• A patient who presents with symptoms suggestive of breast cancer should be referred to a team specialising in the management of breast cancer (D).
• In most cases, the definitive diagnosis will not be known at the time of referral, and many patients who are referred will be found not to have cancer. However, primary healthcare professionals should convey optimism about the effectiveness of treatment and survival because a patient being referred with a breast lump will be naturally concerned (C).
• People of all ages who suspect they have breast cancer may have particular information and support needs. The primary healthcare professional should discuss these needs with the patient and respond sensitively to them (D).
• Primary healthcare professionals should encourage all patients, including women over 50 years old, to be breast aware* in order to minimize delay in the presentation of symptoms (D).

*Breast awareness means the woman knows what her breasts look and feel like normally. Evidence suggests that there is no need to follow a specific or detailed routine such as breast self examination, but women should be aware of any changes in their breasts (see www.cancerscreening.org.uk for further information).

• A woman's first suspicion that she may have breast cancer is often when she finds a lump in her breast. The primary healthcare professional should examine the lump with the patient's consent. The features of a lump that should make the primary healthcare professional strongly suspect cancer are a discrete, hard lump with fixation, with or without skin tethering. In patients presenting in this way an urgent referral should be made, irrespective of age (C).
• In a woman 30 years of age and older with a discrete lump that persists after her next period, or presents after menopause, an urgent referral should be made (C).
• Breast cancer in women younger than 30 years of age is rare, but does occur. Benign lumps (for example, fibroadenoma) are common, however, and a policy of referring these women urgently would not be appropriate; instead, non-urgent referral should be considered. However, an urgent referral should be made in women younger than 30 years of age:
• With a lump that enlarges, (C) or
• With a lump that has other features associated with cancer (fixed and hard), (C) or
• In whom there are other reasons for concern such as family history** (D)
• The patient's history should always be taken into account. For example, it may be appropriate, in discussion with a specialist, to agree referral within a few days in patients reporting a lump or other symptom that has been present for several months (D).
• In a patient who has previously had histologically confirmed breast cancer, who presents with a further lump or suspicious symptoms, an urgent referral should be made, irrespective of age (C).
• In patients presenting with unilateral eczematous skin or nipple change that does not respond to topical treatment, or with nipple distortion of recent onset, an urgent referral should be made (C).
• In patients presenting with spontaneous unilateral bloody nipple discharge, an urgent referral should be made (C).
• Breast cancer in men is rare and is particularly rare in men under 50 years of age. However, in a man 50 years of age and older with a unilateral, firm subareolar mass with or without nipple distortion or associated skin changes, an urgent referral should be made (C).

**See NICE guideline on Familial breast cancer: the classification and care of women at risk of familial breast cancer in primary, secondary and tertiary care (http://guidance.nice.org.uk/CG41) [NICE, 2006].

• In patients presenting with symptoms and/or signs suggestive of breast cancer, investigation prior to referral is not recommended (D).
• In patients presenting solely with breast pain, with no palpable abnormality, there is no evidence to support the use of mammography as a discriminatory investigation for breast cancer. Therefore, its use in this group of patients is not recommended. Non-urgent referral may be considered in the event of failure of initial treatment and/or unexplained persistent symptoms (B [DS]).

The referral timelines used in this guideline are as follows:

• Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary.
• Urgent: the patient is seen within the national target for urgent referrals (currently 2 weeks).
• Non-urgent: all other referrals.