Oncology & 2WW · Full case
Breast Disorders
Breast Disorders · Clinical Reasoning Framework v2
GP & SCA · NICE NG12 · 2-Week Wait · Triple Assessment · Mastalgia · Nipple Discharge · Mastitis · Screening · Family History · Cancer Anxiety
Age ≥30: unexplained lump → 2WWNICE NG12 (2015; updated 2023): any woman aged 30 or over with an unexplained breast lump (with or without pain) should be referred on the 2-week wait (2WW) pathway for suspected cancer. This referral is NOT a cancer diagnosis — it is a request for triple assessment (clinical examination + imaging + histology) which cannot be done in primary care. The 2WW pathway guarantees the patient is seen by a breast surgeon within 14 days of referral. Approximately 90% of women referred on the 2WW pathway do NOT have cancer — but the referral is the appropriate clinical action regardless of how reassuring the clinical features appear. A GP should never attempt to diagnose or exclude breast cancer on clinical grounds alone. Any age: refer if axillary lump; skin changes; nipple changes; unilateral blood-stained nipple discharge.
Triple assessment: clinical + imaging + histologyTriple assessment is the gold standard diagnostic approach for any breast lump and is performed in a specialist breast clinic (not primary care). The three components must all agree before a diagnosis can be made: (1) Clinical assessment by a breast surgeon — palpation; axillary examination; clinical impression. (2) Imaging — mammography for women ≥35 years; ultrasound for women <35 years (mammographic tissue density makes mammography less sensitive in younger women); both may be used in women ≥35. B1–B5 (benign to malignant) scoring system for mammography; U1–U5 for ultrasound. (3) Tissue sampling — core needle biopsy (CNB) preferred over fine needle aspiration cytology (FNAC) as it provides histological diagnosis (R1–R5; B1–B5 grading systems). All three components must be reported as benign for a benign diagnosis to be made. Discordant results (e.g. clinical = suspicious; USS = probably benign) = repeat biopsy or excision biopsy.
Fibroadenoma: most common lump <35Fibroadenoma is the most common benign breast lump in women under 35. Clinical features: smooth; well-defined edges; firm; very mobile (“breast mouse”); non-tender; typically 1–3 cm; most commonly upper outer quadrant. Fibroadenomas arise from a single breast lobule — they are oestrogen-responsive and may enlarge in pregnancy and with the COCP. Giant fibroadenomas (>5 cm) are rare. Management: if triple assessment confirms fibroadenoma (B2/U2): conservative management (watchful waiting) is appropriate for lumps <3 cm in young women (they often spontaneously involute); surgical excision offered if larger; increasing; or if the patient wishes. Never diagnose fibroadenoma in primary care without triple assessment — phyllodes tumours (a rare breast sarcoma) may be clinically indistinguishable from fibroadenoma.
Blood-stained unilateral discharge → 2WWNipple discharge: any unilateral; single-duct; blood-stained (frank blood or haemoserous) nipple discharge requires urgent 2WW referral regardless of age. Most common cause: intraductal papilloma (benign wart-like growth in the duct — approximately 75–80% of cases of blood-stained discharge); but ductal carcinoma in situ (DCIS) and invasive cancer must be excluded. Other high-risk discharge features: unilateral; persistent; spontaneous (occurring without squeezing); associated with a lump. Bilateral milky discharge (>12 months post-partum; non-physiological): galactorrhoea — investigate: prolactin; TSH; pregnancy test; drug history (antipsychotics; TCAs; metoclopramide; domperidone; opioids; methyldopa). Green or creamy bilateral multi-duct discharge: duct ectasia — benign; perimenopause; reassurance; antibiotics if infected (erythromycin or co-amoxiclav).
NHS Breast Screening: 50–71; every 3 yearsThe NHS Breast Screening Programme (BSP) invites women aged 50–71 for mammography every 3 years. This age range is being extended as part of the NHS AgeX trial to 47–73 in some areas. Mammography reduces breast cancer mortality by approximately 20% (relative reduction) in the screened population. Limitations: overdiagnosis (detecting cancers that would never have caused symptoms; estimated 15–19% of screen-detected cancers); false positives (approximately 3–10% recall rate; significant anxiety); interval cancers (cancers developing between screens); reduced sensitivity in dense breast tissue (younger women). Women who miss a screening invitation should be encouraged to contact their local screening programme. Symptom screening (any age; any time): any new breast symptom should be assessed regardless of when the last mammogram was. GP role: ensure women are registered with a GP to receive invitations; encourage uptake; assess symptomatic women regardless of screening status.
Mastitis: flucloxacillin 500mg QDS 10–14 daysLactational mastitis is an infection of the breast parenchyma, most common in the first 6 weeks of breastfeeding. Causative organism: usually Staphylococcus aureus (including MRSA). Treatment: flucloxacillin 500mg QDS for 10–14 days (first-line; S. aureus coverage). MRSA-suspected or penicillin-allergic: co-trimoxazole (trimethoprim-sulfamethoxazole) or clindamycin — discuss with microbiology. Penicillin-allergic (non-MRSA): erythromycin 500mg QDS. All safe during breastfeeding. Critical: CONTINUE BREASTFEEDING throughout treatment — stopping worsens milk stasis and may precipitate abscess formation. Analgesics (paracetamol; ibuprofen): safe during breastfeeding. Warn: if not improving at 48–72 hours; increasing redness; fluctuant area; fever persisting — breast abscess may have developed. Breast abscess: requires surgical drainage (aspiration under ultrasound guidance; or incision and drainage) + antibiotics; same-day surgical referral.
Mastalgia: 95% benign; cyclical vs non-cyclicalMastalgia (breast pain) affects up to 70% of women at some point and is almost always benign. Two types: (1) Cyclical mastalgia: related to the menstrual cycle; worse in luteal phase (7–10 days before menstruation); bilateral; diffuse; typically upper outer quadrant; most common in women aged 25–45 years. Usually benign and self-limiting — 90% resolve without treatment. Hormonal cause (oestrogen:progesterone imbalance; prolactin sensitivity). (2) Non-cyclical mastalgia: not related to menstrual cycle; may be unilateral; localised; less likely to resolve spontaneously. Causes: large breast size; ill-fitting bra; musculoskeletal (Tietze syndrome — costochondritis); duct ectasia; periductal mastitis; rarely cancer (<5% of cancer presentations). Non-cyclical pain with a discrete area of tenderness warrants examination and 2WW referral if a lump is found. The SCA trap: do not reassure “it’s just mastalgia” without excluding a lump by examination.
Breast cancer: 1 in 7 lifetime risk (UK)Breast cancer is the most common cancer in the UK. 1 in 7 women will develop breast cancer in their lifetime. Key risk factors: increasing age; female sex (100× higher risk than males, but male breast cancer exists); family history (BRCA1/BRCA2 mutations — 60–85% lifetime risk; refer to genetics if high-risk family history: first-degree relative <40; bilateral breast cancer; male breast cancer; breast + ovarian cancer; Ashkenazi Jewish family history); hormone exposure (early menarche; late menopause; nulliparity; late first pregnancy; HRT — combined more than oestrogen-only); COCP (modest increased risk; returns to baseline 10 years after stopping); obesity (post-menopausal); alcohol; radiation exposure. Protective factors: breastfeeding; physical activity; parity; oophorectomy (in BRCA carriers). The GP’s role in family history: assess with the Manchester Score or equivalent; refer if high-risk family history criteria met (NICE CG164).
📋 Clinical Stem — Breast Disorders
Mrs. Sarah Mitchell, 42, presenting with a 4-week history of a discrete 2 cm lump in the left upper outer quadrant noticed during self-examination, anxious about cancer, on the combined oral contraceptive pill, with no skin changes or nipple discharge
Mrs. Sarah Mitchell, 42, a secondary school teacher, presents reporting a 2 cm discrete lump in her left breast that she noticed 4 weeks ago during self-examination. She describes the lump as firm and non-tender. There is no nipple discharge; no skin changes visible; no axillary swelling she is aware of. She has no personal or known first-degree family history of breast cancer. She takes Microgynon 30 (combined oral contraceptive pill). Her most recent cervical smear was normal. She has had no previous breast problems. She is clearly anxious: “I’m scared it might be cancer — my friend had a lump and it turned out to be nothing, but I want to be sure.”
This stem tests: recognition that any unexplained breast lump in a woman aged ≥30 requires 2-week wait (2WW) referral regardless of clinical features; correct explanation of the 2WW pathway and triple assessment; cancer anxiety management; assessment of nipple discharge and skin changes; family history screening; mastalgia assessment; and COCP contribution to breast symptoms. The SCA trap: reassuring Mrs. Mitchell that her lump is “probably benign” without making the 2WW referral is a patient safety failure.
Scenario A — Mrs. Mitchell (2 cm discrete lump; age 42; no red flags; COCP) NICE NG12: age ≥30 + unexplained lump = 2WW. Clinical features (smooth; mobile) may suggest fibroadenoma or cyst — triple assessment is still required. COCP: document; breast clinic will consider hormonal contribution. Explain 2WW as diagnostic pathway (not cancer diagnosis). Family history assessed (no high-risk features today). 2WW referral made. Safety-net: 2WW appointment letter within 2 weeks; attend even if lump changes or resolves.
Scenario B — Cyclical mastalgia; no lump Diffuse bilateral breast pain; worse premenstrually; no discrete lump; normal examination. Mastalgia management: reassurance (benign; very rarely cancer); well-fitted bra; reduce caffeine; evening primrose oil (GLA 240–320mg daily). If severe: danazol 200mg OD (licensed; androgenic side effects); tamoxifen 10mg OD (unlicensed; specialist). Review COCP contribution (can worsen cyclical mastalgia). Pain diary: document cycle relationship. Routine referral if not responding to 3–6 months treatment.
Scenario C — Unilateral blood-stained nipple discharge; no lump 2WW referral regardless of age. Intraductal papilloma most likely — but DCIS and invasive cancer must be excluded. Assess: spontaneous or expressed; volume; frequency; associated lump. Bilateral milky discharge: galactorrhoea — check prolactin; TSH; drug history (antipsychotics; metoclopramide; domperidone; TCAs). Non-blood-stained unilateral: routine referral if persistent or ≥age 50 (NICE NG12: unilateral nipple discharge in woman ≥50 = 2WW).
