• Breast cancer is the most common type of cancer diagnosed in Canadian women (excluding non-melanoma skin cancer).
• Over 80% of new breast cancers diagnosed each year in BC are in women age 50 or over.
• The second leading cause of cancer death in Canadian women after lung cancer.
• Also occurs in men, but not as common.
• Each province has mammography programs. BC Breast Cancer Screening.

Presentation

• Classic: painless unilateral breast mass in an older woman.
• New mass in the breast tissue or axillae region.
• Heaviness, burning, pain, pruritus or tenderness of the breast, nipple, or areola.
• Rapid change in shape or increase in size of breast.
• Nipple discharge or change (sudden inverted nipple).
• Axillary adenopathy.
• Skin findings may include: erythema, a pink, reddish, purple, or bruised appearance of the skin thickening, or dimpling of overlying skin (peau d’orange).
• Symptoms/signs of metastatic disease: bones, liver, lungs and brain.
• Paget’s disease of the breast presents with similar clinical findings including a scaly, raw, vesicular or ulcerated lesion on the nipple and areola. Biopsy should be performed to distinguish breast cancer from Paget’s disease of the breast.

Risk Factors

• Early menarche (<12 yo.).
• Late menopause (>55 yo.).
• Nulliparity.
• Long-term use of hormone replacement therapy.
• Breast density.
• Personal / Family history of breast cancer and/or ovarian cancer.
• Personal or family history of mutation of the BRCA1/BRCA2 genes.

Physical Exam

• Clinical breast and axillary lymph node.

Differential Considerations

• Breast sarcomas are rare, histologically homogeneous tumours that arise from the connective tissue within the breast.
• Lymphoma.
• Fibroadenoma, fibrocystic condition.
• Fat necrosis.
• Breast abscess.
• Mastitis.

• For symptomatic women aged ≤ 30 years, diagnostic ultrasound is the recommended initial investigation. Mammography may be subsequently indicated.
• For symptomatic women aged ≥ 30 years, diagnostic mammography and ultrasound are recommended for initial investigation.
• For symptomatic women of any age who are pregnant or lactating, diagnostic ultrasound is the recommended initial investigation (not mammography).
• Refer to a local breast specialist for a definitive assessment.
• Routine labs including liver function tests to assess metastasis.

• Severe pain related to metastatic spread requiring treatment.

• Pain is reasonably controlled, and the patient has a plan for ongoing pain problems.
• Follow-up has been arranged with breast physician/family physician.

1. Berg WA, Zhang Z, Lehrer D, et al. Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA 2012;307:1394-1404.

   
   

2. BCGuidelines.ca – Breast cancer management:

   https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/breast-cancer-management?keyword=breast&keyword=cancer

   
   

3. BCGuidelines.ca – Breast cancer and disease diagnosis.

   
   

4. Breast Cancer. (n.d.). BC Cancer Agency. Retrieved January 06, 2021.

   
   

5. Breast cancer statistics – Canadian Cancer Society. (n.d.). Retrieved January 06, 2021.

   
   

6. Joe, BN. Clinical Features, diagnosis, and staging of newly diagnosed breast cancer. UpToDate [Internet]. [cited 2020 Nov 19].

   
   

7. Mar, C., Sam, J., Wilson, C. Breast cancer screening in British Columbia: A guide to discussion with patients. British Columbia Medical Journal. 2018 Feb;60(1):20-26.