๐ Key Information Summary
- Breast history is the foundation: always elicit lump characteristics, pain/tenderness, nipple discharge, skin changes, menstrual/lactation history, HRT/OCP use, and family history of breast/ovarian cancer before touching the patient.
- Exposure and positioning: examine with the patient sitting upright at 45ยฐ, arms relaxed, then arms above head, then hands on hips with pectoral contraction โ use systematic inspection each time.
- Inspection before palpation: look for asymmetry, contour distortion, skin dimpling (sign of Cooper's ligament tethering), peau d'orange (inflammatory breast cancer or mastitis), and nipple retraction or deviation.
- Palpation technique: use the flat pads of the index and middle fingers in small concentric circles, applying three pressures (superficial, intermediate, deep) at each point in a systematic pattern (vertical strip, concentric circles, or wedge).
- Quadrant-by-quadrant approach: examine all four quadrants and the retro-areolar region; the upper outer quadrant (UOQ) contains the most glandular tissue and is the most common site for breast cancer (~50%).
- Axillary and supraclavicular examination is mandatory: palpate axillary nodes (anterior, posterior, central, lateral, apical groups) with the patient's arm supported; assess supraclavicular fossae and infraclavicular nodes.
- Characterise every lump using the mnemonic SMQT: Size, Mobility, Quality/consistency, Tenderness โ plus shape (irregular vs smooth), margins (defined vs ill-defined), and overlying skin changes.
- Red-flag features requiring urgent two-week wait referral: hard irregular lump fixed to skin or chest wall, bloody nipple discharge, peau d'orange, new nipple retraction in a woman >50, or axillary lymphadenopathy with no obvious primary.
- Triple assessment is gold standard: clinical examination + imaging (mammography ยฑ ultrasound ยฑ MRI) + tissue biopsy (FNA/core biopsy); all three components must be concordant.
- Most breast lumps are benign: fibroadenoma (young women), cysts, fat necrosis, and fibrocystic change account for the majority; however, always exclude malignancy through triple assessment.
- Gynaecomastia is true glandular proliferation (disc-like, concentric, sub-areolar) distinguishable from pseudogynaecomastia (adipose tissue); consider drugs (spironolactone, cimetidine, anabolic steroids), liver disease, hypogonadism, and hypothyroidism.
- BreastScreen Australia provides free biennial mammography for women aged 50โ74; women 40โ49 and โฅ75 are eligible but not actively recruited; Aboriginal and Torres Strait Islander women have lower screening uptake and later-stage diagnoses.
Introduction & Australian Epidemiology
Breast examination is a core clinical skill in general practice, surgery, and women's health. A systematic approach โ combining a focused history with structured inspection, palpation, regional lymph node assessment, and lump characterisation โ enables clinicians to distinguish benign conditions from malignancy and to guide appropriate investigation through the triple-assessment pathway.
In Australia, breast cancer is the most commonly diagnosed cancer in women (excluding non-melanoma skin cancer). The Australian Institute of Health and Welfare (AIHW) estimates that approximately 20,900 new cases of breast cancer were diagnosed in 2023, with a lifetime risk of 1 in 7 for Australian women by age 85. Breast cancer is the second leading cause of cancer-related death in Australian women after lung cancer, accounting for approximately 3,200 deaths per year. Five-year relative survival has improved to approximately 92%, largely due to early detection through the BreastScreen Australia programme and advances in treatment.
Key Australian statistics: Breast cancer accounts for 28% of all cancers in women. Median age at diagnosis is 62 years. Male breast cancer represents ~1% of all breast cancers (~200 cases/year). The incidence is higher in socioeconomically advantaged populations but mortality is disproportionately higher in disadvantaged and Aboriginal and Torres Strait Islander populations.
Beyond malignancy, clinicians frequently encounter benign breast conditions including fibrocystic change, fibroadenomas, breast cysts, mastitis, and mastalgia. A confident breast examination allows accurate triage and reduces unnecessary anxiety and investigation. This article provides a structured approach to breast history, examination technique, lump characterisation, and the assessment of gynaecomastia.
Breast History
A thorough breast history is the single most important component of the clinical encounter. Many diagnoses can be suspected โ or excluded โ from the history alone, and the history directs the examination strategy.
