Breast disease and surgical management of breast cancer

• A breast lump is a very common reason to seek medical help. Most lumps are benign, but the job of the assessment is to tell the few that are cancer from the many that are not.^[1]
• Suspicious and non-suspicious lumps are sorted by triple assessment: a careful clinical history and examination, imaging, and a needle biopsy for cells or tissue. All three should agree; if they do not, the lump is treated as suspicious until proven otherwise.
• The common benign causes are fibroadenoma in younger women, simple breast cysts, lactational mastitis and abscess, and intraductal papilloma causing nipple discharge.
• Breast cancer is the most common cancer in women worldwide: about 2.4 million women were diagnosed and about 694,000 died from it in 2024.^[1] Roughly 80% of breast cancers occur in women who have no modifiable risk factor other than being female and over the age of 40.^[1]
• When found early, breast cancer is usually curable. Surgery removes the tumour: for most early cancers, removing the lump with a rim of normal tissue and following it with radiotherapy gives the same outlook as removing the whole breast.^[2][4]
• Treatment is chosen by the tumour's receptors (ER, PR, HER2) and its stage, by a team that includes surgeons, oncologists, radiologists and pathologists. ^[2][4]
• Family history matters: inherited faults in BRCA1, BRCA2 and PALB2 strongly raise risk, and a history of Jewish ancestry raises the chance of carrying a BRCA mutation 5- to 10-fold.^[1][3]

By the end of this page you should be able to:

1. Sort the common causes of a breast lump by age and presentation, and name the red flags for cancer.
2. Describe the triple assessment and explain why imaging and biopsy together matter.
3. Explain fibroadenoma, cysts, mastitis and abscess, duct ectasia and intraductal papilloma, and state how each is managed.
4. Outline the receptors, subtypes and TNM staging of breast cancer.
5. Plan imaging and staging for a patient with suspected breast cancer, including when axillary ultrasound and chest/abdominal/pelvic staging are needed.
6. Explain breast-conserving surgery, mastectomy, sentinel lymph node biopsy and axillary clearance, and their indications.
7. Outline adjuvant endocrine, anti-HER2 and chemotherapy options without memorising drug schedules.
8. Apply NICE familial breast cancer guidance to BRCA risk, surveillance, chemoprevention and risk-reducing surgery.

Most breast disease is benign. The conditions in this topic group naturally divide into three groups:

• Benign lumps and inflammation: fibroadenoma, simple cyst, galactocele, fat necrosis, and the fibrocystic changes that make breasts lumpy and tender, especially premenstrually.
• Nipple discharge disorders: mammary duct ectasia and intraductal papilloma, which produce spontaneous discharge from one breast.
• Breast cancer and its precursors: invasive ductal and lobular carcinoma, and ductal carcinoma in situ (DCIS), which is non-invasive but needs treatment.

The breast cancer families referred to in this topic are defined by receptors on the tumour cells:

• ER/PR-positive, HER2-negative ("luminal"): the commonest group; driven by oestrogen signalling.
• HER2-positive: tumour cells overproduce the HER2 receptor; treated with anti-HER2 targeted drugs.
• Triple-negative: no ER, PR or HER2; behaves more aggressively and is treated with chemotherapy, with immunotherapy in selected early cases in some systems.^[2]

Receptors are not a label for the whole person; a single tumour may be mixed, and ER/PR/HER2 are re-checked at recurrence because they can change.

• Global burden. In 2024 an estimated 2.4 million women were diagnosed with breast cancer and about 694,000 died from it. Breast cancer was the most common cancer in women in 164 of 186 countries. It accounts for a large share of cancer diagnoses in women worldwide.^[1]
• Sex. About 99% of breast cancers occur in women; 0.5-1% occur in men.^[1]
• Age. Rates rise after puberty and with age. In higher-income countries the majority of cases are detected in screening-age women; elsewhere many present late.
• Risk profile. About 80% of breast cancers occur in women who have no modifiable risk factor other than being female and over 40.^[1]
• Inherited susceptibility. High-penetrance mutations, mainly in BRCA1, BRCA2 and PALB2, greatly increase risk.^[1]
• Survival and inequalities. Age-standardised breast cancer mortality in high-income countries fell by about 40% between the 1980s and 2020. Mortality remains much higher in low-human-development settings, where stage at presentation is later.^[1]
• Screening. WHO describes mammography screening in an apparently healthy population, usually women 50-69 years of age.^[1] The ESMO-adapted guideline recommends screening every 2 years for women aged 45-69, with possible extension to 40-44 and 70-74 years where there is emerging evidence of benefit.^[4] Guidelines differ between countries, so the screening policy of the country you work in is the one to follow.

