History

The history from the patient is essential in helping you to establish the causes of disease and assessing whether there is an increased risk of malignancy. The history should be taken in a private place and it should be done with sympathy, as most breast patients are very anxious. This should cover:

Age of the patient: this is very important. Remember, cancers are uncommon below the age of thirty.

Lump: always ask about: the length of time it has been present. Its relation to the menstrual cycle. Exact location (note which breast). Does its size vary? Is it getting larger?

Pain: is the lump painful? Is this cyclical?

Nipple discharge: ascertain colour, quantity, pattern, frequency.

Skin changes of the breast/nipple.

Shape of breast: ask if she has noticed any nipple retraction, breast distortion.

Metastatic related symptoms: e.g. back pain, shortness of breath, jaundice.

Previous breast disease, and whether this was investigated/treated.

Family history: this is extremely important, and many clinics offer family counselling and screening.

Other risk factors for breast cancer (see Breast cancer Chapter).

Genetics of breast cancer: 5–10% of breast cancers are inherited in a dominant fashion. They are of an early onset and are associated with other tumours e.g. bowel, ovarian. The following genes have been isolated: BRCA1 (chromosome 17q21), BRCA2 (chromosome 13q24), P53 gene on chromosome 17p (associated with Li-Fraumeni syndrome).

Medication: HRT, OCP.

Gynaecological/obstetric history: all these symptoms should be related to the woman's normal cycle.