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Triple assessment in a clinic is a normal way of investigation that you will have to undergo, if you have noticed any breast lump, or a different symptom such as discomfort or discharge. Triple assessment includes clinical assessment, radiology and cytopathology.
Your doctor will decide what particular tests are required depending on your presenting symptoms, the clinical findings and your age. Interpretation of triple assessment in a clinic-The triple test is positive if any of the three components is positive, and negative if all the components are negative.
As discussed above triple assessment includes :-
Clinical assessment: Here your doctor takes a detailed history of your symptoms and does a clinical examination of your breast. In history your doctor may ask you various questions like the time since the lump was first noticed, which breast is affected (one or both), changes in size, its association with nipple or skin problems, if associated with pain, its relation to menstrual cycle, patient age, family history and previous history of breast disease, menopausal status, parity (number of children and pregnancies), breast feeding and use of HRT (hormonal replacement therapy) or other hormonal medications are also needed. During examination you will be made to sit on a couch and examined for signs of asymmetry, skin or nipple changes and obvious lumps in your breast. You have to keep your hands at the sides and rose above the head. Whilst lying on the couch the breasts are then examined. The "normal" breast is examined first to determine the normal consistency and degree of "lumpiness". After this, the affected breast is examined and the presence, nature and site of any lumps or tenderness determined. Next the under arms called the axilla is examined for any signs of spread of cancer or infection. Similarly neck is also examined for the same reason. Finally, the abdomen (looking for liver enlargement), spine (for bony tenderness) and any other indicated body region are examined for signs that might suggest breast cancer.
Radiological assessment: This includes ultrasound of breast and mammogram. Which assessment you require will be decided by your doctor depending on your age. If you are <35 years then your doctor will mostly likely advice ultrasound of breast. If you are >35 years then you may need a mammogram. The technique of ultrasound is very simple and safe. A small quantity of gel is spread on your breast and a high frequency sound probe is moved over your breast. This generates images on a computer screen of the breast tissue which can be compared at a later date also. The lights in the room will be dimmed, so that the pictures on the screen can be seen more clearly. Limitations: The accuracy depends on the quality of the scanner and the operator's experience. It is also limited in its ability to diagnose non-cystic and non-solid breast problems such as fibrocystic change where there is diffuse glandularity and lumpiness throughout the breast. Mammogram is an x-ray picture of your breast. It is advised when your doctor suspects any cancer in your breast and also as a screening procedure if you are more than 35 years (Screening mammogram will be done once in every 1-2 years to detect any early changes in the breast when the family history for cancer is very strong). You are made to stand in front of an x-ray machine and your breast is placed in between two plastic plates. Image of one breast is taken at a time. You may feel uncomfortable as the plates press on your breast, but this helps to get a clear picture. On the day of the mammogram, do not use deodorant, perfume, powders, or ointments under your arms or on your breasts. These substances may hide the images. Also make sure you remove all jewelry from your neck and chest area. Limitations: the main limitation is you are exposed to radiation. Also rarely there may be a false positive alarm, which mean- alarm may be raised for just a non cancerous lump to be a cancer one. This raises your anxiety levels and also further investigations may become necessary.
If you are pregnant or you are breast feeding, then inform your radiologist as you are not supposed to undergo mammogram. If your condition demands mammogram to be done then your belly area will be covered and protected by a lead apron.
Cytopathology: Once the presence of a lump in the breast is confirmed by any of the above procedures it requires further evaluation to know the exact nature of the lump. This is done either by fine needle aspiration cytology (FNAC) or a biopsy. FNAC is a simple, safe and less traumatic diagnostic procedure5 which includes inserting a thin needle attached to a syringe through the skin into the abnormal area. Vacuum inside the syringe causes body fluid or tissue to be suctioned (aspirated) into the needle and syringe. It is then stained, and later examined under a microscope for the diagnosis. The procedure hardly takes 10 minutes. Local numbing drug may or may not be injected. Limitations: As only small samples of cells are taken for examination, the problematic cells may be missed, resulting in a false negative result. Also the cells taken may not enable a definitive diagnosis. If the lump is deeply situated then rarely an ultrasound may be required to first locate the lump and then do the aspiration. The results can be reported as benign, suspicious, malignant or inconclusive.
A biopsy is defined as a surgical procedure of taking a sample of tissue from the body in order to examine it more closely, mainly indicated when the results of FNAC are either malignant or inconclusive. Injection will be given to the area where the biopsy is planned to make it numb so that you do not feel any pain. For a core needle biopsy, a larger needle with a cutting tip is used to draw a column of tissue from the lump or the suspicious area of your breast.
The exact procedure is as follows:
A small nick is made in the skin and the doctor inserts the needle through this nick. At least three or sometimes more samples are taken from each breast mass to ensure an adequate sample. In most cases an imaging technique, such as ultrasound, may be used to help guide the needle into the desired tissue. Steri-Strips are used to close the small cut and a larger bandage is placed on top to protect the wound.10 This specimen is then sent to the pathology department for analysis. A core needle biopsy will provide information about the type of cancer present, whether or not it is invading surrounding tissue and whether or not it is likely to respond to hormonal treatment. This information, especially whether it is invasive, is of paramount importance in determining what type of surgical treatment should be performed.
You need not stay in the hospital overnight. The results of the biopsy will be given in 5-7 days.
Do's and Don'ts after triple assessment in a clinic:
Do not eat or drink anything for several hours before the procedure.
Wash your breast thoroughly before coming for the procedure.
Discomfort following FNAC and biopsy should be relieved by application of an ice-pack for short periods.
If dressing is placed after a core biopsy care of the dressing to keep it dry and clean is very important to prevent any infection.
Common things to expect at home:
If you have undergone mammography then you may have some pain as your breast was pressed with a plate during the procedure. This will settle after some time.
There may be bruising, pain and soreness after an FNAC/Biopsy procedure; it will subside in a few days.
Mammography - you may be exposed to radiation but it is of low energy.
FNAC - Bruising, pain and soreness may be felt. Rarely bleeding or infection at the site of aspiration may occur. If you are regularly taking blood thinning drugs like aspirin, clopidogrel etc. chances of bleeding are high, so discuss with your doctor before hand itself.
Biopsy - Bleeding, pain and infection are the main risk with biopsy.
The follow up visit depends on the result of the triple assessment. If the result is negative, then you need not come for a follow up visit very frequently but consult your doctor only if symptoms persist.
If the result is positive, then your visit depends on the investigations you have undergone. Usually ultrasound and mammogram report will be given on the same day to you. But the FNAC or biopsy report will be ready only after 5-7 days. So you need to visit your doctor after you collect these reports and discuss further line of management then. You can also ask your doctor if you have any queries.