Breast lumps are a frequent concern for women, leading to significant anxiety and numerous visits to primary care physicians. While the majority of these lumps are benign, a systematic and efficient diagnostic approach is crucial to promptly identify and manage breast cancer while avoiding unnecessary investigations and patient distress. This article provides a comprehensive overview of a Breast Lump Diagnosis Algorithm tailored for primary care settings, emphasizing an age-based strategy for effective evaluation and management.
The Importance of a Breast Lump Diagnosis Algorithm
Palpable breast lumps are a common presentation in primary care, with over 25% of women experiencing breast disease in their lifetime. Fortunately, only a small percentage of these lumps turn out to be malignant. However, the challenge lies in differentiating benign from malignant lesions efficiently and effectively. A well-defined breast lump diagnosis algorithm is essential for several reasons:
- Reduces Over-Investigation: A systematic approach helps avoid unnecessary tests and specialist referrals for benign conditions, thereby reducing healthcare costs and patient anxiety.
- Early Cancer Detection: A clear algorithm ensures that suspicious lumps are promptly identified and investigated, facilitating early diagnosis and treatment of breast cancer, which significantly improves prognosis.
- Provides Clear Guidance for Clinicians: An established algorithm offers a structured framework for primary care physicians to confidently assess and manage breast lumps, ensuring consistent and high-quality care.
- Enhances Patient Care: By streamlining the diagnostic process, a breast lump diagnosis algorithm contributes to a more efficient and patient-centered approach to breast health concerns.
Triple Assessment: The Diagnostic Cornerstone
The triple assessment remains the gold standard for evaluating breast lumps. It integrates three essential components to maximize diagnostic accuracy:
History and Physical Examination: Initial Assessment
A thorough history and physical examination are the first steps in evaluating a breast lump. This initial assessment helps stratify risk and guide further investigations.
History Taking:
- Detailed Family History: Inquire about breast, ovarian, prostate, colon, pancreatic, and other cancers associated with genetic mutations (e.g., BRCA1/2, TP53, PALB2). Risk calculators like the Tyrer-Cuzick model can individualize genetic risk assessment.
- Personal Risk Factors: Gather information on the patient’s estrogen window (menarche and menopause age), exogenous hormone exposure (contraceptives, hormone replacement therapy, fertility treatments), childbearing and breastfeeding history, and lifestyle factors (smoking, obesity, alcohol).
- Previous Breast Pathology: Note any prior breast conditions or concerns.
- Current Complaint Characteristics: Explore the lump’s location, duration, size changes, variation with menstrual cycle, pain, swelling, erythema, nipple discharge, or inversion.
Physical Examination:
- Visual Inspection: Observe breast size, shape, and symmetry in sitting and supine positions.
- Palpation: Use finger pads in a slightly cupped hand with the ipsilateral arm raised above the head. Common techniques include radial, vertical strip, and concentric circle methods. Consistency (soft, firm, nodular) and location (quadrant or clock face) of any masses should be documented.
- Lump Characteristics: Record size, shape, texture, mobility, tenderness, and depth of abnormalities.
- Nipple-Areola Complex (NAC) Examination: Palpate the NAC area for abnormalities and assess for nipple discharge by firmly pressing around the areola.
- Axillary and Supraclavicular Fossa Examination: Examine these areas for lymphadenopathy, documenting any palpable abnormalities.
If the patient struggles to locate the lump during examination, ask them to demonstrate the location and position in which they first noticed it. Subtle changes may only be apparent in specific positions. Finding a breast lump with axillary adenopathy raises suspicion for malignancy and requires thorough evaluation.
Imaging: Radiological Assessment
Radiological imaging is a crucial component of the breast lump diagnosis algorithm. Common modalities include ultrasound, mammogram, or both. Breast MRI is less frequently used and typically reserved for high-risk patients or further evaluation of diagnosed breast cancer, ideally requested by a specialist.
Ultrasound:
- First-line for women under 35: Breast ultrasound is the preferred initial imaging modality in younger women due to breast density considerations.
- Characterization of Palpable Lumps: Ultrasound helps visualize and characterize palpable lumps, aiding in diagnosis.
- Whole Breast and Axillary Scan: Routine breast ultrasounds typically include scanning the entire breast and axilla on both sides.
- Benign Features on Ultrasound: Features suggestive of fibroadenoma include:
- Well-defined, homogenous, isoechoic or mildly hypoechoic solid lump, <30mm.
- Ovoid shape, parallel to skin surface, smooth or gently lobulated contour.
- Thin, echogenic pseudocapsule.
- Absence of calcification and acoustic shadowing.
- Advantages: Ultrasound is not affected by breast density and accurately distinguishes between benign and malignant lesions.
- Fibroadenoma Diagnosis: Ultrasound has high sensitivity (81.6%) and specificity (94.7%) in diagnosing fibroadenomas, the most common lumps in young women.
Mammogram:
- Investigation of Choice for women over 35: Mammography is preferred for women over 35, with ultrasound used as an adjunct.
- Tomosynthesis: Modern mammography often includes tomosynthesis (3D mammography), which is particularly helpful in dense breasts to improve detection of small cancers.
- Limitations: Mammogram sensitivity decreases in dense breasts, and some cancers can be missed due to location or tumor characteristics.
- Not Definitive: A normal mammogram does not rule out malignancy in the presence of a palpable lump; biopsy is still necessary to complete the triple assessment.
