Being referred to see a consultant because of a breast problem is, understandably, a very worrying time for many women (or men for that matter).

Fortunately, most people we see do not have breast cancer, and most of the lumps we see are not cancerous lumps, but that doesn’t stop it being stressful until a definite diagnosis is made. This article shows you what to expect when you visit a breast specialist, the sort of investigations you may need and also explains some of the normal changes that occur in the breast tissue.

This article on breast cancer is written by Simon Marsh, Consultant Breast, Groin and Hernia Surgeon, London.

The first thing to do is to understand the make up of the breast and how it changes under the influence of hormones and with age.

The breast can be thought of to consist of gland tissue and fat. There is also some elastic tissue which gives the breast its shape. Normal gland tissue feels quite nodular; a good way to picture it is as a scaled down packet of frozen peas. Now, imagine the breast as a clock face, divided into 4 quadrants. On the right side 3 ‘o’clock is in the middle with 9 ‘o’ clock towards the armpit. The reverse is the case on the left. The bottom half of the breast is mostly fatty tissue and so is softer when compared with the upper half. The quadrant towards the armpit (between 9 and 12 ‘o’ clock on the right and 12 and 3 ‘o’ clock on the left) contains most of the gland tissue and this is the quadrant that feels the most “lumpy”. In fact, lumpy is a bad term as there are not usually any lumps, it is just nodular. The nodularity of the gland tissue can be measured on the “Marsh Packet of Frozen Peas Scale”!

This gland tissue responds to changes in the hormone levels and so, not unexpectedly, is more pronounced just before a period and in pregnant and breastfeeding ladies (who may reach 11 out of 10 on the frozen peas scale(!), normal premenstrual women are around 7). The best time to check the breast is about a week after a period has finished as it tends to be less nodular. The breast also seems to become more nodular in the mid thirties, perhaps as the elastic tissue becomes more fibrous. For a little while before, and after, the menopause the gland tissue turns to fat and so the nodularity decreases. However, as fat has a larger volume there may be a change in size of the breast, often more on one side than the other. Also, most commonly in the late thirties or early forties, the gland tissue seems to become more sensitive to the hormone levels and many women develop breast pain. This is, not surprisingly, mostly in the area of the breast that has most of the gland tissue but can also affect the upper arm and the side.

Changes in nodularity and breast pains are two very common reasons for referral to a breast specialist but any new symptom or sign will be thoroughly investigated to make sure that all is well. The investigation of any breast problem revolves around, what is called, the triple assessment. It is like doing a jigsaw puzzle; pieces (of information) are collected and put together until the whole picture (the diagnosis) becomes clear. Indeed, this is often termed “the diagnostic jigsaw”. In some cases only 2 pieces may be needed, in others 4, but 3 (the triple assessment) is most common. Let’s have a look at what the pieces are.

Firstly, the specialist will ask questions about your symptoms. They will also ask about previous problems, any medications you may be on and if there are any diseases that run in the family. They will also ask about your periods (when they started, when they stopped or when the last one was) and whether you have any children. The specialist will then examine both breasts, looking at the normal side first. How the breast feels when it is examined is the first part of the jigsaw.

If there is a definite area of change (and in some cases examination will be completely normal) then a fine needle aspiration will be carried out. This test uses a normal sized syringe and needle (like for a blood test). The needle is placed into the area of the breast and “jiggled” so that a small amount of material is sucked into the syringe. This is sent away to be looked at under the microscope. The appearance of the cells that have been removed is the second part of the jigsaw.

The final part of the triple assessment involves taking pictures of the breast. In ladies under 35, an ultrasound scan is the commonest way of doing this. In ladies over 35, they will have a mammogram as well. Full field digital mammograms are the most sensitive type available at the moment. What an area of the breast looks like on a mammogram or an ultrasound scan is the third piece of the jigsaw.

If the pieces all fit together and are giving the same diagnosis then nothing further needs to be done. Let’s look at a couple of examples. A fibroadenoma is a common type of benign (non cancerous) lump in young women. It is smooth, often lobulated and seems to move around within the breast. It has a distinctive appearance on an ultrasound scan and a needle test will show normal looking breast cells (sometimes a little active). If a triple assessment produces these results then all is well and nothing further needs doing. In ladies in their forties, the commonest cause of a lump is a breast cyst, again a benign lump. Cysts are round and smooth and full of fluid. They also have a characteristic appearance on mammograms and ultrasound scans. When a needle is put into a cyst, fluid is obtained. The fluid can be pale yellow through to dark brown or even dark green. Once the fluid is removed the lump goes away (although they can come back). Again, if the triple assessment produces the same answer at each stage the result is said to be concordant and nothing further needs to be done.

What if the pieces don’t quite fit and the picture (diagnosis) is not initially obvious (the triple assessment is then said to be discordant)? In this case, another piece of the jigsaw is needed. Most commonly this will involve a test known as a core biopsy. Where the fine needle test removes a few cells from the breast, a core biopsy takes a core of breast tissue about 2 cm long and 2 mm in diameter. This gives the pathologist much more information as to what is going on in that area of the breast. The core biopsy is carried out by first putting some local anaesthetic into the skin of the breast. Once this has worked (it is quite quick) a small nick is made in the skin to allow the core biopsy needle, attached to the biopsy “gun”, to be placed into the breast. When the “gun” is “fired” the needle takes the small biopsy (it also makes a noise a bit like a stapler!). This is often repeated a few times, and although it is not usually painful it often involves a small amount of pushing. This will nearly always produce the final piece that allows the diagnosis to be made. If not, then further tests may be required, such as an MRI scan or even, occasionally an operation to remove the small area for full examination under the microscope. An important part of the triple assessment that is not commonly mentioned is to watch how things change (or not) with time. It would not be unusual to check things a few months later, repeating some, or all, of the assessment to make sure nothing has changed. A thorough triple assessment may actually be a quadruple assessment!

Once again, it should be emphasised that in the majority of cases a triple assessment (or a quadruple one) will reveal that cancer is not present. Most symptoms are age-related changes or benign lumps. However, it is important that any new change is thoroughly investigated by a specialist to make absolutely sure that all is well. It is pleasing to be able to give the news that everything is fine, not to mention to receive it!

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