The mammogram is still the gold standard investigation for detecting early breast cancer and the only screening tool that has been shown to decrease the death rate from breast cancer. The mammogram is able to detect cancer before there is any palpable or visible change in the breast. Internationally, recommendations differ, however a generally accepted consensus is that all women should have an annual mammogram and clinical examination between the ages of 40-70 years. There are times when earlier surveillance will be recommended especially if you have a strong family history (mother/sister) of breast cancer detected before the age of 50 years. The ability of the mammogram to detect cancer will be optimised by having a mammogram done at a breast centre which specialises in mammography where the radiologists who read the mammograms have a dedicated specialist interest and training in breast imaging. Experience and expertise are required to give the best possible results. Mammograms are able to detect 80-90% of cancers and they are able to detect a form of early pre-invasive breast cancer. A clinical examination by a doctor would always be recommended at the time of your mammogram and this can be done by your GP.

Even with the best mammograms not all cancers will be detected. With improved ultrasound technology and specialist training, the ultrasound is now a valued and reliable tool for the detection of early breast cancer. However it should be regarded as complementary to the mammogram rather than a substitute for it. Some studies have shown that a further 8% of cancers can be detected by combining mammography with ultrasound scanning. Those who would most benefit from an additional ultrasound scan are women with a breast symptom (lump, pain, nipple discharge), women with dense breast tissue so that the sensitivity of the mammogram is reduced, and women who are found to have an abnormal mammogram. An ultrasound might also benefit those women at increased risk such as a positive family history.

This procedure involves inserting a needle through your skin into the breast lump and removing a sample of cells for examination under the microscope. Local anaesthetic will often be used to numb the skin through which the needle passes.

A core biopsy is where a biopsy needle is put into the breast and a core of tissue is removed. This is performed under local anaesthetic which numbs the area, then a small nick is made in the skin with a scalpel so the biopsy needle can enter. Using a spring loaded device, the needle is passed into the area. Following core biopsy After the biopsy a steristrip (strip of plaster) is put over the area and covered with a waterproof dressing. We recommend this be removed after 24 hours. You may shower/bath with this dressing on. Some women feel some discomfort in the area when the local anaesthetic wears off. We suggest taking 2 Panadol, 4-hourly for this. Do not take any Aspirin type of medication as this can increase the chance of bleeding or bruising.

The mammotome breast biopsy system enables us to accurately diagnose areas seen on mammogram that are not able to be assessed by clinical examination or breast ultrasound. It is a type of biopsy where two images of an area on the (two dimensional) mammogram are taken to ascertain accurately it's location in three dimensions. This new technique means that we can avoid a general anaesthetic and open surgical biopsy. Although it is safe to drive to and from your mammotome appointment, it is preferable to bring someone with you to drive you home. This procedure requires a little local anaesthetic in the overlying skin and deeper tissue and takes about 45 minutes. You are lying comfortably face down on a special bed with your breast placed through an opening. The breast is semi-compressed between the mammogram plates as the full pressure required for mammogram pictures is not necessary. Using a special computer attachment, we can calculate the precise spot we want to biopsy. Firstly, x-rays are obtained on the digitalised computer screen. Then local anaesthetic is injected into the skin and deeper tissues. Additional x-ray film views are done at this stage to make sure that everything is in the right position. A small cut is made in the skin so we can pass the mammotome needle into the area. Using a gentle suction device, tissue is drawn into the hollow chamber of the probe. Further x-rays may be done at this stage to ensure that the tissue is from the correct area. The system's state-of-the-art technology means several tissue specimens can be obtained through a single needle insertion. When the procedure is finished the mammotome needle is removed and pressure applied. Steristrips are used to close the edges of the cut and a waterproof dressing applied. This should remain in place for 24 hours after which it can be removed. Avoid direct knocks to the breast and strenuous exercise the following day. Stitches are not required to close the wound and any evidence of the procedure will not be apparent after 6 months. We recommend that you remain at the clinic for approximately 40 minutes after the procedure to ensure there is no further bleeding.

Partial versus full mastectomy It is now recognised that, in properly selected women, just removing the part of the breast where the cancer is (partial mastectomy), combined with post-op radiotherapy, has the same survival outcome as removing the whole breast (full mastectomy). However, when the cancer is larger, or cancer is found in more than one part of the breast, or where the amount of breast that would need to be removed would result in a poor cosmetic outcome, then full mastectomy will still be recommended. It is now common practice to offer a breast reconstruction and for many women this can be done at the same time as the mastectomy so that women wake from their surgery with a ‘new breast’. Even with partial mastectomies reconstructive surgery can be offered. The cosmetic outcomes achieved these days can make telling which breast has been reconstructed difficult compared to the natural breast.

Previously, women diagnosed with invasive breast cancer would have all the lymph nodes removed from the axilla (armpit) on the affected side. This is called an axillary clearance. A major complication of this surgery was lymphoedema of the arm on the affected side. Lymphoedema is swelling of the arm and hand due to the surgical disruption of the lymph vessels which drain fluid from the arm back into the body. The swollen arm is more prone to infections and skin ulcers. Lymphoedema is usually a chronic and miserable condition, which requires lifelong treatment. Over recent years a new technique of sentinel node biopsy has been introduced. It is thought that there is a single sentinel (gate-keeper) lymph node in the axilla to which the breast drains and from which all the other lymph nodes are fed. By identifying the sentinel lymph node and removing and testing this node for cancer it is possible to predict if the other nodes will be affected. If the sentinel node is negative for cancer the other lymph nodes do not need removing. This has resulted in a marked reduction in the number of axillary clearances performed and consequently a dramatic reduction in the number of women with lymphoedema following breast cancer surgery. This has significantly improved the quality of life for these women. The sentinel node is identified by injecting a small amount of radioactive isotope into the affected breast prior to surgery and a second injection of blue dye into the affected breast at the start of surgery. The radioactivity and blue dye drain to the sentinel node. Using a gamma counter and looking for blue nodes the sentinel node is identified. Most centres are now offering this technique to women if clinically there is no evidence of cancer in the lymph nodes prior to surgery.

