Woman Discovering A Breast Lump On Self-examination — Free SCA Practice Case
Woman discovering a breast lump on self-examination
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Emma Carter
Age
45 years
Consultation Type
VideoAge
45
Situation
Telephone or Video Consultation.
Reason for Encounter
"I found a lump in my right breast in the shower a couple of weeks ago. I thought it would go away after my period, but it hasn't."
Medical Records
- ●PMH: Mild Asthma, otherwise fit and well.
- ●Medications: Salbutamol inhaler PRN. Mirena Coil (inserted 3 years ago).
- ●Allergies: NKDA.
- ●Recent Notes: Last cervical screening 2 years ago (Normal). No previous breast issues.
Patient Script
For the friend playing the patient role
Character Overview: You are Emma. You are usually a very practical and calm person, but right now, you are terrified. You have a 10-year-old daughter and your mind immediately jumps to the worst-case scenario. You are holding back tears during the consultation. You waited two weeks because you read online that lumps can just be hormonal cysts.
Opening Sentence: "Hi Doctor. I'm really quite scared. I was in the shower about two weeks ago and I felt a lump in my right breast. I told myself it was just hormonal because my period was due, but my period finished days ago and the lump is still there. It actually feels harder now."
History if Asked (Data Gathering Phase)
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The Lump Details:
- ●Location: "It's on the right side, quite high up, towards my armpit." (Upper Outer Quadrant - most common site for malignancy).
- ●Texture/Mobility: "It feels like a frozen pea or a marble. It's hard and it doesn't really move around much when I push it."
- ●Pain: "No, it doesn't hurt at all. I almost wish it did, I read that painless lumps are worse."
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Associated Red Flags (The Clinical Clues):
- ●Skin Changes: "Actually, yes... when I lift my arm up to put deodorant on, the skin over the lump sort of pulls in. It looks a bit like a dimple, or an orange peel." (Peau d'orange / tethering).
- ●Nipple Changes: "No, my nipple looks normal. No bleeding or fluid coming out."
- ●Lymph Nodes: "I haven't felt any lumps under my armpit or in my neck."
- ●Systemic: "No weight loss, I feel fine in myself. Just terrified."
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Risk Factors (Family/Hormones):
- ●Family History: "My mum had breast cancer, but she was in her late 70s when she got it. Nobody young in the family has had it."
- ●Hormones: "I have the Mirena coil. I had my daughter when I was 35."
ICE — Ideas, Concerns, Expectations
(Actor guidance: Do not volunteer any of this unprompted. Respond only if the candidate directly explores your ideas, concerns, or expectations.)
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Ideas: "Honestly? I've convinced myself it's cancer. I've been on Google non-stop since I found it. At first I thought it might just be a cyst because of my hormones, but when it didn't go away after my period and I noticed that dimple thing... I just can't think of what else it could be."
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Concerns: "I keep thinking about my daughter. She's only ten. If something happens to me... I can't even say it out loud. My mum had breast cancer too, and even though she was older, it's all I can think about. I just need to know one way or the other — not knowing is the worst part."
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Expectations: "I want someone to actually look at it properly and tell me what it is. I don't want to be told to wait and see. I want a scan or whatever the test is — I just want to be referred so I can find out for sure."
If Asked — Medical History and Medications
(Actor guidance: Respond only if the candidate asks specifically about your medical history, medications, or past health issues.)
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Asthma / Salbutamol inhaler: "I've had mild asthma since I was a teenager, but it's never been a big deal. I just carry my blue inhaler in my bag. I probably use it once or twice a month if I'm doing something strenuous or if it's cold out. It hasn't been any worse recently."
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Mirena coil: "I had the Mirena put in about three years ago. It's been brilliant, honestly — my periods are really light now, barely there. Before the coil I was on the combined pill for years, probably from my early twenties until I was about 38 or so."
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Cervical screening: "Yes, I had a smear about two years ago and it was all normal. I've never missed one."
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Previous breast issues: "No, I've never had any problems with my breasts before. No lumps, no scans, nothing. This is the first time."
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Allergies: "No, no allergies to anything that I know of."
Social History and Lifestyle Impact
(Actor guidance: This context can be shared naturally during conversation, especially when discussing the emotional weight of the situation or when the candidate asks about your daily life.)
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Occupation / daily life: Emma works as a teaching assistant at a primary school. She is a single mum to her 10-year-old daughter, Lily. She manages everything herself — school runs, homework, cooking, the lot.
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Lifestyle impact of the condition: "I haven't been sleeping properly since I found it. I lie there at night just touching it and thinking. At work I can't concentrate — the kids are asking me things and I'm just miles away. I've not told anyone about it, not even my mum, because I don't want to worry her given her own history. I keep going to the bathroom at work just to check it's still there, which sounds mad, but I can't help it. I've been snappy with Lily too and I hate myself for it — she doesn't deserve that."
If Asked — Associated Symptoms
(Actor guidance: Respond only if the candidate asks directly about these symptoms. Keep answers brief and natural.)
- ●If asked about pain or tenderness in the breast: "No, it doesn't hurt at all. That's what worries me — I read that the bad ones don't hurt."
- ●If asked about nipple discharge or bleeding: "No, nothing like that. No fluid, no blood, nothing."
- ●If asked about nipple inversion or retraction: "No, my nipple looks the same as it always has. It hasn't changed shape or pulled in."
- ●If asked about redness or warmth of the breast: "No, it doesn't look red or feel hot or anything like that."
- ●If asked about swelling of the breast: "I don't think so — they both look the same size to me. I've been checking in the mirror."
- ●If asked about lumps in the other breast: "No, I've checked the left side loads of times and it feels completely normal."
- ●If asked about lumps under the arm or in the neck: "I haven't felt anything there, no. No lumps under my arms or in my neck."
- ●If asked about bone pain or back pain: "No, I haven't had any bone pain or back pain."
- ●If asked about shortness of breath or cough: "No, nothing like that — well, just my usual asthma, but that's no different."
- ●If asked about fatigue or feeling unwell: "I'm tired, but I think that's because I'm not sleeping. I don't feel ill."
- ●If asked about appetite or weight changes: "No, my weight's been the same. If anything, I've been eating less because I feel sick with worry, but I haven't actually lost weight."
- ●If asked about abdominal pain or bloating: "No, nothing like that."
- ●If asked about headaches: "No, no headaches."
- ●If asked about changes in the skin elsewhere: "No, just that dimple thing over the lump. Nowhere else."
- ●If asked about recent trauma to the breast: "No, I haven't knocked it or injured it at all."
- ●If asked about breastfeeding history: "I breastfed Lily for about six months. That was ten years ago though."
Responses to Management (The Negotiation Phase)
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If the Doctor says "I'll refer you to the hospital under the 2-week wait":
- ●Reaction: Panics. "The 2-week wait? Isn't that the cancer pathway? Are you telling me I have breast cancer?!"
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If the Doctor tries to falsely reassure ("It's probably just a cyst"):
- ●Reaction: "But what about the dimple in the skin? My friend had a cyst and she didn't have a dimple. Are you just saying that to make me feel better?"
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If the Doctor asks you to come in for an examination today:
- ●Reaction: Relieved. "Yes, I can be there in 20 minutes. Will you definitely refer me though, even if you aren't sure?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Remote Consulting for Breast Symptoms
- ●The Golden Rule: A breast lump cannot be accurately assessed over the phone or via video. History is essential, but physical examination is mandatory — always bring the patient in face-to-face before initiating referral.
- ●Why examination cannot be skipped: The referral form requires documented clinical findings (lump size, texture, fixity, skin changes, axillary nodes). Referring without examining undermines the quality of the referral.
Red Flag Features of Breast Malignancy
- ●A hard, poorly mobile (fixed) lump in the upper outer quadrant is the classic presentation of breast carcinoma. Softness and mobility favour benign causes; hardness and fixity do not.
- ●Skin dimpling and peau d'orange (oedematous, pitted skin resembling orange peel) indicate tethering of Cooper's ligaments or dermal lymphatic invasion — both are red flags for malignancy regardless of patient age.
- ●Painlessness is a feature that tends to increase, not reduce, concern. Patients often expect a cancer to hurt; correcting this misconception matters for history-taking and patient communication.
- ●Persistence beyond the menstrual cycle is a key discriminating feature. Hormonal cysts and fibrocystic change are typically cyclical; a lump that remains unchanged after menstruation warrants urgent investigation.
- ●Other red flags to screen for: nipple discharge (especially bloody or unilateral), nipple retraction or inversion, axillary lymphadenopathy, and systemic symptoms (weight loss, bone pain, breathlessness) suggesting metastatic disease.
NICE NG12 — Suspected Cancer Pathway (2-Week Wait) Criteria
- ●Refer using a suspected cancer pathway (appointment within 2 weeks) for breast cancer if:
- ●Aged 30 and over with an unexplained breast lump, with or without pain
- ●Aged 50 and over with unilateral nipple symptoms: discharge, retraction, or other change
- ●Consider a suspected cancer pathway referral if:
- ●Any age with skin changes suggesting breast cancer (dimpling, puckering, peau d'orange, erythema)
- ●Aged 30 and over with an unexplained axillary lump
- ●Emma (aged 45) meets the primary referral criterion on age and unexplained lump alone. The skin tethering is an additional indicator. There is no threshold for watchful waiting in this clinical picture.
