🔑 Key Learning

  • Most common cancer in women; may present with painless breast lump or nipple/skin changes
  • Non-invasive types (DCIS, LCIS) have not breached basement membrane; invasive ductal carcinoma is most common overall
  • Paget’s disease and inflammatory breast cancer are rare but often signify underlying malignancy
  • Risk factors: BRCA mutations, early menarche, late menopause, nulliparity, hormonal medications
  • Diagnosis via triple assessment: clinical exam, imaging (US/mammogram), biopsy
  • Screening: mammography every 3 years for women aged 50–70

🧬 Classification

Non-invasive (pre-malignant)

Non-invasive breast cancer - cancer cells have not invaded the basement membrane. They are commonly referred to as pre-malignant, and are at risk of progression into invasive breast cancer. 

  • Ductal carcinoma in situ (DCIS) – from ductal epithelial cells
  • Lobular carcinoma in situ (LCIS) – from lobular epithelial cells

Invasive

  • Invasive ductal carcinoma – most common
  • Invasive lobular carcinoma

Rare types

  • Paget’s disease of the nipple – dry, scaly, itchy ulceration of nipple; often linked to underlying carcinoma
  • Inflammatory breast cancer – aggressive, erythematous, oedematous, painful breast due to lymphatic obstruction

⚠️ Risk Factors

  • Genetic – BRCA1/2 mutations (↑ 40% lifetime risk)
  • Family history
  • Menstrual – early menarche, late menopause
  • Reproductive – nulliparity or late first pregnancy (>30)
  • Hormonal – COCP, combined HRT

👀 Clinical Features

  • Breast lump – painless, hard, irregular, tethered
  • Axillary lymphadenopathy
  • Nipple changes – discharge, retraction, bleeding, Paget’s appearance
  • Skin changes – dimpling, puckering, peau d’orange

📤 Referral (2WW criteria)

  • Breast lump in age >30
  • Unexplained axillary lump in age >30
  • Age >50 with unilateral nipple changes
  • Peau d’orange or other suspicious skin changes
  • <30 with lump – consider non-urgent referral

🧪 Assessment: Triple Assessment

  1. History & examination
  2. Imaging
    • <40: Ultrasound - due to denser breast tissue making mammography less sensitive
    • 40: Mammogram (2 views)
  3. Biopsy – core biopsy or FNA

💊 Management

Surgery

  • Wide local excision
  • Mastectomy
  • Sentinel lymph node biopsy

Chemotherapy & Radiotherapy

  • Used in neoadjuvant or adjuvant settings

Hormonal therapy

  • Tamoxifen (ER+ premenopausal): blocks oestrogen receptors
    • SEs: hot flushes, VTE risk, menstrual disturbance
  • Aromatase inhibitors (postmenopausal – anastrozole, letrozole): block peripheral conversion to oestrogen

Biological therapy

  • Trastuzumab (Herceptin) – monoclonal antibody for HER2+ BC
    • Cardiotoxic - echocardiogram before, during and after 

🧬 Screening & Family History

NHS Breast Screening

  • Women aged 50–70
  • Mammography every 3 years

Specialist referral for family history if:

  • 1st-degree relative with BC <40
  • 1st-degree male relative with BC
  • 1st-degree relative with bilateral BC (first <50)
  • One BC and one ovarian cancer case in the family
  • Three 1st/2nd degree relatives with BC at any age

🔄 Differentials

💧 Breast cyst

  • Smooth, fluid-filled, painful
  • Size typically varies with cycle

🧀 Fibroadenoma

  • Common in young women (20-30)
  • Discrete, rubbery, firm and non tender
  • Highly mobile, so sometimes referred to as “breast mouse”

💥 Fat necrosis

  • A fibrotic lump which occurs following trauma to the breast
  • More common in obese women 

🦠 Breast abscess

  • A painful, inflamed lump with systemic upset such as fever, malaise, SIRS
  • Commonly occurs during breastfeeding
  • Examination - erythematous, warm and tender to touch 

📆 Cyclical breast pain

  • Hormone related breast pain - presents with pain which starts within 2 weeks of menstruation, gradually increases and then improves once period begins
  • Pain is usually bilateral 
  • Management - simple analgesia (paracetamol +/- ibuprofen) 

📝 Exam Clues & Clinchers

  • Painless breast lump in woman >30 → 2WW referral
  • Peau d’orange, nipple retraction, axillary nodes → refer! ?invasive carcinoma
  • Erythematous, scaly nipple → Paget’s disease of the nipple
  • Hot, painful lump while breastfeeding → breast abscess
  • Rubbery, mobile lump in young woman → fibroadenoma
  • Fat necrosis → trauma history, obese woman
  • Family history of early BC or male BC → refer to genetics

🔗 Useful Links and References

NICE CKS. Breast cancer - managing FH [2018]. Available at URL: https://cks.nice.org.uk/topics/breast-cancer-managing-fh/management/breast-cancer-managing-fh/