Risk is multifactorial, and most women who develop breast cancer have no single identifiable cause.

Non-modifiable

• Female sex and increasing age.
• Family history, especially breast or ovarian cancer in first-degree relatives.
• Inherited mutations: BRCA1, BRCA2, PALB2, and others in a smaller fraction.
• Menstrual and reproductive factors: early menarche, late menopause, first pregnancy at older age, nulliparity, never breastfeeding.
• Prior breast disease, in particular atypical hyperplasia or lobular carcinoma in situ.
• Radiation to the chest wall when young.

Modifiable

• Obesity, particularly after the menopause.
• Alcohol intake.
• Tobacco in some populations.
• Postmenopausal hormone replacement therapy.
• Physical inactivity.

Family history needs care. A single relative with breast cancer at older age does not create high risk; certain patterns do. NICE CG164 risk levels for women with no personal history of breast cancer divide families into population, moderate and high risk on the family history, and set different management for each.^[3] Jewish ancestry raises the chance of carrying a BRCA1 or BRCA2 mutation about 5- to 10-fold, above that in non-Jewish populations.^[3]

The normal adult breast is a branching system of ducts ending in lobules, supported by stroma. Breast cancer almost always begins in the epithelium of the ducts or lobules.

1. In situ disease. Abnormal epithelial cells proliferate but stay within the duct or lobule. DCIS is the commonest in situ lesion and is non-invasive but can progress.
2. Invasion. Cells break through the basement membrane into the surrounding stroma, becoming invasive cancer. Invasive ductal carcinoma (now often called invasive carcinoma, no special type) is the commonest.
3. Spread. Invasive cancer spreads first to regional lymph nodes through lymphatics, then haematogenously to bone, liver, lung and brain in advanced disease.
4. Receptor drivers. ER/PR expression reflects dependence on oestrogen for growth. HER2 overexpression amplifies growth signals. Triple-negative tumours lack these targets, so they are driven by other pathways and respond best to chemotherapy.^[1]
5. Hormone exposure. Each menstrual cycle exposes breast epithelium to oestrogen and progesterone; lifetime exposure translates into risk. Pregnancy and lactation, which mature the lobules, reduce risk. This is the biological basis for the reproductive risk factors.

Benign disease follows related but non-cancer pathways: hormonal stimulation enlarges cysts and stromal nodules; blocked ducts and bacterial entry produce mastitis; cystic dilatation and stasis produce duct ectasia.

Symptoms are usually reported by the patient herself. Ask about:

• Lump: site, duration, change over the cycle, tenderness, growth.
• Pain: cyclical mastalgia is very common and usually benign; a persistent focal pain needs assessment.
• Nipple discharge: spontaneous or only on squeezing; from one breast or both; colour (clear, serous, bloody, milky, green) and smell.
• Skin change: dimpling, redness, peau d'orange, nipple retraction or eczema.
• Recent pregnancy or lactation.
• Constitutional symptoms: weight loss, back or bone pain, breathlessness (late disease).
• Risk factors: family history, prior breast disease, radiation, medications.

Red flags for cancer include: a new, hard, irregular, fixed mass; nipple or skin change; spontaneous bloody unilateral discharge; a new axillary node; inflammatory changes in a non-lactating breast; any breast symptom in a man; a non-healing breast wound. These do not always mean cancer, but they demand prompt, structured assessment.^[1]

Inspect with the patient sitting and lying, arms at sides then raised: look for asymmetry, skin and nipple change, indrawing, ulceration, visible veins, and inflammation. Palpate with the flat of the fingers in a systematic pattern (vertical strip is often easiest), covering the whole breast, the tail into the axilla, and each axilla and supraclavicular fossa. Note size, site, shape, consistency, tenderness and mobility; an important benign clue is that fibroadenomas are mobile and cysts smooth. If discharge is not visible, ask the patient to express it before you attempt to.