Presenting Complaint: Breast Lump
- Duration and discovery: when was the lump first noticed? Was it self-detected, incidentally found on imaging, or noted by a partner/clinician? A lump present for years without change is more likely benign (e.g., fibroadenoma).
- Size change: has the lump grown, and if so, over what time frame? Rapid growth (doubling in weeks) may suggest phyllodes tumour, abscess, or inflammatory breast cancer.
- Relationship to menstrual cycle: cyclical changes in size or tenderness suggest fibrocystic change; a lump that varies dramatically may be a cyst.
- Associated symptoms: pain, skin changes, nipple discharge, or axillary lump.
Breast Pain (Mastalgia)
Breast pain is a common presenting complaint, affecting up to 70% of women at some point. It is rarely a presenting feature of breast cancer (<10% of breast cancers present with pain alone).
| Type | Character | Timing | Common Causes |
|---|---|---|---|
| Cyclical mastalgia | Diffuse, heavy, aching; bilateral; often upper outer quadrants | Worse in luteal phase (days 14โ28); improves with menstruation | Hormonal (normal cyclical change, fibrocystic change); OCP, HRT |
| Non-cyclical mastalgia | Localised, sharp, or burning; often unilateral | Unrelated to menstrual cycle | Costochondritis (Tietze syndrome), fat necrosis, duct ectasia, cyst, medication-related |
| Chest wall pain | Reproducible on palpation of chest wall (not breast tissue) | Variable; may be positional or exertional | Musculoskeletal (costochondritis, intercostal muscle strain, rib pathology) |
Nipple Discharge
Nipple discharge is the third most common breast symptom after lump and pain. Key features to document:
- Colour: milky (galactorrhoea), green/black (duct ectasia), serous/straw-coloured (intraductal papilloma), bloody/sanguinous (malignancy until proven otherwise).
- Unilateral vs bilateral: bilateral discharge is more likely hormonal or physiological; unilateral raises concern for intraductal pathology.
- Spontaneous vs expressed: spontaneous discharge is more clinically significant than discharge only provoked by manual expression.
- Single duct vs multiple ducts: single-duct discharge has higher pathological significance.
- Associated mass: a mass with bloody discharge mandates urgent triple assessment.
Red flag: Unilateral, spontaneous, single-duct, bloody or serosanguinous nipple discharge in a woman aged >50 years is malignant until proven otherwise. Refer urgently for triple assessment.
Skin Changes
- Dimpling/retraction: suggests Cooper's ligament invasion (malignancy) or fat necrosis.
- Peau d'orange (orange-peel skin): lymphatic obstruction โ inflammatory breast cancer, mastitis, or advanced malignancy.
- Eczematous changes of the nipple/areola: persistent unilateral eczema unresponsive to topical steroids suggests Paget's disease of the nipple.
- Erythema and warmth: mastitis (puerperal or non-puerperal), inflammatory breast cancer, or abscess.
- Ulceration: locally advanced or neglected breast cancer.
Risk Factor Assessment & Family History
Document the following for every breast presentation:
- Age: risk increases significantly after age 50; 80% of breast cancers occur in women >50.
- Reproductive history: nulliparity, late first pregnancy (>30), early menarche (<12), late menopause (>55) all increase risk.
- Hormone use: combined HRT (oestrogen + progesterone) increases risk; OCP has a small transient increase; oestrogen-only HRT in post-hysterectomy patients has a lower risk.
- Previous breast disease: prior breast cancer, atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), or previous breast irradiation (e.g., mantle radiotherapy for Hodgkin lymphoma).
- Family history: first-degree relative (mother, sister, daughter) with breast cancer approximately doubles risk. Document age at diagnosis, bilateral disease, ovarian cancer, male breast cancer, Ashkenazi Jewish ancestry, and known BRCA1/BRCA2 or other pathogenic variants.
- Lifestyle factors: alcohol consumption (>2 standard drinks/day increases risk), obesity (post-menopausal), physical inactivity.
- Medications: spironolactone, cimetidine, digoxin, anabolic steroids, antipsychotics (risperidone), and oestrogen-containing preparations.