Scenario D — Lactational mastitis Breastfeeding mother; red; hot; painful breast; fever; unwell. Flucloxacillin 500mg QDS 10–14 days (first-line; S. aureus). CONTINUE breastfeeding (stopping worsens stasis; abscess risk). Analgesics (paracetamol; ibuprofen): safe in breastfeeding. Safety-net: if not improving at 48–72 hours or fluctuant area develops — breast abscess; same-day surgical referral. Breast abscess: USS-guided aspiration + antibiotics. MRSA suspected: discuss with microbiology.
Scenario E — High-risk family history; genetic counselling First-degree relative <40 with breast cancer; or bilateral; or male breast cancer; or breast + ovarian; or Ashkenazi Jewish background. NICE CG164: refer to specialist familial breast cancer service. Manchester Score (or similar) to assess BRCA probability. BRCA1/BRCA2 testing if eligible. Risk-reduction options: tamoxifen; raloxifene; anastrozole (post-menopausal); prophylactic mastectomy; enhanced surveillance (annual MRI from age 30 or 5 years before youngest affected relative). Genetic counselling before testing.
Key variables to adapt for Age (30–49 vs 50+; screening eligibility; breast density); lump characteristics (smooth/mobile vs hard/irregular/fixed; skin changes; nipple changes); nipple discharge type (colour; unilateral/bilateral; spontaneous/expressed; blood-stained); family history (first-degree; age at diagnosis; bilateral; male; ovarian; Ashkenazi); hormonal context (COCP; HRT; pregnancy; lactation; post-menopausal); mastalgia type (cyclical vs non-cyclical; with or without lump); skin changes (peau d’orange; erythema; dimpling; tethering; nipple retraction)
Steps:
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Step 1
History — Lump Characteristics · Cancer Red Flags · Family History · Hormonal History · Cancer Anxiety
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Breast history has two objectives: (1) identify features that require 2WW referral; (2) identify and address the cancer anxiety that almost every patient with a breast lump brings. For Mrs. Mitchell: any unexplained lump at age 42 = 2WW under NICE NG12 — the history confirms this decision; it cannot reverse it. Clinical features (smooth; mobile; non-tender) may be reassuring — but the 2WW referral must still be made.
🎓 SCA opener — acknowledge the fear before the clinical history
"I can hear that you are worried about this — and I think anyone who finds something new in their breast would feel exactly the same way. I want to ask you some questions to understand the lump fully, and then we will talk about exactly what happens next. First — tell me in your own words when you found it and what it feels like."
Mrs. Mitchell is frightened. The opener validates her fear before the clinical history begins. The SCA examiner scores Relating to Others from the first words — opening with “how long have you had the lump?” without acknowledging the fear loses marks immediately.
1A — Lump history and cancer red flags
1B — Red flags — features requiring urgent or immediate action
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Red Flags — immediate or same-day action required
| Red flag | Why dangerous | Action |
|---|---|---|
| Rapidly growing breast mass + warmth + erythema + peau d’orange | Inflammatory breast cancer (IBC): rare (1–5% of all breast cancers); but highly aggressive. Often misdiagnosed as mastitis. Key distinction: IBC in a non-breastfeeding woman; does not respond to antibiotics; rapid growth; skin changes. Emergency oncology referral — NOT a standard 2WW. | Same-day oncology / breast team discussion |
| Breast lump + arm swelling (lymphoedema) | Axillary node involvement with lymphatic obstruction suggests locally advanced breast cancer (N2–N3 disease; T4 staging). Lymphoedema with a breast lump in a previously unaffected woman = advanced disease. Emergency oncology discussion — may need palliative systemic therapy before local treatment. | Same-day oncology discussion |
| Suspected Paget’s disease of the nipple | Eczema-like change of the nipple-areolar complex (itching; scaling; erythema; ulceration) that does not respond to topical steroids. Paget’s is associated with underlying DCIS or invasive cancer in approximately 80–90% of cases. Must not be treated as eczema without biopsy. | Same-day or urgent 2WW referral; do NOT treat empirically as eczema |
| Breast abscess: fluctuant mass; high fever; not improving on antibiotics | Breast abscess requires surgical drainage — cannot be managed with antibiotics alone. USS-guided aspiration (preferred; less scarring) or incision and drainage. Breastfeeding women: continue breastfeeding. Non-lactational breast abscess: consider underlying carcinoma (carcinoma can mimic or develop alongside abscess). | Same-day surgical referral; breast USS; aspiration or I&D |
| Bone pain; neurological symptoms; breathlessness in known breast cancer patient | Metastatic breast cancer: most common sites — bone (spine; hip; rib); lung; liver; brain. Bone pain + known breast cancer = bone metastasis until proven otherwise — spinal cord compression must be excluded (urinary; bowel; lower limb neurology). Breathlessness: pleural effusion; lung metastases. Confusion; headache: brain metastases. | 999 if spinal cord compression. Same-day oncology for other features |
| Male breast lump | Male breast cancer is rare (approximately 350 cases/year UK) but has a higher proportion of BRCA2-related cases. Any male breast lump requires 2WW referral (NICE NG12). Also consider: gynaecomastia (common; bilateral; tender; related to drugs; hormonal; liver disease); exclude drug causes before referral if classic gynaecomastia presentation. | 2WW referral; BRCA2 testing consideration; drug history |
🛡️
Safeguarding — Breast Disorders and Vulnerability
Breast cancer and breast disorders can carry safeguarding implications across several domains. Women from certain groups have consistently lower uptake of breast screening and lower rates of self-referral for breast symptoms — these disparities are associated with worse outcomes from delayed diagnosis.
🌐 Health inequality and screening uptake
- Breast screening uptake is lower in deprived areas; Black; Asian and minority ethnic women; women with disabilities; and women who are homeless or in prison
- GP role: actively encourage uptake; ensure patients are registered to receive invitations; address barriers to attendance (language; transport; fear; religious concerns about undressing)
- Offer same-day or female GP appointment for breast examination if cultural or religious concerns about male clinician
💕 Domestic abuse and breast injury
- Breast injuries from domestic violence may present as breast bruising; haematoma; or mastalgia — be aware of this presentation
- Use SAFE or HURT mnemonic; ask sensitively if injury pattern is not consistent with the history
- Breast trauma: breast haematoma can organise and present as a lump — always examine and refer if uncertain
📸 Body image and mental health
- Breast lump investigation (especially biopsy; mastectomy) has profound body image implications
- Cancer anxiety from a breast lump may trigger anxiety disorder or depression even when the lump is benign — PHQ-9 and GAD-7 screening where appropriate
- 2WW pathway: the wait between referral and diagnosis is a period of significant anxiety — explicitly acknowledge this and offer GP contact if anxiety worsens
💻 Cancer risk and BRCA implications
- BRCA1/2 diagnosis has implications for the patient and their blood relatives — a positive result may affect insurance; employment; and family planning decisions
- Pre-test genetic counselling is mandatory before BRCA testing — never order BRCA testing without specialist genetic counselling arranged
- Prophylactic mastectomy discussion: this is a major decision requiring specialist support; psychological assessment; and time — never give definitive advice about prophylactic surgery in primary care
Actions: Ensure female GP examination available if requested; address screening barriers; PHQ-9 screening if significant anxiety related to lump investigation; document explicit safety-netting about 2WW appointment.
1C — PMH · Family history · Drug history · Social
1D — ICE
💡 Ideas
"What do you think the lump might be? Have you had any thoughts about what could be causing it?"
Mrs. Mitchell may believe her lump is cancer (her friend had a lump — she does not say it was benign or malignant; she says “turned out to be nothing” — so she knows benign lumps exist, but she is still scared). She may think a smooth; mobile lump is inherently safe — the GP needs to gently avoid colluding with premature reassurance while also not alarming her unnecessarily. Understanding her internal model allows the GP to build on what she already knows (benign lumps are common) while being honest that triple assessment is still required.
😟 Concerns
"What is worrying you most about it? What is the worst-case scenario in your mind?"
Mrs. Mitchell is scared of cancer. The concern should be named and addressed directly — not avoided. The GP’s response to “is it cancer?” must be honest: “I cannot tell from examining a lump whether it is cancer or not — that is exactly why I am referring you for specialist tests. What I can tell you is that the majority of lumps like this turn out to be benign — but we need to confirm that properly, not just hope for the best.” Naming the concern also allows the GP to provide specific information about what the 2WW pathway involves — reducing the anxiety of the unknown.
🎯 Expectations
"What were you hoping would happen today? Were you expecting tests; or to be seen by a specialist?"
Mrs. Mitchell probably expects to be told what the lump is and to have a plan. The GP must explain that the expectation of “just tell me if it’s cancer” cannot be met in primary care — that requires the specialist triple assessment. The offer is: “I am going to refer you urgently to the breast clinic — they have the specialists and the equipment to assess this properly. You will be seen within 2 weeks.” This reframes the GP’s referral not as “I don’t know — you need to see someone else” but as “I am connecting you to the right expert today.”
1E — Psychosocial context
💔 Cancer fear and intrusive thoughts
Three weeks of waiting before attending: intrusive thoughts; checking the lump repeatedly (which can cause soreness and feed the anxiety loop); difficulty sleeping; health-related internet searching. Cancer anxiety is not irrational — it is appropriate vigilance. The GP’s role: validate the vigilance; give it a constructive direction (the 2WW referral).
"I think you have been worrying about this for a few weeks — and that waiting is really hard. I want to make sure you leave today with a clear plan so the waiting feels purposeful."👤 Body image and identity
A breast lump investigation — biopsy; mammography; potential surgery — touches deeply on body image and sexual identity. For Mrs. Mitchell at 42: concerns about femininity; relationship impact; how she looks; potential scarring. Even before a diagnosis is made, the investigation process can feel body-invasive and frightening.