A regional note: in busy clinics the written record of the mass position (clock face and distance from nipple) is what the surgeon and imager act on; do not rely on memory.

A 52-year-old woman notices a firm lump in her right breast that does not change with her cycle. It is not painful, but she has noticed intermittent clear discharge from the same nipple and mild dimpling of the overlying skin. She has never been screened and has a sister diagnosed with breast cancer at 45. Examination shows a 2.5 cm irregular, fixed mass in the upper outer quadrant and no palpable node. Most lumps at this age are not cancer, but this presentation needs urgent triple assessment and MDT care: possible features include invasive cancer with skin involvement, and a family history that may warrant BRCA testing.

• Fibroadenoma usually occurs in women under 35 and is classically firm, rubbery, smooth, well-circumscribed and mobile, sometimes called a "breast mouse" because it slides under the fingers. It may be multiple and can grow; it is not dangerous but can be uncomfortable and anxiety-provoking.
• Simple cyst peaks in the 30s-50s. It is a smooth, tense, mobile, well-circumscribed lump that can be tender; size can change quickly with the cycle. A simple cyst on ultrasound needs no tissue diagnosis.
• Mastitis and abscess classically occur in lactating women in the first weeks. The breast is tender, red, warm and swollen, with fever and malaise; an abscess becomes a fluctuant, localised, tender collection.
• Intraductal papilloma produces spontaneous discharge, often bloody or serous, from a single duct near the nipple. A lump may or may not be felt.
• Mammary duct ectasia is a duct dilatation of middle life that produces thick, multicoloured discharge from several duct openings, sometimes with periductal inflammation.

Most palpable breast masses in younger women are benign; the chance of malignancy rises with age. The first question is whether the presentation fits a benign syndrome; the second, whether the mass is a cancer.

The key exam point is that no clinical feature alone is 100% reliable. Inflammatory breast cancer can look like mastitis; fat necrosis and phyllodes tumours can look like fibroadenoma. When any doubt remains, biopsy.

The standard way to assess any discrete breast symptom is triple assessment: clinical evaluation, imaging, and pathological (cellular or tissue) diagnosis. Each of the three should agree. Done well, the combination is highly accurate and avoids both missed cancers and unnecessary operations.

• History as above, plus risk factors, medications and menstrual status.
• Examination as above, documenting the mass position.

ESMO-adapted guidance for the symptomatic patient uses bilateral mammography and ultrasound of both breasts and regional lymph nodes.^[4]

• Ultrasound is the best first test in women under about 35-40 and in pregnancy. It distinguishes solid from cystic, evaluates the axilla, and guides needle biopsy. It is fast, cheap and radiation-free. NICE NG101 recommends pretreatment ultrasound evaluation of the axilla for invasive cancer, with ultrasound-guided needle sampling if nodes look abnormal.^[2]
• Mammography is the main screening tool and is also used to assess focal symptoms, especially over age 40. It finds microcalcifications and areas of distortion that ultrasound can miss.
• Digital breast tomosynthesis (3D mammography) and contrast-enhanced mammography are acceptable alternatives where available.^[4]
• MRI is reserved for problems the standard tests cannot settle, or for special situations such as known BRCA/PALB2 mutation, lobular cancer, suspicion of multifocal or multicentric disease, breast implants, dense breasts, and preoperative planning.^[4] NICE recommends MRI pre-operatively when the extent of disease is unclear, when mammographic assessment is difficult because of density, or to plan breast-conserving surgery for invasive lobular cancer.^[2] MRI should not be used routinely for every new lump.^[2]
• Staging imaging. For diagnosed cancer, CT of the chest with abdominal imaging and a bone scan should be considered for patients with clinically positive axillary nodes, large tumours (about 5 cm), aggressive biology, or any sign, symptom or blood test suggesting metastasis. PET-CT is an option for high-risk patients or when conventional imaging is inconclusive.^[4]
• Minimum blood tests before surgery and (neo)adjuvant therapy: full blood count, liver and renal function, alkaline phosphatase and calcium.^[4]

