
A fibroepithelial lesion similar to a fibroadenoma. Its growth is often more rapid than a fibroadenoma and it tends to be larger. Can be benign, borderline or malignant. Lungs are the most common site of distant metastases in malignant phyllodes.12	A core needle biopsy (excisional in some cases) is required to differentiate it from a fibroadenoma.10 Phyllodes have a low metastatic potential but tend to be locally recurrent. Refer patient to a surgeon†.
Radial Scar
Complex sclerosing lesion which can mimic a cancer both mammographically and clinically. A radial scar itself is benign however it has been associated with breast cancer.	If a core biopsy reveals a radial scar, excisional biopsy is recommended to rule out any associated cancer.6
Sclerosing Adenosis
Proliferation of lobules with poorly formed lumina. It has no malignant potential.	May contain microcalcifications on mammograms which leads to a core biopsy.6,9

† Where possible, refer to a surgeon with experience or special interest in the breast.

Resources

References

1. BC Cancer Agency. Available from www.bccancer.ca.
2. Canadian Association of Radiologists. Radiology for patients [Mammography]. Available from: www.radiologyinfo.ca.
3. Fitzpatrick-Lewis D, Hodgson N, Ciliska D, et al. Breast Cancer Screening. 2011. McMaster University, Hamilton, Ontario, Canada. Available from: https://canadiantaskforce.ca/wp-content/uploads/2011/11/2011-breast-cancer-systematic-review-en.pdf.
4. Canadian Association of Radiologists. CAR Diagnostic Imaging Referral Guidelines: Section M Breast disease. 2012. Available at: www.car.ca/en.aspx.
5. Meisner A, Fekrazad, MH, Royce, ME. Breast disease: Benign and malignant. Med Clin N Am. 2008; 92:1115-1141.
6. Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston textbook of surgery (19th edition): The biological basis of modern surgical practice. 2012. ISBN: 978-1-4377-1560-6.
7. Dixon JM, RaviSekar I, Cheety U, Anderson TJ. Periductal mastitis and duct ectasia: different conditions with different aetiologies. Br J Surg. 1996; 83:820-2.
8. Pearlman MD, Griffin JL. Benign breast disease. Obstet Gynecol. 2010; 116:747-58.
9. Miltenburg DM, Speights VO. Benign breast disease. Obstet Gynecol Clin N Am. 2008; 35:285-300.
10. Flint L (Ed.). Breast diseases. Selected readings in general surgery. 2010; 36(6).
11. Santen RJ, Mansel R. Benign breast disorders. N Engl J Med. 2005; 353(3);275-85.
12. Khosravi-ShahiP. Management of non metastatic phyllodes tumors of the breast: Review of the literature. Surgical Oncology. 2011; doi: 10.1016/j.suronc.2011.04.007.

Resources

• BC Cancer Agency, Screening Mammography Program of BC, Hereditary Cancer Program, www.bccancer.bc.ca, which includes many patient resources.
• HealthlinkBC - Health information, translation services and dietitians, www.healthlinkbc.ca or by telephone 811.
• Canadian Cancer Society, www.cancer.ca

Appendices
Appendix A: Algorithms of Breast Cancer & Disease guidelines (PDF, 236KB)
Appendix B: Protocol for the Use of Mammography Services at Diagnostic Facilities (PDF, 114KB)
Appendix C: Diagnostic Imaging Modalities and Procedures of the Breast (PDF, 105KB)
Appendix D: Medication Tables Associated with Mastalgia and Nipple Discharge (PDF, 97KB)

Associated Documents
The following documents accompany this guideline:

• BCGuidelines.ca - Breast Cancer: Management & Follow-up
• Hereditary Cancer Program Referral Form
• Standard Out-Patient Breast Imaging Requisition (HLTH 1906) (PDF, 145KB)

This guideline is based on scientific evidence current as of the Effective Date.

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association, and adopted by the Medical Services Commission.

The principles of the Guidelines and Protocols Advisory Committee are to: encourage appropriate responses to common medical situations recommend actions that are sufficient and efficient, neither excessive nor deficient permit exceptions when justified by clinical circumstances. Contact Information Guidelines and Protocols Advisory Committee PO Box 9642 STN PROV GOVT Victoria BC V8W 9P1 E-mail:  hlth.guidelines@gov.bc.ca Web site: www.BCGuidelines.ca

 

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.