Should I see a breast cancer specialist?

It can be very difficult for GPs to decide who may have a breast cancer and who may have something much more minor that will go away on its own. With many symptoms, it is perfectly right that your GP should ask you to wait to see if they get better or respond to treatment such as antibiotics. If GPs referred everyone who came to see them to a specialist immediately, the system would get jammed and people needing urgent appointments wouldn't be able to get them.

There are particular symptoms that mean your GP should refer you to a specialist straight away. The National Institute for Health and Clinical Excellence (NICE) has produced guidelines for GPs to help them decide which patients need to be seen urgently by a specialist. These guidelines on referrals for breast cancer were reviewed in June 2005. They say that with some symptoms, a specialist should ideally see you within 2 weeks of you going to the GP.

A GP with 2,000 patients is likely to see only one woman a year who has breast cancer. But they will see a lot more women who have non cancerous breast conditions such as

• Cysts - sacs of fluid in the breast tissue (most common in women between 40 to 60 years)
• Fibroadenomas - collections of fibrous glandular tissue (most common in the 20 to 30 age group)
• Diffuse nodularity (lumpy breasts) - which are common in all age groups up to 50
• Breast pain - this is not a usual symptom of breast cancer

According to the NICE guidelines, you should ideally get an appointment within 2 weeks for an urgent referral. The guidelines list symptoms that generally mean your GP should refer you to a specialist within 2 weeks. But they also point out that the GP has to use their own judgement. For instance, they say it may be appropriate to refer someone even more urgently if they've had a worrying symptom for months, but have not been to the doctor before.

The symptoms that need urgent referral for possible cancer of the breast are

• A fixed, hard lump in the breast at any age
• Women aged 30 or over who have a lump that is still there after their next period
• A women with a lump that appears after menopause
• Women under 30 with a lump that is getting bigger, or a lump that is fixed and hard, or who have other particular reasons for concern, such as a strong family history of breast cancer
• Anyone who has had breast cancer before and has another lump or other suspicious symptoms
• A rash on one nipple or in the surrounding area (this is very rare) that has not responded to treatment
• Nipples that have turned in (inverted) recently
• Blood stained discharge from the nipple for no apparent reason
• Men aged 50 or over with a firm lump under one nipple, with or without changes in the nipple shape or in the surrounding skin

The symptoms that need referral, but not urgently, are

• A distinct lump in women under 30
• Breast pain (with no lump) that does not go away with reassurance, wearing a well supporting bra, or painkillers prescribed by your GP

Your GP may send you to a breast clinic for other symptoms that are probably not related to cancer, but still need treatment. These include

• Lumpy breasts that do not go away after your period has finished
• A sore infected area on the breast (called an abscess)
• Sacs of fluid (cysts) in the breast tissue that keep filling up or coming back after treatment
• Any woman under 50 who has a blood stained discharge or a discharge from both nipples that is enough to stain clothing

Your doctor may give you an urgent referral for some of these conditions, so an urgent referral does not necessarily mean that you have breast cancer.

There are certain sets of symptoms that are very unlikely to be cancer. The guidelines say these are

• Young women who have tender, lumpy breasts
• Older women with breasts that are similarly lumpy on both sides
• Minor or moderate breast pain with no lump
• Women under 50 who have a discharge from more than one breast duct, that comes and goes and is not blood stained or troublesome
• Women with a minor family history of breast cancer and no symptoms

It is very common for women to have tender, lumpy breasts in their 20s, 30s and 40s. The lumpiness is most common before a period. If your breasts are equally lumpy on both sides and the lumps come and go, this isn't likely to be cancer.

It can be very hard for GPs if a patient insists on seeing a specialist, but the GP doesn't think that is necessary. Breast pain with no lump is highly unlikely to be breast cancer and so it is fine for your GP to make a non urgent referral to a breast clinic in this situation.

Bear in mind that the risk of getting breast cancer increases with age. Only 5 out of every 100 women (5%) diagnosed with breast cancer are under 40. Only 2 out of every 100 breast cancers (2%) are diagnosed in women under 35.

Unfortunately though, in younger women it is more likely that a breast cancer diagnosis will be delayed, simply because it is more unusual. If you have a symptom listed here as urgent and you are worried your GP isn't taking it seriously, you could print this page and take it to an appointment. Ask your GP to talk it through with you. Then you may be able to decide together whether you need to see a specialist and if so, how soon.