What are the indications for referring a patient with gynaecomastia to secondary care for further evaluation?

Indications for referring a patient with gynaecomastia to secondary care for further evaluation include:

• Presence of suspicious breast signs such as a unilateral breast lump, nipple changes (discharge, retraction), or skin changes suggestive of malignancy, especially in men aged 30 years and over, warranting urgent referral via a suspected cancer pathway.
• Any clinical suspicion of male breast cancer, given the rarity but serious nature of the condition, should prompt urgent secondary care referral.
• Unexplained or persistent gynaecomastia that does not resolve or has atypical features, including rapid onset, pain, or associated systemic symptoms, should be evaluated further in secondary care.
• Patients with a family history of male breast cancer or other related cancers (e.g., ovarian cancer, bilateral breast cancer, sarcoma in young relatives) may require specialist assessment for genetic risk and secondary care referral.
• Uncertainty in diagnosis or management in primary care, or if the patient is not reassured by initial assessment and information, should prompt referral for specialist evaluation.

These recommendations align with NICE guidance on suspected cancer recognition and referral pathways, emphasizing urgent referral for unexplained breast lumps in men aged 30 and over, and consideration of family history and genetic risk factors in referral decisions ⁴,⁵,⁶.