We run a clinic specialising in breast problems usually on a Wednesday morning. Most people are self-referral and others are referred by HMOs and both men and women are seen. The clinic is run in tandem with a specialist Radiologist, so x-rays and ultrasounds can be performed and analysed at the same session when possible. Needle biopsy results are not usually obtained the same day but we will contact you with the results.
We can advise on all aspects of breast disease and concerns. We also see and advise men who have problems in the breast and armpit area. We can also advise on minor general surgery complaints such as lumps and bumps especially on the chest and in the armpit.
For women with breast problems you will be asked at the consultation, about risk factors for breast cancer such as age at which menstrual periods started and any family history of cancer. We also ask about general medical problems and past experience of anaesthetics. Please feel free to bring a friend, partner or supporter.
A breast examination is then performed. This involves undressing to the waist (including the bra). We then carefully inspect the breasts looking for colour changes, distortion and dimpling. You are then asked to lie back on the examination couch and we feel for lumps in each breast, the armpit and the area above the collar bone. A nurse will be present for the examination.
A similar examination is performed for men with lumps in the breast area plus an examination of the abdomen.
If a lump is found that needs further investigation, a needle biopsy can be performed. This involves wiping the skin with antiseptic and inserting a slim needle into the lump. If the lump is full of fluid (a cyst), the fluid can be drawn off and no further intervention is required. If the lump is solid there is a bit of jiggling to draw off cells to send to the lab for analysis. Local anaesthetic is not required – it involves just as big a needle and stings for as long as the test takes. Sometimes there is bruising afterwards, which can be reduced by pressing firmly over the area. Some people do find this test painful but most say it was better than they expected. The less anxious you are the less painful it will be. You can always refuse the test but full reassurance may not be possible without a needle biopsy.
Pain alone is very unlikely to represent a breast cancer but does draw attention to the breasts. We can examine to see if there is an alternative origin for the pain such as that originating from the chest wall joints or nerve roots. Pain specific to a discrete area of the breast will need further investigation.
We follow strict quality guidelines when referring for mammograms and ultrasound examinations. http://guidance.nice.org.uk/CG80/QuickRefGuide/pdf/English Mammograms are x-rays of the breast which can pick up early stages of breast cancer when there is no lump to feel. They can also help us to diagnose lumps we can feel and plan operations. Mammograms are also useful for screening purposes.
Be warned- mammograms are not a perfect test. Some cancers will be missed by mammography and sometimes we find “red herrings” that involve extra tests and anxiety. Mammograms are not suitable for women under 40 years of age because of reduced accuracy. Ultrasounds are not suitable for screening but are excellent for specific problems such as diagnosing lumps.
If the physical findings are not worrying, we will only order mammograms if there is a specific need to do so or early screening mammograms are requested. If there is a lump that we think is benign, we need to confirm this with a mammogram or ultrasound and a needle biopsy. There is no need to remove lumps that we have proven are benign but will do so if requested.
When the findings are unclear or more worrying, further tests may be requested. These include; core needle biopsy, removing the lump under a local or general anaesthetic or additional radiology tests.
A needle core biopsy takes a small slither of tissue from the lump and the relationship of the cells to each other can be studied in the laboratory. We usually perform a needle core biopsy under x-ray or ultrasound guidance or in the minor operating theatre. You will have the area cleaned with antiseptic and local anaesthetic is given. This freezes the area but stings as it is administered. The numbness lasts for 2-4 hours. A small nick is made in the skin and the core needle is passed into the lump and a number of samples are taken. The nurse assistant will press over the area to reduce bruising. A small dressing will be applied. No stitches are required. The main complications are bruising and some discomfort - paracetamol can be taken for this. There is no need to avoid work or driving after this procedure but do not drive if you feel shaky.
Malignant Breast Disease
Breast pain is extremely common and at least 2 out of 3 women will suffer from breast pain at some time in their lives. Although it can be worrying, breast pain is not usually a symptom of breast cancer especially in the absence of other symptoms such as a lump.
There are two general types of breast pain. There are those that occur in relation to the menstrual cycle, so called “cyclical mastalgia” and those where the pain is not related to the menstrual cycle.
