The doctor uses three modalities to assess the breast; this is called the triple assessment. By using all three modalities together there is a negligible chance of missing a cancer:

• Clinical examination

• Mammography and ultrasound

• Needle tissue biopsy: this can be either a fine needle aspiration cytology ('FNAC') or core biopsy

It is important to realise that in most cases it is not necessary for a women to undergo a general anaesthetic to determine whether the lump in her breast is a cancer or not. This is the important concept behind the triple assessment. Once a cancer has been diagnosed there is no harm in taking a few days to discuss the different treatment options. Waiting a day or two and participating in the discussions and understanding what the different treatment options are, will help ensure ultimate psychological, cosmetic and best cancer management.

Clinical examination

The doctor takes a history from the patient, asking questions pertaining to the breast. He/she asks about the family history, particularly with respect to breast cancer. Certain types of breast cancer have a direct genetic background. The doctor asks about:

• Breast lumps

• Nipple discharge

• Breast pain (mastalgia)

• Breast cancer family history - both on father's and mother's side

• Other cancers - family history of stomach, uterine, ovary prostate, colon and skin cancer

• Gynecological assessment - age when started menstruating (menarche) - age of first pregnancy, fertility treatment - breast feeding and length of time of this feeding - length of time on oral contraceptive pill (OCP) - age of menopause - length of time on hormone replacement therapy ('HRT')

• Menstrual history

• General state of health.

Now the doctor does the examination. The routine here is much the same as for self-examination of the breast (see chapter 3).

The important points are:

• The entire upper torso must be exposed, from the umbilicus (belly button) to the head. The breast cannot be adequately examined with the bra being pulled up sequentially as each breast is checked. The bra must be removed.

• The doctor looks at the breast from the front, checking for differences in size, symmetry, contour, lumps, ulcers, puckering etc. (see Figs 3.5a-f).

• Now the doctor palpates the breast, always starting with the normal side. He or she will use the volar or palmar surface of the flat hand (four fingers), gently compressing the breast tissue between the hand and the chest wall (ribs). A circular hand movement is often employed.

• He or she will examine all four breast quadrants, the nipple/areolar complex, the axillary tail, the axilla itself and the supra clavicular fossa (the region above the collar bone).

• All the features described in chapter 3 are looked for. If a lump is found, is it tethered to the skin or fixed to the pectoralis major fascia? Is the lump pulling on the breast ducts, thus causing inversion or retraction of the nipple? Is there a nipple discharge when "milking" the breast towards the nipple?

• The axillae are examined with the shoulder girdle being completely relaxed (the doctor may place the patients hand on his shoulder or use any other position which relaxes the patient). The patient must allow her elbow to hang downwards; this relaxes the shoulder girdle muscles, allowing the doctor to get deep into the axilla and to check all five axillary nodal regions, particularly the central and apical nodes. The left axilla is examined with the doctor's right hand and vice versa.

• The doctor now will do a systemic examination, making sure that there are no other potential medical problems or that the cancer has not spread elsewhere. This helps guide the doctor as to which modality of treatment is the correct one to use. It is important to remember that breast cancer is one of the few cancers that medical treatment can help, irrespective of when the patients presents for treatment and that there are patients surviving for over 10 years with more advanced cancers.

All ladies that present with breast problems should be sent for radiological investigations (mammography/ultrasound).