Senior Consultant, Surgical Oncology, Fortis Hospital, Noida
Part 3 of 9 in Diagnosis and Management of Breast Cancer
The Triple Assessment: Clinical, Radiological and Pathological Workup
November 17, 2024
Every breast lump is worked up through what is called the triple assessment: a clinical evaluation, a radiological evaluation, and a pathological evaluation, run in that order.
Clinical and radiological evaluation
History establishes when the lump appeared and how it has changed, and physical examination determines whether it is palpable or non-palpable. From there, imaging takes over. Mammography is graded using the BI-RADS classification, running from BI-RADS 0 through 6: 0 to 3 is benign, 4 is suspicious, 5 is highly suspicious of malignancy, and 6 is a confirmed malignancy. A speculated density on mammography is the classic appearance that raises suspicion.
When mammography is not enough
Ultrasound of the breast is used when the patient is young, when the breast tissue is dense, or when mammography is inconclusive. MRI of the breast comes in next, typically used in a post-operative setting or when mammography and ultrasound have not produced a clear answer. A PET-CT scan is reserved for after the diagnosis is already confirmed, used specifically to assess how far the disease has spread rather than to make the initial diagnosis.
This article is based on a Jivo Masterclass session conducted by Dr. Jalaj Baxi, Senior Consultant, Surgical Oncology, Fortis Hospital, Noida. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
Looking for a breast cancer consultation or a second opinion? Get in touch with the Jivo team
This guide is based on a live Jivo Masterclass: Dr. Jalaj Baxi taught doctors across Africa on November 17, 2024.
FROM THE LIVE Q&A
Moderator
How does surgery compare with radiotherapy for local control in advanced-stage breast cancer?
Dr. Jalaj Baxi
Radiotherapy is used only when surgery is not possible. If chemotherapy shrinks the tumor enough that surgery becomes feasible, surgery should be done. Radiotherapy has very few indications in advanced disease, so a direct comparison between the two is not really meaningful in this setting.
Frequently Asked Questions
What are the natural causes of breast cancer?▼
There is no true natural cause; the underlying event is always a gene mutation. About 80% of cases are sporadic mutations with no identifiable cause, while 10 to 15% are genetic or familial. Smoking, alcohol, and tobacco all contribute to mutation risk generally and should be avoided, though this applies to cancer as a whole rather than being specific to breast cancer.
On an evolutionary level, how does breast cancer differ between men and women?▼
There is no meaningful difference. The same hormone receptors, estrogen, progesterone, and HER2, apply in both male and female breast cancer, and treatment remains the same regardless of sex.
Is there a correlation between certain cosmetics, such as talc or lipstick, and the development of breast cancer?▼
Various myths and misconceptions exist around this, including the use of talc in the axilla. Some print media point to possible links, but there is no confirmatory or corroborative evidence for a connection between cosmetics and breast cancer.
A 65-year-old woman has metastatic breast cancer and mastectomy is not feasible; she is currently on chemotherapy. What chemotherapy regimens are appropriate?▼
The regimen depends on the tumor's biology, specifically its ER, PR, and HER2 status. Treatment is usually a combination approach built around anthracycline-based chemotherapy along with hormonal therapy where relevant, and HER2-targeted therapy is added when HER2 is positive. A typical course runs six to eight cycles, though HER2-directed therapy in HER2-positive disease can extend to around 18 to 20 cycles.
Can chemotherapy be combined with hormonal therapy, and what other management plans and success rates apply in metastatic disease?▼
Yes, combining chemotherapy with hormonal therapy is possible. Further management depends on how the patient responds to treatment. Roughly 30 to 35% of metastatic breast cancer patients respond well, and where the response is strong enough, it can become possible to address the metastatic sites and the primary tumor surgically as well.
What does the BI-RADS classification on a mammogram mean?▼
BI-RADS runs from 0 to 6: 0 to 3 is considered benign, 4 is suspicious, 5 is highly suspicious of malignancy, and 6 is a confirmed malignancy.
When is a PET-CT scan used in breast cancer workup?▼
Only after the diagnosis is already confirmed, specifically to assess how far the disease has spread, not as part of the initial diagnostic workup.
In This Series: Diagnosis and Management of Breast Cancer
- 1.Diagnosis and Management of Breast Cancer
- 2.How Breast Cancer Presents: Warning Signs Every Referring Doctor Should Know
- 3.The Triple Assessment: Clinical, Radiological and Pathological Workup
- 4.Biopsy Techniques and Receptor Testing in Breast Cancer
- 5.Staging Breast Cancer and How Tumor Biology Drives Treatment Sequencing
- 6.Breast Conservation Surgery vs Mastectomy: When Each Is Appropriate
- 7.Axillary Management: Lymph Node Dissection vs Sentinel Node Biopsy
- 8.Radiation Therapy After Breast Cancer Surgery: When It's Needed
- 9.Chemotherapy, Hormonal and Targeted Therapy: Regimens and Managing Metastatic Disease