Family history thresholds for genetic referral (eviQ/Cancer Council): โฅ3 first- or second-degree relatives with breast/ovarian cancer on the same side of the family; breast cancer in a relative aged <40; bilateral breast cancer; male breast cancer in the family; known BRCA1/2 pathogenic variant. Refer to a familial cancer service for risk assessment and consideration of genetic testing.
Breast Inspection
Inspection is performed before palpation. Always begin with the patient sitting upright (or reclining at 45ยฐ) with both breasts fully exposed from the clavicles to the costal margins and laterally to the mid-axillary lines. Ask the patient to undress to the waist and provide a gown or drape for comfort and dignity.
Preparation and Positioning
- Ensure good lighting; natural daylight or bright white light is preferred.
- The patient should be seated upright at approximately 45ยฐ (semi-reclined) on the examination couch.
- Ensure privacy and explain each step before performing it.
- Chaperone availability should be offered (standard of care in most Australian hospitals and GP practices).
Systematic Inspection โ Positions and What to Look For
Position 1
Arms Relaxed by Sides
Assess overall breast symmetry (normal asymmetry vs pathological asymmetry), contour, size, shape, and colour of the skin and nipples.
Baseline inspection
Position 2
Arms Above Head
Accentuates contour distortions, skin dimpling, and retraction. Look for "tethering" of the breast โ a lump tethering Cooper's ligaments will cause visible dimpling when the arms are raised. Observe for any fixed mass effect.
Accentuates pathology
Position 3
Hands on Hips โ Pectoral Contraction
Press hands firmly on hips to contract pectoralis major. A fixed lesion attached to the muscle or chest wall will become more apparent. Also useful for assessing pectoralis major integrity (e.g., after surgery).
Assesses fixation to chest wall
Inspection Checklist
| Feature | Normal Finding | Abnormal / Concerning |
|---|---|---|
| Symmetry | Mild asymmetry is normal (left breast often slightly larger) | New or progressive asymmetry; one breast appearing larger or differently shaped |
| Contour | Smooth, convex outline | Flattening, bulging, or localised distortion of contour (mass effect) |
| Skin colour | Uniform skin tone | Erythema (mastitis vs inflammatory breast cancer), hyperpigmentation |
| Skin texture | Smooth | Peau d'orange (lymphatic oedema); dimpling; puckering; ulceration |
| Veins | Visible veins in fair-skinned patients are normal | Prominent unilateral venous dilatation (may indicate increased blood flow to a tumour โ "Sentinel vein sign") |
| Nipple position | Both nipples at same level, pointing in same direction | Deviation or retraction (new retraction is concerning; longstanding inversion is usually benign) |
| Nipple/areola skin | Smooth, consistent colour | Eczema, crusting, fissuring, erosion (Paget's disease of the nipple); areolar colour change |
Peau d'orange (skin resembling orange peel due to oedema of the dermal lymphatics) may indicate inflammatory breast cancer โ a rapidly progressive, aggressive malignancy that may not present with a discrete mass. It requires emergent referral.
Skin Dimpling โ Cooper's Ligament Tethering
Cooper's ligaments are fibrous bands that suspend the breast tissue from the superficial fascia to the skin. When a breast cancer infiltrates these ligaments, the overlying skin is pulled inward, producing a visible dimple or retraction. This is best demonstrated by:
- Asking the patient to raise her arms above her head โ this stretches the skin and may unmask a subtle dimple.
- Asking the patient to lean forward โ gravity pulls the breast away from the chest wall and may reveal tethering.
- Gently pressing on the area of the suspected lump โ the overlying skin dimples inward.
Breast Palpation
Palpation follows inspection. Use the flat pads of the index and middle fingers (not fingertips) with a gentle, rotating motion. The hand should be flat against the skin.
Technique
- Three-pressure technique: at each point, apply light pressure (superficial โ subcutaneous tissue), medium pressure (glandular tissue), and firm pressure (deep tissue against the chest wall). Adjust pressure for breast size โ larger breasts require more pressure to reach the chest wall.
- Systematic pattern: use one of three validated patterns:
- Vertical strip: start at the mid-clavicular line and move in vertical strips from the clavicle to the inframammary fold, covering the entire breast. This is the most commonly recommended method in Australian clinical teaching.
- Concentric circles: begin at the nipple and work outward in expanding circles until the entire breast is covered.
