Breast disorders in primary care (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • HHSCP only
  • Primary Care
  • Adults

 

Symptoms and signs

Breast symptoms are a relatively uncommon presentation in primary care. It is estimated that between 0.35% and 0.6% of all consultations in Scotland are for breast symptoms. Many of these consultations will be in young women, whereas the biggest risk factor, after gender, is increasing age. Incidence of breast cancer in women aged 30-35 is 33 per 100,000 population and approximately 81% of breast cancers occur in women over the age of 50.

Breast cancer accounts for 30% of cancers in women and around 4,400 people are diagnosed with breast cancer in Scotland each year; approximately 20 of these are men. The following recommendations seek to improve the referral and effective management of breast symptoms in women and men in primary care.

Guidance for referral to regional genetics centres for those with a family history of breast cancer is available at: Cancer Genetic Services Scotland

GP manageable conditions and when to refer

Conditions that can be managed in general practice:

  • Women with breast pain who do not have a discrete palpable lesion
  • Women with transient nipple discharge which is not serosanguinous (clear yellow liquid with or without red blood staining)
  • Obvious simple skin lesions such as epidermoid (sebaceous) cysts

Healthcare Improvement Scotland have recently published updated guidelines and advice for breast disease and the referral of patients with suspected breast cancer to secondary care.

The Main Features of this group will be:

  • A discrete lump
  • Definite signs of cancer such as;
    • ulceration
    • skin nodule
    • skin distortion or change of contour
  • Inflamed breast in post-menopausal women
  • Eczematous nipple
  • Serosanguinous nipple discharge

A link to the document can be found here: Scottish Referral Guidelines for Suspected Cancer

If you suspect that your patient has breast cancer you should make an "Urgent Suspected Cancer" referral otherwise refer “Routinely”.

It is important that you should only use the classification "Urgent Suspected Cancer" for those patients whose symptoms are highly suggestive of breast cancer as advised in the guidelines.

Other presentations of breast cancer are much less common. Inflammatory Cancers can present with appearances mimicking a breast abscess. However, Non cyclical Breast Pain is an exceedingly common symptom, often musculo-skeletal and referred to the breast rather than due to breast disease and does not confer any increased risk of or is it associated with a diagnosis of breast cancer in the absence of any of the features mentioned above – As such breast pain is now rarely seen in secondary care. There is an extended section on breast pain including a video. Breast pain pathway update | Right Decisions

Advice on the following conditions is contained in these guidelines and within the healthcare improvement Scotland national guidelines.

Please see the section on Good Practice Points Breast cancer | Right Decisions

Please see the section on common breast conditions with advice on management when USC and routine breast clinic referral may not be indicated Breast pathways | Right Decisions

Advice on the following conditions is contained in these guidelines and within the healthcare improvement Scotland national guidelines.

Condition Urgent suspicion of cancer referral Routine referral Primary care management
Breast lump
  • Any new discrete lump (in patients over 30 years)
  • New asymmetrical nodularity that persists at review after two to three weeks (in patients over 35 years)
  • Unilateral isolated axillary lymph node in women persisting at review after two to three weeks
  • Recurrent lump at the site of a previously aspirated cyst
  • Any new discrete lump in patients under 30 years with no other suspicious features
  • New asymmetrical nodularity that persists at review after two to three weeks
  • Women with longstanding tender lumpy breasts and no focal lesion
  • Tender developing breasts in adolescents
Nipple symptoms
  • Nipple discharge that is serosanguinous (clear yellow liquid with or without red blood staining)
  • New, unilateral, and non-reversible nipple retraction
  • Persistent discharge sufficient to stain outer clothes
  • Transient nipple discharge which is not bloodstained
  • Only check prolactin levels when copious white discharge present
  • Longstanding nipple retraction
  • Nipple eczema if eczema present elsewhere
Skin changes
  • Skin tethering and/or fixation
  • Unexplained, new breast ulceration
  
  • Obvious simple skin lesions such as sebaceous cysts
Abscess / infection
  • Abscess, mastitis or breast inflammation which does not settle or recurs after one course of antibiotics 
  

Breast pain

  

 
  • Women with moderate degrees of breast pain and no discrete palpable lesion. (Tenderness is not an indication of a palpable lump or reason for referral)
  • If the pain is clearly originating in rib or intercostal tissue, as indicated by point tenderness on the chest wall, then this should be managed in primary care as musculoskeletal pain.
    Referral for Patient reassurance is not required.
Gynaecomastia A specific lump within the male breast tissue (rather than generalised breast swelling) or other features of concern (such as nipple inversion, nipple discharge or distortion) requires referral to the breast unit.
  • Examine and exclude abnormalities such as lymphadenopathy or evidence of endocrine condition
  • Review to exclude drug causes
  • Exclude or treat any endocrine cause prior to referral Measure hormones (oestrogen, testosterone, prolactin, human chorionic gonadotropin and alpha-fetoprotein)
  • When an obvious cause of gynecomastia is present, further investigation is not necessary. Reassure

Editorial Information

Last reviewed: 07/07/2026

Next review date: 07/07/2029

Author(s): Breast Surgery.

Version: 3

Approved By: TAM subgroup of the ADTC

Reviewer name(s): N Abbott, Consultant Breast Surgeon.

Document Id: TAM113

References

Further information for patients: