01Principles and purposeThe professional or clinical skill and the decisions it supports.
A breast-lump history establishes trajectory and context before any test is chosen. Record onset, growth, cyclical change, pain, nipple or skin symptoms, infection, pregnancy or lactation, previous breast disease and treatment, hormone exposure and relevant family cancers. These details change probability and urgency, but no combination of age, tenderness or mobility can establish histology.
Examination creates the target that imaging and pathology must later explain. With consent and a chaperone where appropriate, compare both breasts in several arm positions, palpate systematically, map the lesion by side, clock position, nipple distance and size, and describe consistency, mobility and skin or chest-wall fixation. Add axillary and supraclavicular findings, then translate the complete phenotype into a tracked referral and concordance plan.
Key points
- Ask when the lump appeared, whether it is enlarging or cyclic, and whether pain, nipple change, skin distortion, fever or systemic symptoms accompany it.
- Record pregnancy, lactation, menopause, previous breast disease, chest irradiation, hormone exposure, anticoagulants and relevant breast, ovarian, pancreatic or prostate cancers in the family.
- Inspect both breasts with changing arm positions, then palpate systematically and map the lump by side, clock face, nipple distance, size, consistency, mobility and fixation.
- Examine axillary and supraclavicular nodes and the overlying skin; a clinically normal contralateral breast does not explain a unilateral target.
- A new unexplained breast lump in a person aged 30 or over meets the NICE suspected-cancer pathway criterion whether or not it is painful.
- Conclude with a problem representation, urgency, intended triple assessment and a tracked results plan rather than labelling a mass benign by feel alone.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Record when the lump was first noticed, whether it varies with the menstrual cycle, and whether size, fixation, skin contour or symptoms are changing rather than accepting a single vague duration.
Ask about focal pain, nipple discharge, new inversion, eczema, ulceration, erythema and swelling; inspect with the arms relaxed, raised and pressing on the hips to reveal tethering.
Establish previous breast imaging or biopsy, breast cancer, chest irradiation, pregnancy or lactation, menopausal status, hormone exposure and medicines that alter bleeding or breast tissue.
Construct a brief three-generation cancer history where relevant, including ovarian, pancreatic and prostate cancer, and ask what the patient fears or hopes the consultation will resolve.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Bilateral clinical examination - Why
- Define the palpable target and search for associated signs before imaging.
- Interpretation and limitations
- Describe side, clock position, distance from nipple, size, surface, consistency, mobility, skin or chest-wall fixation, and axillary or supraclavicular nodes; examination cannot determine histology.
- 02
Diagnostic breast imaging - Why
- Characterise the clinical target and identify occult or multifocal abnormalities.
- Interpretation and limitations
- Selection depends on age, pregnancy, tissue density and clinical concern; the request must mark the palpable site so radiological and clinical findings can be correlated.
- 03
Image-guided core biopsy - Why
- Obtain architecture and tissue diagnosis from a suspicious solid lesion.
- Interpretation and limitations
- A benign label is reassuring only when pathology explains the clinical and imaging appearances; discordance requires multidisciplinary review and often repeat sampling.
- 04
Previous-record comparison - Why
- Establish whether the finding is new or stable and avoid duplicating an incomplete pathway.
- Interpretation and limitations
- Compare actual images and pathology rather than relying on recollection; interval growth or a changed examination can outweigh an old benign report.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked case: integrated breast assessmentApply history and examination of a breast lump to a defined presentationA 46-year-old notices a firm left upper-outer breast lump six weeks ago; it is enlarging, and there is subtle dimpling when she raises her arm but no fever.+
- 1Clarify duration, progression, pain, nipple and systemic symptoms, reproductive and treatment history, then ask about relevant cancers on both sides of the family.
- 2Offer a chaperone and obtain continuing consent; inspect both breasts in several arm positions, palpate systematically, map the lesion and assess axillary and supraclavicular nodes.
- 3State that a new enlarging lump with tethering is clinically suspicious and arrange the appropriate suspected-cancer pathway rather than offering empirical treatment.
- 4At the breast service, correlate examination with imaging and image-guided tissue diagnosis; do not call the assessment complete if one component conflicts with the others.
- 5Verify referral receipt, tell the patient how results will be communicated, and safety-net earlier review for rapid enlargement, erythema or systemic illness.
02Clinical synthesisTurn findings into a referral-quality descriptionHistory and examination have identified a discrete breast lump but its biology remains unknown.+
- 1State the patient’s age, side and duration, then describe whether the lesion is enlarging, cycle-related, inflamed or associated with nipple or skin change.
- 2Give a reproducible lesion map and distinguish a dominant mass from diffuse nodularity; include node findings and any sign of chest-wall or skin fixation.
- 3Name the leading benign and malignant possibilities without claiming that palpation supplies histology, and identify which feature determines urgency.
- 4Request breast-service assessment with the mapped target and relevant pregnancy, medicine, prior-imaging and family information.
03Result reconciliationRespond when the lump remains unexplainedTargeted imaging is reported benign, yet the clinician and patient can still feel the same firm enlarging lesion.+
- 1Confirm that the imaged coordinates and the palpable coordinates match, and ask radiology whether the lesion was actually visualised or merely no abnormality was reported.
- 2Review whether tissue was obtained from the palpable target and whether pathology explains its texture and trajectory; a missed target is not a benign diagnosis.
- 3Escalate unresolved clinical-imaging discordance for breast multidisciplinary review and representative sampling rather than offering long-interval observation.
- 4Document the integrated outcome, the person responsible for review and a clear route for earlier reassessment if size, skin or nipple features change.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- At results review, compare the documented lump dimensions and fixation with baseline rather than relying on the patient’s general impression of change.
- Track the urgent referral until an appointment is accepted; if the pathway rejects or redirects it, record who reassessed the clinical concern.
- Ensure imaging reports identify the palpable site and pathology reports correspond to that site before recording clinical-radiological-pathological concordance.
- After a benign concordant diagnosis, provide symptom-specific follow-up and advise reassessment for growth, a new node, nipple bleeding, tethering or inflammatory change.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Tenderness changes probability, not identity
Fibroadenomas, cysts and cancers may all be painless or tender. Pain can guide the differential, but it cannot replace imaging and tissue correlation for a persistent discrete mass.
Examine the patient, not an isolated breast
Posture, shoulder movement and rib tenderness may identify a chest-wall source, while systemic examination can reveal widespread nodes or metastatic illness. Focused examination still includes clinically relevant context.
Family history needs structure
One relative with late-onset breast cancer differs from several young cancers across related tumour types. Record lineage, cancer type and age at diagnosis before deciding whether genetics assessment is indicated.
Words affect understanding
Describe an urgent referral as timely investigation of a possible cause. Avoid saying cancer is likely or impossible before triple assessment has supplied a concordant explanation.
07Common pitfallsFrequent interpretation and management errors.
- 01
Using smooth, mobile or tender as synonyms for benign overlooks malignant exceptions and prevents a defensible diagnostic plan.
- 02
Examining only the reported breast can miss contralateral findings and removes the comparison needed to judge asymmetry.
- 03
Writing lump present without coordinates, dimensions or fixation makes later imaging correlation and interval assessment unreliable.
- 04
Allowing a benign result from a different site to close the pathway leaves the original palpable target undiagnosed.