- Wedge: divide the breast into wedge-shaped segments and examine each systematically.
- Do not lift the hand off the skin between positions โ slide to the next area to avoid missing tissue.
Quadrant-by-Quadrant Approach
The breast is anatomically divided into four quadrants and the retro-areolar region using the nipple as the central reference point:
| Quadrant | Anatomical Boundaries | Key Clinical Notes |
|---|---|---|
| Upper Outer Quadrant (UOQ) | Above the nipple, lateral to the midline | Contains the most glandular tissue (axillary tail of Spence); ~50% of breast cancers occur here; extends into the axilla |
| Upper Inner Quadrant (UIQ) | Above the nipple, medial to the midline | Less common site for malignancy |
| Lower Outer Quadrant (LOQ) | Below the nipple, lateral to the midline | Fat necrosis can occur here (post-trauma) |
| Lower Inner Quadrant (LIQ) | Below the nipple, medial to the midline | Least common site for pathology |
| Retro-areolar | Beneath the nipple-areola complex | Intraductal papillomas present here; palpate for sub-areolar masses; compress the nipple to check for discharge |
Axillary Lymph Node Examination
Axillary examination is an integral part of every breast examination. The axilla contains five groups of lymph nodes:
- Anterior (pectoral) nodes: along the lateral border of pectoralis major, medial wall of the axilla.
- Posterior (subscapular) nodes: along the subscapularis muscle, posterior wall of the axilla.
- Lateral (humeral) nodes: along the axillary vein, lateral wall.
- Central nodes: in the axillary fat pad โ the most commonly palpable group.
- Apical (infraclavicular) nodes: medial to pectoralis minor at the apex of the axilla โ palpable above the clavicle. These drain into the subclavian trunk.
1
Support the Patient's Arm
Ask the patient to relax her arm at the side or gently support her forearm/elbow with your non-examining hand. A completely abducted arm tenses the pectoralis muscles and makes the axilla harder to examine.
2
Reach Into the Axilla
With the flat pads of your fingers, reach high into the apex of the axilla and sweep downward along the chest wall. Feel for the anterior group against the lateral chest wall (medial wall of axilla).
3
Palpate the Central and Posterior Groups
Sweep from anterior to posterior through the axillary fat pad. Then palpate the posterior wall by pressing against the subscapularis muscle.
4
Assess the Lateral Wall
Palpate along the upper arm/axillary vein for lateral (humeral) nodes. Note: the intercostobrachial nerve runs through the axilla โ the patient may experience referred pain or numbness in the inner arm during examination.
For any palpable axillary node, document:
- Size (in cm)
- Consistency (rubbery, hard, matted, mobile)
- Tenderness
- Number of palpable nodes
- Fixation to skin or deep structures
Supraclavicular and Infraclavicular Node Examination
Stand behind the patient (or to the side). Ask the patient to tilt her head toward the side being examined to relax the sternocleidomastoid muscle. Using the flat pads of your fingers, palpate deeply in the supraclavicular fossa (posterior to the sternocleidomastoid, superior to the clavicle). Also palpate the infraclavicular region (deltopectoral groove). Virchow's node (left supraclavicular โ Troisier's sign) may indicate intra-abdominal or thoracic malignancy.
Hard, non-tender, fixed supraclavicular or apical axillary lymphadenopathy in the context of a breast mass suggests advanced disease (at least Stage IIIB/IIIC). Urgent referral to a breast surgeon is required.
Assessment and Characterisation of a Breast Lump
Once a lump is identified, it must be systematically characterised. Use the mnemonic SMQT-SD (Size, Mobility, Quality, Tenderness, Shape, Depth/Skin) to guide documentation and clinical reasoning.
Systematic Lump Characterisation
| Feature | Benign Characteristics | Malignant Characteristics |
|---|---|---|
| Size | Measured in cm using calipers or ruler; note if it has changed | Size alone does not distinguish benign from malignant; however, rapidly enlarging masses are concerning |
| Shape | Regular, round, or oval (fibroadenoma classically "mouse-shaped" โ smooth, oval, mobile) | Irregular, stellate, or ill-defined margins |
| Consistency | Soft (lipoma, cyst), rubbery/firm (fibroadenoma), fluctuant (cyst) | Hard (rock-hard); "stone-like" feel |
| Mobility | Freely mobile within the breast tissue (fibroadenoma "slips" under the fingers); moves with the breast on chest wall | Fixed to skin (skin dimpling), fixed to pectoralis major (contract the muscle), or fixed to chest wall |
| Tenderness | Tender lumps are more often benign (cyst, abscess, fat necrosis) | Most breast cancers are painless; absence of tenderness does not reassure |
| Overlying skin | Normal, mobile over the lump | Skin tethering, dimpling, fixation, ulceration, peau d'orange |
| Margins | Well-defined, smooth, discrete (fibroadenoma, cyst) | Ill-defined, irregular, infiltrating |
| Depth | Superficial (dermal/subcutaneous) or within glandular tissue | Deep, attached to chest wall (pectoralis/fascia) |
Testing Fixation โ Special Manoeuvres
- Fixation to skin: gently pinch the skin over the lump. If the skin dimples or is tethered, the mass is fixed to the skin (T4a disease).
- Fixation to pectoralis major: with the patient's arm relaxed, mark the position of the lump relative to the chest wall. Then ask the patient to press her hand firmly against her hip (contracting pectoralis major). If the lump becomes less mobile or immobile, it is fixed to the muscle.
- Fixation to chest wall: attempt to move the lump in all planes (medial-lateral, superior-inferior, anterior-posterior). A mass fixed to the chest wall suggests locally advanced disease (T4b).
Differential Diagnosis by Age
| Age Group | Common Benign Causes | Malignancy Risk |
|---|---|---|
| <25 years | Fibroadenoma, cyst, breast abscess (puerperal), normal breast tissue variation | Very low (<2%) but not zero โ do not dismiss solely on age |
| 25โ40 years | Fibroadenoma, cyst, fibrocystic change, fat necrosis, galactocele (lactating) | Low (~5โ10%); ultrasound is the first-line imaging modality in this age group |
| 40โ50 years | Cyst, fibroadenoma, duct ectasia, intraductal papilloma | Moderate; mammography + ultrasound recommended |
| >50 years | Cyst, fat necrosis, lipoma | Higher; any new lump requires mammography + ultrasound + biopsy (triple assessment) |
Triple Assessment Pathway
All clinically significant breast lumps should proceed through triple assessment โ the gold standard for breast lump evaluation in Australia:
1
Clinical Assessment
History and examination as described above, with lump characterisation. Assign a clinical impression: benign, indeterminate, or suspicious/malignant.
2
Imaging
<30 years: Ultrasound first (dense breast tissue reduces mammographic sensitivity). โฅ30 years: Mammography ยฑ ultrasound. High risk or problem-solving: MRI (MBS item 63464). Bilateral mammography is standard (MBS items 59306/59309). Ultrasound-guided biopsy MBS item 55061.
3
Tissue Diagnosis (Pathology)
FNA (fine needle aspiration): quick, minimal discomfort, but lower sensitivity for distinguishing in situ from invasive disease. Core needle biopsy: preferred โ provides histological architecture, allows receptor status (ER, PR, HER2), and distinguishes in situ from invasive carcinoma. Excision biopsy: reserved for lesions not amenable to core biopsy or discordant triple assessment.
Concordance is essential: all three components of triple assessment must be concordant. If any component is discordant (e.g., clinically suspicious but imaging benign, or imaging suspicious but FNA benign), further investigation or excision biopsy is required.
Gynaecomastia
Gynaecomastia is the benign proliferation of glandular breast tissue in males, resulting in a palpable, disc-like or dome-shaped sub-areolar breast enlargement. It must be distinguished from pseudogynaecomastia (lipomastia) and male breast cancer.
True Gynaecomastia vs Pseudogynaecomastia
| Feature | True Gynaecomastia | Pseudogynaecomastia (Lipomastia) |
|---|---|---|
| Palpation | Firm, rubbery, disc-like or dome-shaped glandular tissue concentric to the nipple | Soft, diffuse adipose tissue without a discrete glandular disc; often bilateral and symmetrical |
| Tenderness | Often tender (especially in pubertal and recent-onset gynaecomastia) | Usually non-tender |
| Location | Central, sub-areolar; can be asymmetric or unilateral | Diffuse; follows generalised adiposity pattern |
| Nipple | Nipple may be prominent; can have nipple discharge | Normal nipple; no discharge |
| Associated features | May have signs of hypogonadism, liver disease, thyroid dysfunction | Generalised obesity; truncal fat distribution |
The "Breast Exam" in Males
When palpating the male breast, place the patient supine with the examining hand behind the head (to flatten pectoralis major). Using the flat pads of two fingers, palpate systematically from the nipple outward. True gynaecomastia presents as a concentric, disc-like, firm-to-rubbery mass directly beneath the areola. It should be mobile and distinct from the surrounding adipose tissue.
Physiological Gynaecomastia
- Neonatal: maternal oestrogen transfer; bilateral, self-resolving within weeks.
- Pubertal: affects 50โ70% of adolescent boys; usually bilateral; self-resolves within 1โ2 years in 90%. Unilateral or persistent >2 years warrants investigation.
- Senile (ageing): declining testosterone, increasing aromatase activity in adipose tissue; common in men >65.
Pathological Causes of Gynaecomastia
| Category | Examples |
|---|---|
| Drugs (most common pathological cause, ~25%) | Spironolactone, cimetidine, anabolic steroids, oestrogens (including topical oestrogen creams absorbed by partners), antipsychotics (risperidone, haloperidol), calcium channel blockers (verapamil, nifedipine), digoxin, HAART (e.g., efavirenz), methotrexate, isoniazid, finasteride, marijuana, alcohol |
| Hepatic | Cirrhosis (alcoholic liver disease most common); increased aromatisation of androgens to oestrogens |
| Endocrine | Primary hypogonadism (Klinefelter syndrome โ 47,XXY), secondary hypogonadism, hyperthyroidism, Cushing syndrome, adrenal tumour, testicular tumour (Leydig cell, Sertoli cell), hCG-secreting tumour (testicular germ cell, hepatocellular carcinoma, bronchogenic carcinoma) |
| Renal | Chronic kidney disease (uraemic hypogonadism); patients on haemodialysis and peritoneal dialysis |
| Other | Ref refeeding after starvation, HIV infection, spinal cord injury |
Investigations for Gynaecomastia
Initial investigations should include:
- Liver function tests (LFTs), urea, creatinine, eGFR
- Thyroid function tests (TSH, fT4)
- Serum testosterone (total and free), sex hormone-binding globulin (SHBG)
- Oestradiol
- Luteinising hormone (LH) and follicle-stimulating hormone (FSH)
- ฮฒ-hCG (to exclude germ cell tumour)
- Prolactin (if galactorrhoea or pituitary symptoms present)
- Karyotype (if bilateral gynaecomastia with small testes and tall stature โ Klinefelter syndrome)
Red Flags in Male Breast Examination
Male breast cancer features: hard, irregular, non-tender, fixed mass (not a disc); bloody nipple discharge; skin ulceration or tethering; axillary lymphadenopathy. Male breast cancer accounts for ~1% of all breast cancers and typically presents later than in women. Refer for urgent triple assessment. Risk factors include BRCA2 mutation, Klinefelter syndrome, obesity, liver disease, and prior chest wall irradiation.
Management of Gynaecomastia
Tamoxifen
Nolvadex-Dยฎ ยท Selective oestrogen receptor modulator (SERM)
Adult dose
10โ20 mg PO once daily for 3โ6 months
Indication
Symptomatic or persistent gynaecomastia (>12 months); painful pubertal gynaecomastia unresponsive to observation
Renal adjustment
None required
PBS status
โ PBS General Benefit (for breast cancer; gynaecomastia is off-label use)
Danazol
Danocrineยฎ ยท Androgen derivative
Adult dose
100โ200 mg PO BD for 3โ6 months
Indication
Second-line for painful gynaecomastia when tamoxifen is contraindicated or ineffective
Renal adjustment
Use with caution
PBS status
โ Authority Required
Surgical management: subcutaneous mastectomy (via peri-areolar incision) or liposuction-assisted mastectomy is considered for gynaecomastia that is persistent (>12โ18 months), causing significant psychological distress, or unresponsive to medical therapy. Referral to a plastic surgeon or breast surgeon is appropriate. Histological examination of excised tissue is mandatory.
