Breast Lump

  1. Given a well woman with concerns about breast disease, during a clinical encounter (annual or not):
    1. Identify high-risk patients by assessing modifiable and non-modifiable risk factors
    2. Advise regarding screening (mammography, breast self- examination) and its limitations.
    3. Advise concerning the woman’s role in preventing or detecting breast disease (breast self-examination, lifestyle changes).
  2. Given a woman presenting with a breast lump (i.e., clinical features):
    1. Use the history, features of the lump, and the patient’s age to determine (interpret) if aggressive work-up or watchful waiting is indicated.
    2. Ensure adequate support throughout investigation of the breast lump by availability of a contact resource.
    3. Use diagnostic tools (e.g., needle aspiration, imaging, core biopsy , referral) in an appropriate manner (i.e., avoid over- or under-investigation, misuse) for managing the breast lump.
  3. In a woman who presents with a malignant breast lump and knows the diagnosis:
    1. Recognize and manage immediate and long-term complications of breast cancer.
    2. Consider and diagnose metastatic disease in the follow- up care of a breast cancer patient by appropriate history and investigation.
    3. Appropriately direct (provide a link to) the patient to community resources able to provide adequate support (psychosocial support).


  • Not a lump
    • Prominent rib
    • Costochondral junction
    • Firm margin at edge of breast
    • Defect secondary to previous biopsy
  • Lump
    • Normal glandular tissue (upper/outer quadrant)
    • Fibrocystic changes (25%)
      • Nodular nondiscrete tender mass, changes with menses, cyclical or constant pain
    • Cancer (10%)
      • Infiltrating ductal (most common)
      • Infiltrating lobular and inflammatory breast cancer often present with no discrete mass
    • Gross Cyst
      • Galactocele - milk retention cyst in breasfeeding women
    • Fibroadenoma
    • Fat necrosis
      • Trauma, associated with ecchymosis

Risk for Malignancy

  • Female
  • Age >70 (RR 18)
  • Prior hx of breast CA
  • BRCA1/2 (RR 3-7)
  • Prior hx of biopsy (RR 1.7-3.7)
  • 1st degree relative with breast CA (RR 2.6)
  • Unopposed estrogen
    • Bone density - High (RR 2.7-3.5)
    • Nulliparity/Age at first birth* >30 (RR 1.9-3.5)
    • Menarche<12 (RR 1.5)
    • Menopause >55yo (RR 2)
    • HRT* (RR 1.2)
    • OCP* (RR 1.07-1.2)
  • Alcohol* (RR 1.4)
  • Radiation (Mantle radiation in Hodgkin's)
  • Benign breast disease

Protective factors

  • Oophorectomy <35yo (RR 0.3)
  • Postmenopause BMI* <22.9 (RR 0.63)
  • Exercise* (RR 0.70)
  • Parity* ≥5 (RR 0.71)
  • Breastfeeding* ≥16mo (RR 0.73)
  • Aspirin* ≥weekly for ≥6 mo (RR 0.79)



  • Change in breast mass (increase/decrease in size, change in symmetry)
    • Changes with menstrual cycle (benign if prominent premenstrual and regress during follicular phase)
  • Skin changes
  • Nipple discharge
  • New (acquired) nipple inversion
    • Benign (ectasia)
      • Central, symmetric, transverse slit with normal areola
    • Malignant
      • Asymmetrical, areola changes, flattened nipple, varied nipple position

Physical Exam

  • Inspection with arms by side, raised above head, pressing on hips leaning forward
  • Regional lymph nodes
    • Cervical, supraclavicular/infraclavicular, axillary, mammary chain
  • Skin changes
    • Ecchymosis/erythema
    • Peau d'orange
    • Ulceration
    • Dimpling/retraction
  • Nipple/Areolar changes
    • Discharge/crusting
    • Inversion/retraction
  • Breast Mass
    • Obvious/Subtle
    • Well-defined/Nondiscrete margins
    • Density - Soft/Firm/Hard
    • Mobile/Fixed to chest wall or skin
    • Tender/Non-Tender

Initial management

  • Feature of cancer (hard irregular fixed mass, palpable ipsilateral nodes, peau d'orange)
    • Mammography, U/S, core biopsy, breast surgeon referral
  • Benign


  • Triple Test:
    • Clinical exam, Imaging, Non-excision biopsy (FNAC/Core)
      • Any abnormal result requires surgical referral +/- further investigation
  • First-line Imaging
    • <35yo or Pregnancy/Lactation - Ultrasound*
      • Mammography in all age groups if suspicious findings
    • 35-50yo - Mammography + Ultrasound
    • >50yo - Mammography
  • Follow-up
    • Reassess benign masses that change or persist

  • Women 50-74yo routine mammography q2-3y (weak recommendation)
    • Benefits:
      • Reduces absolute risk of death from breast cancer by 0.13-0.22%
    • Risks:
      • False positive mammogram 20-25%
      • Unnecessary breast surgery 0.5%
  • Clinical breast examination and Breast self-examination has not been shown to provide benefit (no reduction in mortality) and good evidence of harm (RR1.5 for benign biopsy)
  • Consider genetics referral if risk factors present
    • Personal Hx Breast CA ≤ 40 or Ovarian CA at any age
    • Fam Hx Breast CA ≤ 50
  • Consider Gail Model for Breast Cancer risk in women ≥ 35yo with risk factors