STEP 2: Presentation, initial investigations and referral of patients with suspected breast cancer
This step outlines the process for the general practitioner to initiate the right investigations and refer to the appropriate specialist in a timely manner. The types of investigations the general practitioner undertakes will depend on many factors, including access to diagnostic tests, the availability of medical specialists and patient preferences.
At least one-third of breast cancers are found in apparently asymptomatic women through routine breast cancer screening, and participation in BreastScreen Australia should be encouraged for eligible women. The remaining women have symptomatic presentations.
The following signs and symptoms should be investigated:
- a persistent new lump or lumpiness, especially involving only one breast
- a change in the size or shape of a breast
- a change to a nipple, such as crusting, ulceration, redness or inversion
- a nipple discharge that occurs without manual expression
- a change in the skin of a breast such as redness, thickening or dimpling
- axillary mass(es)
- an unusual breast pain that does not go away (Cancer Australia 2020b; Walker et al 2014).
People with symptoms as described above should not attend BreastScreen because they will require diagnostic imaging either publicly or privately.
A patient with signs and symptoms that may suggest breast cancer should be seen by a general practitioner within two weeks.
The types of investigation undertaken by a general practitioner depend on many factors including access to diagnostic tests and medical specialists and the patient’s preferences. General practitioners should refer all patients with a suspicious sign or symptom to a breast assessment clinic.
General practitioner examinations and investigations should include a triple test of three diagnostic components:
- medical history and clinical breast examination
- imaging – mammography and/or ultrasound
- non-excision biopsy – preferably core biopsy (Cancer Australia 2017a; Farshid et al. 2019). Pathologists should expedite such testing as part of routine clinical care. Funding through the Medicare Benefits Schedule is accessible for receptor profile evaluation of screen-detected cancers, including immunohistochemistry for ER, PR and HER2 and, when necessary, in situ hybridisation to assess HER2 gene amplification.
Fine-needle aspiration biopsy does not permit distinction between invasive cancer and in situ malignancy. Evaluation of grade and subtype are not reliable, and cytology is inappropriate for assessing a cancer’s receptor profile (ER, PR, HER2), critical for optimal treatment planning, including suitability of neoadjuvant therapy. Fine-needle aspiration cytology may be considered if the clinical and imaging features suggest a benign process, particularly a cystic lesion. If cytology results are non-diagnostic, atypical, suspicious or malignant, core biopsy is needed.
Based on the best available evidence, the triple test provides the most effective means of excluding breast cancer in patients with breast symptoms. A positive result on any component of the triple test warrants referral for specialist surgical assessment and/or further investigation, irrespective of any other normal test results. This implies that not all three components of the triple test need to be performed to reach the conclusion that appropriate referral is needed. The triple test is positive if any component is indeterminate, suspicious or malignant (Cancer Australia 2017a).
For screen-detected lesions, a 2020 review by Cancer Australia established that core biopsy (including vacuum-assisted core biopsy) is the procedure of choice for assessing most screen-detected breast abnormalities (Cancer Australia 2020c). Fine-needle aspiration in the screening setting is appropriate for simple cysts, some complex cystic lesions, axillary lymph nodes and rare situations where a core biopsy is hazardous or technically difficult.
BreastScreen Australia services take responsibility for screening and investigation of screen-detected lesions, including needle biopsies. After multidisciplinary assessment and review of results, recommendations are made for the next steps in management. The woman and her general practitioner are advised of these recommendations in writing. Surgery and ongoing care are typically not part of the BreastScreen program and must be coordinated by the general practitioner through appropriate surgical referral.
To enable timely treatment planning, including consideration of neoadjuvant therapies, it is preferable that the histologic findings, including the receptor profile results, be available in time for the patient’s first consultation with the treating surgeon. Information could be provided to patients to enable them to make an informed decision on neoadjuvant therapy. See Breast Cancer Trials ‘Neoadjuvant patient decision aid’ brochure.
Optimally, tests should be done within two weeks.
Any patient with symptoms suspicious of breast cancer can be referred for specialist assessment as first line. If the diagnosis of breast malignancy is confirmed or the results are inconsistent or indeterminate, referral to a BreastSurgANZ member breast surgeon is warranted. See BreastSurgANZ ‘Find a surgeon’ for a directory.
Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.
Referral for suspected or diagnosed breast cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:
- important psychosocial history and relevant medical history
- family history, current symptoms, medications and allergies
- results of current clinical investigations (imaging and pathology reports with ER, PR and HER2 receptor profile)
- results of all prior relevant investigations
- notification if an interpreter service is required.
Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.
If access is via online referral, a lack of a hard copy should not delay referral.
The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.
Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources – Checking for cancer and Cancer from the Cancer Australia website.
A positive result on any component of the triple test warrants specialist surgical referral. Ideally, the surgeon should see the patient with proven or suspected cancer within two weeks of diagnosis. If necessary, prior discussion should facilitate referral.
The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required. See validated screening tools mentioned in Principle 4 ‘Supportive care’.
A number of specific needs may arise for patients at this time:
- assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression, interpersonal problems and adjustment difficulties
- access to expert health professionals with specific knowledge about the psychosocial needs of breast cancer patients
- encouragement and support to increase levels of exercise (Cormie et al. 2018; Hayes et al. 2019).
For more information refer to the National Institute for Health and Care Excellence 2015 guidelines, Suspected cancer: recognition and referral.
For additional information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.
The general practitioner is responsible for:
- providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
- outlining their potential role and that of the primary care team throughout treatment and follow-up care (Cancer Australia 2020d)
- considering referral to a breast care nurse such as a McGrath breast care nurse or a nurse in a local breast cancer centre
- considering referral to Breast Cancer Network Australia’s ‘My Journey online tool’ and local community-based support such as peer support
- requesting that patients notify them if the specialist has not been in contact within the expected timeframe
- considering referral options for patients living rurally or remotely
supporting the patient while waiting for the specialist appointment (Cancer Council nurses are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information; patients can contact 13 11 20 nationally to speak to a cancer nurse).
Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.
