Breast history

The breast history should focus of system-specific questions relating to disease of the breast.

A breast history focuses the consultation on key clinical features that affect the breasts. The hallmark of breast disease is a breast lump and you should feel confident in exploring the features of a breast lump in full detail.

It is important within your history to determine any systemic features that may indicate an underlying malignancy (e.g. fever, weight loss, loss of appetite) and to tease out any significant risk factors for breast disease. For example, mastitis is more likely to occur if the patient is breastfeeding and a strong family history of breast cancer may indicate a hereditary cause (e.g. BRCA mutation).

A breast lump is one of the cardinal clinical features of breast disease.

There are a limited number of presentations of breast disease so it is important you can quickly and efficiently explore the major symptoms. The cardinal feature of breast disease is a lump, which we focus on below.

The key features to determine in the breast history include:

• Breast lump
• Mastalgia (breast pain): bilateral or unilateral.
• Nipple discharge
• Altered appearance: skin, size, asymmetry. Usually in association with a lump.

Breast lump

When discussing a breast lump you must gather how the patient first noticed it. Was this a self-examination or found incidentally on imaging (e.g. CT scan or breast cancer screening)?. There are many different aspects to explore that will help you determine whether the lump is benign or malignant.

Consider the following features in the history of a breast lump:

• Site: the actual location of the lump
• Size: rough estimation
• Timing: when was the lump first noticed?
• Change in size: has the lump changed in size? In what time frame?
• Consistency: does the lump feel soft or soft? Is it mobile or fixed?
• Pain: is the lump painful or painless?
• Preceding injury
• Associated lumps or bumps: are there any lymph nodes present or adjacent lumps?
• Associated features: any change to surrounding skin? Any distortion of the breast appearance?

Features suggestive of malignant disease include a hard, painless, and fixed breast lump. Distortion of breast tissue and associated skin are highly concerning for a malignant process. This may include:

• Skin puncturing
• Retraction of the nipple
• New asymmetrical breast size
• Retraction of skin on the chest
• Destruction of skin.

These changes may occur in association with enlarged lymph nodes and nipple discharge.

Nipple discharge

Ensure you clarify whether the discharge is unilateral or bilateral and then focus on the colour, consistency, and volume. Determine whether the discharge is bloody. Bloody nipple discharge is concerning for a more sinister pathology.

Establishing a proper obstetric and gynaecological history is important to work out any risk factors for breast disease.

An obstetric and gynaecological history are needed to determine the risk of certain breast diseases and is needed to guide further management and treatment options.

Gynaecological

Ask specifically about the last menstrual period (LMP) and establish a menopausal state (i.e. pre-, peri-, or post-menopausal). Patients with early menarche and late menopause are at increased risk of breast cancer.

Enquire about any broad gynaecological symptoms (e.g. abnormal bleeding, abnormal discharge).

Obstetric

Ask about any obstetric history and whether they are currently breastfeeding. Patients who are breastfeeding are at increased risk of mastitis and breast abscess.

Determine the gravidity and parity:

• Gravidity: number of times a patient has been pregnant
• Parity: number of times a patient has given birth to a child ≥24 weeks (regardless of alive or stillborn)

With each pregnancy, it is important to establish the age of the pregnancy, any antenatal problems, birthing history (e.g. C-section or normal vaginal delivery) and any perinatal problems (e.g. perianal tear).

Patients who are nulliparity are at increased risk of breast cancer (e.g. never given birth).

Ask about any previous history of breast cancer and determine the timeline of treatments.

It is critical that you ask about any previous breast disease, but particularly focusing on previous cancer. Make sure you ask about previous treatments, which may include:

• Breast surgery (e.g. mastectomy, lumpectomy, breast reconstruction)
• Chemoradiotherapy: was this neoadjuvant (i.e. before surgery) or adjuvant (i.e. post-surgery)
• The intention of treatment (e.g. curative or palliative)
• Last follow-up or treatment
• Side-effects (e.g. chemotherapy side-effects, lymphoedema)

Hormone replacement therapy (HRT) increases the risk of breast cancer.

Clarify current medications including prescribed, over-the-counter and herbal remedies. Also, enquire about any recent medications, for example, has the patient had any recent antibiotics for a breast abscess?

Make sure you enquire about hormonal therapies:

• Contraceptive use (e.g. oral, subcutaneous, IUS)
• Hormone-replacement therapy (HRT)

Ask about the type of hormonal therapy and the duration of use. All types of systemic HRT increase the risk of breast cancer after 1 year of use, but some more than others. It is important to ask about hormonal use even if the patient is no longer using them.

Breast cancer may be hereditary due to the inheritance of an abnormal gene (e.g. BRCA).

Determine a full family history with a particular focus on the presence of breast cancer. Is the patient aware of any inherited conditions that run within the family?

Ask about any first degree-relatives (e.g. mother, father, sister, brother, children), and then if relevant enquire about second-degree relatives (e.g. grandparents, aunts, uncles). Make sure you establish whether maternal or paternal second-degree relatives.

Smoking, alcohol, and obesity are all risk factors for the development of breast cancer.

Take a full social history like any history to establish the fitness of the patient and any relevant risk factors (e.g. smoking, alcohol). Use the mnemonic LOLAS DIET to help. See Basic history note.

Always end by discussing the patient’s ideas, concerns & expectations.

1. Do you have an idea about what could be going on?
2. Is there anything that is worrying/concerning you at the moment?
3. Is there anything you were hoping for from this consultation?
4. Do you have any further questions today?