"I know this process can feel quite intrusive — the tests involve examining the breast very carefully. If at any point you have concerns or anxieties about the process itself, please don’t hesitate to come back to us."💼 Occupational impact
Mrs. Mitchell is a secondary school teacher. A cancer diagnosis or intensive treatment would have significant occupational implications. The period of uncertainty between referral and diagnosis may itself cause occupational difficulties (concentration; anxiety; colleagues noticing). Proactively: acknowledge this and offer sick notes if anxiety is affecting work before the diagnosis is established.
"If the waiting is affecting your ability to work — or if you need any documentation for your employer before you have your results — do come back and we can help with that."💋 Relationships and disclosure
Has Mrs. Mitchell told her partner? Her family? The decision to disclose a breast lump before a diagnosis can be a source of stress — she may not want to worry her family unnecessarily. Equally, she may need support and feel isolated carrying this alone. The GP can acknowledge this without advising who to tell.
"Do you have someone who can come with you to the breast clinic appointment? Having support with you can make a real difference."🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills
Key phrases
"You have done exactly the right thing coming in — you found this yourself and you came straight away. That is important. I cannot tell from examining a lump whether it is cancer or not — that requires a specialist team. What I can tell you is that the majority of lumps in women your age turn out to be benign — but we need to confirm that properly."
"I am going to refer you urgently to the breast clinic — they will be in touch within 2 weeks. This is what we call a 2-week wait referral. It is not a diagnosis — it is a request for the right tests, done by the right team."
Deductions
- Reassuring Mrs. Mitchell that the lump “feels benign” and deferring the 2WW referral — clinical features cannot exclude cancer; the referral must be made
- Ordering GP-based USS or mammography and waiting for results before referring — the 2WW pathway bypasses this; GP imaging delays specialist review
🔴 Red
Cancer fear not acknowledged; 2WW referral not made; told “probably benign” without triple assessment; GP mammography ordered instead of referral; family history not assessed; nipple discharge not assessed; skin changes not examined
🟠 Amber
2WW referral made; cancer anxiety acknowledged; nipple discharge asked; family history incomplete; COCP not documented in referral; 2WW process not explained; safety-net about appointment timing not given; closing question absent
🟩 Green
Cancer fear acknowledged first; ICE fully explored; 2WW referral made and explained; “most lumps are benign but we need to confirm properly”; skin; nipple; axillary assessment; family history (no high-risk features); COCP documented in referral; breast awareness advice; safety-net: 2WW letter within 2 weeks; attend even if lump resolves; come back if anxiety worsening; closing question
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Step 2
Triage — Emergency · 2-Week Wait · Routine · Reassure and Monitor
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Breast triage is essentially a referral decision: same-day emergency vs 2WW vs routine vs no referral. Mrs. Mitchell: age 42 + unexplained lump = 2WW (NICE NG12). This is non-negotiable — clinical features cannot change this.
🔴 Emergency / Same-Day
Same-Day Oncology / Surgical Discussion
Same-day- Inflammatory breast cancerRapidly growing; warm; red; peau d’orange; does not respond to antibiotics — same-day oncology
- Breast abscessFluctuant; fever; antibiotic failure — same-day surgical referral; USS aspiration
- Spinal cord compression in known breast cancer999; urgent MRI; dexamethasone
- Paget’s disease of nippleSame-day or urgent 2WW; do not treat as eczema
🟠 2-Week Wait (Urgent)
NICE NG12 Criteria Met
Refer within 1 week; seen within 2- Age ≥30: unexplained breast lump (Mrs. Mitchell)With or without pain; regardless of clinical features
- Any age: blood-stained unilateral nipple dischargeSingle duct; spontaneous; blood-stained
- Any age: skin or nipple changes suggesting cancerPeau d’orange; tethering; dimpling; nipple retraction; erythema
- Any age: unexplained ipsilateral axillary lumpOr women ≥50: unilateral nipple discharge
🟩 Routine / Non-urgent
GP Management or Routine Referral
GP; routine referral- Cyclical mastalgia; no lump; normal examinationReassurance; lifestyle; evening primrose oil; pain diary; routine referral if >3 months no improvement
- Lactational mastitis; no abscessFlucloxacillin 10–14 days; continue breastfeeding; GP-managed
- Gynaecomastia in male with drug cause identifiedDrug review; routine referral if not resolving; exclude malignancy if asymmetric
🎓 SCA Checkpoint — Step 2Tasks
2WW explanation — not a cancer diagnosis
"I am going to make a referral for you to the breast clinic today. It is called a 2-week wait referral — not because we think you have cancer, but because NICE guidelines say that anyone with a new lump like yours should be seen by specialists within 2 weeks so they can do the right tests. Most people referred on this pathway do not have cancer — but the way to know for sure is the specialist assessment."
Deductions
- Saying “I am referring you on the cancer pathway” without explaining that this is diagnostic; not a cancer diagnosis — this framing increases unnecessary alarm
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Step 3
Examination — Inspection · Palpation · Axillae · Characteristics · Documentation
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GP breast examination: describe the lump systematically (size; shape; consistency; mobility; margin; tenderness; skin; nipple; axilla). The referral letter must contain an accurate clinical description — never refer without examining. A female chaperone should always be offered.
🎓 SCA Checkpoint — Step 3TasksRelating to Others
Examination consent and safety
"I would like to examine your breasts properly — this is really important so I can give the breast clinic an accurate description of what I find. I will need you to undress to the waist. I have a chaperone available and I would encourage you to have one present — would that be OK?"
Deductions
- Not offering a chaperone for intimate examination — GMC guidance requires this; mandatory documentation
- Referring without examining — the referral letter must contain a clinical description of the lump; this is required for appropriate breast clinic triage
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Step 4
Investigations — What GPs Do · What Specialists Do · Galactorrhoea Screen · Family History Tests
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GPs do not investigate breast lumps with imaging — the 2WW pathway ensures this is done correctly in the specialist setting. GP investigations are indicated for: galactorrhoea (prolactin; TSH); family history risk assessment (pre-referral genetics); suspected Paget’s (skin biopsy — usually by dermatology); or inflammatory markers if mastitis (FBC; CRP if systemic illness).
🎓 SCA Checkpoint — Step 4Tasks
Avoiding GP imaging
"I am not going to arrange a scan or X-ray from here today — and here is why. The breast clinic is set up to do all of those tests together in one visit, and they do them with the full clinical picture in front of them. If I arranged a scan from here, it could actually slow things down. The right thing is to get you to the specialists directly."
Deductions
- Ordering GP breast USS or mammography instead of 2WW referral — this delays specialist assessment and may produce false reassurance from a non-specialist reading
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Step 5
Diagnosis — Explaining Triple Assessment · Benign vs Malignant Features · DDx · Plain Language
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In primary care, the “diagnosis” stage for a breast lump is not about diagnosing the lump — it is about explaining what the specialist process (triple assessment) will determine, and setting realistic expectations about the timeline and what the tests involve.
🗣️ Explaining the process to Mrs. Mitchell — say something like this
"Let me explain what I found when I examined you. There is a lump in your left breast — about 2 centimetres, which is roughly the size of a grape. When I felt it, it was smooth around the edges and moved when I pressed on it — which can sometimes suggest a benign cyst or a benign growth called a fibroadenoma. However — and this is important — I cannot tell from feeling a lump alone whether it is benign or not. That is not something any GP can do reliably. What the specialists will do is called a ‘triple assessment’: first they will examine you themselves; second they will do a scan — and possibly a mammogram; third they may take a small sample of tissue using a needle test, which sounds worse than it actually is. All three results together give a definitive answer. In most women your age referred to this clinic, the result is reassuring — but I would not be doing my job if I just told you not to worry without getting those tests done properly."
💬 Addressing specific concerns
"Is it cancer?"
"I honestly cannot answer that question today — and I would not be telling you the truth if I said I could. What I can say is that most women referred to the breast clinic with a lump like yours do not have cancer. But I need you to have the proper tests to know for certain, and that is exactly what I am arranging today."
"What happens if it is cancer?"
"If it turns out to be cancer — and that is still unlikely at this point — then you will have caught it early; you will have access to excellent specialist care; and early breast cancer is highly treatable. I know that is scary to think about, but the fact that you came in quickly is exactly the right thing to have done."
Likely Benign Diagnoses — specialist confirmation required
Confirmed by triple assessment
Fibroadenoma: smooth; well-defined; mobile; firm; 1–3 cm; most common <35. Conservative management if <3 cm confirmed at triple assessment. Breast cyst: tense; smooth; fluctuant or firm; can disappear on aspiration; most common 40–50. Normal breast tissue: nodular; lumpy; areas — hormonal variation. Fat necrosis: post-trauma; may mimic cancer on clinical exam (hard; irregular); tell-tale history of trauma.
Features raising cancer concern
Hard; irregular; fixed mass
Infiltrative malignancy: invades Cooper’s ligaments and pectoralis fascia. Hard; non-mobile; irregular margins. May have skin dimpling; tethering; nipple retraction ipsilateral.
Inflammatory breast cancer
Peau d’orange; warm; erythematous; rapidly growing; often mistaken for mastitis (key: does not respond to antibiotics; occurs outside lactation).
Emergency features — same-day action
Peau d’orange + rapid growth
Inflammatory breast cancer. Same-day oncology. NOT mastitis.
Paget’s disease of nipple
Eczema-like NAC change. Do not treat as eczema. 80–90% associated with underlying DCIS or cancer. Urgent referral.
🎓 SCA Checkpoint — Step 5TasksRelating to Others
Triple assessment explanation
"What the specialists will do is called a ‘triple assessment’ — they examine you; they do a scan and possibly an X-ray; and they may take a tiny needle sample. All three together give a definitive answer. I cannot give you that answer today — but the breast clinic can. And that is exactly what I am arranging."
Deductions
- "The lump feels benign so I do not think you need the 2-week referral" — clinical features do not determine referral need in NICE NG12; this is a patient safety failure
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Step 6
Referral — 2WW Criteria · What to include in the Referral Letter · Familial Cancer Service
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The 2WW referral letter must be high-quality — the breast clinic uses it to triage and plan the appointment. A poor referral letter delays triple assessment or misclassifies the urgency.
