1 - THE PALPABLE BREAST LUMP - INFORMATION AND RECOMMENDATIONS TO ASSIST DECISION-MAKING WHEN A BREAST LUMP IS DETECTED

Objective: To provide information and recommendations for assisting wo men and their I physicians in making the decisions necessary to establ ish or exclude the presence of cancer when a lump is felt in the breas t. Evidence: Guidelines are based on a systematic review of published evidence and expert opinion. References were identified through a comp uterized citation search using MEDLINE (from 1966) and CANCERLIT (from 1985) to January 1996. Nonsystematic review of breast cancer literatu re continued to January 1997. Benefits: Exclusion or confirmation of t he presence of cancer with the minimum of intervention and delay. Reco mmendations: Investigation of women with a breast lump or suspicious c hange in breast texture starts with a history, physical examination an d usually mammography. The clinical history should establish how long the lump has been noted, whether any change has been observed and whet her there is a history of biopsy or breast cancer. Risk factors for br east cancer should be noted, but their presence or absence should not influence the decision to investigate a lump further. The physical exa mination of the breast should aim to identify those features that dist inguish malignant from benign lumps. Mammography can often clarify the nature of the lump and detect clinically occult lesions in either bre ast. Fine-needle aspiration can establish whether the lump is solid or cystic. When a tumour is solid, cells can be obtained for cytologic e xamination. Ultrasonography is an alternative method to fine-needle as piration for distinguishing a cyst from a solid tumour. Whenever reaso nable doubt remains as to whether a lump is benign or malignant, a bio psy 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 n ormal tissue. Core biopsy, either clinically or image-guided, can usua lly establish or exclude malignancy, thus reducing the need for surgic al biopsy. Thermography and light scanning are not recommended diagnos tic procedures. The value of magnetic resonance imaging is still under investigation. It is nota 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 wor k-up should be completed expeditiously and the patient kept fully info rmed throughout. Even when malignancy is not found, it may be prudent, in some cases, to arrange followup surveillance. Validation: Guidelin es 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.