Doctors Revision

Oncology

Breast Cancer

Malignant tumour arising from the cells of the breast. Predominantly affects women, but can occur in men. Most common type is invasive ductal carcinoma.

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Referral and warning signs

When to refer

Urgent referral to specialist/Breast Clinic for ANY suspicious breast lump or significant nipple/skin changes for Triple Assessment. Refer confirmed cases to specialized cancer centre.

Red flags

  • Discrete hard lump, especially if fixed
  • Skin changes (dimpling, peau d'orange, redness, ulceration)
  • Nipple retraction or bloody discharge
  • Palpable axillary lymph nodes

Signs and symptoms

  • Breast lump or thickening (often painless, hard, irregular margins).
  • Change in breast size or shape.
  • Skin changes: Dimpling, puckering, redness, oedema ('peau d'orange').
  • Nipple changes: Retraction/inversion, discharge (especially bloody or unilateral), eczematous changes (Paget's disease of nipple).
  • Axillary lymph node swelling/lump.
  • Breast pain (less common presenting symptom).
  • Symptoms of metastatic disease (bone pain, cough/dyspnoea, jaundice, headache).

Risk factors

  • Female gender
  • Increasing age
  • Personal history of breast cancer
  • Family history of breast or ovarian cancer (esp. 1st degree relatives, early onset).
  • Inherited gene mutations (BRCA1, BRCA2, PALB2, etc.).
  • History of certain benign breast conditions (e.g., atypical hyperplasia).
  • Dense breast tissue on mammography.
  • Early menarche (<12 years) / Late menopause (>55 years).
  • Nulliparity or late age at first full-term pregnancy (>30 years).
  • Not breastfeeding.
  • Long-term use of combined Hormone Replacement Therapy (HRT).
  • Obesity (especially postmenopausal).
  • Alcohol consumption.
  • Previous radiation therapy to chest.

Diagnosis

Clinical assessment

Suspect based on palpable breast lump or other breast changes found on clinical breast examination (CBE) or breast self-examination (BSE - for awareness). Assess lump characteristics, skin/nipple changes, axillary/supraclavicular nodes.

Investigations

  • Triple Assessment: 1. Clinical Examination. 2. Imaging (Mammography +/- Ultrasound, MRI in specific cases). 3. Pathology (Biopsy - Core Needle Biopsy preferred for histology and receptor status - ER/PR/HER2).
  • Staging Investigations: Chest X-ray/CT, Liver Ultrasound/CT, Bone Scan +/- PET-CT depending on stage/symptoms.

Diagnostic criteria

Histopathological confirmation from core needle biopsy or excisional biopsy.

Management

Non-pharmacological management

  • Referral to specialized multidisciplinary team (Breast Surgeon, Oncologist, Radiation Oncologist, Pathologist) at Cancer Centre.
  • Surgery: Breast Conserving Surgery (Lumpectomy) + Radiotherapy OR Mastectomy. Axillary Lymph Node Assessment (SLNB or ALND).
  • Radiotherapy: Post-lumpectomy, sometimes post-mastectomy, or palliative.
  • Rehabilitation: Physiotherapy, Lymphoedema management, Psychosocial support, Prosthetics/reconstruction.

Pharmacological treatment

  • Systemic Therapy: Based on stage and ER/PR/HER2 status.
  • - Chemotherapy (Neoadjuvant/Adjuvant/Metastatic).
  • - Endocrine (Hormonal) Therapy (ER/PR positive): Tamoxifen, Aromatase Inhibitors.
  • - HER2-Targeted Therapy (HER2 positive): Trastuzumab, Pertuzumab, etc.
  • - Other targeted therapies (CDK4/6 inhibitors etc for metastatic).
  • - Bisphosphonates / Denosumab (Bone mets/adjuvant).

Monitoring

Regular clinical follow-up. Surveillance mammography. Monitor for treatment side effects (lymphoedema). Monitor for recurrence/metastases.

Complications

  • Local recurrence
  • Metastatic disease (bone, lung, liver, brain)
  • Lymphoedema
  • Pain
  • Psychosocial distress
  • Complications of treatment

Prevention

  • Maintain healthy weight.
  • Regular physical activity.
  • Limit alcohol consumption.
  • Breastfeeding.
  • Avoid long-term combined HRT.
  • Chemoprevention (Tamoxifen etc for high-risk women).
  • Prophylactic mastectomy (high-risk gene carriers).

Patient education

  • Breast awareness.
  • Explain diagnosis, stage, tumour characteristics (ER/PR/HER2).
  • Discuss treatment options and rationale.
  • Potential side effects.
  • Importance of follow-up.
  • Genetic counseling if indicated.
  • Support groups.
  • Lymphoedema prevention/management.

Uganda-specific notes

Most common cancer in Ugandan women after cervical cancer. Often presents at later stages. Access to mammography, biopsy/pathology (including receptor testing), surgery, radiotherapy, chemotherapy, and especially targeted/endocrine therapies is limited but available at specialized centres.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 12, Section 12.3.2

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