A pain that occurs in the breast at different times of the menstrual cycle is a sign of the sensitivity of the breast tissue to the normal fluctuations in hormone levels during the monthly cycle. Although this is a common symptom for most women it rarely causes interference with personal relationships or physical activity. The usual time for cyclical breast pain is in the week or two weeks leading up to menstruation. The pain is usually relieved by the onset of menstruation. Cyclical mastalgia is not related to breast cancer or the future development of cancer. The most likely part of the breast to be affected is the outer part of the breast as the breast tissue heads towards the armpit as this is where there is the highest concentration of the milk producing tissue.
Treatment Strategies for Cyclical Mastalgia
Non-cyclical breast pain
The pain originating from the breast itself
Single areas of tenderness in the breast may indicate an area of unusual growth, this may be simply what is termed as “benign breast change” which is disorganised turnover of normal breast tissue. This may be the formation of cysts that are collections of fluid within the breast and can be painful or it may be related to inflammation following injury and lastly may be due to infection. If the pain is persistent or severe or there are any associated skin changes or lumps you should consult your doctor who will refer you as appropriate. It is very unlikely for these symptoms alone without a lump or distortion of the skin of the breast to be indicative of breast cancer.
Nerve endings to the breast may become hyper sensitive if the nerve pathways they share with other structures are over active, for example, if there is localised inflammation in the joints of the ribs, the overlying breast is likely to feel more sensitive than usual. Similarly if there is a trapped nerve root in the spine the nerves to the breast are affected and the breast itself will feel more sensitive. This pain is more likely to be “nagging” in nature, worse on movement and difficult to pinpoint. Referred pain or localised inflammation can often settle with a short course of anti-inflammatories (eg ibuprofen or Neurofen). Occasionally further treatment such as osteopathy or acupuncture is required.
Breast pain alone is not a reason for performing a mammogram. However, if you are over 40 and there is also a lump associated with a pain then a mammogram may be an appropriate investigation. Cysts, which are small collections of fluid, can be drained without the need for mammography. For women under 40 the breasts are too dense to make any meaningful interpretation of a mammogram and an ultrasound is often requested if there is a lump accompanying your pain.
Breasts change constantly, from puberty to the menopause, as a result of fluctuating levels in oestrogen. Once breasts are fully developed, changes relating to the menstrual cycle are common.
Breast awareness is an important aspect of women caring for their bodies. Familiarity with their breasts means women will be aware of normal changes. More importantly they will notice anything unusual. Regular self-examination helps ensure any changes are noticed early.
The basis of breast awareness is:
Benign Breast Change
Most women seen in a breast clinic will not have breast cancer. Many will not have a definite lump and most lumps are not cancer but are due to other benign conditions such as breast cysts or fibroadenomas. Many women present with areas of nodularity in the breast that may also be painful or tender and these areas are often referred to as benign breast change.
The presence of extra breast tissue that may be associated with extra nipples. Often found towards the armpit.
An infection of the breast with a collection of pus in the breast tissues
This occurs when bacteria get into the breast. It is particularly likely to occur during breastfeeding, due to the milk ducts in the breast being more exposed than normal.
The absence of the mammary glands (either through surgery or developmental defect)
The dark area that surrounds the nipple
Areola-sparing mastectomy is defined as resecting the nipple and any existing surgical biopsy scar, removing all breast parenchyma, and leaving a natural envelope of skin (including the areola), which may improve the aesthetic result of immediate reconstruction. Suitability for this type of reconstruction will depend on the type of cancer present.
Arimidex is a type of hormonal therapy used in the treatment of breast cancer in women who have had their menopause. It is an aromatase inhibitor (see below.)
Aromasin is a type of hormonal therapy that is used in the treatment of breast cancer in women who have had their menopause. It is an aromastase inhibitor (see below.)
These are drugs that block the formation of oestrogen.
The absence of nipples
Abnormal cells in the breast milk ducts which are considered to show a higher risk of developing breast cancer. Patients with ADH should have regular check-ups.
An overgrowth of the cells in the breast lobule in a disorganized way that may represent the earliest form of instability within the breast.
The armpit region.
A procedure which dissects the lymph nodes in the axilla (armpit) during surgery, usually performed in conjunction with breast cancer surgery.
The glands in the armpit region. There are around 20 lymph glands in each armpit which can increase in size if infected, or if invaded by cancer cells.
Also known as benign mammary dysplasia, cystic mastitis, fibroadenosis and fibrocystic change is a condition occurring as a result of normal hormonal activity during the menstrual cycle.
A harmless breast lump which is not cancerous.