The information outlined below on common breast conditions and treatments is provided as a guide only and it is not intended to be comprehensive.

WHAT TO EXPECT

You will be seen initially by Miss Michelle Mullan who will review your medical history and perform a breast examination in the presence of a breast care nurse. She may then request any further tests as appropriate to obtain accurate diagnosis.

What other tests will I need?

If other tests are necessary they will be done during this visit and will usually include a Mammogram (an x- ray technique for taking pictures of the breast) and an ultrasound scan. Depending on your symptoms and the results of these tests additional tests may also be carried out during this visit including a Fine Needle Aspiration (FNA) or a Needle Core Biopsy.

What happens next?

After the necessary tests have been performed, Miss Mullan with her breast care nurse will see you again to explain the results and answer any questions you may have.

What if I need more treatment?

Happily, for the majority of patients no serious problems are identified and no further tests or follow up are necessary. In a small percentage of cases, further investigation and an operation may be needed to make a definite diagnosis. If this is the case you will be given all the options about continuing with your treatment privately.

With digital mammogram and MRI machines at the Priory and Spire, your treatment will be conducted in state-of-the-art facilities, ensuring the best care possible.

Breast Cancers

Ductal Carcinoma in situ (DCIS)

What is ductal carcinoma in situ (DCIS)?

DCIS is an early form of breast cancer, where the cancer cells have developed within the milk ducts but remain there (so called ‘in situ’ ) as the cells don't have the ability to spread outside the ducts into the surrounding breast tissue or to other parts of the body. So it is usually described as a pre-invasive, intraductal or non-invasive cancer. Both men and women can develop DCIS, however it is very rare in men. As a result of being confined to the breast ducts, a diagnosis of DCIS has a very good outlook.

What are the symptoms of DCIS?

DCIS often has no accompanying symptoms and it is usually identified on a mammogram. The image of the breast appears as though it has irregular microcalcifications. However, some people may notice a change in the breast such as a lump, discharge from the nipple or more rarely, a type of rash involving the nipple (called Paget’s disease)

How is DCIS diagnosed?

If the radiologist who read your mammogram suspects you have DCIS, he or she will arrange for you to have a mammographically guided (stereotactic) biopsy. The biopsy can often be done the same day, you will be given an idea of the most likely diagnosis and the biopsy report will follow within a few days.

What is the treatment for DCIS?

Local excision with radiation therapy. Most patients have great success rates having a wide local excision (lumpectomy or breast conserving treatment ) and radiation treatment.
Mastectomy. Some women have more extensive DCIS occupying several ducts or quadrants of the breast (known as extensive DCIS), or the noninvasive breast cancer is found at several areas throughout the breast, known as multicentric breast disease. For women with this presentation of the cancer, their physician may recommend a mastectomy may be the more appropriate surgical treatment instead of a lumpectomy. This would generally be accompanied with a lymph node biopsy from the armpit at the same time and is unlikely to require any additional radiotherapy afterwards. Mastectomy can often be accompanied by immediate breast reconstruction should this be required.
Chemotherapy. Chemotherapy is not needed for DCIS, since the disease is noninvasive.
Hormonal Therapy. Hormonal therapy is only occasionally recommended as part of a clinical trial if the DCIS has a prognostic factor of being hormone receptor positive.

What is the prognosis for DCIS?

Women with DCIS have an excellent prognosis. By treating DCIS in a specialist centre you ensure your health is in the best possible hands.

It is important to maintain a rigorous screening schedule to monitor for local recurrence in the original breast and to monitor the opposite healthy breast. By definition, there is no risk of distant recurrence since the cancer is noninvasive.

Invasive Ductal Carcinoma (IDC)

Invasive ductal carcinoma (IDC), also known as infiltrating ductal carcinoma, is cancer that began growing in the duct and has invaded the fatty tissue of the breast outside of the duct. IDC is the most common form of breast cancer, representing 80 percent of all breast cancer diagnoses.

What are the symptoms of invasive ductal carcinoma?

As with any breast cancer, there may be no signs or symptoms. A mammogram may reveal a suspicious mass, which will lead to further testing. A woman may also find a lump or mass during a breast self-exam. The following are possible signs of breast cancer and should immediately be reported to your physician for further evaluation:

• Lump in the breast
• Thickening of the breast skin
• Rash or redness of the breast
• Swelling in one breast
• New pain in one breast
• Dimpling around the nipple or on the breast skin
• Nipple pain or the nipple turning inward
• Nipple discharge
• Lumps in the underarm area
• Changes in the appearance of the nipple or breast that are different from the normal monthly changes a woman experiences

How is invasive ductal carcinoma diagnosed?

We know how quickly patients want results from a biopsy or scan if there is a suspicion of breast cancer. We follow strict guidelines for biopsies and pathology reports. Most of our patients will receive the probability of cancer immediately following their biopsy procedure and a pathology confirmation within 48 hours.

Steps of diagnosis include:

• Digital mammography
• Ultrasound
• MRI
• Staging workup
• Biopsy
• Pathology

What is the treatment for invasive ductal carcinoma?

Treatment for all types of IDC is determined by the exact type of cancer and staging. Depending on the size and spread of the tumour(s), most women will undergo a combination of any of the following treatments:

• Lumpectomy (Wide Local Excision)
• Mastectomy
• Sentinel node biopsy
• Axillary node dissection
• Breast reconstruction
• Radiation
• Chemotherapy
• Hormonal therapy
• Biologic targeted therapy

What is the prognosis for invasive ductal carcinoma?

Based on individual markers and prognostic factors, including the staging of your tumor, your physician will work to give you a prognosis. Miss Mullan and her team of breast cancer specialistsare dedicated to developing cutting-edge techniques for surgery, breast reconstruction, chemotherapy, biologic targeted therapy, radiation therapy and other hormonal therapies. Our research allows us to make great strides forward for patients with breast cancer.

Additional types of invasive ductal carcinoma:

There are four types of invasive ductal carcinoma that are less common:

Medullary Carcinoma – This type of cancer is rare and only three to five percent of breast cancers are diagnosed as medullary ductal carcinoma. The tumor usually shows up on a mammogram and it does not always feel like a lump; rather it can feel like a spongy change of breast tissue.
Mucinous Carcinoma – This occurs when cancer cells within the breast produce mucous, which also contains breast cancer cells, and the cells and mucous combine to form a tumor. Pure mucinous ductal carcinoma carries a better prognosis than more common types of IDCs
Papillary Carcinoma – This cancer looks like tiny fingers under the microscope. It is only in rare cases that this kind of cancer becomes invasive. Common among women age 50 and older, this kind of cancer is treated like DCIS, despite being an invasive cancer.
Tubular Carcinoma – This is a rare diagnosis of IDC, making up only two percent of diagnoses of breast cancer. Tubular ductal carcinoma is more common in women older than 50 and are usually small, estrogen-receptor positive cancers, which means they respond to hormones. The name comes from how the cancer looks under the microscope; like hundreds of tiny tubes.

Invasive Lobular Carcinoma (ILC)

Invasive Lobular Carcinoma (ILC), also known as infiltrating lobular carcinoma, is the second most common form of breast cancer diagnosed in the United States, representing 10-15 percent of diagnosed invasive breast cancers. This type of cancer is more difficult to see on imaging because of the way it grows with spreading branches.

How is invasive lobular carcinoma (ILC) diagnosed?

Miss Mullan and her team of breast specialists understand how quickly patients want results from a biopsy or scan if there is a suspicion of breast cancer, so we follow strict guidelines for biopsies and pathology reports. Patients are told the probability of cancer immediately following their biopsy procedure, and receive pathology confirmation within 48 hours.

Steps of diagnosis include:

• Digital mammography
• Ultrasound
• MRI
• Staging workup
• Biopsy
• Pathology

What is the treatment for invasive lobular carcinoma?

Women with a diagnosis of ILC must choose their surgeon carefully. For any breast cancer surgery to be a success, it’s important that the cancerous area is surrounded by clear margins. The branch-like growth pattern of ILC makes this difficult. To be sure cancer the cancer has been removed, the surgeon must clear the cancer from the tissue all the way around the tumor, including any growth that may not be evident on imaging. In some cases, re-excision is necessary.

ILC is treated with a lumpectomy or mastectomy, depending on the size and location of the tumor. In addition, your medical oncologist and radiation oncologist may recommend chemotherapy and/or radiation, hormonal therapy or biologic targeted therapy.

What is the prognosis for invasive lobular carcinoma?

Based on individual markers and prognostic factors including the staging of your tumor, your physician will provide you with information about your prognosis. Early stage breast cancers carry a higher survival rate than advanced stages.

Lobular Carcinoma in situ (LCIS)

While lobular carcinoma in situ (LCIS) sounds like a type of breast cancer, it is really a risk factor or marker for an increased risk of developing breast cancer.

What can I do if I have LCIS cells in my breast?

First, there is no need to panic. LCIS simply means that we have identified that you may be at higher risk for developing breast cancer. The most important thing to do now is to contact Miss Mullan who will advise you whether any breast surgery needs to be performed or if you just need regular check-ups with annual mammograms.

Phyllodes Tumor

Phyllodes tumours are rare tumours that can be found in the breast. Most Phyllodes tumours are benign (non-cancerous). Only 1 in 10 Phyllodes will turn out to be malignant, and this makes up less than 1% of all breast cancers seen in the UK.

What are the symptoms of Phyllodes tumours?


