MANAGEMENT OF BREAST DISEASE
Guidelines for SHOs and HOs1. Indications for Mammograms:
:::::::: a) Symptomatic patients above the age of 35;
:::::::: b) Previous breast cancer;
:::::::: c) Screening for patients between 50 and 65;
2. Indications for USS of the breast:
:::::::: a) Symptomatic patients below the age of 35;
:::::::: b) Palpable abnormalities in pregnant women;
:::::::: c) As an adjunct to mammography to differentiate between solid and cystic;
:::::::: d) Lumps and for further evaluation of indeterminate lumps;
3. Triple assessment (Clinical examination, imaging, cyto/histology):
:::::::: a) All symptomatic patients above the age of 35;
:::::::: b) Under 35 all patients with fibroadenomas;
4. Breast pain (Mammograms if above 35 yrs old):
:::::::: a) Cyclical
::::::::::::::::::::: Efamast 4 capsules bd for 6 months
::::::::::::::::::::: Second line* – Danazol 200mg daily for three months
::::::::::::::::::::: Third line*-Bromocriptine 2.5mg bd for three months;
::::::::::::::::::::: Fourth line*-Tamoxifen 20mg daily for three months;
::::::::::::::::::::: Additional measures- use of correctly fitting bra;
:::::::: b) Non-Cyclical
::::::::::::::::::::: NSAIDs – for musculoskeletal pain/Teitze syndrome
::::::::::::::::::::: Firm correctly fitting bra worn 24 hours a day;
::::::::::::::::::::: Well localised pain – local anaesthetic with steroid;
5. Nipple discharge (Mammograms for >35 and USS for <35):
:::::::: a) Clear/green;
::::::::::::::::::::: Reassure;
::::::::::::::::::::: Efamast if associated with pain or nodularity;
:::::::: b) Blood – stained;
::::::::::::::::::::: Microdochectomy for single duct discharge;
::::::::::::::::::::: Excision of ducts for multiple duct discharge*
6. Breast lumps:
:::::::: a) Diffuse nodularity;
::::::::::::::::::::: Reassure;
:::::::: b) Focal nodularity;
::::::::::::::::::::: Triple assessment;
::::::::::::::::::::: Excision biopsy if any modality of triple assessment indeterminate or suspicious;
:::::::: c) Cysts;
::::::::::::::::::::: Multiple-Efamast;
::::::::::::::::::::: Single-aspirate and reassess at 6-8 weeks;
::::::::::::::::::::: Repeat aspiration if recurs;
::::::::::::::::::::: If still recurs then excise;
::::::::::::::::::::: If residual thickening after aspiration – excise;
:::::::: d) Fibroadenoma;
::::::::::::::::::::: Age <25 and no family history – reassure and reassess at 6 months if increases in size at follow up – ::::::::::::::::::::: excise;
::::::::::::::::::::: Age>25 advise excision if not palpable easily needs USS marking on day of surgery*
:::::::: e) Indeterminate Lumps:
::::::::::::::::::::: Cyto C3-core biopsy, image guided if necessary;
::::::::::::::::::::: Cyto C4-excision biopsy even if core biopsy benign;
:::::::: f) Malignant lumps:
::::::::::::::::::::: Invasive cancer - </= 4cm WLE + Axillary clearance (if under 65 or palpable
::::::::::::::::::::: disease in the axilla);
::::::::::::::::::::: Invasive cancer - > 4cm Mastectomy +Axillary clearance (if under 65 or palpable disease in the ::::::::::::::::::::: axilla)*
7. Re-excision:
:::::::: a) DCIS- if DCIS alone then involvement of margins or if within 4mm of margin advise re-excision*
:::::::: b) Invasive disease involving margins or within 5mm of margin*
:::::::: c) Imphatics does not need re-excision as long as the invasive tumour is adequately cleared as patient will be ::::::::::::::::::::: give radiotherapy;
8. Radiotherapy:
:::::::: a) All breast conserving cancer surgery except perhaps <1cm tubular or Grade 1 cancers*
:::::::: b) Mastectomy flaps if poor grade or multifocal disease especially in premenopausal patients;
9. Chemotherapy:
:::::::: a) All pre-menopausal patients who have;
::::::::::::::::::::: Systemic metastases;
::::::::::::::::::::: Positive nodes;
::::::::::::::::::::: Poor grade (III) tumour;
::::::::::::::::::::: Large tumour (>4cm);
::::::::::::::::::::: Lymphatic or vascular invasion;
::::::::::::::::::::: Multifocal tumours;
10. Anti-oestrogens:
::::::::::::::::::::: All post-menopausal patients;
::::::::::::::::::::: Premenopausal patients who are ER positive;
::::::::::::::::::::: Recurrent disease*
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