Information for breast care patients

Your specialist will decide the appropriate scan after taking a short history and performing a clinical examination.

• Mammogram: Mammogram is the standard method of imaging for patients above the age of 40 and involves using Xrays to image the breast. We use digital mammography and usually take two views of each breast (vertical and oblique). Please inform us if you had a mammogram within the last 12 months. You may not need a mammogram if you had one in the last year. The advantage of mammograms is that they can check the whole of both breasts and allow the radiologist to compare left with right as well as comparing with previous mammograms. 
• Ultrasound scan: Ultrasound scan (gel scan): your specialist might decide that you need an ultrasound scan. This will be performed by one of our experienced radiologists or radiographers. The advantage of ultrasound is that it can be used in younger patients and to check an area of concern in detail. It can sometimes detect abnormalities that do not show up on mammogram. 
• MRI: Magnetic resonance imaging (MRI) is only used in certain circumstances, such as when a patient diagnosed with invasive lobular breast cancer is considering breast conserving surgery or when a breast cancer does not show up well on mammogram or ultrasound. The consultant radiologist will advise as to whether a MRI is required. MRI is very sensitive and frequently identifies areas of the breast that require further investigation such as “second-look ultrasound” or further biopsies. 
• CT scan: Computerised tomography (CT) scans are rarely used in the initial diagnosis of breast cancer but sometimes a patient has a CT scan for another reason which detects an abnormality in the breast incidentally. In these cases, the doctor who organised the scan may refer the patient to Breast Care for clinical examination and mammograms or ultrasound scan as necessary. A CT scan is sometimes useful after breast cancer has been diagnosed to look for any breast cancer deposits (metastases) elsewhere in the body. This is usually requested on the advice of the oncologists. 

A biopsy is when a sample of cells or tissue is taken so that it can be examined under the microscope by the pathologist. The majority of breast lumps are benign (not cancers). Taking a biopsy is sometimes very important to confirm the diagnosis. 

If you need a biopsy, this will be explained to you. Once you had the biopsy performed, you will receive a leaflet about post biopsy care. We will give a further appointment to receive your biopsy results. This will be usually in a week. 

There are four sorts of biopsies that are carried out in Breast Care: fine needle aspiration cytology, core biopsy, skin punch biopsy and vacuum biopsy. All medical procedures can result in complications and we take steps to minimise the risks. The commonest complication after a biopsy is bleeding, which may result in a haematoma, so if you have a clotting disorder (such as haemophilia) or take anything that thins your blood (for example, warfarin, aspirin or clopidogrel) you should tell us. Most people will get some bruising after their biopsy. 

• Fine needle aspiration cytology: Fine needle aspiration cytology is where a needle and syringe are inserted into the area of concern and a sample of cells are taken. These are then sent to the pathologist to be examined under the microscope. 
• Core biopsy: Core biopsy is a procedure where an injection of local anaesthetic is used to numb the skin before a needle is introduced through a small cut in the skin. Once the needle is in the area of concern, the biopsy is taken – there is a loud click as this is being done as the biopsy needle is spring-loaded. Several core biopsies may need to be taken to get a representative sample. These are then sent to the pathologist to be examined under the microscope. 
• Skin punch biopsy: Skin punch biopsy is used when the area of concern is on the skin of the breast rather than the underlying breast tissue. This biopsy is done after an injection of local anaesthetic to numb the skin. A small circle of skin is then removed and is sent to the pathologist to be examined under the microscope. 
• Vacuum biopsy: This biopsy is rarely done on the first visit – it is usually done when an initial biopsy has not produced enough tissue for the pathologist to make the diagnosis. Sometimes vacuum biopsy can be used to remove small abnormalities completely. All the tissue removed is then sent to the pathologist to be examined under the microscope. 

The words used in breast cancer treatment are often unfamiliar at first and this page is intended to clarify what some of the terms we use mean to you. 

Once you have been diagnosed with breast cancer, you will be offered treatment. There are a number of different ways of treating breast cancer and most people will be offered a combination of treatments. For example, you may be offered surgery, followed by chemotherapy. Your treatment plan will depend on the features of your cancer (such as size of the cancer, microscopic appearances on biopsy, lymph node involvement); whether you are fit to undergo a particular treatment and your preferences (such as whether you want to have a mastectomy with breast reconstruction). 