Phyllodes usually present as a smooth lump beneath the skin. They are often fast growing so should be investigated promptly. They tend to occur in women in their 30s and 40s, but women of any age can have a Phyllodes. The breast may become red or warm to the touch. Symptoms can also mimic those of other types of breast cancer, but they can also be mistaken for fibroadenomas.

How is a Phyllodes diagnosed?

When you are seen by Miss Mullan, she will take a history from you, examine your breasts and obtain a mammogram and breast ultrasound. A needle core biopsy will be performed either by Miss Mullan in the Consulting Suites or by the Consultant Radiologist using ultrasound guidance. The biopsy results are usually ready within a week.

What is the treatment for Phyllodes tumours?


While the tumours are most often benign, it is still critical to remove the entire breast lump with a healthy margin of around 1cm of normal breast tissue. Even if one cell is left behind, it will grow back. Miss Mullan will perform a “lumpectomy” to remove the Phyllodes, usually as a day case operation under a general anaesthetic. You will not need any surgery to your armpit as Phyllodes tumours do not tend to spread anywhere else in the body.

What is the prognosis for Phyllodes tumours?


For women with a benign Phyllodes tumour, the outlook is excellent.

Women with malignant Phyllodes tumours, the prognosis depends on size, prognostic factors and other information obtained from the pathology results. Malignant Phyllodes tumours are different from the more common types of breast cancer. They do not respond to hormone therapy and are less likely than most breast cancers to respond to radiation therapy or the chemotherapy drugs normally used for breast cancer.

Miss Mullan will review your pathology report with you, following the Multidisciplinary Meeting, and advise you if you need any additional treatment. .

How do Phyllodes tumours affect your risk for breast cancer?

Having a benign Phyllodes tumour that’s not cancer does not affect your breast cancer risk, but you will be followed up by Miss Mullan in the outpatient clinic on an annual basis for a few years, as these tumours can come back after surgery. Miss Mullan may choose to also get some extra surveillance mammograms or ultrasound scans during this time, to keep an eye on your breast health.

Paget’s Disease

Paget’s disease is a rare type of breast cancer that occurs in the ducts adjacent to the nipple and areola and spreads to the skin of the nipple and the areola. Accounting for only one percent of breast cancers, it is a rare presentation.

Paget’s disease is usually associated with ductal carcinoma in situ (DCIS) and is limited to the nipple and areola area of the breast. It accounts for only one percent of all breast cancer cases.

What are the symptoms of Paget’s disease?

• Redness and irritation of the nipple and/or areola
• Crusting and scaling of the nipple area
• Bleeding from the nipple/areola
• Oozing from the nipple/areola
• Burning and/or itching of the nipple/areola

How is Paget’s disease diagnosed?

Most women can learn within 48 hours of being seen by our breast cancer specialists if they have breast cancer or not. We follow strict guidelines for biopsies and pathology reports. Our patients are given the probability of cancer immediately following their biopsy procedure, and receive a pathology confirmation usually within 48 hours.

Because of the skilled expertise of Miss Mullan we are able to accurately diagnose Paget’s disease. As with any cancer, early detection and diagnosis results in better outcomes for the patient. Despite the rarity of this type of breast cancer, the specialists at our Breast Center are experienced in managing the evaluation and treatment of this disease.

What is the treatment for Paget’s disease?

If the breast cancer is limited to Paget’s disease, treatment includes the surgical removal of the nipple and areola, as well as a margin of healthy tissue around the areola. This can usually be accomplished through lumpectomy, or mastectomy if preferred. Miss Mullan may recommend a combination of any of the following:

Lumpectomy – Due to the location of this cancer, some women will opt to have the nipple and areola removed along with a sufficient amount of tissue underneath to ensure removal of the cancer cells. This is known as a central lumpectomy. It is followed by radiation.
Mastectomy
• Radiation therapy
• Hormonal therapy


What is the prognosis for Paget’s disease?

If the biopsy shows DCIS, stage 0 cancer and no invasive cancer, the prognosis is excellent.



Treatments and Investigations

Breast Screening

Breast screening is carried out by the NHS Breast Screening Programme either at special clinics or mobile breast screening units. The procedure is carried out by female members of staff who take mammograms. You will get a letter within 14 days of your mammogram to say if your mammograms are ok, or if you need further assessment. If breast screening say you need to see a surgeon, Miss Mullan can see you as a priority.

About one in eight women in the UK are diagnosed with breast cancer during their lifetime. There's a good chance of recovery if it's detected in its early stages. Breast screening aims to find breast cancers early. It uses an X-ray test called a mammogram that can spot cancers when they are too small to see or feel.

Breast screening starts at 47 and goes up to 73. As the likelihood of getting breast cancer increases with age, all women who are aged 47-73 and registered with a GP are automatically invited for breast cancer screening every three years.