• Fine-needle aspiration (FNA) obtains cells. Useful for cysts and for confirming simple cysts; it is less reliable for distinguishing invasive from in situ disease and for receptor testing.
• Core needle biopsy (CNB) obtains tissue and is the standard for a solid or complex mass. It gives histological type, grade, ER, PR, HER2, Ki-67 and a denominator for receptors.
• Open surgical biopsy is now seldom needed; reserved for discordant or non-diagnostic needles, or when a lesion cannot be sampled safely.
• ER, PR and HER2 should be assessed together and quantitatively, at the initial diagnosis.^[2][4]

A simple cyst diagnosed by classic imaging and aspiration fluid that is clear can be observed. A complex cyst (internal echoes, septations, or solid components) or an aspirate that is bloody or contains atypical cells needs histology. Fluid from atypical cysts should have cytological assessment. Surgery is indicated for cysts that recur despite aspiration, that have an intracystic solid element on ultrasound, or that contain atypical cells.^[4]

When all three parts of triple assessment agree on benign disease, the patient can be reassured with confidence. If they disagree, the lesion is managed as suspicious.

Breast cancer is diagnosed by histology, usually on core biopsy. Staging uses the WHO classification of breast tumours and the 8th edition of the TNM system, based on size (T), nodes (N) and metastasis (M).^[4]

• T0-T4: size and chest wall/skin involvement.
• N0-N3: number and location of involved lymph nodes.
• M0/M1: absence or presence of distant metastasis.

Staging groups (0-IV) guide treatment. A key modern point is biological staging added alongside anatomy: receptor status and, where needed, genomic assays such as Oncotype DX or EndoPredict for node-negative, ER-positive disease can change adjuvant decisions. Early, node-negative ER-positive tumours have an excellent prognosis that is driven more by biology than by size alone.^[2][4]

Receptors (ER, PR, HER2) are assessed on every invasive cancer at the time of histopathological diagnosis and recorded at both pre- and postoperative multidisciplinary meetings.^[2]

• Specialist MDT. Where available, treatment should be carried out in a specialised breast unit by a multidisciplinary team of surgeons, oncologists, radiologists, pathologists, nurses and allied professionals.^[4]
• Shared decisions. Decisions are taken with the patient, and should be documented at the MDT.^[2] People with breast cancer should have a named clinical nurse specialist or equivalent key worker to support them from diagnosis through follow-up.^[2]
• Assess the person, not just the tumour: age, menopausal status, general health, comorbidities, fertility wishes, preferences. Age alone should not be the main determinant.^[4]
• Pretreatment planning. Tumour profile and receptors are assessed before surgery; axillary ultrasound and possible node sampling guide the operation.^[2][4]

Fibroadenoma

• Confirmation: clinical and imaging agreement; core biopsy if uncertain, growing, or atypical on imaging.
• Most small, classic, non-growing fibroadenomas in young women can be observed after explanation and imaging.
• Excise if the diagnosis is uncertain, if the lump grows, if it is giant (with or without juvenile growth), if it is painful or worrying, or if the patient prefers. A surgical excision with a cosmetically placed incision is straightforward.

Cyst

• Simple cyst: reassurance; aspiration if symptomatic; no surgery needed.
• Aspirate and observe if the cyst recurs.
• Excise complex or atypical cysts, or those with recurrence or an intracystic solid element.