BI-RADS (Breast Imaging Reporting and Data System):
- Standardized Reporting: BI-RADS standardizes breast imaging terminology, report organization, assessment, and classification for mammography, ultrasound, and breast MRI.
- Clear Communication: Enables radiologists to communicate results clearly and consistently with referring physicians, providing management recommendations and cancer risk assessment.
- Categories and Management: BI-RADS categories range from 1 (negative) to 6 (known malignancy), each with specific management recommendations and associated malignancy risk. Categories 1 and 2 are benign, category 3 requires short-term follow-up, and categories 4 and 5 necessitate biopsy.
Biopsy: Tissue Diagnosis
Biopsy is the definitive step in the breast lump diagnosis algorithm when imaging is suspicious or when clinically indicated.
- Core Needle Biopsy: The current gold standard for breast lump diagnosis. It provides histological samples for accurate diagnosis and allows for immunohistochemistry (IHC) testing.
- Immunohistochemistry (IHC): IHC detects receptors on tumor cells, classifying breast cancers into different subtypes. Receptor status guides treatment decisions, including surgery and chemotherapy sequencing.
- Confirmation for FNAB: Breast cancers diagnosed by fine needle aspiration biopsy (FNAB) require confirmatory core needle biopsy with IHC before multidisciplinary team treatment planning.
Age-Based Breast Lump Diagnosis Algorithm: Tailoring the Approach
Recognizing that breast cancer risk increases with age, an age-based approach to breast lump investigation is a cost-effective and clinically sound strategy. This breast lump diagnosis algorithm tailors investigations based on age, minimizing unnecessary interventions in low-risk groups while ensuring thorough evaluation in higher-risk populations.
Adolescence (Under 20 Years)
- Low Malignancy Risk: Breast cancer in adolescents is extremely rare. Over-investigation should be avoided.
- Common Causes: Fibroadenomas (95% of lumps), cysts, hamartoma, fat necrosis, abscess. Giant juvenile fibroadenomas (>5cm) are the most common indication for surgery.
- Clinical Examination Focus: For typical, mobile, 2-3cm lumps consistent with fibroadenoma on clinical exam, reassurance and 6-month follow-up are appropriate. Document lump size for comparison.
- Red Flags and Imaging: Ultrasound is indicated if red flags are present:
- Significant family history of breast cancer under 40.
- Irregular, firm mass.
- Skin erythema or tethering.
- Bloody nipple discharge.
- Nipple retraction.
- Rapidly enlarging mass.
- Biopsy: Core biopsy is guided by ultrasound findings if red flags are present.
Referral Indications:
- Red flag symptoms with ultrasound suggestive of cancer.
- Giant juvenile fibroadenoma.
Patients 20-25 Years
- Fibroadenomas Remain Common: Fibroadenomas, inflammatory conditions, cysts, and hamartomas are prevalent. Breast cancer remains rare but possible.
- Ultrasound Indicated: Ultrasound is recommended for all women in this age group presenting with a breast lump, following history and physical examination.
- Benign Ultrasound Features: For lesions with typical fibroadenoma appearance on ultrasound and no red flags, reassurance and follow-up are sufficient. 6-month follow-up ultrasound to confirm stability is recommended.
- Biopsy and Referral: Ultrasound-guided core biopsy is warranted for enlarging lesions or suspicious ultrasound features to rule out cancer. Surgical removal of fibroadenomas <5cm is generally not necessary unless enlarging or suspicious.
Referral Indications:
- Red flag symptoms with ultrasound suggestive of cancer.
- Fibroadenomas >5cm.
- Palpable fibroadenomas <5cm when patient requests removal.
- Diagnosis of breast cancer.
Patients Over 25 Years
- Increased Cancer Risk: Breast cancer risk significantly increases with age.
- Triple Assessment Recommended: Full triple assessment is recommended for all women over 25.
- Fibroadenomas Still Common (25-30 years): Fibroadenomas are still prevalent in women 25-30, but breast cancer incidence rises with age.
- Lower Threshold for Excision: A more aggressive approach is often taken in this age group. Excision or close follow-up is considered.
- Follow-up for Non-Excised Lesions: Non-excised lesions require 6-monthly clinical exams and ultrasound for at least two years to document stability.
Referral Indications:
- Patients 25-30 years with palpable lump requesting removal.
- Patients over 30 with palpable lump.
- Diagnosis of breast cancer.
Conclusion: Implementing the Breast Lump Diagnosis Algorithm
Breast lumps are a common clinical challenge. Utilizing an age-based breast lump diagnosis algorithm offers a safe, cost-effective, and systematic approach to evaluation and management in primary care. By integrating triple assessment and tailoring investigations to age-related risk, clinicians can effectively differentiate benign from malignant conditions, ensuring timely diagnosis and optimal patient care while minimizing unnecessary interventions and patient anxiety. This algorithm empowers primary care physicians to confidently navigate breast lump assessment, contributing to improved breast health outcomes.
Acknowledgements
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
F.M., D.N., H.M., L.C. and L.R. contributed equally to this work.
Ethical considerations
This article followed all ethical standards of research without direct contact with human or animal subjects.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
Data sharing is not applicable to this article as no new data were created or analysed in this study.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.
Footnotes
How to cite this article: Malherbe F, Nel D, Molabe H, Cairncross L, Roodt L. Palpable breast lumps: An age-based approach to evaluation and diagnosis. S Afr Fam Pract. 2022;64(1), a5571. https://doi.org/10.4102/safp.v64i1.5571
References
Associated Data
Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analysed in this study.