🎓 SCA Checkpoint — Step 6Tasks
2WW referral communication
"I am going to send a referral to the breast clinic today. They will contact you within 2 weeks to give you an appointment. The letter I write will include a detailed description of the lump so they can plan the right tests for you. If you have not received an appointment letter within 2 weeks, please call us and we will chase it."
Deductions
- Not giving explicit timelines (“they’ll be in touch” is insufficient — “within 2 weeks” sets a measurable expectation)
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Step 7
Management — Anxiety · Mastalgia · Mastitis · Galactorrhoea · Chemoprevention · Shared Care
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7A — Address Mrs. Mitchell’s expectation first
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Mrs. Mitchell wants to know if it is cancer — validate; explain what the process will answer; offer a plan for the anxiety during the wait
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Validate — her concern is entirely appropriate
She found the lump; she came in promptly; she is asking the right question. The GP validates this without false reassurance.
"You have done exactly the right thing. You found something; you came straight away. That is good breast health in practice — and it means if there is anything to find, we are finding it early."2
Explain — why you cannot answer “is it cancer?” today
Not because it is not an important question — but because clinical examination cannot answer it. The honest, specific explanation of why builds trust.
"I cannot give you that certainty today — not because I am hiding anything — but because the only way to get the definitive answer is the three-part specialist assessment. What I can tell you is that I am sending you there today, and most women who go through this process are reassured."3
Offer — support during the wait
The 2 weeks between referral and appointment is when anxiety peaks. The GP can offer a specific action plan for managing this period.
"While you wait — if the anxiety is really getting on top of you or affecting your sleep, please call us. And if the lump changes — grows; becomes painful; any new nipple changes — call us immediately and we will escalate the referral."7B — Treatment goals (primary care scope)
Primary care management goals
2WW referral made and confirmed within 1 working dayClinical description in referral letter complete and accurate
Cancer anxiety addressed; coping strategies for 2-week waitSafety-net: clear criteria for escalation before appointment
Family history assessed; familial cancer service referral if criteria metBreast awareness advice given
Mastalgia/mastitis/galactorrhoea managed in primary care if relevantShared care plan with specialist post-diagnosis if cancer confirmed
Anxiety management during the 2-week wait
"The 2 weeks between now and your appointment can feel very long when you are worried. Here are some practical things that help: try to maintain your normal routine; avoid spending hours online searching for information — it almost always increases anxiety rather than reducing it. Do things that help you relax. And if the anxiety is really affecting your sleep or your ability to function — please call us."
PHQ-9 + GAD-7 at this consultation if anxiety appears significant. NHS Talking Therapies referral if moderate anxiety (GAD-7 ≥8). Breast cancer charities: Breast Cancer Now; CoppaFeel — provide peer support and information during the diagnostic wait.
7C — Breast awareness and non-medication management
Breast Awareness (not “self-examination”)
Know your normal; report changes promptly; no specific monthly technique requiredNHS approach — breast awareness not formal self-examination
The NHS does not recommend a specific formal breast self-examination technique (evidence shows it does not reduce mortality and may increase harm from unnecessary biopsies). Instead: breast awareness — know what is normal for you; look and feel occasionally; report any new change promptly. Changes to report: new lump or thickening; skin change (dimpling; redness; unusual texture); nipple change (new retraction; discharge; change in position or appearance); pain (persistent; new; unexplained; localised). Mrs. Mitchell: she is already breast-aware — acknowledge this positively; reinforce the behaviour.
NHS Breast Screening Participation
50–71 (extending to 47–73); every 3 years; attend all invitationsScreening for Mrs. Mitchell
Mrs. Mitchell is 42 — not yet within the standard NHS Breast Screening Programme (age 50–71; extending to 47–73 in AgeX trial areas). Advise: she will receive her first invitation at approximately age 50. Encourage attending when invited. Symptomatic screening (i.e. this current presentation) is separate from the screening programme. If family history is significant and she is referred to familial services: enhanced annual MRI from age 30–40 may be recommended.
Lifestyle Risk Reduction
Reduce alcohol; maintain healthy BMI; physical activity; limit HRT durationEvidence-based lifestyle factors
Alcohol: each additional unit/day increases breast cancer risk by approximately 7–10%. Obesity (post-menopausal): BMI >30 significantly increases risk via adipose oestrogen production. Physical activity: 150 minutes moderate exercise/week reduces risk by approximately 20–30%. Breastfeeding: reduces lifetime risk by approximately 5% per year of breastfeeding. These are population-level risk reductions — useful to mention at general breast health reviews; do NOT attribute Mrs. Mitchell’s lump to any of these factors.
Cyclical Mastalgia — Non-Drug Management
Well-fitted bra; caffeine reduction; pain diary; evidence-limited but safeFirst-line (no drug required)
Well-fitted bra (sports bra; 24-hour support in severe cases): reduces ligament tension and mechanical breast pain. Caffeine reduction: weak evidence; harmless to advise — some women report significant improvement. Pain diary: correlates symptoms with menstrual cycle; helps distinguish cyclical from non-cyclical; validates the benign nature; reassures. Evening primrose oil (GLA 240–320mg daily): modest evidence; NICE does not recommend routinely but widely used; safe; cheap. Reassurance: 90–95% of women with cyclical mastalgia are symptom-free within 3 months; 50% resolve spontaneously by 3 months.
Mastitis — Non-Drug Management
Continue breastfeeding; empty the breast; adequate analgesia; warm compressNon-antibiotic management (always alongside antibiotics)
Continue breastfeeding: the most important non-drug intervention. Stopping breastfeeding worsens milk stasis and dramatically increases abscess risk. If the affected breast is too painful: pump to empty. Empty the breast frequently (every 2–3 hours): reduces milk stasis; removes bacterial load. Warm compress before feeding: improves milk flow. Adequate analgesia: paracetamol and ibuprofen are safe in breastfeeding and should be taken regularly (not PRN). Rest. Hydration. Review at 48–72 hours: if not improving — consider MRSA; abscess; review antibiotic choice.
Cancer Anxiety — Psychological Support
Normalise; structure; avoid internet searching; peer support; NHS Talking Therapies if significantThe 2-week wait period
The 2 weeks between GP referral and breast clinic appointment is characterised by peak anxiety. Specific advice: maintain normal routine (avoid “pre-grieving”); limit internet searching (cancer survival statistics found online are often outdated and context-free); use trusted sources (Breast Cancer Now; NHS.uk); consider who to tell (may want support; may not want to worry family unnecessarily). If anxiety is GAD-7 ≥8: NHS Talking Therapies referral. CoppaFeel! charity: peer support; specific resources for young women with breast changes. MacMillan Cancer Support: resources even during investigation (before diagnosis confirmed).
7D — Prescribing guide for GP-managed breast conditions
For Mrs. Mitchell (breast lump): no GP prescribing required — the management is the 2WW referral + anxiety support. GP prescribing is relevant for: mastalgia (evening primrose oil; danazol); mastitis (flucloxacillin); galactorrhoea (after prolactin investigation — cabergoline is specialist-initiated). Shared care post-cancer diagnosis: tamoxifen; aromatase inhibitors; bisphosphonates.
Mastalgia — stepwise GP management
- Step 1: Reassurance + pain diary + well-fitted bra + caffeine reduction. 90% of cyclical mastalgia resolves spontaneously — time is a treatment.
- Step 2: Evening primrose oil (GLA 240–320mg daily ×3–6 months): safe; cheap; modest evidence; NICE evidence insufficient but widely used
- Step 3: Danazol 200mg OD (licensed for cyclical mastalgia; androgenic side effects — acne; hirsuitism; voice changes; teratogenic; contraception mandatory): use minimum dose for minimum duration
- Step 4: Tamoxifen 10mg OD (unlicensed for mastalgia; specialist or shared care; effective; thrombosis and uterine cancer risk)
- Review: if not responding to 3–6 months GP treatment — routine breast clinic referral
Mastitis — antibiotic treatment
- Flucloxacillin 500mg QDS 10–14 days: first-line; covers S. aureus
- Penicillin-allergic: erythromycin 500mg QDS or clindamycin 300mg TDS
- MRSA suspected (hospital-acquired; not improving on flucloxacillin): co-trimoxazole (trimethoprim-sulfamethoxazole) or clindamycin; discuss with microbiology
- Abscess suspected: USS-guided aspiration + antibiotics; same-day surgical referral
- Continue breastfeeding throughout — ALL antibiotics listed are safe in breastfeeding
- Review at 48–72 hours: if not improving — suspect abscess or MRSA; reassess
Post-breast cancer shared care (GP role)
- Tamoxifen 20mg OD (pre-menopausal; ER+ cancer): DVT risk; PMB = urgent gynaecology; hot flushes; weight gain; 5 years (or 10 years extended)
- Anastrozole 1mg OD; letrozole 2.5mg OD; exemestane 25mg OD (post-menopausal; aromatase inhibitors): arthralgia; osteoporosis — DEXA; bisphosphonate if indicated; no PMB risk
- Denosumab; zoledronic acid (bone metastases; bone protection in AI use): specialist-initiated; GP co-prescribes
- Trastuzumab; pertuzumab; palbociclib (systemic cancer treatment): specialist only; GP aware of toxicities; cardiac monitoring
7E — Decision aid
Select breast presentation for management guidance
Breast management guidance
Age ≥30 + unexplained lump = 2WW referral (NICE NG12); do not order GP imaging; clinical description in referral letter; cancer anxiety addressed; family history assessed; breast awareness advice. Age <30 + lump: refer urgently (within 2 weeks) — NICE NG12 age threshold is 30 for 2WW but any age unexplained lump with concerning features warrants 2WW. Cyclical mastalgia (no lump): reassurance + pain diary + well-fitted bra + GLA (evening primrose oil 240–320mg daily ×3 months). If severe: danazol 200mg OD (licensed; androgenic side effects; teratogenic). Routine breast referral if not responding at 6 months. Lactational mastitis: flucloxacillin 500mg QDS 10–14 days; CONTINUE breastfeeding; empty breast frequently; warm compress; paracetamol + ibuprofen (safe in breastfeeding); review 48–72 hours (abscess safety-net). Nipple discharge: blood-stained unilateral or woman ≥50 unilateral = 2WW. Bilateral milky: prolactin; TSH; drug history; pregnancy test; endocrinology if hyperprolactinaemia confirmed. Family history: refer to familial cancer service if: FDR <40; bilateral; male breast; breast+ovarian; Ashkenazi Jewish. Do NOT order BRCA without genetic counselling.