Breast reconstruction can be achieved in several different ways and the options and methods that would be suitable will be discussed with each individual woman. The aim is to restore symmetry and femininity and there is strong evidence that this type of surgery makes it easier for women to come to terms with the diagnosis and subsequent treatment of their cancer. Symmetry can be achieved by restoring the affected breast to match the normal side or by reducing the normal side to match the affected breast or by a combination of these techniques. A new breast can be created using either implanted material or taking your own tissue from another site to make a breast. Expander Reconstruction Tissue expanders are silicone shells placed behind the muscles of the chest wall, which can be gradually inflated with saline over a period of weeks to achieve the size required. Some of these are designed to be left in place whilst others are removed once fully inflated and silicone or saline implants placed in the pocket created. LD and TRAM Reconstruction Tissue reconstruction involves moving skin, fat and muscle from another part of the body to create a breast mound. The two most common sites to harvest this tissue are the back (Latissimus dorsi – LD flap) or lower abdomen (transverse rectus abdominus muscle –TRAM flap). The tissue reconstructions usually give a superior cosmetic result but at the cost of additional scarring at the site from which the tissue is taken. The additional advantage of the TRAM flap is the resultant tummy tuck when the tissue is taken away.

Breast augmentation is now a widely accepted procedure and in women with breast cancer the same technique can be used to increase the size of a small non affected breast to match a reconstructed breast. This offers women an element of choice for their ultimate matched breast size post breast cancer surgery which perhaps can be regarded as some sort of silver lining. Most commonly a small incision is made in the crease under the breast and a cohesive silicone gel implant is placed behind the breast tissue or behind the chest wall muscle. Based on the size and shape of the breast to start with and the desired result requested, the size, shape and profile of the implant is chosen.

The majority of women having breast reduction surgery do not have cancer but do have medical symptoms of upper back, shoulder and neck discomfort. There can be a stooping posture and shoulder indentation from bra straps. There are frequently rashes in the crease under the breasts. All these symptoms can be improved with a breast reduction procedure. This technique can also be used in women with breast cancer to make the non affected breast smaller to match a partial mastectomy. A lesser procedure can also be done to lift a droopy non affected breast to match the more pert appearance of an implant or reconstruction. In this situation less breast tissue but more skin is removed to tighten and lift the breast tissue.

Benign breast disease is very common and in many cases does not require any treatment other than diagnosis and an explanation of the condition. Any breast symptom can cause alarm however, and it is important that they are checked out promptly and referred for specialist evaluation when required. The most common breast condition for which a woman will see her doctor is breast pain (mastalgia). This is extremely common, and will affect up to 90% of women at some stage. It is the only symptom of breast cancer in less than 2% of cases. In most cases mastalgia is self limiting and only a small proportion of cases will require treatment. Mastalgia is divided into cyclical (i.e. shows a definite relationship to menstruation) and non-cyclical. Non-cyclical mastalgia often has an origin outside of the breast, and a search should be made for chest wall tenderness or Tietze’s syndrome. Cyclical breast pain is often bilateral, radiates into the arm and may be associated with cyclical nodularity. If mild to moderate, it often responds well to evening primrose oil. More severe pain may need specialist assessment and drug treatment with tamoxifen, danazol or bromocriptine may be considered. Most breast lumps are benign, and many can be considered as aberrations of normal development and involution (ANDI). For example, fibroadenomas are an aberration of normal lobular development in the early reproductive years, and cysts are an aberration of lobular involution. For this reason, these lumps rarely require excision. Cyclical nodularity is seen in many women and may be associated with mastalgia. A woman may notice a particular nodule which feels more prominent. Often she can be reassured by a comparison with the opposite breast. If there is any doubt, an ultrasound scan will show if there is any discrete abnormality. A biopsy is rarely required. Fibroadenomas are common, particularly in the teens and twenties. Once a diagnosis is made by triple assessment (clinical examination, imaging and needle biopsy), they only require excision if they are enlarging or if the woman wishes it. Occasionally, a biopsy may show some atypical features suggestive of a phylloides lesion, and biopsy is usually advised. Cysts are very common in the thirties through to fifties age group. About one in ten women in this age group will get a symptomatic cyst. These are commonly multiple or recurrent. They have a very typical appearance on ultrasound. Symptomatic cysts are easily aspirated under ultrasound guidance. Cytology is only required if: the aspirate is bloodstained, there is a residual lump or the cyst refills rapidly after a previous aspiration. Nipple discharge is a symptom which often alarms women. In most cases, it is physiological or due to duct ectasia. These harmless types of nipple discharge are often creamy in consistency and may be coloured green or brown. They are often bilateral and can be seen to come from more than one duct. Women with this type of discharge, particularly if it is not spontaneous, can usually be reassured. Intervention is only required if the discharge is profuse enough to be socially embarrassing. Prolactinomas are extremely rare, but serum prolactin should be checked if the discharge is profuse and appears milky. Nipple discharge should be referred on if it is spontaneous, unilateral, single duct and either clear or bloodstained. The most common underlying cause is a benign duct papiloma, but malignancy needs to be excluded. Many of these conditions do not require surgery and we will work together to find out the best treatment plan for you.