The palpable breast lump: information and recommendations to assist decision-making when a breast lump is detected. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Association of Radiation Oncologists.

OBJECTIVE

To provide information and recommendations for assisting women and their physicians in making the decisions necessary to establish or exclude the presence of cancer when a lump is felt in the breast.

EVIDENCE

Guidelines are based on a systematic review of published evidence and expert opinion. References were identified through a computerized citation search using MED-LINE (from 1966) and CANCERLIT (from 1985) to January 1996. Nonsystematic review of breast cancer literature continued to January 1997.

BENEFITS

Exclusion or confirmation of the presence of cancer with the minimum of intervention and delay.

RECOMMENDATIONS

Investigation of women with a breast lump or suspicious change in breast texture starts with a history, physical examination and usually mammography. The clinical history should establish how long the lump has been noted, whether any change has been observed and whether there is a history of biopsy or breast cancer. Risk factors for breast cancer should be noted, but their presence or absence should not influence the decision to investigate a lump further. The physical examination of the breast should aim to identify those features that distinguish malignant from benign lumps. Mammography can often clarify the nature of the lump and detect clinically occult lesions in either breast. Fine-needle aspiration can establish whether the lump is solid or cystic. When a tumour is solid, cells can be obtained for cytologic examination. Ultrasonography is an alternative method to fine-needle aspiration for distinguishing a cyst from a solid tumour. Whenever reasonable doubt remains as to whether a lump is benign or malignant, a biopsy should be carried out. When surgical biopsy is used, the aim is to remove the whole lump in one piece along with a surrounding cuff of normal tissue. Core biopsy, either clinically or image-guided, can usually establish or exclude malignancy, thus reducing the need for surgical biopsy. Thermography and light scanning are not recommended diagnostic procedures. The value of magnetic resonance imaging is still under investigation. It is not a routine diagnostic procedure at this time. The choice of procedure should take into account the experience of the diagnostician and availability of the technology in question. The work-up should be completed expeditiously and the patient kept fully informed throughout. Even when malignancy is not found, it may be prudent, in some cases, to arrange follow-up surveillance.

VALIDATION

Guidelines were reviewed and revised by the Writing Committee, expert primary reviewers, secondary reviewers selected from all regions of Canada and by the Steering Committee. The final document reflects a consensus of all these contributors.