In common with most breast cancer units in the UK, any significant treatment recommendations for you will have been discussed in a meeting of the multi-disciplinary team (MDT). As a minimum, this team consists of a specialist breast oncologist, surgeon, radiologist and pathologist, meeting twice weekly. In practice, the MDT meeting usually includes several representatives from each discipline, along with a co-ordinator, unit manager, breast care nurses and advanced nurse practitioners as well as doctors in training and medical students. In your next clinic appointment after the meeting, your treatment plan or options will be discussed with you. Many people find it helpful to bring a friend or family member to your clinic appointments. As sometimes there is a lot of information to take on board, one of the breast care nurses will usually be present in the consultation and afterards will make sure you have any written information you need to take away. 

Breast cancer surgery 

Most people who are diagnosed with breast cancer will  be offered surgery as part of their treatment. If you are offered surgery, there are two main considerations: what surgery you wish to undergo to remove the cancer from the breast and what surgery is needed to the lymph nodes in your armpit (the armpit is also called the “axilla”, and hence surgeons talk about “axillary surgery”). 

Breast surgery 

Breast surgery to remove the cancer falls into two main groups: mastectomy (removing the whole breast) and breast conserving surgery (BCS, wide local excision (WLE), therapeutic mammoplasty, “lumpectomy”) in which the cancer is removed from the breast. If you have a mastectomy, breast reconstruction may be an option for you. Your surgeon and breast care nurse will be able to discuss your surgical options with you. 

Axillary surgery 

Axillary surgery has changed in recent years – but in general we need to remove some lymph nodes from your armpit at the same time as your breast surgery so that the pathologist can look at them under the microscope and find out whether any cells from your breast cancer have spread to the lymph nodes in your armpit. This is important to know as it can affect what treatments you need after your surgery (eg chemotherapy). The commonest axillary surgery is sentinel lymph node biopsy (SLNB) in which between one and four lymph nodes are removed from your armpit and sent to the pathologist to look at under the microscope. If you are found to have significant deposits of breast cancer cells in those nodes, you may be advised to come back for further surgery, which would be axillary node clearance (ANC). If you are already known to have cancer deposits in your armpit before your surgery (eg from a needle biopsy), you may be advised to have axillary node clearance (rather than sentinel lymph node biopsy) at the same time as your breast surgery. 

The nurse-led seroma clinic takes place twice a week in the Breast Care Centre. The clinics are normally Tuesday and Friday afternoons 2-4pm. Patients should refer themselves to the clinic if they feel they have a seroma  

following breast surgery. To arrange an appointment the telephone number is 0116 2583341 or 0116 2583735.

The nurse-led lymphoedema clinic takes place in the Breast Care Centre at Glenfield Hospital once a week. 

The Breast Care Nurses have undergone additional training in the management of lymphoedema. The service offers assessment and treatment plan on an individual basis in line with The British Lymphology Society guidelines. The service will accept referrals from GPs and Consultant Breast Surgeons / Oncologists for patients who have developed mild to moderate, uncomplicated lymphoedema of the arm as a result of breast cancer treatment. 

 Complementary therapies (dropdown) 

Complementary therapies used alongside conventional cancer treatments may help you with the emotional and physical effects of breast cancer and its treatments, for example: 
 

• Acupuncture     
• Aromatherapy
• Art therapy 
• Herbal medicine 
• Counselling 
• Homeopathy 
• Hypnotherapy 
• Massage 
• Mindfulness 
• Reflexology 
• Reiki 
• Shiatsu and acupressure 
• Yoga, Tai Chi and Chi Gung 

However, it is very important that before you commence any complementary therapy, you must speak to your Surgeon, Oncologist, Breast Care Nurse (Key-Worker), Chemotherapy Nurse or GP beforehand, to check whether it is compatible with your treatment. 
Some complementary therapies may interact with your breast cancer treatment. You will be advised to avoid certain complementary therapies if the way in which your breast cancer treatment works could be affected. This is because your cancer treatment may become less effective or the side effects of the cancer treatment may be increased. This is particularly the case with some herbs and dietary supplements. 

Coping with Cancer provide some complementary therapies free of charge for cancer patients and their families in Leicestershire and Rutland. You can refer yourself or ask your Breast Care Nurse (Key-Worker) to refer you. 

