Breast Cancer Diagnosis and Management: A Guide for GPs

Breast cancer diagnosis and management follow a sequence that a general practitioner can apply in any setting: recognise the presentation, confirm it with triple assessment (clinical, radiological and pathological), define the stage and the tumour's receptor biology, then match treatment to both. Dr. Jalaj Baxi, Director Surgical Oncology, Fortis Hospital, Noida, India, with more than 27 years of experience, built his masterclass around exactly that sequence.

He chose the angle deliberately. He expected most of his audience to be general physicians and practising doctors rather than oncologists, so he set aside the finer points of oncological treatment and concentrated on what a first-contact doctor needs to know: how to diagnose breast cancer, and how its management is organised once the diagnosis is made. Dr. Jalaj Baxi is currently Director Surgical Oncology at Fortis Hospital, Noida, India.

This guide covers the pathway end to end. Two stages have their own articles: the diagnostic workup in breast cancer biopsy types, imaging and receptor testing, and local treatment in breast surgery, the axilla and when radiotherapy follows. Drug treatment and advanced disease are covered in breast cancer chemotherapy and metastatic disease options. A separate masterclass by Dr. Sahil Bambroo is summarised in a medical oncology guide to breast cancer management.

The scale of breast cancer for doctors in Africa

Dr. Baxi opened with two figures. Breast cancer accounts for about 11.5 per cent of all cancers worldwide, and Africa contributes 8.6 per cent of the world's breast cancer patients. Every general practice will meet the disease, and the quality of the first consultation decides how quickly a patient reaches definitive treatment.

His message to patients is equally direct. He tells them that breast cancer is "the best cancer", because treatment exists at every stage and several distinct modalities are available. For a referring doctor the implication is practical: no stage of breast cancer is beyond treatment, so no patient should be sent away without a plan.

Breast cancer warning signs: how patients present

A breast lump is the commonest presentation. Dr. Baxi listed the others a general practitioner should recognise:

• Nipple discharge. The character of the discharge matters: it may be white, yellow or bloody. A bloody discharge raises concern for cancer, although most cases are caused by benign intraductal papillomas, so the finding calls for full assessment rather than assumption either way.
• Changes in the nipple itself, such as distortion or retraction.
• Breast pain.
• A lump in the axilla with no lump in the breast. An axillary mass can be the first and only sign.
• An incidental finding. Years of awareness campaigns have changed how patients arrive. Many now detect the lump themselves through breast self-examination, after which imaging confirms the diagnosis.
• Symptoms of metastasis. Bone pain or fatigue can be the presenting complaint, and lung metastases can present with cough and breathlessness.

The last group is the one most easily missed. A patient with back pain or a persistent cough may never mention a breast lump unless asked and examined. Population screening schedules by age, which complement this symptom-led approach, are set out in cancer screening guidelines from mammography to colonoscopy.

Triple assessment: the standard for diagnosing a breast lump

Whenever there is a lump in the breast, Dr. Baxi said, the diagnosis depends on triple assessment. The three components are:

1. Clinical assessment. The history establishes how the lump was found, when, and how long it has been present. Examination establishes whether the tumour is palpable or non-palpable.
2. Radiological assessment. Mammography comes first, with ultrasound, MRI and PET-CT used for specific indications.
3. Pathological assessment. A tissue diagnosis, now usually by core needle biopsy.

A fourth step follows the tissue diagnosis. Immunohistochemistry, a special stain applied to the biopsy tissue, tests for three receptors: the oestrogen receptor (ER), the progesterone receptor (PR) and HER2, a growth-signalling receptor on the cancer cell surface. Dr. Baxi calls this the biological assessment of the tumour. When all three receptors are negative, the cancer is triple negative, which he described as the worst kind of breast cancer a patient can have.

Breast cancer staging: early, locally advanced and metastatic

Staging follows the National Comprehensive Cancer Network (NCCN) guidelines, which Dr. Baxi's team uses as most centres worldwide do. The TNM system scores three things: the size of the tumour (T), the status of the regional lymph nodes (N) and the presence of distant metastasis (M). These combine into stage groups from stage 1 to stage 4.

For treatment decisions, Dr. Baxi groups patients into three clinical categories:

• Early breast cancer (EBC): stages 1, 2 and 3A up to T3 N1, that is, tumours from T1 to T3 with no nodes or N1 nodal disease.
• Locally advanced breast cancer (LABC): disease beyond that boundary but still confined to the breast and regional nodes. In standard definitions this covers tumours that involve the chest wall or skin, and fixed, matted or more extensive regional nodal disease.
• Metastatic breast cancer (MBC): spread to distant organs, stage 4.

Alongside the clinical stage sits the biological classification: hormone receptor positive, HER2 positive or triple negative. A patient therefore carries two labels, such as "early, hormone positive" or "locally advanced, triple negative", and both drive the plan.

What decides breast cancer treatment

Dr. Baxi bases management on four factors:

1. The clinical stage.
2. The receptor status established by the biological assessment.
3. The age of the patient.
4. The individual patient's preference.

The options available for any breast cancer are surgery, chemotherapy, radiation therapy, hormonal therapy, targeted therapy and immunotherapy. What differs from patient to patient is which comes first and which are needed at all.

Breast cancer treatment sequence by stage and tumour biology

The order of treatment is where stage and biology meet. Dr. Baxi's approach in summary:

Neoadjuvant chemotherapy has changed surgical practice, Dr. Baxi noted. It is the first step in locally advanced disease, and he gives it before surgery in triple-negative and HER2-positive cancers even when they are operable. Dr. Rajesh Kumar Jain sets out a comparable framework from a separate masterclass in his breast cancer treatment protocol by stage and subtype.

What causes breast cancer, and what does not

Asked about natural causes, Dr. Baxi was clear that there is no natural cause as such: the underlying event is always a mutation in a gene. About eight in ten cases are sporadic, meaning no cause can be identified. Familial or genetic cancers, in his figures, make up 10 to 15 per cent.

Prevention advice is therefore general rather than specific. Smoking, alcohol and tobacco all contribute to mutation, so avoiding them reduces cancer risk. Dr. Baxi was careful to frame this as advice about cancer as a whole, not breast cancer in particular.

Two other questions from the session concern beliefs patients bring to the consultation:

• Cosmetics. Myths persist about talc applied to the axilla and about lipsticks. Some print media point to a link, but Dr. Baxi stated that there is no confirmatory or corroborative evidence for it.
• Breast cancer in men. Dr. Baxi sees no fundamental difference. The receptors are the same, most male and female breast cancers are hormone receptor positive, and the treatment remains the same.

Genetic risk has one direct surgical consequence, risk-reducing mastectomy, which is covered in the article on breast surgery.

Why patients decline after the diagnosis

A doctor in the session asked why many patients seem to deteriorate immediately after being told they have breast cancer. Dr. Baxi attributes this largely to psychology rather than to the disease. He described a cancer phobia: once the diagnosis is given, the patient loses a sense of control over their own life and begins to fear an early death or inadequate treatment.

His response is education. He explains to each patient the type of disease they have and the realistic treatment outcomes. Knowing that there is still a fight left, and that it can be fought, improves how patients cope. For a general practitioner, who is often the first to deliver or discuss the diagnosis, this is part of management rather than an aside.

Breast cancer diagnosis and management where resources are limited

Dr. Baxi acknowledged the constraints doctors in many African settings work under. Early in his own career he worked in a place where nothing was available, and the lesson he drew was to tailor both the investigations and the treatment to what exists, so that the patient still receives the best care possible. Some tools he described are not available everywhere: frozen section is not offered at all centres, even in India, and sentinel node biopsy is not done everywhere.

His purpose in presenting the full pathway was awareness: referring doctors should know which investigations and treatments exist, so that they can use what is available locally and refer when a patient needs more. The questions doctors put to him at the end of the session, from risk-reducing mastectomy to a metastatic case on chemotherapy, are collected in the Live Discussion from this masterclass. More on cancer care across the network is on the oncology specialty page.