Breast Lump on the CCFP exam

Approach

• Take the family history on both sides: who had breast or ovarian cancer, and at what age. Ask about a known gene change in the family.
• Ask about radiation to the chest at a young age, and about her own past breast disease.
• Name the risks she can change: alcohol, weight gain after menopause, too little exercise, and long use of hormone therapy.
• Gene testing starts with a relative who had cancer. Defer predictive testing in a minor: nothing changes for years, and the choice should be hers as an adult.
• The 2024 Task Force draft covers average and moderately raised risk. Moderate means a 12 to 20% lifetime risk, from dense breasts or one first-degree or two second-degree relatives diagnosed after 50.
• A known gene change, a strong family history, past breast cancer or symptoms fall outside the draft. Refer to genetics or high-risk screening, or work up the symptom.
• Offering mammography: give benefits and harms in absolute numbers and decide together. The CFPC took mammography off its Choosing Wisely list in May 2024; the choice rests on her values.

Approach

• Ask how long the lump has been there, whether it changes with periods or grows, and about pain, nipple discharge or skin change.
• Examine both breasts, both armpits and above the collarbones. A hard, fixed or irregular lump, or one pulling the skin, raises concern at any age.
• Match imaging to the patient's age and findings. A suspicious lump goes on to tissue diagnosis and a surgeon.
• A normal scan does not clear a lump that feels suspicious.
• A child with a disc under the areola has a breast bud. Do not needle or remove it. Look for early puberty: a growth spurt, pubic hair, body odour.
• Give a name and number to call while results are pending, and say when you will call. If a referral date never comes, phone the clinic yourself.

Approach

• Well, with no new symptoms: skip blood tests and body scans hunting for spread. Often they do not help her live longer or better, and they add worry.
• At each visit, ask about new bone pain, cough or breathlessness, headache, weight loss and belly pain. A new symptom earns a test aimed at it.
• In a patient with bone spread, tamoxifen can raise calcium in its first few weeks. With known bone spread, check it then. Check it any time she is thirsty, confused or constipated.
• Tamoxifen raises the risk of uterine cancer and of clots in the legs and lungs. Investigate abnormal vaginal bleeding promptly.
• Tamoxifen needs a liver enzyme, CYP2D6, to work. Where possible, avoid paroxetine, which blocks it, for her hot flashes or mood.
• Letrozole and other aromatase inhibitors thin bone and raise fracture risk. Check bone health and cholesterol during treatment.
• Ask about mood, fear of the cancer coming back, body image, sex and money. Link her to a cancer support line, a peer group or a social worker.