Mr Ragheed Al Mufti MB BCh BAO MSc,MD(QUB) FRCS(Eng) FRCSEd(GenSurg) is a Consultant Breast/General Surgeon at St Mary’s Hospital and Bupa Cromwell Hospital.
Breast symptoms are very common, and the majority of patients presenting to the Breast Surgical Clinic have benign conditions. The most common presenting symptoms (in over two-thirds of patients) are a specific breast lump or a painful ‘lumpiness’ of the breast.
When a patient presents at a GP surgery with a breast lump, lumpiness or nipple symptoms, the concern is always whether this may be cancer rather than something that can be managed by the GP. National BASO Guidelines have been issued concerning early referrals to the breast clinic (these are updated regularly), and urgent referral to the breast clinic is needed in a significant number of cases.
Although benign breast lumps are far more common than malignant ones, breast cancer is the most common cancer for women in the UK, with 1 in 8 women in England expected to develop the disease in their lifetime, and 1 in 20 to die as a result. The rate of breast cancer 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, mostly due to earlier diagnosis and better multi-disciplinary team management.
'Bathsheba Bathing' Rembrandt © Agence Photographique de la Réunion des musées nationaux
The best historical example of a breast cancer was illustrated in the famous painting by Rembrandt, “Bathsheba bathing”. The model was Rembrandt’s mistress, and he clearly demonstrated the lump and associated skin indentation from the cancer in her left breast, as shown on the left.
When a patient presents to the GP with a breast lump, an assessment of the characteristics of the lump is necessary to determine if it is discrete or a diffuse nodularity. A discrete lump stands out from the surrounding breast tissue, and is usually felt with measurable borders, whilst a generalised nodularity is ill-defined lumpiness which 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 lump is important to rule out cancer. A cancerous lump can often look or feel the same as a benign one, and only triple assessment in a rapid access breast clinic would make the diagnosis. Triple assessment includes a clinical surgical examination, breast imaging (mammography and/or ultrasound) and cytology/ histology assessment.
Conditions that require referral to the Rapid Access Breast Clinic
- All patients with a discrete breast mass or lump. Fine needle aspiration by General Practitioners is not recommended.
- Any multi-duct nipple discharge in patients aged over 50 years.
- Any single-duct nipple discharge in women of any age.
- Bloodstained, persistent or troublesome discharge in women of all ages.
- Severe mastalgia that interferes with the patient’s lifestyle or sleep, which has failed to respond to wearing a well-fitted supporting bra and common analgesia medications.
- Nipple retraction and distortion, changes in skin contouror any nipple eczema.
- Asymmetrical nodularity that persists after menstruation.
- Request for assessment of a patient with high risk family history of breast cancer.
- Patients who have tested positive for the breast cancer gene mutation (BRCA 1&2).
- Patients with developmental and congenital breast abnormality.
- Patients with macromastia, especially causing neck and back pain.
The differences between NHS and private breast clinics
Breast clinics in the NHS have been established to run as “One-Stop / Rapid Access” clinics, in which patients are seen urgently and receive a full breast assessment (history, clinical examination, breast imaging and cytology/histology). Until recent years, the set-up in the NHS was well organised, but financial restraints have put pressure on the NHS Rapid Access Clinics, and diagnosis and assessment can often be delayed (taking up to three or four weeks before the final diagnosis is made), up to three visits required instead of one-stop assessments, and appointments required. The rise of high quality ‘Rapid Access’ breast assessment clinics in the private sector offers an attractive alternative for many patients.
Breast Assessment Services at Bupa Cromwell Hospital
Patients coming to Bupa Cromwell Hospital’s Breast Clinic are seen within a couple of days of the referral, are offered a triple assessment during the first appointment, and usually given the diagnosis and treatment plans in a one-stop clinical set-up.
The BASO (British Association of Surgical Oncology) 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. However, in view of the limited staff, facilities and resources in the NHS, these time limits are only met in up to 85% of clinic waiting times and 70% of treatment waiting times across the country.
Thus why some patients who get their initial assessment carried out at a One-Stop NHS clinic then opt to have their treatment carried out privately. They can have their treatment or surgery for the cancer carried out urgently, by a senior consultant onco-plastic specialist breast surgeon. All subsequent specialist scans and tests are carried out very quickly (within a couple of days), without any delay in the patient’s management (an MRI scan for example is done within 1-2 days, instead of 2-3 weeks in the NHS).
The One-Stop Breast Assessment Clinic at Bupa Cromwell Hospital
Bupa Cromwell’s One-Stop breast clinic offers a comprehensive assessment of patients with any breast symptoms in a safe, rapid and caring environment. An initial clinical assessment is carried out by a consultant breast surgeon, who would then request an urgent mammogram, ultrasound scan, MRI, cytology or a core biopsy.
Tests are carried out during the same visit wherever possible (subject to availabilty) and a diagnosis made within a couple of hours (or within 48 hours of the patient’s initial assessment). The service offers speed and accuracy, allowing patients with cancer to proceed to treatment very quickly, and offering swift reassurance for patients with a benign lump or condition. It can establish a diagnosis of a cancerous breast lump in a high proportion of patients, although they may require further tests to confirm the breast cancer diagnosis.
The One-Stop breast clinics at Bupa Cromwell Hospital are supported by a specialist breast multi-disciplinary team, where leading breast surgeons, radiologists, cyto-pathologists and the breast care specialist nurse discuss all patient cases to ensure the highest quality clinical service.
The concept of the One-Stop clinic is summarised below:
- Patient with a breast lump or symptoms of concern
- Referred to the One-Stop Rapid-Access Breast Clinic
- The patient is seen by a Specialist Consultant Breast Surgeon
- Clinical Examination
- Breast Imaging by a Specialist Radiologist (e.g. Mammogram, Ultrasound Scan)
- Fine Needle Aspiration Cytology and/or Core Biopsy (Patient seen again at the same clinic by the Specialist Surgeon to discuss the results and plan any necessary treatment)
The Family Breast Cancer Clinic
Patients with a family history of breast cancer fall into three categories; low, moderate and high risk. Thankfully 90-95% of patients with a family history of breast cancer fall into the low cancer risk category, and only a very small minority have a high risk of developing breast cancer.
It is recommended that any patient who has a very strong family history of breast cancer should be referred to a specialist family breast cancer clinic (part of Bupa Cromwell Hospital’s Rapid Access Breast Clinic), as they will require a special breast screening programme and genetic counselling to identify any inherited or genetic predisposition.