Prior to a clinical assessment, a detailed history should be obtained from the woman. This not only gives the clinician the information required to help make a diagnosis and assess her risk factors for developing breast cancer but also helps to relax the woman.

The details obtained should include:

It is also very important to note the woman’s presenting symptom, noting the duration of the symptom and whether it is cyclical in nature.

The environment in which the woman is examined is very important. A gown should be provided to ensure the woman’s dignity and the door should be locked to ensure privacy. If the examiner is a male, a chaperone should be present.

The clinical examination is divided into two parts:

A mammogram is a low-dose X-ray of the breast tissue. With modern techniques a dose of less than 1 mGy is used.

A full explanation should be given to the woman prior to the procedure. To obtain the mammogram, the breast has to be compressed between two plates while the exposure is made, which may be uncomfortable. Two views are normally obtained. The oblique view is taken across the breast lengthways, and the craniocaudal is looking at the breast from head to toe.

In women under 35 years old, the breast is relatively radiodense, so a mammogram is rarely indicated in women in this age group. If a woman over 35 years old has a palpable lump, a mammogram may be performed.

Ultrasound is a painless technique which uses high-frequency sound waves. The reflections are detected and turned into an image. A conductive jelly is placed on the breast, and a probe is used to scan the breast. Ultrasound is used if there is a palpable lump in a woman under the age of 35 years. It is also used as an aid to mammography, as it can differentiate between a cystic and a solid lesion.

Magnetic resonance imaging (MRI) scans and scintimammography are other radiological imaging procedures that can be used in addition to mammography. These are not routine investigations and are usually advised by the consultant radiologist.

This test is performed in the outpatient department. If there is a palpable lump, the clinician is able to perform a fine-needle aspiration (FNA). A full explanation is given to the patient prior to the test. The skin is cleaned and a fine needle (21 G or 23 G) attached to a 10-mL syringe is introduced into the skin. Suction is applied by withdrawing the plunger of the syringe. Several passes are made into the lump in different directions, to ensure a good sample is obtained from the lump. The plunger is then released and the needle is withdrawn. The material is then spread thinly onto slides and left to air dry, or is fixed with an alcohol fixative (depending on the cytologist’s preference). The cytologist then examines the slides under the microscope and a cytological diagnosis can be made (Button et al, 2004).

Results are usually given a numerical scoring (Table 21.1). The advantage of FNA is that, if a cancer is diagnosed, the woman and her family know prior to surgery what they are dealing with, and can make an informed choice.

If the cytology from the fine-needle aspiration is not conclusive, or if a histological diagnosis is required, a core biopsy can be taken.

This procedure can be performed in the outpatient department. A full explanation should be given to the patient prior to the procedure. If a biopsy gun is used, the patient should hear the sound made, as it can cause her to jump if she is not prepared. Local anaesthetic is injected into the breast, and once this has taken effect a small puncture is made by a scalpel blade over the site of the lump. The trocar is inserted through the puncture until the tip touches the tumour, and the central trocar is advanced into the mass. A core of tissue is obtained, inserted into a pot of formalin and sent to the histology department.

Pressure should be applied to the breast to help to prevent bruising, and a pressure dressing should be applied. Extra caution should be taken with patients on warfarin – their INR (international normalized ratio) needs to be checked prior to the procedure and extra pressure exerted afterwards.

If a breast cancer is diagnosed, the woman will need to have further investigations to assess if there has been any metastatic spread. These tests are usually performed as an outpatient at the time of diagnosis, and the appropriate treatment can then be planned. The following blood tests are usually performed:

If any of the above tests is abnormal, the following investigations can be arranged if appropriate.

The most common breast lump to be surgically removed is a fibroadenoma, which is a benign fibrous lump. They are most commonly found in women in the 15–30 year old age group, and account for approximately 13% of all palpable breast lumps (Dixon and Mansel, 2000).

Fat necrosis is usually caused by trauma to the breast, which causes fat cells to burst open. The body does not recognize these altered fat cells, and so reacts to them as if they were a foreign body. Intense scarring occurs, which feels like a firm irregular lump. The scar tissue then contracts, pulling on the Cooper’s ligament, causing skin dimpling. Thus, it mimics a cancer (Dixon and Sainsbury, 1993).

A microdochectomy (excision of a duct) is performed to excise an intraduct papilloma. Duct papillomas are ‘warty’-like growths within a duct. They can either be single or multiple. There is a very low malignant potential, if any (Dixon and Mansel, 2000). Microdochectomies are also performed to investigate a bloodstained discharge and to cure a chronic serous discharge.

Breast abscesses can occur in the non-lactational or lactational breast.