What happens during breast screening?

Breast screening is carried out at special clinics or mobile breast screening units. The procedure is carried out by female members of staff who take mammograms.

During screening, your breasts will be X-rayed one at a time. The breast is placed on the X-ray machine and gently but firmly compressed with a clear plate. Two X-rays are taken of each breast at different angles.

Miss Mullan operates on over 50 NHS breast screening patients per year and is fully breast screening trained.

Read more on the NHS pages here.

Mammography

What is a mammography?
A mammogram is a specialist X-ray of the breast. It uses low amounts of radiation and the risk to your health is small.

Benefits
The mammogram can detect small changes in breast tissue, which may indicate cancers that are too small to be felt either you or your doctor. It is able to show up areas of calcium which are not able to be felt.

The procedure
A mammogram is carried out by a radiographer who will position your breasts on the specially designed digital mammography machine. In order to obtain a good, clear picture the breast must be held tightly between two pieces of plastic. You may find the scan uncomfortable or painful as the breast tissue needs to be held firmly to ensure a good image is obtained, but this will only last a few seconds. Both front and side images of the breast are taken. Please do not use spray deodorant or talcum powder on the day of the mammogram, as this may affect the quality of the X-ray.

Results
Miss Mullan will usually be able to give you the results of your mammogram on the day of the One Stop Breast Clinic

Ultrasound

What is an ultrasound scan?
Ultrasound uses high frequency sound waves to create pictures of the inside of your breast. It can usually tell if a lump is liquid (a cyst) or solid. Ultrasound is our first investigation of choice for women under the age of 40 and is often also used in older women, along with mammograms.

Having an ultrasound
Having a breast ultrasound is not painful and you are not exposed to radiation. When you have a breast ultrasound scan you will be asked to lie on the bed. A clear gel will be applied to the breast, which helps the machine to make secure contact with the body. The consultant radiologist will then scan your breast to get a picture. Sometimes biopsies of an abnormal area in the breast are performed using the ultrasound machine to pinpoint the site of interest.

Biopsies

Core Needle Biopsy
This biopsy is undertaken either by Miss Mullan in the Consulting Suites or by one of the Consultant Radiologists in the XR Department once an abnormal area is identified within the breast. The breast is frozen with local anaesthetic and a sample of the breast tissue is taken using a small biopsy gun. The procedure is pain-free and does not leave any scars, although you may be a little bruised for a few days afterwards.

The results of the core biopsy are ready within one week. Miss Mullan is mindful of the fact that her patients want results as quickly as possible. However, strict protocols are in place for all breast specimens. Michelle makes sure all of her patients are discussed in the Multidisciplinary Team Meeting (of which she is Chair), where Consultant Radiologists and Pathologists are also present. She will give you an indication at the time of your initial consultation if she suspects breast cancer.

Breast Excision Diagnostic Biopsy

Occasionally, even after a core needle biopsy, a firm diagnosis of what is going on in the breast cannot be made by the Multidisciplinary Team. If this is the case, an excision biopsy (under general anaesthetic) is recommended to obtain more tissue for the Pathologists to analyse.

During this operation, an area of abnormal breast tissue or a lump is removed (excised) through the smallest and most appropriate incision. This is a day case procedure. The sample of breast tissue (usually less than 30g) is sent to the laboratory to be analysed. The results will be back within 2 weeks, and Miss Mullan will see you in the Consulting Suites following your operation.

Stereotactic or Guidewire Excision Biopsy

This type of excision biopsy is indicated when patients have an abnormality that is visible on a mammogram or ultrasound but cannot be felt in clinical examination.  To assist Miss Mullan, the site of the abnormality to be biopsied is marked by a Consultant Radiologist, with a guide-wire or skin marking (localisation), using either mammography or ultrasound. 


At the time of surgery, the wire is removed along with the abnormal area and a margin of normal breast tissue. The results will be back within 2 weeks, and Miss Mullan will see you in the Consulting Suites following your operation. 


Sentinel Node Biopsy

If you are having a breast cancer operation, you will have had your armpit (“axilla”) scanned on your initial visit. If this scan is clear of cancer, Miss Mullan will recommend a sentinel node biopsy of the axillary lymph nodes at the time of your breast cancer operation. This is a targeted operation to remove one or two sentinel lymph nodes. The sentinel node is found by injecting a radioactive isotope and blue dye into the breast .  If the sentinel node is clear, it usually means that the other nodes are free of cancer and removal of further lymph nodes under the arm is not be necessary.
 


Axillary Node Clearance

If your armpit scan shows that the breast cancer has moved up into the armpit, Miss Mullan will remove all your lymph nodes at the time of your breast surgery. This is called an axillary node clearance, and gives the Multidisciplinary team extra information about whether or not to recommend chemotherapy or radiotherapy to the armpit.

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