breast lump and nipple symptoms (recognition + 2ww referral)

Breast presentations are common in primary care; most are benign, but timely referral matters when NG12 criteria are met. The NHS breast clinic model is typically triple assessment: clinical assessment + imaging + biopsy where indicated.

• 2-week-wait (NG12): aged ≥30 with an unexplained breast lump (with or without pain).
• 2-week-wait (NG12): aged ≥50 with unilateral nipple discharge, unilateral nipple retraction, or other unilateral nipple changes of concern.
• Don’t miss: inflammatory breast cancer (rapid onset erythema/oedema), Paget disease (eczema-like nipple change not resolving), a new axillary lump, or a suspicious male breast mass.

• History: duration, change over time, cyclical pain, pregnancy/lactation, trauma, infection symptoms, nipple discharge (spontaneous vs expressed; unilateral vs bilateral; blood-stained), systemic symptoms.
• Risk context: age, prior breast cancer, prior chest irradiation, family history / known pathogenic variants, HRT use, alcohol, BMI.
• Exam: inspect (asymmetry, tethering, peau d’orange, ulceration), palpate lump (size, texture, mobility), check axillary/supraclavicular nodes, examine nipple/areola.

Benign-leaning patterns (still safety-net): diffuse bilateral cyclical mastalgia, symmetrical nodularity, clear discharge only on expression, classic sebaceous cyst.

• Breast pain only (no lump): consider musculoskeletal causes; consider non-urgent imaging if focal persistent pain in older patients per local pathway.
• Suspected mastitis/abscess (esp. lactation): treat and review; urgent same-day if systemic illness, spreading cellulitis, or suspected abscess requiring drainage.
• Nipple discharge: red flags include spontaneous, unilateral, single-duct, blood-stained discharge; consider NG12 threshold at age ≥50 for unilateral discharge/retraction/changes.
• Male breast symptoms: gynaecomastia is common and usually bilateral; unilateral hard subareolar mass, skin/nipple changes, or bloody discharge (often age ≥50) should be referred urgently via local suspected cancer pathways.

• Immediate / urgent escalation: rapidly progressive swelling/erythema (inflammatory cancer vs severe infection), systemic sepsis, or suspected abscess needing drainage.
• Re-review if: symptoms persist beyond 4–6 weeks, a “cyst” changes character, new axillary lump appears, or a presumed dermatitis of the nipple/areola does not respond to treatment.
• Document: size/location (clock face + distance from nipple), node findings, and explicit safety-net advice.