7F — Drug reference cards
Flucloxacillin (Lactational Mastitis)
Flucloxacillin 500mg QDS · 10–14 days · S. aureus coverage · Safe in breastfeeding · Continue breastfeeding throughout
✓ First-line lactational mastitis — continue breastfeeding; review 48–72 hours; abscess safety-net
First-line lactational mastitis — CONTINUE breastfeeding500mg QDS; 10–14 days; on empty stomach; review 48–72 hours
✓ Role and rationale
Flucloxacillin covers Staphylococcus aureus — the most common organism in lactational mastitis. Takes 30–60 min before food (absorption reduced by food). 10–14 days minimum course — do not shorten course. Continue breastfeeding throughout: milk is not harmful to the baby; stopping breastfeeding worsens stasis and dramatically increases abscess risk. Safe in breastfeeding: only trace amounts in breast milk. Analgesics (paracetamol; ibuprofen): safe in breastfeeding; should be taken regularly (not just PRN) to control fever and pain and to allow comfortable breastfeeding.
✗ Alternatives; contraindications
Penicillin allergy (non-anaphylactic): erythromycin 500mg QDS (safe in breastfeeding) or clindamycin 300mg TDS. Penicillin allergy (anaphylactic): clindamycin only. MRSA-suspected: co-trimoxazole (trimethoprim-sulfamethoxazole) or clindamycin; discuss with microbiology. Co-amoxiclav: covers broader spectrum (including Gram-negatives; anaerobes); use if: non-lactational breast abscess; mixed infection suspected; perinipple abscess. Breast abscess: antibiotics PLUS USS-guided aspiration or I&D — antibiotics alone insufficient for established abscess.
⚠ Side effects and monitoring
GI: nausea; diarrhoea (take with empty stomach); rarely cholestatic hepatitis. Rash: stop if anaphylaxis or severe rash. Review at 48–72 hours: if fever persisting; increasing erythema; fluctuant area developing — suspect abscess; same-day surgical referral. MRSA: if not improving on flucloxacillin — take swab (nipple; wound); discuss with microbiology. Not improving at 5 days despite antibiotic compliance: mastitis vs inflammatory breast cancer (rare; but misdiagnosis with mastitis is a known error — refer if non-lactational or non-responding).
🔬 Monitor
48–72 hour phone or face-to-face review. Temperature resolving? Redness improving? Lump (if present) reducing? If: temperature persists; erythema spreading; fluctuant area — USS for abscess; same-day surgical referral. Non-lactational mastitis not responding to antibiotics: biopsy (inflammatory breast cancer must be excluded).
💬 Breastfeeding safety message
"I want to emphasise — please carry on breastfeeding. The infection does not get into your milk in a way that is harmful to your baby, and stopping would make the problem worse, not better. Feed as often as you can from the affected side — or pump if it is too painful. I will call to check how you are doing in 48 hours."
Flucloxacillin for mastitis: the critical counselling point is CONTINUE BREASTFEEDING — stopping is the most common patient mistake and leads to abscess. 10–14 days; empty stomach; 48–72 hour review; abscess safety-net. SCA: not advising continuing breastfeeding = Tasks deduction.
Co-amoxiclav (Non-Lactational; Abscess; Mixed Infection)
Co-amoxiclav 625mg TDS · Augmentin · Broad spectrum · Non-lactational breast abscess · Perinipple; subareolar abscess · 7–14 days
✓ Non-lactational mastitis; mixed infections; perinipple abscess — broader spectrum than flucloxacillin alone
Second-line or for non-lactational / mixed infection breast infections625mg TDS (500mg amoxicillin + 125mg clavulanate); with food; 7–14 days
✓ When co-amoxiclav is preferred
Subareolar (perinipple) abscess: often polymicrobial (anaerobes; Gram-negatives; S. aureus); co-amoxiclav provides broader coverage including anaerobes. Non-lactational mastitis: not always pure S. aureus; co-amoxiclav provides broader coverage. Diabetic or immunocompromised patient with mastitis: broader-spectrum coverage preferred. Breast abscess (post-drainage): maintain antibiotics until healing. Note: safe in breastfeeding.
✗ Contraindications
Penicillin allergy: do not use. Jaundice / hepatic impairment from previous co-amoxiclav: contraindicated (co-amoxiclav is the most common antibiotic cause of cholestatic jaundice). GI upset more common than with flucloxacillin — take WITH food (unlike flucloxacillin). Hepatotoxicity: rarely significant; if jaundice develops during course: stop and liver function tests.
⚠ Important note: non-lactational breast infection
Non-lactational breast infection in a woman who is not breastfeeding: always consider whether inflammatory breast cancer (IBC) could present similarly. IBC features: rapid growth; peau d’orange; does not respond to antibiotics; no fluctuant abscess. If non-lactational “mastitis” is not responding to co-amoxiclav at 5–7 days: urgent 2WW referral; do not continue antibiotics indefinitely without specialist assessment. Squamous carcinoma has been found within breast abscesses at surgery — any non-resolving breast lump post-abscess drainage requires biopsy.
🔬 Monitor
48–72 hour review. Temperature; erythema; lump. If not responding: USS (abscess); surgical referral; consider IBC if non-lactational. LFTs if prolonged course (>14 days) or if symptoms of hepatitis develop (jaundice; dark urine; pale stools; RUQ pain).
💬 Counselling
"Take this tablet three times a day with food — it is stronger than plain penicillin and works well for infections in this area. If you are not feeling better in 2–3 days, I want to know — please call us. And if you notice the skin getting redder, spreading, or a hard fluctuant area developing, come in or go to A&E the same day."
Co-amoxiclav: broader spectrum than flucloxacillin; preferred for non-lactational; perinipple; mixed-infection breast abscess. With food (unlike flucloxacillin). Key SCA teaching: non-lactational mastitis not responding to antibiotics — consider inflammatory breast cancer; do not continue treating empirically without specialist referral.
Evening Primrose Oil (GLA) — Cyclical Mastalgia
GLA (gamma-linolenic acid) 240–320mg daily · Efamol; EPO; evening primrose oil capsules · 3–6 month trial · OTC; not prescribable on NHS
✓ Cyclical mastalgia — modest evidence; safe; cheap; widely used; OTC supplement
Step 2 cyclical mastalgia — after reassurance and lifestyle; before prescription drugsGLA 240–320mg daily (usually 3–4 capsules EPO 500mg); 3–6 month trial; OTC; not prescribable NHS
✓ Role in cyclical mastalgia
Evening primrose oil contains gamma-linolenic acid (GLA); an omega-6 fatty acid. Proposed mechanism: GLA is a precursor to prostaglandin E1 (anti-inflammatory); women with mastalgia may have abnormal fatty acid profiles. Evidence: RCT evidence is inconsistent; NICE evidence review found insufficient evidence to recommend routinely; however meta-analyses suggest modest benefit; and it is widely used in practice. Benefits: safe; cheap; no serious adverse effects; does not interact with COCP; safe in pregnancy and breastfeeding. Limitations: not prescribable on NHS FP10; patient purchases OTC; takes 3–6 months for full effect.
✗ Limitations
Not prescribable on NHS — patient purchases OTC. Evidence is not strong — inform patient that the evidence is limited but the risk is low. Teratogenicity: may be associated with increased risk in animal studies — advise against use in pregnancy (conflicting evidence; cautious approach). Drug interactions: may increase anticoagulant effect of warfarin (modest interaction; monitor INR if on warfarin).
⚠ What to tell patients
“This is an OTC supplement — you can buy it at a pharmacy or health food shop. Take it for 3–6 months to judge whether it helps you. Most women with cyclical breast pain are reassured to know that it is not a symptom of cancer, and many find the pain reduces over time on its own or with this supplement. If it has not helped by 6 months, come back and we have stronger prescription options.”
🔬 Monitor
Pain diary: is cyclical pattern confirmed? Is pain reducing at 3 months? OSDI equivalent for mastalgia: VAS (Visual Analogue Scale) or Cardiff Breast Pain Chart. If not helping at 6 months: step up to danazol (prescription) or routine breast clinic referral.
💬 Counselling
"The reassuring thing first: breast pain is almost never cancer. The most common reason for cyclical breast pain is hormonal changes through the cycle. One supplement that some women find helpful is called evening primrose oil — it contains a type of fatty acid that may help with the sensitivity. You can buy it over the counter. Give it 3 months and keep a diary."
GLA / evening primrose oil: step 2 cyclical mastalgia; after reassurance + lifestyle; before prescription drugs. OTC (not NHS-prescribable). 3–6 month trial. Modest evidence but safe. SCA: offering GLA after adequate reassurance and lifestyle advice demonstrates knowledge of mastalgia management stepladder.
Danazol — Cyclical Mastalgia (Licensed)
Danazol 200mg OD · Licensed for cyclical mastalgia · Androgenic side effects · Contraception mandatory (teratogenic) · Minimum effective dose; minimum duration
✓ Severe cyclical mastalgia not responding to first-line — licensed; androgenic side effects; contraception mandatory
Step 3 cyclical mastalgia — prescription; after GLA fails; androgenic; teratogenic200mg OD (can titrate to 100mg OD if effective); minimum effective dose; minimum duration; contraception essential
✓ Mechanism and efficacy
Danazol is a synthetic androgen derivative. It inhibits pituitary gonadotrophin release → reduces LH and FSH → reduces oestrogen/progesterone cycling → reduces breast tissue hormonal stimulation. Efficacy: approximately 70% of women with cyclical mastalgia respond. Licensed in UK for cyclical mastalgia. Minimum effective dose: 200mg OD (some respond to 100mg OD); use lowest dose for shortest period. NICE recommends: if used, for the shortest effective period (typically 3–6 months).
