How should I approach the diagnosis of breast cancer in a patient presenting with a palpable breast lump?

When a patient presents with a palpable breast lump, the initial approach should involve a thorough clinical assessment followed by appropriate urgent referral and diagnostic investigations to exclude breast cancer. For patients aged 30 and over with an unexplained breast lump, NICE recommends urgent referral via a suspected cancer pathway to ensure timely specialist assessment and diagnosis NICE NG12. For those under 30, a non-urgent referral or specialist advice may be considered depending on clinical judgement NICE NG12.

Following referral, the diagnostic workup typically includes triple assessment: clinical examination, imaging (mammography and/or ultrasound), and tissue sampling (fine needle aspiration or core biopsy) to establish a definitive diagnosis NICE NG101. Ultrasound evaluation of the axilla should be performed, and if abnormal lymph nodes are detected, ultrasound-guided needle sampling is advised to assess nodal involvement NICE NG101.

Throughout the diagnostic process, it is essential to provide the patient with clear information and psychological support, including access to a named clinical nurse specialist or key worker, to help them navigate the pathway and make informed decisions NICE NG101.

In addition, consideration of familial risk factors and genetic testing for BRCA1, BRCA2, and TP53 mutations should be integrated into the care plan when appropriate, ideally within four weeks of diagnosis, to guide management and surveillance strategies NICE CG164.

Overall, the approach to diagnosis balances prompt referral and comprehensive assessment to confirm or exclude malignancy, while supporting the patient emotionally and considering genetic risk factors NICE NG101,NICE NG12,NICE CG164.