Mastitis and breast abscess

• Lactational mastitis is managed with supportive care: analgesia, continued breastfeeding or pumping to empty the breast, warm or cool compresses, and antibiotics against Staphylococcus aureus when there is bacterial infection. Encourage fluids and rest.
• Abscess: if a tender, fluctuant collection forms, drain it. Ultrasound-guided needle aspiration is now preferred to open incision and drainage; open surgery is reserved for large, loculated, skin-involved or recurrent collections.
• Always think of inflammatory breast cancer if a patient who is not lactating has a red, hot, swollen breast that does not respond to antibiotics within about 2 weeks, or when the picture is atypical. Biopsy is needed.
• Non-lactational (periductal) abscesses are strongly associated with smoking and diabetes; screen for new diabetes.^[4]

Nipple discharge

• Physiologic discharge is bilateral, multi-duct, non-spontaneous, and clear/milky/green: reassure, avoid squeezing, review medications (including oral contraceptives and antipsychotics), check thyroid and prolactin if needed.
• Pathologic discharge is spontaneous, unilateral or single-duct, and especially bloody or serous (watery). It must be investigated.
• Imaging: ultrasound of the symptomatic duct (and mammography by age); mammography and ultrasound detect many lesions, but a papilloma can be too small to see. MRI can find occult discharge sources.
• Most pathologic nipple discharge in premenopausal women is due to intraductal papilloma.
• Excision is indicated for spontaneous bloody or single-duct discharge, a palpable mass, a radiologic lesion, or any papilloma with atypia. Excising the involved duct segment removes both the cause and the small risk of coexisting malignancy.

For most early breast cancers (EBC), breast-conserving surgery (BCS) plus postoperative radiotherapy is the recommended default. It preserves the breast without sacrificing outcome.^[4]

• Patient preference matters. Some women prefer mastectomy for anxiety, symmetry, or to avoid radiotherapy.
• Mastectomy is appropriate for: multifocal or multicentric disease, a large tumour relative to breast size, inflammatory breast cancer, recurrent disease after prior conservation, contraindication to radiotherapy, or patient choice.^[2][4]
• Margins and re-excision. After BCS, if invasive cancer or DCIS is present at the radial margin ("tumour on ink", 0 mm), offer further surgery (re-excision or mastectomy, as appropriate). If tumour cells are within 1 mm (invasive) or within 2 mm (DCIS) of, but not at, the margin, further surgery should be considered alongside the patient's circumstances, comorbidities, tumour features and planned radiotherapy.^[2]
• Radiotherapy after BCS is recommended. Hypofractionated schedules are strongly preferred: moderate (15-16 fractions of 3 Gy or less) and, for whole-breast or chest wall without reconstruction, an ultra-hypofractionated course of 26 Gy in five daily fractions.^[4]
• Post-mastectomy radiotherapy (PMRT) is recommended for high-risk EBC: involved margins, four or more involved axillary nodes, T3-T4 tumours, or a combination of risk factors; and should be considered in intermediate risk, including 1-3 positive nodes and lymphovascular invasion.^[4]
• Breast reconstruction should be offered to anyone after mastectomy, immediate or delayed, unless comorbidities rule it out or urgent systemic/radiotherapy would be compromised. Early reconstruction does not worsen cancer outcomes.^{[2][4] [3]}

This is a separate decision from the breast operation.

• Sentinel lymph node biopsy (SLNB) is the standard axillary procedure for clinically node-negative disease. It is performed with a dual technique (isotope plus blue dye) where available.^[2][4]
• Positive sentinel nodes. If one or more sentinel nodes contain macrometastasis, further axillary treatment (clearance or radiotherapy) is usually advised.^[2]
• Micrometastases and isolated tumour cells do not need further axillary treatment; they are classified as node-negative for management.^[2]
• 1-2 affected sentinel nodes after BCS plus whole-breast radiotherapy and systemic treatment do not need further axillary surgery (ACOSOG/Z0011 principle). Axillary node clearance in that group is generally reserved for suspected high nodal burden or when the result would change adjuvant therapy.^{[4] [2]}
• Proven positive nodes before surgery on ultrasound-guided biopsy warrant axillary node clearance.^[2]
• Modified radical mastectomy plus clearance remains necessary for inflammatory breast cancer, clinically heavy nodal disease, and where SLNB is not possible.

Lymphoedema is the most common long-term complication after axillary surgery. Arm measurements, exercise, and avoiding infection and trauma on the operated side all help. Early referral to a lymphoedema therapist is useful; ESMO and NICE note that full axillary clearance carries the highest risk.

