Breast symptoms are very common, and the majority of patients presenting to the Breast Surgical Clinic have benign conditions. The commonest presenting symptoms in patients attending a breast clinic (in over two-thirds of patients) are a breast lump or a painful lumpiness of the breast.
When a patient presents to the general practitioner with a breast lump, lumpiness or nipple symptoms, the concern is always whether there is any chance this is cancer or not, and whether the general practitioner can manage this at the surgery. National BASO (British Association of Surgical Oncology) guidelines, which are updated regularly, have been issued concerning early referrals to the breast clinic, and prompt, urgent referral is needed in a signifi cant number of cases.
Although benign breast lumps are far more common than malignant ones, breast cancer is one of the most important diseases of women. Breast cancer is the most common cancer in women in the United Kingdom – one in eight of the country's women can expect to develop the disease in her lifetime, and one in 20 women will die from breast cancer. The rate of diagnosis has more than tripled over the past three decades, but breast cancer mortality has gone down from 69% in 1979 to 21% in 2010.
When a patient presents to the general practitioner with a breast lump, assessment of the character of the lump is necessary, to determine whether the lump is discrete or if it is a diffuse nodularity. A discrete lump stands out from the surrounding breast tissue, and is usually felt with measurable borders, but a generalised nodularity is ill-defi ned lumpiness that changes with the menstrual cycle and is often present in both breasts.
Over 90% of patients seen at the breast clinic with a lump have a benign lump, but a full urgent assessment of any breast lump is important to rule out cancer. It is quite often that a cancerous lump may look or feel similar to a benign lump, and only triple assessment in a Rapid Access specialised breast clinic would make the diagnosis. Triple assessment would involve surgical clinical, breast imaging (mammography and/or ultrasound) and cytology/histology assessments.
At King Edward VII's Hospital, patients are seen urgently, within hours or a couple of days of referral, and are then offered the triple assessment at the same day clinic. They are given the diagnosis and treatment plans at the same clinic, in a one-stop clinical set-up.
The BASO guidelines indicate that all patients with breast symptoms that require a one-stop clinic assessment should be seen within two weeks, and that treatment for cancer should be scheduled within four weeks. All subsequent specialist scans and tests are carried out urgently within a couple of days, without any delay in the patient’s management.
The One-Stop Breast Assessment Clinic at King Edward VII's Hospital provide a comprehensive way of assessing and investigating any patient with breast symptoms – including patients with breast lumps, nipple discharge or retraction, breast contour changes or any other cause for concern – in a safe, friendly and caring environment.
This clinic carries an initial clinical assessment of the patient by a specialised consultant breast surgeon, who would then request an urgent mammogram (special X-ray of the breast), ultrasound scan (scanning of the breast using special sound waves), MRI (Magnetic Resonant Scan), cytology (taking cells from a lump for examination under the microscope using a fine needle aspirate, or a core biopsy (taking a very small piece as a specimen of tissue under a local anaesthetic for a special microscopic histological examination).
The benefit of running a One-Stop Breast Assessment Clinic is that all these tests are carried out at the same clinic visit and that the diagnosis is made within a couple of hours at the clinic (or within 48 hours of the patient’s clinic visit). This method is an excellent and an accurate way of assessing more than 95% of breast lumps, and is of great value in reassuring patients with benign breast lump or benign conditions of the breast. It can also establish a diagnosis of a cancerous breast lump in a large proportion of patients very quickly, although such patients may require further tests to confirm the diagnosis of breast cancer.
In a minority of patients with breast cancer, the One-Stop Clinic can have an adverse psychological effect if a patient is attending the clinic alone and is then informed of the diagnosis of cancer unexpectedly. Accordingly, all patients attending the one-stop rapid access breast clinic are advised to bring a spouse, a friend or a relative with them.
The One-Stop Breast Assessment Clinic has been running smoothly, due to the availability of various expert personnel of a specialist “Breast Multi-Disciplinary Team” at one site –comprising the surgeon, radiologist, breast radiographer, cyto-histo-pathologist and breast-care specialist nurse – in a friendly and safe clinical environment.
In the private breast clinics at King Edward VII's Hospital, patients are seen in a state-of-the-art private consulting room. There are many top-quality breast-specialist consultant surgeons and cancer specialists available, dealing with a large number of patient referrals with breast symptoms. In addition, specialist consultant radiologists and pathologists are available on site to provide expert services for running a rapid-access diagnostic breast clinic.
Patients with a family history of breast cancer fall into three categories – low risk, moderate risk and high risk. Thankfully, more than 90% of patients with a family history of breast cancer fall into the low-risk category, and only a very small minority of patients with a family history have a high risk of developing breast cancer themselves.
It is recommended that any patient who has a very strong or significant family history of breast cancer should be referred to our specialised family breast cancer clinic (which is part of the rapid-access breast clinic), as they will require a special breast screening programme and genetic counselling and genetic screening, in order to identify any inherited or genetic predisposition.
High-risk patients will require genetic testing and may require prophylactic bilateral mastectomy and breast reconstructions (ie removing the breasts to prevent future cancers). Such specialised family cancer clinic is available in our specialised cancer centre at King Edward VII's Hospital.