Risk Factors for Breast Cancer — What to Elicit and Why
- ●Family history: A first-degree relative with breast cancer increases lifetime risk. However, age at diagnosis is critical to risk stratification — a mother diagnosed in her late 70s carries a substantially lower inherited risk implication than a mother diagnosed under 50. Do not conflate the two.
- ●Prolonged combined oral contraceptive (COC) use: Associated with a small but measurable increase in breast cancer risk, which diminishes after stopping. Emma's use from early 20s to age 38 (~15–16 years) is a relevant hormonal exposure.
- ●Levonorgestrel IUS (Mirena): Current evidence suggests a small increased risk with progestogen-containing IUDs, though the absolute risk remains low. Note this in the hormonal history.
- ●Age at first pregnancy: First pregnancy after age 30 is associated with modestly increased risk compared to earlier first pregnancy, due to the delayed protective effect of full-term pregnancy on breast tissue.
- ●Breastfeeding: Breastfeeding is protective and should be recorded; Emma breastfed for 6 months.
- ●Nulliparity and obesity are established risk factors; parity and BMI are worth establishing in the history.
Differential Diagnosis of a Breast Lump
- ●Breast carcinoma: Hard, irregular, poorly mobile, painless. Associated with skin changes (dimpling, peau d'orange), nipple changes, or lymphadenopathy. Most common malignant cause.
- ●Fibroadenoma: Smooth, highly mobile ("breast mouse"), rubbery, non-tender. Commonest in women aged 15–35. Rarely presents for the first time at 45.
- ●Breast cyst: Smooth, round, fluctuant or firm (like a grape). Common in women aged 35–55. Often tender and cyclical — but a cyst does not cause skin tethering or peau d'orange.
- ●Fibrocystic change: Bilateral, diffuse nodularity, cyclical tenderness. Not a discrete lump. Resolves or improves after menstruation.
- ●Fat necrosis: History of trauma; can mimic malignancy with skin tethering. No trauma in this case.
- ●The key clinical discriminator in this case: Skin tethering with peau d'orange is not compatible with a simple cyst or fibroadenoma. It must be investigated urgently.
Triple Assessment — What to Tell the Patient
- ●The breast clinic typically operates as a one-stop clinic. Patients should be prepared for all three components in a single visit:
- ●Clinical examination by a breast specialist
- ●Imaging: Ultrasound is first-line in women under 40 due to breast density; in women aged 40–49, both ultrasound and mammography are usually performed; mammography alone may be used in women over 50. Emma (45) will likely have both.
- ●Histology: If imaging identifies a solid lesion, a tissue sample will be taken — either core biopsy (preferred; provides histological diagnosis) or fine needle aspiration cytology (FNAC) — under local anaesthetic.
- ●Results from a one-stop clinic are typically available within 1–2 weeks of the appointment. Setting this expectation reduces anxiety and prevents premature catastrophising.
Explaining the 2-Week Wait Without Causing Panic
- ●The phrase "2-week wait" is widely associated with cancer in the public consciousness. Patients will often interpret it as a diagnosis rather than an investigation pathway.
- ●Recommended framing: "The 2-week wait is a fast-track route the NHS uses to investigate breast symptoms quickly and safely — it's designed to give people answers as quickly as possible. Most people seen on this pathway — around 9 in 10 — do not have cancer. What it means is that we take your symptoms seriously and we want you seen by the right people quickly."
- ●Avoid using the word "cancer" first; let the patient's own language lead. If the patient uses the word directly, engage with it honestly rather than deflecting.
- ●Acknowledge that uncertainty is genuinely difficult, particularly for a single parent, and name that explicitly.
Safety-Netting
- ●Advise Emma to contact the surgery if the breast clinic appointment has not arrived within two weeks of the referral being submitted.
- ●She should seek urgent medical review if she notices: rapid increase in lump size, new lumps in the same or opposite breast, nipple changes (discharge, bleeding, inversion), new axillary swelling, or any systemic symptoms (bone pain, breathlessness, unexplained weight loss).
- ●Signpost to Breast Cancer Now (helpline and online resources) and Macmillan Cancer Support as sources of information and peer support during the waiting period, making clear these are for anyone with a breast concern, not only those with a diagnosis.
Mapped to the RCGP curriculum topic: Gynaecology and Breast.
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