Special Populations
Pregnancy & Lactation
Physiological changes: breast enlargement, increased vascularity, engorgement, and Montgomery's tubercle prominence are normal.
Lactational mastitis: affects ~10% of breastfeeding women; presents with unilateral erythema, warmth, pain, and fever. Most commonly caused by Staphylococcus aureus (including CA-MRSA in some communities). First-line: flucloxacillin 500 mg PO QDS for 10โ14 days (safe in breastfeeding). If CA-MRSA suspected: clindamycin 450 mg PO TDS or TMP-SMX (avoid near term).
Breast abscess: fluctuant, tender mass; requires ultrasound-guided aspiration or incision and drainage. Continue breastfeeding from the affected breast if possible (or express).
Breast cancer in pregnancy: rare (~1 in 3,000 pregnancies) but the most common cancer in pregnancy after cervical cancer. Ultrasound is safe. Mammography can be performed with abdominal shielding (low radiation dose). Core biopsy is safe. MRI without gadolinium is preferred if further imaging needed. Referral to a multidisciplinary team (breast surgeon, obstetrician, oncologist) is essential.
Note: any persistent, non-resolving mass in a lactating woman should be investigated โ do not attribute all lumps to "milk ducts."
Paediatric & Adolescent
Pubertal breast budding: normal thelarche in girls aged 8โ13; unilateral budding is common and asymmetric development is normal.
Adolescent gynaecomastia: affects 50โ70% of boys aged 12โ15; bilateral in 75%; usually self-resolving within 6โ24 months. Reassurance is the mainstay. Investigation only if persistent >2 years, unilateral, rapidly enlarging, or associated with signs of endocrine disease.
Fibroadenoma: the most common breast mass in adolescent and young adult women; "giant" fibroadenoma (>5 cm) may require excision due to tissue destruction rather than cancer risk.
Phyllodes tumour: rare in adolescents but should be considered in rapidly growing breast masses. Requires wide local excision.
Paediatric breast cancer: extremely rare before age 20. A suspicious mass should still be investigated via ultrasound ยฑ biopsy regardless of age.
Note: avoid unnecessary mammography in patients <30 years; ultrasound is the preferred first-line imaging modality.
Elderly
Higher malignancy risk: any new breast lump in a woman >60 years should be considered malignant until proven otherwise. Breast cancer incidence increases with age.
Senile gynaecomastia: very common in men >65; related to declining testosterone and increased peripheral aromatase activity. Exclude drug causes (spironolactone, digoxin, cimetidine) and liver disease.
Mammographic considerations: breast tissue becomes more fatty (radiolucent) with age, improving mammographic sensitivity. Screening remains effective into the 70s and beyond.
Comorbidity-aware management: treatment decisions for breast cancer should consider life expectancy, frailty, and comorbidities. Not all elderly patients require aggressive surgical management; primary endocrine therapy (e.g., aromatase inhibitors) may be appropriate for frail patients with ER-positive tumours.
Note: BreastScreen Australia invites women aged 50โ74. Women โฅ75 may self-refer but are not actively recruited.
Renal Impairment
Chronic kidney disease (CKD): uraemic hypogonadism contributes to gynaecomastia in men on dialysis. Renal transplant recipients may develop gynaecomastia from immunosuppressant medications (e.g., cyclosporine, tacrolimus, mycophenolate).
Dose adjustments: flucloxacillin dose adjustment may be required in severe renal impairment (eGFR <10 mL/min). Always check renal function before prescribing antibiotics for mastitis/abscess.
Imaging considerations: avoid gadolinium-enhanced MRI in patients with eGFR <30 mL/min (risk of nephrogenic systemic fibrosis).
Note: tamoxifen does not require renal dose adjustment.
Hepatic Impairment
Liver disease and gynaecomastia: cirrhosis (especially alcoholic) is a common cause of gynaecomastia due to impaired oestrogen clearance and increased aromatisation. Alcoholic liver disease is the most common hepatic cause in Australian men.
Hepatocellular carcinoma: may produce hCG, causing secondary gynaecomastia โ consider AFP and liver ultrasound in at-risk patients.