✗ Androgenic side effects — mandatory counselling
Androgenic side effects: acne; hirsutism; weight gain; voice changes (may be irreversible — warn explicitly; deepening of voice is a reason to stop immediately). Menstrual irregularity (amenorrhoea). TERATOGENIC: causes virilisation of female fetus — effective contraception is mandatory throughout treatment and for several months after. Do NOT use in pregnant women or women planning pregnancy. Liver toxicity: rarely. Thrombotic risk: increased (VTE risk similar to COCP — UKMEC assessment before prescribing). Not for lactation.
⚠ Monitoring
LFTs before and during treatment (hepatotoxicity; peliosishepatis — rare). BP (androgenic effect on cardiovascular risk). Review at 3 months: significant improvement? If yes: attempt dose reduction to 100mg OD; plan discontinuation at 6 months. If voice changes: stop immediately (may be irreversible). Contraception confirmed at every review (barrier + hormonal or IUD; NOT COCP — danazol reduces COCP efficacy).
💬 Counselling — voice warning mandatory
"This tablet can cause some androgenic side effects — similar to male hormones — including skin changes and possibly irregular periods. The most important one to tell you about: in rare cases it can cause the voice to deepen slightly. If you notice any change in your voice at all — stop taking it and call us immediately, because that change could be permanent. Also: this tablet can harm a pregnancy — so you must use reliable contraception throughout."
Danazol: licensed for cyclical mastalgia; androgenic side effects; teratogenic (contraception mandatory; voice change warning = most important counselling point; may be irreversible — stop immediately if voice changes). Minimum dose; minimum duration. LFTs. SCA: prescribing danazol without voice change warning and contraception counselling = deduction.
Tamoxifen — Mastalgia (Unlicensed) & Breast Cancer Prevention & Shared Care
Tamoxifen 10mg OD (mastalgia — unlicensed) · 20mg OD (breast cancer adjuvant — licensed) · Endometrial cancer risk · DVT risk · PMB = urgent referral · Hot flushes
✓ Cyclical mastalgia (unlicensed; 10mg) or ER+ breast cancer adjuvant (licensed; 20mg) — PMB monitoring essential
Mastalgia: step 4 (specialist or shared care); Breast cancer: standard adjuvant (post-specialist initiation)Mastalgia: 10mg OD (unlicensed; off-label). Cancer adjuvant: 20mg OD; 5–10 years; monitor for PMB; DVT; hot flushes
✓ Role in mastalgia and cancer
For mastalgia: tamoxifen 10mg OD (off-label; not licensed for this indication in UK) reduces cyclical mastalgia significantly (RCT evidence); more effective than danazol with fewer androgenic effects. Used when danazol has failed or is not tolerated; typically in shared care with a breast clinic. For ER+ breast cancer: tamoxifen 20mg OD is the standard adjuvant endocrine therapy for pre-menopausal women with oestrogen receptor positive early breast cancer — reduces mortality by approximately 30%; reduces recurrence by approximately 50%. Duration: 5 years (standard); 10 years (ATLAS trial data in high-risk patients). GP role in shared care: prescribe; monitor; manage side effects; refer PMB or concerning symptoms.
✗ Critical monitoring points
Postmenopausal bleeding (PMB) in any woman on tamoxifen: URGENT gynaecology referral (endometrial cancer risk is approximately 2× background; absolute risk small but must be investigated promptly). DVT/PE risk: approximately 3× background; stop before elective surgery; thromboprophylaxis if prolonged immobilisation; no COCP or HRT with tamoxifen. Hot flushes: very common (70%); manage with venlafaxine; gabapentin; clonidine (not HRT — increases cancer recurrence risk). Pregnancy: tamoxifen is teratogenic; effective contraception essential. Stop tamoxifen before fertility treatment; discuss with oncologist.
⚠ Tamoxifen and eye side effects
Tamoxifen retinopathy (rare): visual disturbance; colour changes; report immediately; ophthalmology. More common: tamoxifen-related cataract (slightly increased risk after ≥5 years). Annual eye check in long-term users is reasonable.
🔬 GP monitoring in shared care
Annual mammogram (oncology or breast clinic arranges). Any PMB: urgent gynaecology (2WW). Any new thrombotic symptoms (unilateral leg swelling; pleuritic chest pain; breathlessness): same-day DVT/PE assessment. Annual liver function (tamoxifen very rarely causes hepatotoxicity in long-term use). Compliance support: 5–10 year course; fatigue; side effects are reasons for early discontinuation — discuss these at every annual review.
💬 Counselling — PMB is the critical message
"There is one thing I want to make absolutely clear about this tablet: if you ever have any bleeding from your vagina — even just spotting — call us immediately. It needs to be checked urgently. This tablet affects the lining of the womb and any bleeding needs to be looked at right away. Hot flushes are the most common side effect — we have treatments for those if they are troublesome."
Tamoxifen: PMB = URGENT gynaecology (2WW); DVT risk — stop before elective surgery; hot flushes (venlafaxine; NOT HRT — increases recurrence); teratogenic; 5–10 year compliance. SCA: not advising that PMB on tamoxifen requires urgent gynaecology referral = serious missed red flag.
Cabergoline / Bromocriptine — Hyperprolactinaemia / Galactorrhoea
Cabergoline 0.5mg twice weekly (first-line) · Bromocriptine 2.5mg BD–TDS (alternative; worse tolerated) · Endocrinology-initiated · GP continues in shared care
✓ Hyperprolactinaemia confirmed — specialist initiates; GP continues; MRI pituitary first; endocrinology referral
Specialist-initiated — after MRI pituitary and endocrinology assessment; GP prescribes in shared careCabergoline 0.5mg twice weekly (start; titrate up over weeks; endocrinology-guided). Bromocriptine 2.5mg BD–TDS alternative (worse GI tolerance)
✓ GP role: investigate; refer; do not initiate
GP role in galactorrhoea: (1) Check prolactin; TSH; pregnancy test; full drug history. (2) Identify drug causes (antipsychotics; TCAs; metoclopramide; domperidone; SSRIs at high doses; methyldopa; opioids; H2 blockers) — a drug cause is the most common cause and removing the drug may resolve galactorrhoea. (3) If prolactin is significantly elevated (>1000 mIU/L): MRI pituitary; endocrinology referral. (4) Endocrinology will initiate cabergoline (dopamine agonist — suppresses prolactin secretion). (5) GP continues prescribing in shared care. Cabergoline preferred over bromocriptine: twice-weekly dosing (compliance); better GI tolerability; more effective; lower cardiac valvulopathy risk at standard prolactinoma doses.
✗ Contraindications and monitoring
GI: nausea; vomiting (take with food; titrate slowly). Postural hypotension: particularly on starting; warn patient. Cardiac valvulopathy: at high doses used in Parkinson’s disease — at standard prolactinoma doses (0.5–2mg/week), risk is very low; baseline ECHO before initiating at higher doses. Fibrotic reactions (pleural; retroperitoneal) at high doses: monitor ESR; CRP; renal function; CXR. Pregnancy: women with prolactinoma who wish to conceive should discuss with endocrinology before stopping cabergoline. Cabergoline during pregnancy: generally stopped at confirmed conception unless macroadenoma.
🔬 GP monitoring in shared care
6-monthly prolactin: confirming normalisation. 6-monthly TSH. MRI pituitary at 6–12 months after starting treatment (tumour regression confirmed by endocrinology). Annual ECHO if dose escalated above 2mg/week. Drug history review at every consultation: has the causative drug been stopped? Is cabergoline dose appropriate? Attempt dose reduction after 2 years if prolactin normalised and MRI shows tumour regression.
💬 Investigation explanation
"I want to do a blood test to measure your prolactin level — that is the hormone that is involved in milk production. If it is elevated, we need to find out why — sometimes it is medication that causes it; sometimes it is a small change on the pituitary gland. If the level is significantly raised, I will arrange for you to have a brain scan and see a hormone specialist."
Galactorrhoea: GP role = investigate (prolactin; TSH; pregnancy test; drug history); identify drug cause (most common); refer to endocrinology if prolactin significantly elevated; MRI pituitary. Cabergoline: endocrinology initiates; GP continues in shared care. SCA: GP should not initiate cabergoline without endocrinology assessment and MRI pituitary result.
7G — Psychosocial impact
🧑️
The 2-week wait period and the investigation process have profound psychological impacts that the GP must acknowledge and address proactively
For most women, the period between GP referral and breast clinic appointment is characterised by intense anxiety; intrusive thoughts; and significant psychological distress. Even when the lump is benign, the investigation process itself has psychological costs. The GP must acknowledge this and provide specific, structured support — not just “try not to worry.”
Cancer Fear During the Wait
The 2-week wait is named for maximum diagnostic speed — but it is still 14 days of not knowing. Intrusive thoughts; checking the lump repeatedly; health-related internet searching; difficulty sleeping. The GP can provide structure: “If you notice the lump changing before your appointment — call us immediately. If the anxiety is affecting your sleep or your daily life — call us.”
"I want you to have our number as a resource — if the waiting is really getting on top of you, or if you notice any change before your appointment, please call us."Body Image and Identity
A breast lump investigation — and particularly any potential intervention (biopsy; surgery) — touches directly on femininity; body image; and sexual identity. Even during the investigation phase, before any diagnosis, the anticipatory grief about potential breast changes is real and valid.
"I know this process can feel quite personal and intrusive — the specialist team is used to supporting women through this, and you can always ask them about anything that worries you."Relationships and Disclosure
Mrs. Mitchell faces a decision about who to tell and when. Telling a partner or family before a diagnosis may cause unnecessary worry. Not telling anyone may lead to isolation. The GP can acknowledge this without directing the decision.
"Do you have someone who can come with you to the breast clinic appointment? Having support on the day can make a real difference — you do not have to go alone."Occupational Impact
Mrs. Mitchell is a teacher — the anxiety during the 2WW may affect her ability to concentrate; manage her class; and maintain professional performance. Acknowledge this: offer sick note if needed; support letter if she needs to take time off for appointments without disclosing the reason to her employer.
"If the appointments or the worry are affecting your ability to work — I can write a letter or a sick note without necessarily stating what the appointments are for."Confirmed Cancer — Emotional Impact
If the triple assessment returns a cancer diagnosis: the GP has a critical role in supporting the patient through the initial diagnosis period. Breaking bad news from a referral result letter — never by leaving a message; always face-to-face or by phone if face-to-face is not possible.
