EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Lisa’s breast lump?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What benign conditions should also be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What clinical features increase suspicion for malignancy?
• Prompt: What initial investigations would be appropriate?

Q3. How would you manage Lisa’s condition?

• Prompt: What is the role of the triple assessment?
• Prompt: When would you refer her to a breast surgeon?

Q4. Lisa is anxious about the possibility of cancer. How would you counsel her?

• Prompt: How would you explain the need for further tests while managing her anxiety?
• Prompt: What support services or resources could you offer?

Q5. What preventive strategies can Lisa implement to monitor her breast health?

• Prompt: How can she reduce her modifiable risk factors?
• Prompt: What is the recommended breast cancer screening approach?

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THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Lisa’s breast lump?

Lisa’s most likely diagnosis is breast cancer, given her age >50, firm non-tender lump, and family history of breast cancer. However, other conditions should be considered.

Key Differential Diagnoses:

1. Breast Cancer (Most Likely) – Firm, non-mobile mass, painless, no overt signs but requires urgent triple assessment.
2. Fibroadenoma – More common in younger women (<40 years), typically smooth, mobile, and well-defined.
3. Breast Cyst – Fluctuant, often tender, may change with menstrual cycle.
4. Fat Necrosis – Common after trauma, may mimic malignancy but often resolves spontaneously.
5. Mastitis/Abscess – Associated with pain, erythema, fever, and often seen in lactating women.

Further assessment and triple testing (clinical exam, imaging, biopsy) are needed to confirm the diagnosis.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent referral:

• Firm, non-tender, non-mobile lump.
• Nipple changes (retraction, ulceration, discharge, Paget’s disease signs).
• Skin dimpling or peau d’orange (lymphatic involvement).
• Palpable axillary or supraclavicular lymph nodes.
• Unexplained breast pain or asymmetry.

Initial Investigations:

• Bilateral mammogram + ultrasound (first-line imaging).
• Core needle biopsy (if suspicious features are present).
• FNA of lymph nodes (if palpable).

Lisa requires an urgent breast clinic referral for triple assessment.

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Q3: How would you manage Lisa’s condition?

1. Immediate Steps:

• Urgent referral for triple assessment (clinical exam, imaging, biopsy).
• Ensure Lisa understands the process and reasons for urgency.

2. Multidisciplinary Management (if cancer confirmed):

• Surgical referral (lumpectomy vs mastectomy).
• Oncology referral (chemotherapy, radiotherapy if indicated).
• Genetic testing if high-risk family history.

3. Supportive Care:

• Breast cancer nurse referral.
• Psychosocial support – Encourage family involvement, counselling.
• Discuss prognosis and treatment expectations.

Regular GP follow-up is essential to coordinate ongoing care and mental health support.

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Q4: Lisa is anxious about the possibility of cancer. How would you counsel her?

1. Acknowledge and Validate Her Anxiety
   • “I understand this is a worrying time, and it’s normal to feel anxious.”
2. Explain the Next Steps Clearly
   • “We are arranging urgent tests to ensure we get a diagnosis quickly.”
   • “A breast lump can have many causes, and not all are cancerous.”
3. Offer Emotional Support and Resources
   • “Would you like to bring a support person to your appointments?”
   • Refer to Breast Cancer Network Australia (BCNA) for guidance.
4. Safety Netting and Follow-Up
   • Arrange timely follow-up to discuss results.
   • Ensure Lisa knows how to access support if she feels overwhelmed.

Effective counselling reduces distress and enhances trust in the management process.

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Q5: What preventive strategies can Lisa implement to monitor her breast health?

1. Routine Breast Cancer Screening:
   • Biennial mammograms (every 2 years for women aged 50–74 via BreastScreen Australia).
   • Consider annual screening if high-risk (e.g., strong family history).
2. Self-Breast Awareness:
   • Encourage monthly self-examinations, looking for new lumps, nipple changes, or asymmetry.
3. Lifestyle Modifications to Reduce Risk:
   • Limit alcohol to <4 standard drinks/week.
   • Maintain a healthy weight (BMI <25) to reduce oestrogen-related risks.
   • Regular physical activity (150 min/week).
   • Smoking cessation, if applicable.
4. Family Risk Assessment & Genetic Testing:
   • Consider referral for BRCA testing if multiple family members affected.

Long-term breast health depends on regular screening, lifestyle modifications, and early detection.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing benign from malignant breast conditions.
• Identification of red flags, ensuring urgent referral and triple assessment.
• Structured, evidence-based management plan, including specialist referral, imaging, and biopsy.
• Clear patient-centred counselling, addressing Lisa’s anxiety and support needs.
• Preventive strategies, including breast screening, lifestyle changes, and genetic risk assessment.

PITFALLS

• Delaying referral, leading to missed early breast cancer diagnosis.
• Failing to identify red flags, increasing risk of late-stage presentation.
• Providing false reassurance, instead of explaining the need for further tests.
• Not discussing psychological impact, leading to unaddressed patient distress.
• Lack of structured follow-up, risking missed or delayed diagnosis.

REFERENCES

• RACGP – RACGP Guidelines for Breast Cancer Investigation
• GP Exams – Malignant neoplasm breast (female)

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Takes a sensitive and structured history of breast symptoms.
1.2 Provides clear explanations of the diagnosis, investigations, and next steps.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a thorough breast examination and assesses risk factors.
2.2 Identifies red flags requiring urgent imaging and referral.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between benign and malignant breast conditions.
3.2 Determines when referral to a breast surgeon or oncologist is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate investigation and management plan.
4.2 Provides holistic care, addressing physical, emotional, and psychosocial aspects.

5. Preventive and Population Health

5.1 Educates on breast cancer risk factors, screening, and self-examination.

6. Professionalism

6.1 Delivers difficult news with empathy and supports patient autonomy.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation, urgent referrals, and follow-up.

9. Managing Uncertainty

9.1 Recognises when further investigations (e.g., biopsy) are required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and facilitates timely management of breast cancer.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD