Referral criteria

Private referral is not a clinical alternative to the NHS 2-week-wait pathway for suspected cancer — it is a route alongside it. Both pathways deliver the same standard of triple assessment. The differences are in:

• Time to first appointment private clinic typically same week; NHS 2-week-wait pathway up to 14 days from referral.
• Continuity of consultant at Breastory, every visit is with Dr Tsang-Wright; in NHS clinics, you are seen by the team on duty, which may include registrars and may differ between visits.
• Convenience and choice appointment time, location, and surgeon are within the patient’s choice in private practice; NHS allocation is determined by capacity and geography.
• Cost covered by private insurance or self-pay privately; covered by the NHS otherwise.

For most patients with a suspected cancer, either route is clinically appropriate as long as the patient is seen and assessed promptly. Where a patient has private insurance and a presentation that warrants assessment, private referral is often a reasonable choice — and one Breastory’s same-week pathway is designed for.

Breast lump

Refer (private or NHS 2WW):

• Any new discrete breast lump in a patient aged 30 or over.
• Any new lump in a patient under 30 that is enlarging, painful, or with suspicious features (hard, irregular, fixed, or associated skin or nipple change).
• A lump persisting through more than one menstrual cycle in a patient under 30, even if it has typical benign features.

Reasonable to monitor briefly:

• A patient under 30 with a small, mobile, smooth lump and no other features — review in 4–6 weeks across the menstrual cycle. Refer if unchanged or increasing.

For background, see breast lump glossary entry.

Nipple discharge

Refer:

• Single-duct discharge particularly if clear, watery, blood-stained, or brown. These usually warrant assessment for an underlying intraductal lesion.
• Spontaneous nipple discharge in a non-lactating patient that is unilateral and persistent.
• Any nipple discharge in a postmenopausal patient.
• Discharge with associated lump, skin change, or nipple inversion.

Reasonable to reassure:

• Bilateral, multi-duct, milky or pale-yellow discharge in a patient on a known galactorrhoea-inducing medication (some psychotropics, prokinetics) — review the medication first.
• Discharge expressed only with manipulation, in a patient with no other features. Advise to stop expressing and review if it becomes spontaneous.

For background, see nipple discharge assessment and intraductal papilloma.

Breast pain

Refer if:

• Pain is unilateral, localised, and persistent beyond a few weeks.
• Pain is associated with a lump, skin change, nipple change, or other concerning feature.
• Pain is severe and disrupting daily life despite first-line measures.

Reasonable to manage in primary care:

• Cyclical breast pain in a premenopausal patient — usually responds to lifestyle measures (well-fitting bra, simple analgesia, evening primrose oil if the patient wishes), and is rarely associated with breast cancer.
• Generalised breast tenderness on hormonal contraception or HRT — review the medication.

Most cyclical and generalised breast pain does not warrant specialist referral. The exception is where the pain is focal, persistent, and the patient cannot be confidently reassured without specialist examination and imaging.

For background, see breast pain assessment.

Skin and nipple change

Refer:

• Nipple inversion that is new (months rather than long-standing) in an adult.
• Nipple eczema that does not respond to steroid cream, particularly if unilateral — Paget’s disease of the nipple is rare but important not to miss.
• Skin tethering, dimpling, or peau d’orange.
• Persistent localised skin redness of the breast that does not settle with treatment of an obvious cause (mastitis, eczema).

For background, see skin and nipple changes assessment.

Mastitis and breast abscess

Refer urgently (same-day or next-day):

• Mastitis not responding to 48 hours of appropriate antibiotic treatment.
• A palpable, fluctuant lump within an inflamed area suggesting abscess.
• Severe systemic symptoms in lactational mastitis.

The practice can usually arrange a same-day or next-day appointment for these presentations. See mastitis and breast abscess.

Refer for genetic counselling and risk assessment (NHS or private) when:

• One first-degree relative with breast cancer under 40, or multiple first-degree relatives with breast cancer at any age.
• A relative with bilateral breast cancer, male breast cancer, ovarian cancer, or pancreatic cancer in the family pattern.
• A known BRCA1, BRCA2, PALB2, TP53, or other high-risk mutation in the family.
• A patient who has met threshold criteria on a family-history risk tool (Manchester score, Tyrer-Cuzick, BOADICEA).

NHS family-history clinics and clinical genetics services are usually the most appropriate first port of call for risk assessment and genetic testing. Once a high-risk result is identified, surgical consultation about risk-reducing options can sit alongside the genetics pathway — Breastory accepts referrals for risk-reducing mastectomy consultation.

Patients sometimes seek a second opinion on a treatment plan from another centre — a common and entirely reasonable thing to do, particularly for breast cancer where surgical options often involve trade-offs. The practice welcomes these referrals.

What helps in the referral:

• A copy of the histology report, imaging report, and MDT note from the original centre.
• The proposed treatment plan as it has been explained to the patient.
• What the patient is uncertain about a question that helps focus the second consultation.

Second-opinion appointments typically run 45–60 minutes; the patient leaves with a written summary that they can take back to their original team.

Patients with confirmed high-risk genetic mutations (BRCA1, BRCA2, PALB2, TP53) considering risk-reducing mastectomy can be referred for surgical consultation. The genetic testing and counselling is usually completed first; the surgical conversation is then a separate strand.

For patients who have already had a breast cancer and are considering contralateral risk-reducing mastectomy, the same applies — refer once the index cancer treatment plan is clear, with the histology and MDT decision attached.

Dr Tsang-Wright is one of the few private breast surgeons in the UK who routinely sees adolescent and young-adult patients. Most adolescent breast presentations are benign — fibroadenomas, breast pain, asymmetry — but they warrant specialist review and a clinician comfortable explaining the findings to a younger patient and their family.

Refer for adolescent breast assessment if:

• A new discrete lump that does not regress over 4–6 weeks.
• Persistent localised pain.
• Asymmetry causing significant distress.
• Concerns about pubertal breast development.

Refer male patients with:

• A new breast lump (most are benign gynaecomastia, but assessment is appropriate to confirm).
• Nipple discharge, skin change, or asymmetry.
• A family history that includes male breast cancer, particularly with a known BRCA mutation.

Some presentations do not need specialist referral and can be reassured in primary care:

• Bilateral, generalised, cyclical breast pain without a focal feature.
• Bilateral, multi-duct, milky discharge related to medication.
• Long-standing, stable nipple inversion with no associated change.
• Asymptomatic breast nodularity in a patient with no new symptom and a recent normal screening mammogram.

Patients in these groups can be reassured. If, on review, any feature changes, refer at that point.