Adjuvant treatment is biological and stage-driven. The principles, rather than drug doses, are what every student should know; doses and combinations change with trials and funding.

• Endocrine therapy for all ER-positive invasive cancers.^[2] For premenopausal women, tamoxifen, or ovarian function suppression with tamoxifen or an aromatase inhibitor for those at higher risk. For postmenopausal women, an aromatase inhibitor (or tamoxifen if low risk or aromatase inhibitors not tolerated). Adjuvant endocrine therapy reduces recurrence of hormone-positive cancer by nearly half when taken for years.^[1][2] Extended endocrine therapy past 5 years is considered for those with higher risk features such as node positivity.^[2]
• Anti-HER2 therapy: trastuzumab for 1 year, 3-weekly, for HER2-positive invasive cancers above very small size (T1c and above), with caution in cardiac disease (basal LVEF of 55% or less requires careful balancing). Trastuzumab emtansine is used when residual invasive disease remains after neoadjuvant therapy. Pertuzumab combinations are used in higher-risk node-positive disease in many systems.^[2]
• Chemotherapy: where indicated, regimens containing a taxane and an anthracycline are standard; dose-dense schedules are preferred where available.^[2][4]
• Triple-negative EBC: where neoadjuvant chemotherapy is used, a platinum-containing regimen improves pathological complete response and survival compared with non-platinum regimens, based on recent trials. Pembrolizumab with chemotherapy, then continued alone as adjuvant therapy, is recommended for high-risk triple-negative disease in some systems.^[2]
• High-risk, receptor-positive disease: abemaciclib or ribociclib with endocrine therapy are now used as adjuvant therapy for node-positive high-risk disease; bisphosphonates reduce recurrence and treatment-related bone loss in postmenopausal women.^[2][4]
• BRCA-mutation carriers with HER2-negative high-risk disease: 1 year of adjuvant olaparib (PARP inhibition) improves outcomes after (neo)adjuvant chemotherapy. It is given with endocrine therapy in HR-positive disease and must not be combined with abemaciclib.^[2][4]
• Neoadjuvant therapy (chemotherapy before surgery) is used to shrink larger tumours, allow breast conservation, and test tumour response in vivo. Response predicts long-term outlook and guides further treatment.

A clinical pearl: "the tumour's biology, not just its size, drives both treatment and outcome." Small, node-negative, well-differentiated, ER-positive, HER2-negative cancers can have an excellent prognosis, whereas a clinically small triple-negative or HER2-positive tumour may warrant systemic therapy.

NICE CG164 (published 2013, last updated 14 November 2023) is the main UK source for family history.^[3]

• Taking a good family history in secondary care means recording three generations of cancers, ages of diagnosis, bilaterality, male breast cancer and ovarian cancer.^[3]
• Risk classification. Women without a personal history fall into population, moderate or high risk by family pattern. Those at near-population risk are managed in primary care; secondary care or specialist genetic clinics take the higher-risk groups.^[3]
• Genetic testing is offered when the combined BRCA1 and BRCA2 mutation carrier probability is 10% or more, usually starting with an affected relative. Fast-track 4-week testing is reserved for clinical trials.^[3]
• Jewish ancestry raises the BRCA carrier chance 5- to 10-fold.^[3]
• Germline testing should also be offered when a woman aged under 50 has triple-negative breast cancer, even with no family history, and to anyone who may benefit from adjuvant olaparib.^[2]
• Surveillance for high-risk women with no cancer: offer annual mammography from 40 (or 30-39 in some high-risk groups), and annual MRI for 30-49-year-olds with a known BRCA1/2 mutation (or at high probability). MRI is not needed for moderate-risk or high-risk women with a low carrier probability. Women post-bilateral-mastectomy do not need surveillance.^[3]
• Chemoprevention: offer tamoxifen for 5 years to premenopausal women at high risk, and anastrozole for 5 years to postmenopausal women at high risk, with tamoxifen or raloxifene options when anastrozole is unsuitable or not wanted. Chemoprevention is considered for moderate-risk women.^[3]
• Risk-reducing surgery: bilateral risk-reducing mastectomy and/or salpingo-oophorectomy are appropriate only for a small proportion of high-risk women and must be managed by a multidisciplinary team, with genetic counselling first. All such women should hear about reconstruction options from a surgeon with oncoplastic skill. Risk-reducing bilateral mastectomy does not remove all risk but reduces it very substantially.^[3][1]
• Counselling: families should understand the meaning of a positive or negative test, variants of uncertain significance, and the limits of what screening can do.

