The outpatient consultation
At Sarum Road Hospital, I run a clinic specialising in breast problems usually on a monday morning. Most people are referred by their general practitioner and both men and women are seen. The clinic is run in tandem with Dr Cheetham so x-rays and ultrasounds can be performed and analysed at the same session. Needle biopsy results are obtained the same day.
www.bmihealthcare.co.uk/sarumroad/
I can advise on all aspects of breast disease and concerns. All consultations are at the request of a GP or specialist colleague for new patients. Patients that have seen me in the past and have a similar problem can refer themselves; for example those that have recurrent breast cysts. I also see and advise men who have problems in the breast and armpit area. I can also advise on minor general surgery complaints such as lumps and bumps and hernias. Part of my NHS commitment involves gallbladder surgery.
For breast problems at the consultation, you will be asked about risk factors for breast cancer such as age at which menstrual periods started and any family history of cancer. I also ask about general medical problems and past experience of anaesthetics. Please feel free to bring a friend, partner or supporter.
A breast examination is then performed. This involves undressing to the waist (including the bra). I then carefully inspect the breasts looking for colour changes, distortion and dimpling. You are then asked to lie back on the examination couch and I feel for lumps in each breast, the armpits and the area above the collar bone. A nurse will be present for the examination.
If a lump is found that needs further investigation, a needle biopsy can be performed. This involves wiping the skin with antiseptic and inserting a slim needle into the lump. If the lump is full of fluid, the fluid can be drawn off and no further intervention is required. If the lump is solid there is a bit of jiggling to draw off cells to send to the lab for analysis. Local anaesthetic is not required – it involves just as big a needle and stings for as long as the test takes. Sometimes there is bruising afterwards which can be reduced by pressing firmly over the area. Some people do find this test painful but most say it was better than they expected. The less anxious you are the less painful it will be. You can always refuse the test but if advised any reassurance will be incomplete without a needle biopsy.
Pain alone is very unlikely to represent a breast cancer but does draw attention to the breasts. I can examine to see if there is an alternative origin for the pain such as that originating from the chest wall joints or nerve roots. Pain specific to a discrete area of the breast will need further investigation.
I follow NICE and NHS guidelines when referring for mammograms
and ultrasound examinations. http://www.nice.org.uk/page.aspx?o=203193
Mammograms are x-rays of the breast which can pick up
early stages of breast cancer when there is no lump to
feel. They can also help us to diagnose lumps we can feel
and plan operations. Mammograms are also useful for screening
purposes. They are available free on the NHS every 3 years
after the age of 50 years (you will be contacted) and
yearly between 40 and 49 years for those at high risk
(you risk needs to be assessed in the clinic). For those
at lower risk there is some evidence from trials in the
United States that mammograms every 2 years between 40
and 49 years confers a survival advantage and you can
request these checks through the radiology department
at Sarum Road Hospital. www.bmihealthcare.co.uk/sarumroad/
Be warned- mammograms are not a perfect test. Some cancers
will be missed by mammography and sometimes we find “red
herrings” that involve extra tests and anxiety. Mammograms
are not suitable for women under 35 years of age because
of reduced accuracy. Ultrasounds are not suitable for
screening but are excellent for specific problems such
as diagnosing lumps. http://www.cancerscreening.nhs.uk/breastscreen/
If the physical findings are not worrying, I will only order mammograms if there is a specific need to do so or early screening mammograms are requested. If there is a lump that we think is benign, we need to confirm this with a mammogram or ultrasound and a needle biopsy. It is a unit policy to review all these lumps about six weeks later as a double check. There is no need to remove lumps that we have proven are benign but will do so if requested.
When the findings are unclear or more worrying, further tests may be requested. These include; core needle biopsy, removing the lump under a local or general anaesthetic or additional radiology tests.
A needle core biopsy takes a small slither of tissue from the lump and the relationship of the cells to each other can be studied in the laboratory. The laboratory needs at least 48 hours to process the specimen. We usually perform a needle core biopsy under x-ray or ultrasound guidance or in the minor operating theatre. You will have the area cleaned with antiseptic and local anaesthetic is given. This freezes the area but stings as it is administered. The numbness lasts for 2-4 hours. A small nick is made in the skin and the core needle is passed into the lump and a number of samples are taken. The nurse assistant will press over the area to reduce bruising. A small dressing will be applied. No stitches are required. The main complications are bruising and some discomfort - paracetamol can be taken for this. There is no need to avoid work or driving after this procedure but do not drive if you feel shaky. Occasionally, we do not get a representative sample and the process has to be repeated or another test arranged.
A letter about the consultation will be sent to your referring doctor and general practitioner. Please feel free to request a copy for you own records. If I know in advance I can interpret “medical speak”.
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