CCE-CBD-190

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How do you differentiate between cyclical and non-cyclical breast pain?
• Prompt: What features would raise suspicion for malignancy?

Q2. What are your initial management steps?

• Prompt: What lifestyle modifications and pharmacological options could help?
• Prompt: When would you recommend imaging or specialist referral?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you address her concerns about breast cancer?
• Prompt: What reassurance and follow-up plan would you provide?

Q4. What preventive measures can help reduce her symptoms and long-term risk?

• Prompt: What role does breast awareness and lifestyle play?
• Prompt: When should she begin routine breast cancer screening?

Q5. What are the red flags that would necessitate urgent imaging and referral?

• Prompt: What clinical features suggest a high risk of malignancy?
• Prompt: How would you manage a suspicious breast lump?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

Breast pain, or mastalgia, can be classified into cyclical and non-cyclical causes, with further differentiation into benign and malignant conditions.

Differential Diagnoses:

1. Cyclical Mastalgia (Most Likely Diagnosis)
   • Key features: Pain varies with menstrual cycle, worse premenstrually.
   • Hormonal fluctuations are the main cause.
   • Common in women aged 30-50 years.
2. Non-Cyclical Mastalgia
   • Musculoskeletal pain: Costochondritis or referred pain.
   • Duct ectasia or cysts: May cause persistent focal pain.
   • Trauma-related breast pain.
3. Breast Cancer (Less Likely Here but Must Be Considered)
   • Key features: Painless lump, nipple changes, skin retraction, lymphadenopathy.
   • No lump found on examination, but family history is noted.
   • Requires further workup if red flags present.
4. Medications Contributing to Breast Pain
   • Oral contraceptive pill (OCP), hormonal therapy, SSRIs, or spironolactone can cause mastalgia.

Most Likely Diagnosis:

• Cyclical mastalgia based on premenstrual exacerbation, absence of red flags, and normal breast exam.

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Q2: What are your initial management steps?

Answer:

1. Reassurance and Lifestyle Measures:

• Reassure that cyclical breast pain is common and usually benign.
• Supportive bras may help, especially during the luteal phase.
• Reducing caffeine, high-fat foods, and alcohol can improve symptoms.

2. Pharmacological Therapy (If Symptoms Are Severe):

• Simple analgesia: Paracetamol or NSAIDs.
• Evening primrose oil (EPO): Some evidence for pain relief.
• Tamoxifen or Danazol: Used in severe refractory cases under specialist guidance.

3. Investigations (If Red Flags or Atypical Symptoms):

• Mammogram and/or ultrasound if:
  • Focal persistent pain in one area.
  • Associated with a lump or skin changes.
  • Family history is strong (e.g., multiple first-degree relatives).

4. Follow-Up:

• Review in 4-6 weeks if symptoms persist or worsen.
• Refer to a breast specialist if red flags emerge.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Your symptoms are consistent with cyclical breast pain, which is common and related to hormonal changes during your menstrual cycle.”
• “There are no signs of breast cancer, and your examination was normal.”

Treatment Plan:

• “We will start with simple measures, including a well-fitted bra, reducing caffeine, and using NSAIDs if needed.”
• “If pain persists, we can try evening primrose oil or discuss hormonal adjustments.”
• “There is no need for imaging at this stage, but we will monitor closely.”

Safety-Netting:

• “If you develop a lump, nipple discharge, skin changes, or persistent pain in one area, come back immediately.”
• “We will review in 4-6 weeks to reassess symptoms.”

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Q4: What preventive measures can help reduce her symptoms and long-term risk?

Answer:

• Breast awareness: Encourage regular self-examinations.
• Weight management and exercise: Reduces oestrogen levels, improving symptoms.
• Dietary changes: Reduce saturated fats, caffeine, and alcohol.
• OCP modification: Consider alternative contraception if symptoms are severe.
• Routine breast screening:
  • Screening mammograms from age 40 for high-risk patients.
  • Discuss formal genetic testing if multiple family members had breast cancer.

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Q5: What are the red flags that would necessitate urgent imaging and referral?

Answer:

• New or persistent breast lump.
• Nipple retraction, discharge (especially bloody or spontaneous).
• Skin changes: Peau d’orange, dimpling, redness.
• Axillary lymphadenopathy.
• Pain that is focal and persistent, not cyclical.
• Strong family history with early breast cancer.

Management of a Suspicious Breast Lump:

• Triple assessment:
  • Clinical examination.
  • Imaging (mammogram ± ultrasound).
  • Biopsy (core needle biopsy preferred if concerning findings).
• Urgent referral to a breast specialist if malignancy suspected.

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SUMMARY OF A COMPETENT ANSWER

• Correctly differentiates cyclical from non-cyclical breast pain.
• Recognises cyclical mastalgia as the most likely diagnosis.
• Provides clear reassurance and evidence-based lifestyle advice.
• Knows when to escalate care with imaging and referral.
• Recognises red flag symptoms requiring urgent action.

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PITFALLS

• Over-investigating a clear case of cyclical mastalgia without red flags.
• Failing to consider non-cyclical or musculoskeletal causes.
• Not addressing patient anxiety about breast cancer.
• Delaying referral for a suspicious lump.
• Not providing clear follow-up and safety-netting advice.

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REFERENCES

• RACGP – RACGP Guidelines on Breast Symptoms
• GP Exams – Pain, 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 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to breast pain.
2.2 Identifies red flag symptoms requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between cyclical and non-cyclical breast pain and considers concerning causes.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including reassurance and lifestyle modifications.
4.2 Recognises when further imaging or specialist referral is needed.

5. Preventive and Population Health

5.1 Provides education on breast health awareness and self-examination.

Competency at Fellowship Level

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