Coping with Cancer is open: Monday to Friday, 8:30am to 4:30pm. 
Tel: 0116 2230055  Email: [email protected]  Website: www.c-w-c.org.uk 

The Haven provides support, information and complementary therapies for anyone affected by breast cancer. Its services are free of charge and they are located in London, Hereford, Yorkshire, Wessex and Worcestershire, but anyone can attend as there are no geographical restrictions. You can refer yourself or ask your Breast Care Nurse (Key-Worker) to refer you. 
Tel: 02073840099  Email: [email protected]  Website: www.thehaven.org.uk 

For more information on complementary therapies, please refer to: 

• www.breastcancercare.org.uk 
• www.cancerresearchuk.org 
• www.macmillan.org.uk 

The checklist below was kindly written by a patient, to help future patients with coming into hospital and leaving for home. The patient expressed:

“A few days before the operation, being slightly anxious, I found that I had forgotten some of the information and couldn’t remember where I had read it”.
  
DO 
□ Take all medication into hospital 
□ Check at pre-op which of your usual medications to take on morning of surgery 
□ Toiletries 
□ Towel 
□ Dressing gown with pockets 
□ Nightwear (loose fitting, preferably that buttons at the front) 
□ Pair of slippers/flip flops/shoes 
□ Small change for newspapers etc 
□ Possibly credit card for TV 
□ Something to read or a puzzle book 
□ Label glasses, hearing aids 
□ Wear clothing that doesn’t need to go over your head (may be difficult after surgery) 
□ If you have cotton pants you can wear your own during operation 
□ Mobile phone (but on silent so as not to disturb other patients) 
□ If having a marker on day of surgery, maybe worthwhile wearing a vest as it is difficult to put your bra on 
□ Bras: sports bras can be comfortable after operation (but not underwired), or soft bra with no lace 
□ Get measured for a bra before going into hospital to get the right fitting 
□ Bra extenders can be useful for after surgery 
□ Wedding ring can be worn but will be taped during the operation 
□ Let staff know any special diet requirements 
□ Write any questions down that you have forgotten to ask at the pre-op (you will be able to ask the consultant on the day) 
□ Check the visiting policy 
□ Shower 2 days before the operation and on the morning with the anti-bacterial soap to reduce the risk of MRSA (provided at the pre-op) 
□ Apply the antibacterial nasal ointment two days before and on the morning of the operation to reduce the risk of MRSA 

DON’T 
□ Don’t shave under the arms for a week before the operation 
□ Avoid deodorant, talcum powder or body lotion on the morning of surgery (best to avoid these after surgery until the wounds have healed) 
□ Don’t take valuables into the hospital (wedding ring allowed) 
□ Don’t eat or drink after 12 midnight before the operation 
□ Don’t wear nail varnish on day of operation 
□ Don’t wear makeup on day of operation 
□ Don’t wear any jewellery (other than wedding ring) or any piercings during the operation 
□ False teeth may have to be removed during the operation, you will be asked if any of your teeth are crowned 
□ Don’t chew gum after 12 midnight before the operation 

The UK Medicines and Healthcare products Regulatory Agency (MHRA) published a statement regarding breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) in July 2017. This is a condition which can arise in people who have breast implants, whether for breast reconstruction following mastectomy or for cosmetic breast augmentation. The condition is rare and as it has only been recognised in the past few years, work is currently being carried out to learn more about it. 

The MHRA advise patients that: 

“The most common symptom for ALCL in women with breast implants is a seroma (a collection of fluid) that forms around the breast implant six months or more after the breast implant surgery. 

Most cases have happened years after surgery. Very rarely it has been found when a lump develops next to the implant or within the tough fibrous tissue building up around the implant (known as capsular contracture). 

ALCL is very rare but it is important healthcare professionals and women who have implants know about it. If you develop a seroma, a breast lump or swelling around your implant more than six months after having the breast implant (regardless of how many years later), you should seek advice from your surgeon or clinic. 

If the surgeon or clinic which did the original implant operation is no longer available then the patient should see their GP for referral to another surgeon. 

As with any implant it is important anyone undergoing breast implant surgery discusses the risks and benefits with their surgeon. 

If you have had an issue with a breast implant you should report it via the Yellow Card Scheme so we can investigate further.” 

In response to the Department of Health’s “Review of the Regulation of Cosmetic Interventions“, known as the “Keogh Report”, NHS Digital launched the Breast & Cosmetic Implant Registry in October 2016.

The intention is that if in the future, there are safety concerns or product recalls relating to breast implants, such as occurred with PIP implants, the patients involved can be traced and contacted promptly.

Magseed is designed to replace the guidewire system that we use currently. It enables the surgeon to locate and remove cancers that are too small to feel. Approximately 1/3rd of breast cancers are diagnosed (eg by routine screening mammograms) when they are still too small to feel. Currently on the morning of surgery, the patients are sent from the ward down to the breast care unit and have a guidewire inserted into the cancer under ultrasound or Xray guidance. The wire is then coiled up under a dressing and the patient goes back to the ward and waits for their operation. The guidewire has to be placed on the day of surgery because it can become dislodged if it is left too long. It is not pleasant for the patients to have a wire sticking out of their breast, even if only for a short time pre-operatively. If Magseed is placed before the day of surgery, the patient may be scheduled first on the operating list and so be more likely to be discharged home on the same day.  
 
The Magseed is about the size of a grain of rice and made of surgical grade steel and sterilised. It can be injected into the breast by the radiologists under either ultrasound or Xray guidance up to 30 days before the patient’s breast cancer operation. In the operation the surgeon uses a handheld probe called Sentimag to find the location of the Magseed in the breast. Sentimag works like a metal detector but the technology inside is actually more like a handheld MRI machine. From the skin surface, the surgeon can detect the location of the Magseed in the cancer and then plan the incision and operation accurately. This is an improvement on the wire because although it is obvious where the guidewire enters the breast, the entry point can be quite a way from the cancer itself. With Magseed we can remove the cancer just as effectively as we do with a guidewire but with less dissection to access the right area, we are causing a smaller “injury” and so we hope the patients recover better as a result.  
 
Just as importantly there are some knock-on benefits to other patients – currently we see most of our new referrals (eg patients referred by their GP with a lump) in the morning “one-stop” breast clinic. We have limited equipment, radiology manpower and space so the wires are placed first and only after that can the radiologists start seeing the new patients and doing their mammograms, ultrasound scans and biopsies. If Magseeds are placed a few days before surgery, the radiologists will be able to start seeing the new patients earlier and reduce the time each new patient spends in the department waiting to have their tests. 
 
This is a pilot study and we have been given approval by the UHL NIPAG committee for a pilot of 10 Magseeds, which have been donated by the suppliers, Sysmex UK and EndoMag. The pilot is being led by two Consultant Oncoplastic Breast Surgeons, Mr Simon Pilgrim & Miss Monika Kaushik alongside two of our specialist breast Consultant Radiologists, Dr Moin Hoosein and Dr Miaad Al-Attar, but has involved considerable help from colleagues of all disciplines in Breast Care and Glenfield operating theatres. I am especially grateful to those patients who have helped to draft our patient information as well as the patients who have volunteered to take part in the pilot. As of 15/2/18, we have used 6 Magseeds successfully. More than half of the breast surgeons have been to theatre to see the system in action and we have even had interest from our thoracic surgical colleagues with ideas for potential applications in lung cancer treatment. Although the cost of each Magseed is more expensive than a guidewire, we think the improved patient experience and the improvements to efficiency in clinic and theatre will offset this to a large extent. Once the pilot is complete we hope to submit a business case to use Magseed routinely instead of the wires. Wires will still need to be used in some patients, for example those with pacemakers as the magnetic field of the Sentimag probe could interfere with the functioning of the pacemaker unit. 
 
As a unit we are constantly working to try to improve our outcomes but it is just as important to improve the experience of our patients while they are being treated. We don’t think Magseed will improve breast cancer outcomes or survival. We believe Magseed will improve the patient experience for those patients who would otherwise be having a wire as well as the patients who attend the one-stop clinic which will run better as a consequence. The breast ward at Glenfield already scores the highest of any ward in the hospital for patient satisfaction (100% scores for 15 consecutive months) but we still want to do better. 
 
There are likely to be some interesting developments in breast cancer treatment in the next one or two years, particularly in reducing the number of lymph nodes we need to remove from the axilla (armpit) as part of breast cancer surgery after chemotherapy. Subject to licensing approvals, we already have some ideas as to how Magseed could be used in this setting as well.