- Breast cancer
- Breast Cancer
- What is breast cancer
- Types of breast cancer
- Am I at risk
- Increased risk
- HRT and Breast Cancer Risk
- Reducing risk
- Breast lumps
- What Happens at the clinic
- Emotional Reaction to a Diagnosis
- Treatment Options for Breast Cancer
- Hormonal Therapy
- Breast Reconstruction
- Treatment of Non-invasive Breast Cancer
- Follow-up Clinic
What Happens at the Breast Clinic?
Remember only 10% of patients referred with breast lumps turn out to have breast cancer, so if you are referred, do not panic! The breast specialist will ask you questions to help determine the likely nature of the lump.
- When did you first notice the breast lump?
- Has the lump changed in size?
- Is there any associated pain?
- Is there discharge from the nipple? If yes, what colour is it?
- Did any of your relatives have cancer of the breast or ovary?
- Do you have any children? If yes, how old were you when you had your first child and your last pregnancy?
- At what age did your menstrual periods start?
- How long ago was your last menstrual period?
- Are you taking (or have you ever taken) either the contra-ceptive pill or HRT?
- Have you had a previous breast biopsy?
The specialist will then proceed to examine your breasts and armpits. After that, the specialist will decide on whether there is any abnormality of the breast that requires further investigation. If the specialist finds a lump in the breast, he/she will arrange the following tests.
The doctor is able to obtain a small quantity of cells (biopsy) from the breast lump by inserting a thin (or fine) needle attached to a syringe. Inserting a needle in the breast causes mild discomfort, similar to that experienced when having a blood test, and occasionally causes slight bruising of the breast that fades away in a few days. This test is also called fine needle aspiration cytology and the procedure is shown below.
The cells obtained from the biopsy are stained with special dyes and then looked at under the microscope by a specialist, called a cytologist. The cytologist will decide whether the cells have any abnormal features that may indicate that they are cancerous. In practice, the cells are assessed (or graded) from C1 to C5.
|Sample inadequate for testing
Normal breast cells
Cells abnormal but more likely to be benign
Highly suspicious of cancer
Cancer cells present
The accuracy of this test depends upon the breast specialist obtaining a sample from the lump, and upon the cytologist accurately grading the cells under the microscope. If the test is positive (i.e. grade C5) then it is almost certain (99.5%) that the lump is a cancer. However, a negative test (i.e. grade C2) does not exclude the possibility of cancer but merely makes the diagnosis of cancer less likely. If the needle biopsy result is graded C1, it usually implies the sample was inadequate for analysis and the test should be repeated.
An ultrasound machine uses sound waves to image parts of the body, including breast lumps. The sound waves are transmitted through a probe, which is placed over the breast. Lubricating gel is placed on the breast skin to improve contact. The sound waves are reflected within the breast back to the ultrasound machine, which transforms them into a computer image viewed on a display monitor.
The ultrasound examination is carried out by the radiologist, who decides whether the lump is a cyst (bag full of fluid) or a solid lump (Figure 5). A solid lump is more likely to be a cancer, particularly if it has irregular borders, vertical orientation and an increased blood supply. A breast cyst can be treated straight away using a needle and syringe.
Ultrasound is highly accurate in distinguishing cysts from solid lumps, and in assessing the lump size.
Ultrasound examination does not usually cause pain, but occasional mild discomfort may be experienced due to the ultrasound device pressing against the breast. This is particularly true if the scan is performed around the time of the period in a younger woman. Ultrasound scan is recommended in all younger women (less than 35 years of age) who have breast lumps.
As mentioned earlier in the section entitled Mammography (Breast X-ray), mammograms (Figure 6) are difficult to interpret in young women (below the age of 35). Therefore the specialist may not suggest this test in a younger woman who has a lump in the breast, unless there is a very strong family history of breast cancer. A cancer usually appears as a white shadow with an irregular edge and with breast distortion, or as fine white spots (called micro-calcifications). It is important to know that a normal mammogram does not exclude cancer - up to 15% of breast cancers are missed by mammography. Digital mammography with computer-aided detection has recently been introduced in some centres. The technology achieves better image quality and allows easier storage, transmission and manipulation of images.
This test is performed under local anaesthetic using a wide needle (wider than that used in the fine needle test mentioned earlier) to allow a larger number of cells to be collected. The test causes more bruising than the fine needle test, but has the advantage of distinguishing between invasive and non-invasive breast cancer. The test is not essential in most cases as the fine needle test is usually adequate in making a diagnosis.
If the physical examination, fine needle test, mammogram and ultrasound scan do not detect a cancer, then the breast lump can be safely left alone if the patient so wishes, provided that the lump is re-evaluated in six months' time. It is the author's opinion that all palpable lumps should be excised in women over the age of 40 to ensure that breast cancer diagnosis is not missed. In many breast units, it is often possible to undergo all the tests mentioned above and obtain the results on the same day. Such clinics are called 'one-stop breast clinics'.
Suros Biopsy System
A major advancement in clinical equipment, the Suros system enables clinicians to accurately remove non-cancerous masses of the breast in a minimally invasive way, using accurate targeting under ultrasound guidance. As the needle enters the breast, an aperture in the needle opens and a vacuum gently pulls down the targeted tissue. A sophisticated and patented rotating cutting system acquires tissue, which is then pulled through the hand piece and into a tissue collection filter under the lump has been removed.