Drug metabolism: tamoxifen is hepatically metabolised; use with caution in severe hepatic impairment (Child-Pugh C); avoid or reduce dose in severe disease.
Note: LFTs should be part of the routine workup for any man presenting with gynaecomastia.
Immunocompromised
HIV/AIDS: gynaecomastia is associated with HAART (especially efavirenz) and lipodystrophy (pseudogynaecomastia). HIV-positive women may present with breast infections (non-lactational mastitis, abscess) caused by unusual organisms.
Transplant recipients: immunosuppressant-related gynaecomastia (cyclosporine, tacrolimus). Breast cancer surveillance should follow standard guidelines.
Biologic therapy: checkpoint inhibitors (pembrolizumab, nivolumab) may rarely cause autoimmune mastitis or hypophysitis leading to secondary hypogonadism and gynaecomastia.
Note: consider a broader differential for breast infections in immunocompromised patients โ atypical mycobacteria, fungal infections, and opportunistic organisms may be causative.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
Aboriginal and Torres Strait Islander women experience a higher mortality rate from breast cancer compared with non-Indigenous Australian women, despite a similar overall incidence. The disparity is driven by later-stage diagnosis, lower screening participation, reduced access to specialist services, and the compounding effects of social determinants of health.
Closing the Gap: The National Aboriginal and Torres Strait Islander Cancer Framework (Cancer Council Australia / NACCHO) prioritises improving cancer outcomes for First Nations Australians. Clinicians should actively promote BreastScreen participation, provide culturally safe breast examinations, and ensure timely referral for any breast symptom in Aboriginal and Torres Strait Islander women and men. Use of the AIHW Indigenous health check items (MBS 715) provides an opportunity to discuss breast health and screening.
๐ References
- 1. Australian Institute of Health and Welfare (AIHW). Cancer data in Australia. Canberra: AIHW; 2023. Available from: https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia
- 2. BreastScreen Australia. About BreastScreen Australia. Australian Government Department of Health and Aged Care; 2024. Available from: https://www.health.gov.au/our-work/breastscreen-australia
- 3. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice (Red Book). 9th ed. Melbourne: RACGP; 2016 (updated 2023).
- 4. Cancer Council Australia. Clinical practice guidelines for the management of early breast cancer. 2nd ed. Sydney: Cancer Council Australia; 2020 (updated 2023). Available from: https://wiki.cancer.org.au/australia/Guidelines:Early_breast_cancer
- 5. National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the management of advanced breast cancer. Canberra: NHMRC; 2001 (updated by Cancer Council Australia).
- 6. Talley NJ, O'Connor S. Clinical examination: a systematic guide to physical diagnosis. 9th ed. Chatswood: Elsevier Australia; 2021. Chapter 14: The breasts.
- 7. British Association of Surgical Oncology (BASO). Guidelines for the management of symptomatic breast disease. Eur J Surg Oncol. 2005;31(Suppl 1):1โ21.
- 8. National Institute for Health and Care Excellence (NICE). Suspected cancer: recognition and referral (NG12). London: NICE; 2015 (updated 2023).
- 9. Dickson G. Gynecomastia. Am Fam Physician. 2012;85(7):716โ722.
- 10. Niewoehner CB, Schorer AE. Gynaecomastia and breast cancer in men. BMJ. 2008;336(7646):709โ713.
- 11. eviQ Cancer Treatments Online. Referral guidelines for breast cancer. Cancer Institute NSW; 2024. Available from: https://www.eviq.org.au/
- 12. Cancer Council Australia; National Aboriginal Community Controlled Health Organisation (NACCHO). National Aboriginal and Torres Strait Islander Cancer Framework. Sydney: Cancer Council Australia; 2023.
- 13. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023.
- 14. Committee on Publication Ethics (COPE). Ductal carcinoma in situ and Paget disease. In: Lakhani SR, Ellis IO, Schnitt SJ, Tan PH, van de Vijver MJ, editors. WHO Classification of Tumours of the Breast. 4th ed. Lyon: IARC; 2012.
- 15. Australasian Society of Clinical Immunology and Allergy (ASCIA). Not applicable directly but referenced for differential in atopic eczema vs Paget's. Consultation document: Paget's disease nipple. RPA Hospital, Sydney.