Breast Surgery

Breast cancer

A malignant tumour of breast epithelium whose diagnosis, prognosis and treatment depend on whether it is in situ or invasive, its stage, grade and ER, PR and HER2 profile.

In a nutshell

Breast cancer is diagnosed by specialist triple assessment and managed by stage, grade and ER/PR/HER2 biology. Refer promptly for an unexplained breast lump or concerning unilateral nipple or skin change; assess the axilla with ultrasound and needle sampling, using sentinel-node biopsy rather than automatic clearance when appropriate. Treatment may combine surgery, radiotherapy, endocrine therapy, chemotherapy, anti-HER2 treatment, immunotherapy or PARP inhibition, with current NICE criteria checked for each subtype.

Classic presentation

A person notices a new hard or irregular breast lump, with or without skin tethering or nipple change; some cancers are impalpable and screen-detected.

Key points

Triple assessment combines clinical examination, appropriate imaging and core biopsy.
Every invasive tumour needs a documented ER, PR and HER2 profile plus grade and anatomical stage.
NICE suspected-cancer referral: age 30 or over with an unexplained breast lump; age 50 or over with unilateral concerning nipple discharge, retraction or other change; consider referral for suggestive skin change or an unexplained axillary lump at age 30 or over.
A normal axillary ultrasound or negative needle sample supports sentinel-node biopsy rather than automatic axillary clearance.
DCIS is non-invasive; sentinel-node biopsy is not routine with breast-conserving surgery for DCIS but is offered when mastectomy is performed.
High-risk triple-negative early or locally advanced disease may receive neoadjuvant pembrolizumab with chemotherapy then adjuvant pembrolizumab under TA851.
ER-positive disease is treated with endocrine therapy; aromatase inhibitors need a postmenopausal endocrine environment or ovarian-function suppression.
NICE TA886 supports adjuvant olaparib for selected germline BRCA1/2-mutated, HER2-negative high-risk early breast cancer after chemotherapy; TA1040 covers selected advanced disease.
In England, routine population screening is every 3 years from age 50 up to the 71st birthday; symptomatic assessment is separate and must not be delayed by a normal screening result.

First-line investigation

Prompt specialist breast assessment with clinical examination, imaging and core biopsy of a suspicious lesion, plus axillary ultrasound and needle sampling when indicated.

Management

Escalate suspicious and emergency presentations

Use NICE NG12 suspected-cancer referral for the current breast lump, nipple, skin and axillary criteria; urgently assess inflammatory change, pathological fracture, spinal cord compression, hypercalcaemia and neurological compromise.^4,2,10

Complete triple assessment and tumour profiling

Combine clinical assessment, appropriate breast imaging and core biopsy; record invasive versus in situ disease, grade, ER, PR and HER2 status.^1,5
Perform axillary ultrasound and needle sampling if abnormal; use MRI only when the extent of disease remains unclear, breast density limits assessment or invasive lobular carcinoma needs sizing for surgical planning.¹

Support shared decisions and function

Discuss fertility, menopause, reconstruction, body image, psychosexual health, work, lymphoedema prevention, arm and shoulder rehabilitation and clinical-trial opportunities from diagnosis onward.^1,6,5

Sequence local and systemic treatment by biology

Use breast-conserving surgery with radiotherapy or mastectomy according to extent and preference; stage the axilla with sentinel-node biopsy when ultrasound is normal or needle sampling is negative.¹
Use neoadjuvant pembrolizumab-based treatment for selected high-risk triple-negative disease and select endocrine, chemotherapy, anti-HER2, immunotherapy or PARP treatment by receptor profile, stage and current NICE criteria.^1,9,7,3

Monitor recurrence, treatment effects and metastatic complications

Provide current mammographic surveillance, rehabilitation and lymphoedema support; safety-net new breast, chest-wall, nodal, bone, respiratory or neurological symptoms and reassess recurrent tumour receptors if the result would change treatment.^1,2,11

Exam traps

A breast lump can be painful, mobile or occult on mammography and still require assessment; do not use classic textbook texture to rule out cancer.
Inflammatory breast cancer can mimic mastitis; persistent or recurrent erythema needs specialist assessment.
Aromatase inhibitors are not adequate endocrine therapy for a person who remains premenopausal unless ovarian function is suppressed.
DCIS cannot metastasise as DCIS, but occult invasion is possible and axillary management depends on the planned breast operation and risk.
Do not automatically clear the axilla after every positive or suspicious result; use the current ultrasound, needle-sampling, sentinel-node and MDT pathway.
Do not list one universal metastatic regimen: receptor profile, prior therapy, organ function, genomic result and current NICE appraisals determine treatment.

Illustrations

Spiculated breast mass on mammographyMammography showing an irregular spiculated mass, with labels explaining why a suspicious imaging finding proceeds to specialist triple assessment rather than being diagnosed from imaging alone.Jamil M et al., Cureus 2026, CC-BY-4.0 · CC-BY-4.0

Receptor subtypes and targeted treatmentA diagram mapping ER, PR and HER2 status to broad treatment pathways, with a reminder that stage, grade, prior treatment and current NICE appraisal criteria also determine the final MDT plan.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.