This information indicates steps to be
taken in determining the risk that a presenting problem is breast
cancer. The individual patient history and circumstances (eg. a
very strong family history or previous personal history of breast
cancer) must be taken into account and may influence the investigative
process for any particular woman.
The NHMRC National Breast Cancer Centre* and the
RACGP have developed a guide to maximise the effectiveness of investigation
of women who present to their general practitioner seeking medical
advice with a new breast symptom.
These steps may be followed
before or after referral to a specialist breast surgeon or clinic,
and are a guide to appropriate practice subject to the medical practitioner’s
judgement of each individual case.
The critical issues for
the investigative pathways were identified as:
For women presenting with
a breast lump:
- The accuracy of the triple test (here defined as clinical examination,
mammography and fine needle aspiration cytology).
- The use of ultrasound in addition to mammography.
- The use of ultrasound as an alternative to mammography in younger
women.
For women presenting with
nipple discharge:
- The value of information about age, clinical features and cytology
in determining the probability of cancer.
- A triple test positive was found in 99.6% of breast cancers.
- Any positive result therefore requires specialist referral and
further investigation, with the likelihood of cancer increasing
if more than one component is positive.
- A triple test negative on all components provides good evidence
that cancer is unlikely (less than 1%) and further investigation
can be avoided for most of these women (if there are no other
high risk factors).
- Ultrasound has a lower false positive rate
and is more sensitive in younger women than mammography. Its use
as the preferred first imaging modality in women under 35 may
therefore avoid unnecessary further investigations.
- FNAB (Fine Needle Aspiration Biopsy) is highly
sensitive and specific for breast cancer. FNAB or core biopsy
should be performed by experienced operators, after clinical examination
and imaging, to confirm a diagnosis. This may eliminate the need
for open biopsy in some cases, or assist in the planning of surgery.
The source for the evidence and graphs used in this document is
the report to the The National Breast Cancer Centre* Evidence Relevant
to Guidelines for the Diagnosis of Symptomatic Women 1996 Prof.
Les Irwig
*
In February 2008, National Breast Cancer Centre (NBCC) changed its name to National Breast and Ovarian Cancer Centre (NBOCC).
›
›
