THE GRH BREAST CARE WEB SITE Referral Guidelines Guidance for GPs on symptom investigation The majority of women who present to the General Practitioner or Practice Nurse with breast symptoms will not have breast cancer. It is essential hat all General Practitioners have established links with appropriate secondary care providers and are able to arrange urgent referral when required. Contracts must include provision for communication to the GP of the diagnosis and proposed treatment. We would ask you to give us as much information as possible for us to decide the urgency of the referral in your letter. As well as using referral forms, please feel free to write a letter as well, general information about the patient is always welcomed and helpful. Recommendation ·Initial investigation of breast symptoms should be by clinical examination. If there is any doubt in the General Practitioner's mind that the breast is anything other than normal then an opinion from a breast surgeon should be sought. Symptoms requiring URGENT opinions are: Discrete lump or nodularity persisting after menstruation (if in doubt in a premenopausal woman, re-examine at different time of menstrual cycle) · Blood stained or serous nipple discharge from a single duct and clear discharge in post menopausal women · Nipple eczema · Skin or nipple tethering / inversion NON URGENT referral includes: Breast pain but normal examination Multiple duct nipple discharge Non-sinister nipple changes - congenital inversion Guidance on the aspiration of breast lumps by General Practitioners Recommendations · Breast lumps should only be aspirated by General Practitioners when they have experience in the technique and when it is very likely that the lump is a cyst ie: when the lumps is smooth and when the patient has had a previous cyst aspirated. · Cyst fluid should not routinely be sent for cytology unless it is bloodstained. The advantage of the GP aspirating a cyst is the immediate relief of anxiety and avoidance of an out-patient referral. The disadvantage is that if the lesion is solid rather than cystic the imaging appearance may be distorted and interpretation of a subsequent fine needle aspirate may be very difficult. Also a lump may be caused by needling (haematoma) leaving the surgeon uncertain, at subsequent referral, as to whether he/she would have thought that a true lump was present in the first instance. The particular skill and training of the breast surgeon lies in deciding whether a true lump is present or not. It is often difficult to differentiate between a true lump and a lumpy area, even for a surgical specialist in breast disease. Guidance on the indications for mammography Recommendation · Direct access for General Practitioner referral for mammography is not available or recommended. Open access mammography is unnecessary as access to the clinic is rapid. Mammography is a screening test and is not appropriate as the sole or initial diagnostic test for symptomatic breast disease. Diagnosis of a breast lesion is based on three complementary aspects - clinical, imaging and cytology, often known as Triple Assessment. A mammogram is not required in all women with breast symptoms. Mammography alone does not exclude a breast cancer and (apart from screening) needs to be performed in conjunction with these other diagnostic modalities. It is seldom appreciated that even palpable breast cancers may not be visible on a mammogram, particularly in younger women. Even though the radiation dose used in mammography is very low, it is inappropriate under the age of 35 unless there are very special reasons; surgeons should follow the local radiological guidelines. Women on Hormone Replacement Therapy Recommendation · Thereis no evidence that women on Hormone Replacement Therapy require mammograms more frequently than is received through the National Breast Screening Programme. Screening for women under the age of 50 Recommendation · There is no evidence that women who are apparently of ordinary risk of breast cancer under the age of 50 benefit from screening mammography (this also applies to women who are placed onto HRT at this age). Elevated Risk Programme Criteria for acceptance onto elevated risk programme Based on BASO guidelines - Aged over 35 or 5 years younger than the youngest affected near relative - Aged under 50 (Risk lower at this age and will enter NHS 3 yearly screening programme) and:- Either a, 1 first degree relative with breast cancer diagnosed before age 40. Or b, 1 second degree paternal relative with breast cancer diagnosed before age 40. Or c, 2 first or second degree relatives (or one of each) with breast cancer diagnosed before 60. Or d, 2 first or second degree relatives (or one of each) with either breast cancer diagnosed before age 60 or ovarian cancer at any age. Or e, 1 first degree relative with bilateral breast cancers both diagnosed before age 60. Or f, 1 first or second degree relative with both breast and ovarian cancer at any age. Or g, 3 first or second degree relatives with breast or ovarian cancer at any age. Or h, 1 first degree Male relative with breast cancer at any age. (1st degree=Mother, Sister or Daughter, 2nd degree=Grandmother or Aunt) These criteria broadly cover a greater than 3x relative risk of developing breast cancer. The screening offered will be initial assessment of the family tree to calculate the risk of carrying a gene and the subsequent risk of developing breast cancer, examination, and if appropriate ultrasound scanning or mammography. Follow-up will be with 18 monthly mammography. Homepage