RCGP SCA Algorithm — UK Primary Care
Most breast symptoms are benign, but the referral decision is made on age and examination findings — not on how benign the lump feels. If an NG12 criterion is met, refer first; do not arrange imaging first.
NICE NG12 (updated April 2026) sets the breast criteria by age: an unexplained lump at 30 and over, or a change of concern in one nipple at 50 and over, warrants a suspected cancer pathway referral; skin changes and an unexplained axillary lump at 30 and over warrant consideration of one. The criteria apply to men as well as women.
Inflammatory breast cancer is easily mistaken for mastitis — a red, swollen, peau d'orange breast in a woman who is not lactating, or one that fails to settle with antibiotics, needs specialist assessment. Breast cancer is the commonest source of metastatic spinal cord compression; new back pain in a patient with a breast cancer history needs a low threshold for urgent assessment.
Spontaneous, single-duct, one-sided or bloodstained discharge is pathological; bilateral, multi-duct discharge produced only on squeezing is usually physiological. Galactorrhoea (milky, bilateral) needs a pregnancy test, prolactin and drug review rather than a breast referral. Screening mammography is for women without symptoms — a woman with a new symptom needs a symptomatic referral even if her last screen was recent.
Benign and malignant lumps cannot be reliably told apart clinically — a smooth, mobile lump in a woman over 30 still needs triple assessment. A careful description lets the breast team and any later GP compare. Testicular examination in a man with gynaecomastia screens for a hormone-secreting testicular tumour.
One-stop breast clinics are designed to complete triple assessment at the first visit. Ultrasound is preferred under 40 because dense breast tissue limits mammography. In men, gynaecomastia bloods screen for liver, thyroid, gonadal and tumour causes; a raised hCG suggests a germ-cell tumour.
Age is the biggest single discriminator: under 30, breast cancer is rare and fibroadenoma is common, which is why NICE uses age 30 as the lump threshold. Even so, a young woman with a lump that is hard, fixed, enlarging, or with a strong family history needs prompt specialist assessment on clinical judgement.
The NHS Faster Diagnosis Standard expects cancer to be diagnosed or ruled out within 28 days of a suspected cancer referral. Keep NICE's wording: "refer" for a lump at 30 and over and nipple change at 50 and over, "consider" for skin changes and axillary lumps. Many breast services also accept non-urgent symptomatic referrals for under-30s — follow your local pathway.
Next steps: see Benign breast disorders · Breast cancer · Mastitis and breast abscess
Effective milk removal is the core treatment of lactational mastitis — stopping feeding on the affected side increases the risk of abscess. Flucloxacillin is safe in breastfeeding. Repeated antibiotic courses for a breast that will not settle delay the diagnosis of abscess and inflammatory breast cancer.
Breast awareness is preferred over formal monthly self-examination — the aim is prompt reporting of change. Alcohol, post-menopausal obesity and inactivity are the main modifiable risk factors for breast cancer.
Failure to follow up referrals is a recurrent theme in delayed cancer diagnosis. Document examination findings, the chaperone offer, the referral route and the safety-net advice.