By Dr Michael Yunaev – Oncoplastic Breast Surgeon
Benign breast disorders are a common group of conditions, with frequent presentations to General Practitioners. Identifying patients with straightforward problems that require reassurance alone versus the ones that require specialist breast surgeon referral can cause some anxiety to both patients and their primary physicians.
However, in reality most of these disorders do not represent a significant threat to patient’s health and well-being and therefore much of the role of GP is centered around excluding cancer, providing an explanation on the nature of the condition and educating and reassuring the patient that the symptoms are not dangerous.
It should be remembered that approach to any breast complaint involves a thorough history and physical examination as initial assessment.
These are followed by imaging, which may include a mammogram +/- ultrasound and in some cases a radiological or surgical biopsy. Together they comprise the so-called triple test.
However, not all patients will require a biopsy and this can be substituted in some instances by an interval imaging modality to reassess the complaint in appropriate timeframe.
Therefore, there are several possible outcomes following these investigations. These include a clinical reassessment in a specific timeframe, reimaging of the complaint in a specified timeframe or a referral to a breast specialist for further assessment and management (with or without biopsy).
It should be noted that if surgical intervention is required, Oncoplastic Breast Surgery is a particularly useful tool in benign setting to minimise aesthetic sequela from surgical excision and patients can often be reassured about the effects of surgery if these approaches are used.
Hence, a GP should consider a referral to a Breast Specialist if the possibility of cancer or atypia is confirmed or not excluded or in the benign setting in the following circumstances:
Mastalgia is a very common condition that may be managed by the GP or in breast specialist rooms. A referral may need to be considered particularly in cases of non cyclical mastalgia, which is unremitting and no other cause has been identified. In these situations specialized medications may need to be considered and are best discussed in a specialist setting(3).
Localised nodularity may require further reassurance from a specialist breast surgeon,
particularly if there is any concern regarding need for tissue diagnosis(2).
Fibroadenomas are a very common finding during breast assessment. These can be managed conservatively most of the time but should be referred to breast surgeon if there is an interval progressive increase in size of the lesion or if the lesion is greater than 2-3cm, in which case excision should be considered(2).
In addition, multiple fibroadenomas are associated with some rare cancer syndromes, such as Maffucci syndrome, Cowden syndrome and Carney complex. Fibroadenomas that develop in these kindred should be excised(1).
Breast cysts are the most common pathology relating to breast complaints presenting to GPs. Normally these require reassurance only. However, they do need specialist assessment in cases where they are symptomatic or if the imaging and biopsy assessment indicates atypical, complex cysts, because of possibility of cancer in these lesions(4).
Nipple discharge and Papillomas do present significant anxiety to both patients and their doctors. However, only a small proportion of these have a risk of cancer associated with them.
Nevertheless referral should be considered particularly for patients with a spontaneous, unilateral, single duct discharge with clear, serosangenous or bloody discharge. These patients will need surgical investigation of their symptoms to rule out the possibility of cancer and to excise the papillomas(4).
Gynaecomastia presenting in male patients after thorough medical assessment for its cause and if non–physiological in origin should also be referred for further breast surgical consultation for correction of the problem. This is often highly debilitating condition psychologically and hence does justify surgical intervention.
Pseudoangiomatous Hyperplasia (PASH), is often incidentally discovered on biopsy performed for another reason, or could be the cause of the incident, such as a large new lump.It can mimic fibroadenoma or a phylloides tumour or angiosarcoma and can be rapidly growing to a large size and therefore can cause a lot of distress to the patient.
These patients should be referred for further breast surgery consultation and are likely to need further surgical intervention, as biopsy and imaging may be unreliable with this diagnosis.
In summary, if there is any evidence of atypia, malignancy or ambivalence about diagnosis or the patient simply needs reassurance, consider referring patient for further assessment. Often the anxiety associated with breast complaints mind at ease.
If you have any questions or concerns regarding benign breast disorders please discuss with your General Practitioner, and if needed, please contact Breast And Body Clinic on 02 9819 7449.
If you are a General Practitioner and wish to discuss your questions about patients and management dilemmas, please feel free to contact Dr Michael Yunaev – a breast cancer surgeon in Sydney at 02 9819 7449.
(1) Jayasinghe Y, Simmons PS. Fibroadenomas in adolescence. Curr Opin Obstet Gynecol 2009;21(5):402–6.
(2) Management of benign breast conditions – painful breasts, M. Brennan, N.Houssami, J.French, Australian Family Physician, 03/2005, Volume 34, Issue 3
(3) Management of benign breast conditions -breast lumps and lesions, M. Brennan, N.Houssami, J.French, Australian Family Physician, 04/2005, Volume 34, Issue 4
(4) Benign breast disease, Amin, Amanda L, Purdy, Anna C,Mattingly, Joanne D, The Surgical clinics of North America, 04/2013, Volume 93, Issue 2