"When your result comes through — whatever it shows — I want you to come in and see me so we can go through it together, whatever it says."Prognosis and Hope
If the lump is benign: the reassurance must be specific. “The specialist team has confirmed this is not cancer — it is a fibroadenoma; a benign growth.” If cancer: early breast cancer has excellent outcomes. “The fact that you came in promptly means this has been found at an early stage — and early breast cancer is highly treatable.”
"Most women who go through the breast clinic — even those who are anxious like you — are told their lump is benign. I hope that is what you will hear."7H — Follow-up
T
Today — 2WW referral sent; cancer anxiety addressed; breast awareness; family history
2WW referral made (cancer pathway not delay pathway). Clinical description documented in letter. Family history assessed (no high-risk features today). COCP documented in referral. Breast awareness advice given. Anxiety support: what to do during the wait; when to call us; who to tell. PHQ-9 / GAD-7 if anxiety significant. Safety-net: if lump changes; if anxiety worsening — call us.
2
Post-breast clinic — result review and plan
After breast clinic appointment: Mrs. Mitchell returns with the result letter. If benign (B2/U2): reassure; breast awareness; routine follow-up (may include short-interval surveillance USS for certain fibroadenoma). If B3 (probably benign): explain plan (short-interval imaging; possible surgical excision). If B4/B5 (suspicious/malignant): break news sensitively; explain MDT process; oncology support; Macmillan referral; shared care plan.
3
Annual breast awareness check — encourage screening when eligible
Mrs. Mitchell will enter the NHS Breast Screening Programme at approximately age 50. Annual health check: breast awareness; COCP review (discuss breast cancer risk in context of continued use; shared decision); alcohol; BMI. Annual family history update (new family members diagnosed with breast or ovarian cancer). PHQ-9 if any residual cancer anxiety.
4
If mastalgia: 3–6 month mastalgia review
Pain diary: confirming cyclical pattern; assessing improvement. GLA: improvement at 3 months? If not: step up to danazol (with contraception; voice warning). Cardiff Breast Pain Chart if available. If mastalgia persists beyond 6 months: routine breast clinic referral. Assess COCP contribution: is cyclical mastalgia better or worse since starting COCP?
5
If mastitis: 48–72 hour review; end-of-course check
48–72 hours: temperature resolving; erythema improving; breastfeeding continuing? If not improving: abscess USS; antibiotic review; MRSA swab; surgical referral. End of 10–14 day course: infection resolved? Breastfeeding established? Any residual lump post-infection: recheck at 4–6 weeks (post-mastitis lump may be fat necrosis; granuloma — but must not be assumed benign without follow-up; refer if persistent).
7I — Monitoring
BREAST monitoring mnemonic
Biopsy result received and acted upon (2WW result documented; plan enacted). Reassurance specific (“most are benign” — not “don’t worry”). Exclusion of red flags (skin; nipple; axillary; discharge). Anxiety addressed (structured support; PHQ-9/GAD-7; NHS Talking Therapies if needed). Screening at 50–71 years (encourage uptake; address barriers). Tamoxifen PMB: urgent gynaecology at any vaginal bleeding on tamoxifen.
7J — Safety-netting
⚠ Three critical safety-nets
🔴 Emergency — changes in the lump before the appointment
"If anything changes before you get to the breast clinic — the lump gets bigger quickly; you notice skin changes over the lump such as redness or dimpling; any nipple changes or discharge — call us immediately and we will escalate your referral. Do not wait for your appointment."
Inflammatory breast cancer; rapidly progressive malignancy; or abscess may develop in the 2-week wait period. Explicit criteria for escalation gives Mrs. Mitchell agency and prevents “I didn’t want to bother you.”
💊 Appointment — if you haven’t heard within 2 weeks
"The breast clinic will contact you within 2 weeks with an appointment. If you have not received anything by [date 14 days from today] — please call us immediately and we will chase it. Do not assume ‘no news is good news’ if the appointment has not arrived."
2WW referrals occasionally fall through administrative gaps. Giving a specific date (14 days) with an explicit instruction to call if not received is a medico-legal safety-net and reduces the risk of delayed diagnosis from administrative failure.
🟠 Anxiety — if the waiting is overwhelming
"The next 2 weeks can be very hard when you are worried. If the anxiety is really affecting your sleep or your daily life — please call us or book in to see me. You do not have to wait. And please do try to avoid spending too much time searching online — the information there is almost always alarming and not specific to your situation."
Unaddressed 2WW anxiety can lead to panic; unnecessary urgent presentations; and poor engagement with the breast clinic result. Providing a specific action (call or book in) gives the patient an outlet other than health anxiety spirals.
Documentation requirements
2WW referral made and date confirmed; reason documented: “Age 42; unexplained 2 cm breast lump LUQ; NICE NG12 criteria met”
Clinical description documented: “Left UOQ; 10 o’clock; 2 cm; smooth; firm; mobile; non-tender; well-defined margins; no skin changes; no nipple discharge; no axillary lymphadenopathy”
Chaperone offered and accepted (or declined — document decision)
Family history assessed: “No first-degree family history of breast or ovarian cancer; familial cancer service referral criteria not met today”
Safety-net: “Patient advised to call immediately if: lump changes; skin changes; nipple changes before appointment. Advised to call if 2WW appointment not received by [date].”
Anxiety acknowledged and support offered; PHQ-9 / GAD-7 result documented; NHS Talking Therapies referral if indicated
ImmediatelyLump changes; skin/nipple changes — call us to escalate referral
14 days2WW appointment letter should have arrived; chase if not
Post-clinicBook GP appointment when result received; go through together
🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills
Closing consultation
"Let me summarise what we have done today. I have examined the lump carefully and I have noted everything down so the breast clinic have a clear picture. I cannot tell from the examination alone whether this is benign or not — and I would not be telling you the truth if I said I could. That is what the specialists are for."
"I am making the referral right now — you will be seen within 2 weeks. If you have not heard anything by [date], call us. And if anything changes before your appointment — the lump changes; any skin changes; any discharge — call us immediately."
"The majority of women referred on this pathway are told their lump is benign — but the way to know for certain is the test, not hoping for the best. You have done the right thing coming in promptly."
"Is there anything you want me to explain again? And is there anything else you need from me today before you go?"
Deductions
- Cancer anxiety not acknowledged — opening with clinical questions without addressing the fear
- 2WW referral not made — the single most important action; not discretionary
- “It feels like a fibroadenoma — I don’t think you need the cancer pathway” — clinical diagnosis not possible in primary care; 2WW is mandatory at age 30+
- GP mammography / USS ordered instead of 2WW — delays specialist assessment
- Chaperone not offered for intimate examination
Tasks summary
- NICE NG12: 2WW criteria met (age 42; unexplained lump)
- 2WW referral made with full clinical description
- Red flag features assessed (skin; nipple; axillary; discharge)
- Family history assessed; familial service criteria considered
- Triple assessment concept explained (not GP diagnosis)
- Safety-net: lump changes; appointment timing; anxiety
Relating to Others
- Cancer fear named and acknowledged
- ICE: ideas; concerns; expectations all explored
- “Most are benign — but we need to confirm properly”
- 2WW explained as diagnostic (not cancer) pathway
- Anxiety support during the wait; specific actions given
🔴 Red
Cancer fear not acknowledged; 2WW not made; “probably benign” without triple assessment; GP imaging ordered instead; chaperone not offered; family history not assessed; skin/nipple/axillary not examined; safety-net absent
🟠 Amber
2WW made; anxiety partially acknowledged; lump described in referral; skin/nipple not examined; family history not assessed; COCP not documented in referral; 14-day safety-net not explicit; triple assessment not explained
🟩 Green
Cancer fear acknowledged; ICE fully explored; chaperone offered; examination complete; NICE NG12 criteria articulated; 2WW made with clinical description; triple assessment explained; COCP in referral; family history assessed; anxiety support + NHS Talking Therapies; safety-net (lump changes; 14-day appointment; anxiety access); closing question
Breast Disorders — SCA Consultation Scorecard
NICE NG12 · 2WW (age ≥30 + unexplained lump) · Triple assessment explained · Cancer anxiety addressed · Chaperone · Family history · Skin/nipple/axillary · Do not order GP imaging
0/ 33 pts
Global Skills
Safety; communication; examination
0/7
Tasks
Clinical reasoning; referral; red flags
0/15
Relating to Others
Empathy; communication; breaking news sensitively
0/11
RAG Self-Assessment
🔴 Red
Cancer fear not acknowledged; 2WW not made; “probably benign” without triple assessment; GP imaging ordered instead; chaperone not offered; skin/nipple/axillary not examined; family history not assessed; safety-net absent
🟠 Amber
2WW made; anxiety partially acknowledged; lump described; skin/nipple not systematically examined; family history not assessed; COCP not documented; 14-day safety-net not specific; triple assessment not explained; chaperone not documented
🟩 Green
All: cancer fear named and acknowledged; ICE fully explored; chaperone offered and documented; systematic examination; NICE NG12 2WW made with description; GP imaging not ordered; triple assessment explained; COCP in referral; family history; anxiety support; NHS Talking Therapies if needed; breast awareness; 14-day safety-net; closing question
Complete the checklist to see your score and feedback
"I found a lump in my left breast about 4 weeks ago — I was in the shower and I just felt it. I’ve been putting off coming in but I’m scared it might be cancer. My friend had a breast lump 2 years ago and it turned out to be nothing — but I just can’t stop worrying about it."
Who you are
Sarah Mitchell, 42, secondary school English teacher. Healthy; no significant PMH. Microgynon 30 (COCP) for contraception. No family history of breast cancer. No nipple discharge; no skin changes that she has noticed. Non-smoker; alcohol 8 units/week; BMI 24. Lump: left breast; 2 cm; noticed self-examination; 4 weeks ago.
Hidden agenda — disclose only if doctor creates space
Cancer fear (disclose if asked what worries her most): “My mum died of ovarian cancer 5 years ago. I know that’s not the same as breast cancer — but I have this constant fear that something similar is happening to me.” This maternal history should prompt the GP to ask about breast cancer specifically in family members — the patient will clarify that the mother had ovarian cancer; no known breast cancer in FDRs.
Obsessive checking (disclose if asked about behaviour since finding lump): “I’ve been checking it every day — sometimes twice a day. I know I probably shouldn’t but I can’t help it.”
Responses to key conversations
- If GP says “it feels benign” and doesn’t refer: Initially relieved, but as patient asks follow-up questions she reveals she is not fully reassured: “But how can you be sure? Is there a test you can do?”
- On the 2WW referral: “The cancer pathway? Does that mean you think it IS cancer?” — Respond well to explanation that it is a diagnostic pathway; most are not cancer.
- On triple assessment needle test: “A needle? That sounds really scary.” — Respond well to “it sounds worse than it is — local anaesthetic; takes seconds; you get the results the same day usually.”
Clinical details
- Left UOQ; approximately 2 cm; smooth; firm; mobile; non-tender when examined
- No skin changes; no peau d’orange; no tethering or dimpling visible on inspection
- No nipple discharge; no nipple retraction
- No palpable axillary lymphadenopathy
- Anxious; slightly tearful; GAD-7 likely 10–12 if administered
"When you said 2-week wait — does that mean you think it’s cancer? Why else would you refer me so urgently?"
Ideal GP response: “No — the 2-week wait referral is a guideline for any new breast lump in a woman your age, because we want you to be seen by specialists within 2 weeks — not because we think it IS cancer. The way I explain it: the 2WW is the fast track to getting the answer. Most women who go through it are told their lump is benign. But the only way to know for certain is the three-part assessment at the breast clinic.” Mrs. Mitchell: “OK — I feel better knowing it’s about getting the right answer, not because you think the worst. Thank you for explaining that.”
Clinic Quick Reference
Breast Disorders — Clinical Decision Framework
NICE NG12 · 2WW age ≥30 · Triple assessment · Do not GP-image · Mastitis: flucloxacillin + continue breastfeeding · Mastalgia stepwise · Family history: NICE CG164 · Tamoxifen: PMB = urgent
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💊 1 — Breast Triage Algorithm
Breast presentation → Exclude emergency → 2WW criteria (NICE NG12)? → Refer or manage in GP
🔴 Emergency / Same-Day
- Inflammatory breast cancer (peau d’orange; rapid growth; non-response to abx)
- Breast abscess (fluctuant; antibiotic failure; same-day surgical)
- Paget’s disease of nipple (do not treat as eczema)
- Spinal cord compression in breast cancer patient
Same-day oncology / surgical discussion
🟠 2-Week Wait (NICE NG12)
- Age ≥30: unexplained breast lump ± pain
- Any age: blood-stained unilateral nipple discharge
- Any age: skin changes (peau d’orange; tethering; erythema; dimpling)
- Any age: nipple changes (new retraction; inversion; distortion)
- Any age: unexplained axillary lump; woman ≥50 unilateral discharge
2WW referral — do not order GP imaging first
🟩 GP-managed
- Cyclical mastalgia; no lump; normal exam: reassurance + GLA; stepwise
- Lactational mastitis: flucloxacillin; continue breastfeeding
- Gynaecomastia with identifiable drug cause
Primary care management; refer if not responding
📊 2 — Key Clinical Numbers
Age ≥30 + lump = 2WW
Regardless of clinical features. Never say “it feels benign” as a reason not to refer. Clinical palpation cannot diagnose or exclude breast cancer.
Do NOT order GP imaging
GP-requested USS/mammography delays specialist assessment. 2WW provides triple assessment in specialist setting. Ordering GP imaging instead = incorrect management.
Triple assessment: 3 components must agree
Clinical + imaging (B/U 1–5) + histology (B/C 1–5). All three reported benign = benign diagnosis. Discordant = excision or repeat biopsy.
Mastitis: continue breastfeeding
Most important non-drug intervention. Stopping = milk stasis = abscess. Flucloxacillin 500mg QDS 10–14 days. 48–72h review.
Blood-stained unilateral discharge = 2WW
Any age; intraductal papilloma most likely; DCIS and cancer must be excluded. Bilateral milky: galactorrhoea — prolactin; TSH; drug history.
Tamoxifen PMB = urgent gynaecology
Any vaginal bleeding on tamoxifen = 2WW gynaecology (endometrial cancer risk). DVT risk: stop before elective surgery. Hot flushes: venlafaxine NOT HRT.
NHS Breast Screening: 50–71; 3 years
Extending to 47–73 (AgeX trial areas). Encourage uptake. Symptomatic women: refer regardless of screening status.
Mastalgia: 95% benign
Cyclical: reassurance + pain diary + GLA. Severe: danazol (voice change warning; contraception mandatory). Most resolves spontaneously within 3 months.
Fibroadenoma <35: “breast mouse”
Smooth; mobile; firm; well-defined. Most common benign lump <35. Still requires triple assessment — phyllodes tumour clinically indistinguishable.
Familial: FDR <40 = refer
FDR <40; bilateral; male breast; breast+ovarian; Ashkenazi Jewish → familial cancer service (NICE CG164). Do NOT order BRCA without genetic counselling.
Danazol: voice change = stop
Licensed for cyclical mastalgia. Androgenic: acne; hirsutism; voice changes (may be irreversible — stop immediately if voice changes). Teratogenic: contraception mandatory.
Chaperone: mandatory for breast exam
GMC guidance: offer chaperone; document offer and outcome (accepted or declined). Never examine breasts without offering a chaperone.
⚠ 3 — BREAST Monitoring
| BREAST | Parameter | Timing | Action |
|---|---|---|---|
| Biopsy result | 2WW result received and acted upon? | Post-appointment (2–3 weeks) | Benign: reassure; breast awareness. B3: surveillance plan. B4/B5: break news; shared care; Macmillan; oncology. |
| Reassurance | Anxiety resolved post-result? PHQ-9? | Post-result visit | Persistent anxiety: NHS Talking Therapies; CBT; breast cancer charities. |
| Exclusion (red flags) | Skin; nipple; axillary; discharge assessed? | Every breast consultation | Any new red flag post-benign diagnosis: urgent 2WW or same-day. |
| Anxiety | GAD-7; NHS Talking Therapies; support during 2WW? | At referral; post-result | GAD-7 ≥8: NHS Talking Therapies; CoppaFeel; Breast Cancer Now support. |
| Screening | Eligible (50–71)? Uptake? | Annually from 47–50; every 3 years 50–71 | Not attending: address barriers; encourage; ensure GP-registered for invite. |
| Tamoxifen PMB | Any vaginal bleeding on tamoxifen? | Every review; any between consultations | PMB: urgent 2WW gynaecology immediately. |
SCA Exam Quick Reference
Breast SCA — Acknowledge cancer fear · 2WW (not GP imaging) · Triple assessment · Chaperone · Red flags · Family history · Anxiety support · 14-day safety-net
NICE NG12 · Mrs. Mitchell: 42; unexplained 2cm lump · COCP · Anxious · No red flags · 2WW + explanation · BREAST mnemonic
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💬 Opening & ICE
Opener — acknowledge cancer fear first: “I can hear how worried you are — finding something new in your breast is genuinely frightening. Tell me in your own words when you found it and what it feels like.”
ICE — Ideas: “What do you think it might be?”
ICE — Concerns: “I suspect cancer is the worry you are carrying. What is the worst scenario in your mind?”
ICE — Expectations: “What were you hoping would happen today?”
Triple assessment explanation: “What the specialists will do is called triple assessment — examination; scan; needle sample. All three together give the definitive answer. I cannot give you that from examining the lump.”
2WW challenge response: “The 2WW is a diagnostic pathway — not a cancer diagnosis. Most people referred do not have cancer — but the only way to know is the specialist tests.”
✅ Key SCA Tasks (15pt)
2WW referral made (2pt): NICE NG12: age 42 + unexplained lump = 2WW. Non-negotiable. Full clinical description in letter. Reason: “Age ≥30; unexplained breast lump; NICE NG12.”
Examination with chaperone (2pt): Inspection (3 positions); palpation (systematic; all quadrants); axillae; nipple. Chaperone offered and documented.
Red flags assessed (2pt): Skin changes; nipple changes; discharge; axillary lymphadenopathy — all asked AND examined. All documented.
Family history assessed (2pt): FDRs with breast or ovarian cancer. High-risk criteria (NICE CG164) considered. Familial cancer service if criteria met.
GP imaging NOT ordered (2pt): Actively deciding not to order USS/mammography — 2WW provides triple assessment. Documented.
COCP in referral (1pt): Microgynon 30 documented in referral letter.
Breast awareness (1pt): Positive reinforcement; screening at 50; NHS BSP.
PHQ-9/GAD-7 (1pt): Anxiety assessed; NHS Talking Therapies if ≥8.
14-day specific safety-net (1pt): “If no letter by [date] — call us.”
🔴 Not making 2WW referral = most serious SCA fail
🔴 GP imaging instead of 2WW = incorrect management
🔴 Chaperone not offered = GMC documentation fail
👥 Relating to Others (11pt)
Cancer fear acknowledged first (1pt): Before clinical questioning; specific; not generic
ICE: Ideas (1pt): What she thinks the lump might be
ICE: Concerns — cancer named directly (1pt): Not euphemistic; direct and compassionate
ICE: Expectations (1pt): What she hoped; linked to triple assessment explanation
Self-examination positively reinforced (1pt): “You did exactly the right thing”
Honest reassurance (1pt): “Most are benign — but we need to confirm properly”
2WW explained as diagnostic (1pt): Not cancer pathway; most are not cancer
Anxiety support specific (1pt): Avoid internet; maintain routine; call if worsening
Support offered — accompaniment to clinic (1pt): “Do you have someone who can come with you?”
What to expect at breast clinic (1pt): Demystifies; needle test explained (sounds worse than it is)
Closing question + pause (1pt): Mrs. Mitchell: “What if it IS cancer?” — answered honestly
🟩 Mrs. Mitchell: “Thank you for explaining that — I feel better knowing there’s a plan.”
💊 Breast Quick-Pick