Question

In which cases should the general practitioner refer the patient to other specialists?

Recommendation

The general practitioner refers the patient to a breast care team or breast clinic if clinical breast examination yields the following symptoms:

  • Signs of malignancy
  • Local palpable abnormality with a suspicious mammogram
  • Persistent complaints (3 months) with a non-suspicious mammogram:
    • Local palpable abnormality
    • A lump felt by the patient
    • Local pain or sensitiveness in one breast
  • Brown or bloody nipple discharge

 

It is sufficient for the general practitioner to refer the patient to a radiology department:

  • Localised palpable abnormality without signs of malignancy
  • A lump felt by the patient without signs of malignancy
  • Localised pain or sensitiveness in one breast without signs of malignancy
  • Diffuse lumpy breast tissue with complaints of mastopathy

 

If no abnormalities are found on clinical breast examination, then nipple discharge that is not brown or bloody and diffuse pain in both breasts is not an indication for imaging.

 

Mastopathy is not a radiological diagnosis.

Literature summary

Criteria for referral of symptomatic patients by the general practitioner to the second-line

The guideline development group has decided to adopt the referral criteria from the NHG Standard 2008 [de Bock NHG, 2008].

 

In first instance, women with breast complaints turn to the general practitioner. He/she should pay attention to each complaint with a focused medical history and clinical breast examination. Given the frequent occurrence of a familial history in the case of breast cancer, each woman should be asked for possible occurrence of breast cancer in the maternal or paternal branch (see 1.3.2, Table 1). The nature of complaints as well as the age of the woman plays a role in determining further steps to be taken. The urgency for additional examination and referral is therefore greater with older women than younger women. Classification in one of the following categories can be made on the basis of the nature of the complaints, from which further actions can be undertaken:

Local complaints or abnormalities

-          If there are signs of malignancy (irregular or poorly defined tumour margins, tumour that is stuck to the skin/and or sublayer, scaling or eczema of the nipple (and not only the areola), skin and/or nipple withdrawal, regional lymph node swelling, non puerperal mastitis that does not heal rapidly): refer directly to the breast clinic.

-          If there is a local palpable abnormality without indications of malignancy and an age of 30 years or older: perform a mammogram. In young women an ultrasound is sufficient, unless the abnormality has disappeared in another phase of the cycle.

  • If the result is suspect: refer to the breast clinic
  • If the result is benign: follow-up after 3 months. If the palpable abnormality remains or increases in size: refer to the breast clinic

-          The woman feels a lump, the general practitioner does not: check after 2 weeks. If the woman continues to feel something: perform a mammogram (an ultrasound in women younger than 30). If complaints persist: refer to the breast clinic

-          If there is local pain or sensitiveness in one breast: check after 2 weeks and, if complaints persist, after 3 months; if complaints persist: perform a mammogram. If pain persist 3 months after a negative result in mammogram: refer to the breast clinic

Diffuse complaints or abnormalities

-          Diffuse lumpy breast tissue (often there are also complaints of pain) usually indicates mastopathy. Dense, firm, lumpy breast tissue may mask a carcinoma and is therefore an indication for a mammogram. Watch for women with dense breast tissue on a mammogram and repeat the mammogram if there are new complaints.

-          Diffuse sensitiveness or painful breasts without abnormalities on physical examination are not an indication for a mammogram.

Nipple discharge

-          A malignancy should be suspected if there is brown or bloody nipple discharge. Another cause could be a milk duct fistula with a fistula opening on the edge of the areola. Refer to a breast clinic if there is nipple discharge because a mammogram is insufficient.

-          One-sided or bilateral, milky or clear nipple discharge is not suspicious for breast cancer and is not an indication for mammography or referral.

 

If a woman presents with new complaints, a recent mammogram without abnormalities (e.g.national breast screening programme) is not a reason to deviate from the formulated guidelines.

If additional imaging is indicated for women older than 30 years, this should consist of a mammogram, supplemented with an ultrasound if required. In women younger than 30 years, ultrasound is the method of choice due to the low positive predictive value of mammography in this group. Obviously, evaluation on the basis of mammography is indicated if the ultrasound provides insufficient information. When requesting imaging, the general practitioner provides adequate information to the radiologist about the indication (in line with the above classification), the side(s) involved, nature and localisation of abnormalities found during the clinical breast examination, and important information from the medical history (familial history, mastitis, any prior breast surgery etc).

Considerations

Mastopathy is a collective term for various complaints and disorders of one or both breasts in both men and women. The definition used here is: dense, granular and lumpy breast tissue, sensitive on palpation and sometimes spontaneously painful, especially during the premenstrual phase. In addition, there may be non-cyclical complaints or pain in the chest wall. This definition includes both palpation findings and patient complaints. Terms such as mastalgia, mastodynia and fibrocystic disease are sometimes used, but only cover part of the problem [Knuistingh Neven, 2007].

The following histological changes can be seen in mastopathy: fibrocystic changes, adenosis, sclerosing adenosis and epithelial proliferation. Mammography shows that there is not always dense breast tissue, but that there may be micro- or marcocysts, a granular or more irregular glandular structure, either in or not in combination with dense tissue, microcalcifications and milk of calcium. Ultrasound is a good supplement if there are cysts. Regarding the sensitivity of MRI results of the still limited study results vary, partly because there is a correlation in the various studies with density but not with the clinical presentation [Boyd, 2006; Kriege, 2006; Warren 2002].

Patients with mastopathic complaints and breasts that can be easily examined with low density breast tissue on the mammogram may be reassured. Caution is advised with patients who present with recurring complaints, persistent lumpiness and dense breast tissue (see above), partly given the extra risk of breast cancer in the case of dense breast tissue [McCormack, 2006; Boyd, 2010].

 

A pitfall is the palpable, but not very alarming abnormality that is diagnosed to be malignant after all in second instance. There is a risk that follow-up is not organised well enough. The appointment to return 3 months later is the joint responsibility of the patient and physician. The physician must explicitly instruct the patient to do so.

Authorization date and validity

Last review : 13-02-2012

Last authorization : 13-02-2012

Initiative and authorization

Initiative : Nationaal Borstkanker Overleg Nederland

Authorized by:
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging voor Heelkunde
  • Nederlandse Vereniging voor Pathologie
  • Nederlandse Vereniging voor Radiologie
  • Nederlandse Vereniging voor Radiotherapie en Oncologie

Method of development

Evidence based