Seeing your doctor

What should I do if I have breast symptoms?

Whenever you experience any symptoms relating to your breasts the first person to consult is your GP. The priority for your GP is to decide whether there is a chance that you have any serious disease within the breast and, if not, whether the problem can be sorted out without referring you to hospital.

If you have a definite lump or you have a symptom for which your doctor wishes to seek further advice, you will be referred to a hospital breast clinic. Alternatively your GP may decide that your breast should be checked again – perhaps at a different point in your menstrual cycle – and he or she will ask you to come back for a follow-up examination.

The hospital breast clinic

The doctor at the clinic will ask you to describe your symptoms in detail and also ask how long you have had them. If your problem is pain or a lump he or she will also want to know whether this varies in relation to your monthly cycle.

You will then have a breast examination. If you are seeing a male doctor he will ask for a female nurse to be present during the examination. During this examination you will be asked to strip to the waist (remove clothes from top half of body).

Physical examination

The doctor will look at your breasts first with your arms by your side, then above your head and finally with your arms pressing on your hips. By looking carefully at the outline of the breast in these various positions, the doctor may see changes that help to identify the site and cause of any problem.

Next, your breasts will be examined with you lying flat with your arms tucked underneath your head. If during the examination the doctor finds a lump, he or she may concentrate on this area, examining it with the fingertips and measuring the lump.

After checking your breasts, the doctor will usually examine the lymph glands in the armpit and those in the lower part of the neck. Should you need any further investigations, the breast specialist who sees you will order these tests and explain why these are necessary.

Mammograms (breast X-rays)

If you are over 35 years and have not had a breast X-ray within the past year the clinic doctor is likely to send you to have mammograms. For more information.

Some breast units arrange for patients to have mammograms before they are seen by the clinic doctor so that the X-rays are reported when you see the doctor. The results of the X-rays are usually ready for during the time that you are at the clinic.

Ultrasound scanning

X-rays do not pass easily through the dense breast tissue in the breasts of women under the age of 35 years and this usually makes it difficult to obtain images of sufficiently good quality in younger women. In these women and in older women with a lump an extra test called an ultrasound scan may be performed.

Ultrasound is familiar to many women because it is used to look at babies during pregnancy. It is used in the breast to tell whether any lump is filled with fluid (cystic) or whether it is solid.

A special gel is spread on to the breast and a small device that emits high-frequency sound waves is passed over the area. The echoes are converted into a picture of the breast tissue by a computer. This scan is painless and takes just a few minutes.

Ultrasound is not useful as a screening test but is useful to investigate an abnormality on the X-ray or to assess a localised area of lumpiness. If the lump is solid on ultrasound it is usually possible to tell whether it is a benign (non-cancerous) lump, or likely to be more serious.

Ultrasound is also a very good way of looking at the lymph glands under the arm. It is now routine practice for women suspected of having breast cancer to have an ultrasound of the lymph glands under the arm. If any abnormal lymph glands are seen, these can be sampled with a small needle using the ultrasound to guide the needle into the lymph node.

Needle tests

There are two types of needle test commonly used to diagnose breast lumps.

Core biopsy

The most commonly used takes a small sliver or portion of tissue and is known as a core biopsy. Before this test is carried out the skin and the area surrounding the lump or abnormality are numbed with local anaesthetic. Provided that sufficient local anaesthetic is injected into the breast and left for several minutes to work, it is not a painful test.

When the anaesthetic wears off, however, the breast can be tender and patients are usually advised to take painkillers, similar to those used for headaches such as paracetamol or ibuprofen.

Fine-needle aspiration

The other needle test uses a small fine needle of the same size as that used to take blood; this is called fine-needle aspiration. This test removes a sample of cells. It can be performed either with or without a local anaesthetic. In some clinics results from this needle test are available within an hour.

After core biopsy or fine-needle aspiration the area may become bruised and swollen. Both a core biopsy and a fine-needle test can be carried out in the clinic or the X-ray or radiology department. In small lumps or small areas of abnormality detected on scans or X-rays, a needle can be guided into the problem area using X-ray or ultrasound guidance to make sure that the correct area is sampled. Your doctor will discuss with you what type of needle biopsy you need and exactly how the test will be carried out.

Usually the doctor at the breast clinic is able to tell you at your first clinic visit whether the lump is benign or could be more serious.

Vacuum-assisted biopsy

The predominant reason why an accurate diagnosis is not obtained by core biopsy is a failure to sample the right area or failure to obtain sufficient tissue. These problems can be largely overcome by using a larger needle with the addition of suction or a vacuum to take more tissue.

Vacuum-assisted biopsies are better at sampling calcification than core biopsy and allow biopsy of more awkward areas in the breast.

Local anaesthetic solution is injected into the skin and the breast and left in place for a few minutes to work. A small cut is then made in the skin and the needle for the biopsy is introduced into the breast.

Most vacuum-assisted biopsy devices need to be inserted into the breast once only which is a distinct advantage over core needles, which need to be removed from the breast after each core to remove the sample from the needle.

As vacuum-assisted biopsies can remove most of an area of calcification, the doctor performing the biopsy may leave a metal marker in the breast at the site where the biopsy has been performed. This means that, if the area needs to be removed at operation, it is possible to find the area accurately using the metal marker as a guide.

Needle localisation biopsy

To remove an area of concern within the breast, which cannot be felt by the surgeon as a lump, it is necessary to mark this area using a thin wire with a hook at one end. Before surgery you will go down to the X-ray department and after injection of local anaesthetic a wire is placed into the breast using either the mammogram machine or ultrasound to guide it to the area that is to be removed.

After placement of a wire, X-rays are taken to check the position of the wire in relation to the area that is to be removed. Sometimes two wires are inserted either because the first wire was not inserted in a satisfactory position or because there are two areas of abnormality that need to be marked, or two wires are placed, one at each end of the abnormality, to help the surgeon remove the whole of the correct area.

When the wire(s) are in a satisfactory position you return to the ward where you are usually given something to make you feel sleepy (a pre-med). Later in the day you are taken to the operating theatre and have the operation under general anaesthetic.

A small cut is made in the skin of the breast and the surgeon finds the wire and follows it to the area of abnormality. The area of breast tissue around the wire is then removed by the surgeon. While you are still under the anaesthetic an X-ray is taken of the tissue sampled to check that the correct area has been removed.

There are other techniques that can be used to mark an abnormal area, one of which is to inject a radioactive substance into the breast around the abnormal area. The surgeon then uses a hand-held probe in the operating theatre, which detects radioactivity and allows the abnormal area to be identified and removed.

Open biopsy/excision biopsy

It used to be common to remove a lump by surgery to find out what it was (an open or excision biopsy).

Nowadays it is rarely necessary to remove a lump or an abnormal area on mammogram or on screening to find out its exact cause. It is usually possible with needle tests to diagnose what the lesion is. Most women who are informed that a lump or abnormalities detected in their breasts are benign do not request removal, but some women do wish to have their lump removed.

If either the doctor has advised you to have a lump removed or you have decided to have it removed, this is usually performed under a general anaesthetic, although it can be performed using a local anaesthesia.

Follow-up visits

If you do not receive the results of all your tests on the same day as they are performed you will be given a follow-up appointment to come back to get the results. Sometimes the results of the tests do not provide a definite answer, in which case you may have to have further investigations.

If a core biopsy or fine-needle aspirate has not shown a definite cause for the lump it is possible at your second visit that the doctor will suggest that the lump should be removed (an excision biopsy or needle localisation biopsy – see above).

What the tests mean

Needle tests are very accurate and are rarely ever wrong if they show cancer. Occasionally the mammogram or ultrasound scan is reported as showing a cancer but, when tested with a needle or removed, it turns out to be non-cancerous.

This might happen in 1 of 20 cases. This is why the doctor will often tell you that the lump might be cancer but it is impossible to be absolutely sure until the lump has been tested with a needle or until the lump has been removed and analysed. The combination of:

• performing a careful examination

• taking X-rays and/or scans

• performing a needle test of the lump

is very accurate. It is known as triple assessment or the triple test.

If you have all these three tests it is very rare, if a cancer is present, for it to be missed. If all the tests show that the lump is not serious, it is not therefore necessary to have the lump removed and you can be safely reassured and discharged.

Other tests that may be performed

Bone scan

Sometimes a bone scan is performed in a patient with a breast cancer to check that there is no abnormality in the bones.

For this scan a very small amount of mildly radioactive liquid is injected into a vein, usually in your arm. After the injection you will have to wait for two or three hours before the radioactivity gets to the bone, so you may want to take a book or magazine with you. Taking a friend for company is also worthwhile. The radioactive material injected is completely safe and quickly loses activity. It disappears from the body within a few hours.

A scan is then taken. Abnormal bone takes up more of the radioactive substance than normal bone and abnormalities show up on the scan as a bright area or hot spot.

Areas of previous injury or arthritis can also show up on the scan as hot spots. To sort out whether a hot spot is related to previous injury you may be asked to have further X-rays of these areas. If there is a hot spot and there is evidence of damage to the bone, this might indicate that this is related to cancer that has spread to the bones.

Magnetic resonance imaging

This test does not use X-rays but magnetism to build up a picture of your body. It can be used to look at the breasts or other areas of the body, particularly bones.

This is a difficult test if you suffer from claustrophobia. During the scan you will be asked to lie very still on a couch inside a long chamber for up to 40 minutes. If you cannot lie in enclosed spaces you should mention this to your doctor or the radiographer when you attend for the scan.

Magnetic resonance imaging (MRI) is also very noisy but you will be given earplugs or headphones to reduce the noise. Some MRI departments invite you to bring your own music with you to listen to while you are having your MRI done. It is also usually possible for you to take somebody with you to keep you company.

As the scan chamber is a very powerful magnet, before entering the room you need to remove all metal belongings. People who have pacemakers or certain surgical pins or clips should not have an MR scan, so you need to tell your doctor if you have any.

Breast MRI

MR scans of the breast are very accurate but they take a long time to perform so they are used only in certain groups of women. They are very accurate at looking at young women’s breasts and are particularly useful for looking at the breasts of young women who have a very strong family history of breast cancer.

Breast MRI is also valuable in women who have a lump under their arm which is shown to contain cancer cells that have spread to a lymph node, but where there is no obvious abnormality in the breast on X-rays or an ultrasound scan. MRI can sometimes find a cancer in the breast that has been missed by other tests.

In women who have had surgery and/or radiotherapy to the breast MR scans are particularly useful. Surgery and radiotherapy can cause scarring and it can be difficult on X-ray to be certain whether an abnormality in the breast of a woman who has had previous surgery and radiotherapy is the result of scarring or there is a more serious abnormality present.

MRI is also the best way of getting a picture of woman’s breasts that have breast implants in place. If there is concern that an implant is leaking or ruptured, MRI is the best way of telling whether the implant is intact or leaking.

Whole body MRI

Sorting out whether an abnormality on a bone scan is related to a previous injury or arthritis, or spread from a cancer, is not always easy and MR scans are a very accurate way of looking at bone. They are sometimes needed in patients with hot spots on bone scans to determine whether there is a serious cause for the bone scan abnormality.

MR scans of the liver, brain and spinal cord are useful in women with breast cancer who develop symptoms to suggest that there may be an abnormality in these areas.

Ultrasound scan of the liver

In women with larger cancers, where there are signs that the liver is not functioning normally, or where tests have shown spread to the bone or lungs, a liver ultrasound scan or CT scan of the liver can help to assess whether cancer has spread to the liver. If you are asked to have an ultrasound scan to check your liver this is a painless test and takes only a few minutes.

It will probably be done in the hospital scanning department. You will be asked to lie on a couch, a gel will be spread on to your tummy and a small device that sends out sound waves will be passed over the area. The echo of the sound waves is converted into a picture by a computer.

CT scan of the liver

If ultrasound does not get a very good picture of the liver, the doctor may suggest that you have a CT scan. CT stands for computed tomography. It uses X-rays to build up a picture of what the body looks like at one particular level in the body. By taking these pictures at multiple levels it is possible to get a very accurate picture of the liver and see if there are any abnormalities in it. In some units CT scans of the liver are preferred to ultrasound scans.

Computed tomography is also used for looking at other areas of the body, including the lungs, bone and brain. It can help to show whether any abnormality on an X-ray or ultrasound scan is due to spread from the breast cancer.

Positron emission tomography

Commonly known as PET, this technique relies on the fact that cancers grow faster than normal cells. By using labelled glucose, which is a fuel for cells, those cells that are growing faster take up more glucose and therefore show up as abnormal on these scans.

This allows breast cancers that have spread to be seen on the PET scan. The main problem with PET is that it is very expensive and available only in certain centres. It can be combined with CT and is then known as CTPET.

It is also not clear whether PET scans provide any additional benefit for patients with breast problems compared with the other investigations already widely available in most hospitals.

KEY POINTS

• If your GP thinks that you have significant breast symptoms he or she will refer you to a hospital breast clinic

• At the hospital breast clinic various tests will be carried out to determine the cause of the symptoms

• These tests commonly include physical examination of the breast area, a mammogram, scans and needle (biopsy) tests

• It is usually possible to establish a definite diagnosis of a lump or X-ray abnormality by a needle test performed after injecting local anaesthetic

• Other tests can check for possible areas to which a cancer may spread including the bone (bone scan) and liver (liver ultrasound)