• Male breast cancer is rare (0.5-1% of breast cancers) but is usually ER-positive. Men are treated with mastectomy followed by radiotherapy as indicated and endocrine therapy (tamoxifen). Genetic testing (especially BRCA2) is often appropriate.^[1][2]
• Pregnancy. Breast surgery and some systemic therapies can be given in pregnancy, but chemotherapy is avoided in the first trimester; decisions are MDT and obstetric-specific.
• Older adults. Fitness and frailty, not age, guide treatment; primary endocrine therapy alone is only for those in whom surgery is unsafe.^[2]
• Inflammatory breast cancer presents as a red, hot, swollen breast without a discrete mass early on; it is locally advanced and managed with systemic therapy before surgery and radiotherapy.

The WHO Global Breast Cancer Initiative focuses on strengthening the basics that every setting can deliver. Priorities that transfer well:

• Find symptoms early. Breast awareness, prompt assessment of any new lump, and reliable referral pathways from primary care to district hospitals to cancer centres. This alone reduces mortality.
• Where mammography is unavailable, clinical breast examination and prompt diagnosis of symptomatic disease, coupled with completion of treatment, are the realistic levers (WHO notes that this can be done even without mammographic screening).^[1]
• Triple assessment on palpable masses remains the core skill: clinical examination, ultrasound where available, and core or FNA biopsy. A core biopsy requires only a trained operator and basic pathology.
• Generic drugs for breast cancer (tamoxifen, aromatase inhibitors, common chemotherapies, trastuzumab where approved) are on the WHO Essential Medicines List, so cost should not be used as a blanket reason to withhold standard treatment.^[1]
• Surgical simplicity: a safe mastectomy with axillary clearance is better than no surgery, and it should be available at regional hospitals; SLNB needs resources that centralise this step.
• Complete treatment once started. Partial treatment is less effective. Patient navigation (a single named key worker or support person guiding the patient through each step) improves completion.^[1]

Of breast cancer itself: nodal involvement; metastasis to bone, liver, lung, brain; lymphoedema from nodal blockage; skin and chest wall ulceration; pleural effusion; marrow suppression with advanced disease.

Of surgery: bleeding, seroma, wound infection, arm lymphoedema, shoulder stiffness, altered sensation, chronic pain (post-mastectomy pain syndrome), flap or implant loss, asymmetry.

Of radiotherapy: skin reaction, breast or chest wall pain, fatigue; late effects include fibrosis, telangiectasia, pneumonitis, and (rare, years later) rib fractures or second cancers.

Of systemic treatments: cytopenias, alopecia, neuropathy, menopausal symptoms, arthralgia, osteoporosis, cardiac dysfunction with trastuzumab (monitor LVEF), and thrombosis with tamoxifen.

Prognosis depends most on stage at diagnosis and biology. Early, small, node-negative, ER-positive cancers have a very high cure rate with modern therapy, while metastatic disease is incurable but controllable for years in many subtypes. Exact outcomes are trial and population-specific and should be quoted to patients from validated tools such as PREDICT (validated in UK populations; less accurate for very young, very old, or very large tumours and for some ethnic groups).^[2]

The best medicine is detection before symptoms: cancers found by screening are smaller and less likely to have spread. High-income countries have cut age-standardised breast cancer mortality by about 40% since the 1980s through the combination of screen detection and modern systemic therapy; low- and middle-income countries now carry a growing share of deaths because of late presentation.^[1]

Population screening

• Breast awareness: all women should know what is normal for their own breasts and report change promptly. WHO and NICE stress this at all risk levels.^[3]
• Mammography: WHO's fact sheet describes screening as mammography in apparently healthy women, usually 50-69 years of age.^[1] ESMO recommends screening every 2 years for 45-69-year-olds, with possible screening at 40-44 and 70-74 where emerging evidence supports benefit.^[4] National programs set their own start age (for example 40 years in some systems, 50 in others) and interval; follow the policy of the country you work in.
• MRI plus mammography is offered to women carrying BRCA1, BRCA2 or TP53 mutations from young adult life, under CG164 surveillance rules.^[3]

Personal risk reduction

• Alcohol moderation, healthy weight, physical activity, limited smoking, and limiting long-term HRT, especially combined oestrogen-progestin.
• Breastfeeding reduces risk.
• Chemoprevention (tamoxifen, anastrozole) for moderate- and high-risk women without a personal history, with the trade-offs of thrombosis, menopausal symptoms and bone loss discussed and documented.^[3]
• Risk-reducing surgery only for the small group at genuinely high genetic risk.

• Most breast lumps in premenopausal women are benign: fibroadenoma, cysts, fibrocystic change, infection.
• Triple assessment (clinical, imaging, pathology) is mandatory for any discrete new breast mass, and all three components must agree before a mass is called benign.
• Fibroadenoma: firm, rubbery, smooth, mobile lump of young women; observe if classic, excise if uncertain or growing.
• Simple cysts: smooth, tense, mobile; on ultrasound simple cysts need no biopsy.
• Mastitis/abscess: usually lactational; early treatment with emptying, analgesia and antibiotics; drainage only when an abscess forms; always exclude inflammatory breast cancer if not lactating.
• Nipple discharge: single-duct spontaneous discharge, especially bloody, is pathologic and needs investigation and often duct excision.
• Breast cancer is the most common cancer in women worldwide: about 2.4 million diagnoses and 694,000 deaths in 2024.^[1]
• Roughly 80% of breast cancers occur in women with no modifiable risk factor other than being female and over 40.^[1]
• High-penetrance inherited faults (BRCA1, BRCA2, PALB2) and Jewish ancestry strongly raise risk.^[1][3]
• Early breast cancer is usually curable. For most early cancers, breast-conserving surgery plus radiotherapy matches mastectomy for outcome.^[2][4]
• Receptors (ER, PR, HER2) drive treatment and prognosis. ER-positive cancers get endocrine therapy; HER2-positive cancers get trastuzumab; triple-negative cancers get chemotherapy (often with a platinum and immunotherapy in selected high-risk disease).
• Staging: TNM 8th edition based on the WHO classification.^[4] Pre-treatment staging imaging is reserved for higher stage or aggressive disease.^[4]
• SLNB is the standard axillary staging for node-negative cancers; further clearance is usually needed only for macrometastases or proven preoperative node involvement.^[2][4]
• Endocrine therapy reduces recurrence of ER-positive cancer by nearly half over years of treatment; aromatase inhibitors for postmenopausal, tamoxifen (often with ovarian suppression) for premenopausal high-risk patients.^[1][2]
• Adjuvant chemotherapy (taxane plus anthracycline) is used when the risk of relapse is high enough to justify it; use validated tools (PREDICT with appropriate caveats).
• HER2-positive disease at T1c and above gets 1 year of adjuvant trastuzumab, with cardiac monitoring.^[2]
• High-risk BRCA carriers (HER2-negative, high-risk) receive adjuvant olaparib for 1 year after (neo)adjuvant chemotherapy.^[2][4]
• MDT working, specialist breast units, and patient navigation improve outcomes and completion of treatment.
• Risk-reducing bilateral mastectomy and salpingo-oophorectomy are only for a small, genetically high-risk group, after counselling.^[3]
• NICE CG164 defines surveillance, chemoprevention and risk-reducing surgery for familial risk.^[3]
• Low-resource essentials: breast awareness, prompt referral, triple assessment with core biopsy, completion of generic treatment, and navigation.

No verified MedGrasp topics are linked from this page yet. Once the surgery and oncology pages of this library are published, this page should link to the breast cancer overview, lymphoedema, scar and wound healing, pain, and oncology drug topics. Discussion of systemic treatment belongs with those pages; this one covers the surgical and diagnostic backbone.