Triple Assessment for Breast Cancer – All you need to know
With increasing awareness, most women are aware of the early signs of breast cancer – a mass or lump in breast. However, a palpable mass in the breast can be a benign or malignant lesion. Any breast lesion requires correct diagnosis, which is essential for optimal treatment planning. Any single test may not be accurate enough to make the right diagnosis for a breast lesion. The accuracy of diagnosis can be increased by using a multimodality test, such as the triple assessment.
In this article, we discuss every aspect of triple assessment for breast cancer that one should know.
What is triple assessment? What does it constitute?
Triple assessment is a combination of three diagnostic components to assess a patient presenting with a palpable breast lesion. It involves clinical (medical history and clinical examination), radiological (mammography and/or ultrasound), and pathological (fine needle aspiration cytology and/or core biopsy) evaluation of a breast lesion.
Triple assessment has a sensitivity of 99%; thus, has a low risk of missing a breast cancer diagnosis. The sensitivity of triple assessment is greater than any of the individual components alone.
Indications for triple assessment
Triple assessment is indicated in the following settings:
- significant breast cancer symptoms or signs identified at screening
- significant mammographic abnormality
- significant MRI abnormality in women at high risk
All patients with a suspected breast lump and other associated symptoms, should undergo triple assessment. According to the Association of Breast Surgeons, a non-operative breast cancer diagnosis should be achieved by triple assessment, wherever possible.
Benefits of triple assessment
The benefits of triple assessment include:
- Early and rapid detection of breast cancer
- Non-invasive, easily available, good accuracy rate
- Reduces requirement of unnecessary open biopsies
The sensitivity of triple assessment is 99.6%, which means that the test will detect cancer in 99.6% of women with breast cancer. The specificity of the triple test is 62%, which means that women who have no cancer will get a normal result in 62% of the cases.
How is triple assessment done?
The triple assessment involves three diagnostic components:
- medical history and clinical examination
- mammography and/or ultrasound
- fine needle aspiration cytology and/or core biopsy
These components are discussed in detail.
Patient history and clinical examination:
The following are noted while taking the relevant patient history:
- current medications
- recent changes in medications, particularly hormones such as the pill or hormone replacement therapy
- hormonal status and menstrual history
- previous breast problems
- risk factors like family history of breast /ovarian cancer
- previous or recent imaging or other breast investigations and their results
The history of the presenting symptom, with respect to its site (constant or changing) and duration (when and how it was first noted), changes since it was first noticed, relationship to menstrual cycles or exogenous hormones, and associated symptoms, are also recorded.
For clinical breast examination, the patient will be asked to remove all clothing from the upper half of the body. The doctor will observe the breasts for any visible changes while the patient is seated. After this, the patient will be asked to lie down, and a thorough physical examination of the whole breast area, including both breasts, nipples, armpits and up to the collarbone, is performed. The physical examination will help detect if there is any discrete lump or an area of textural change and determine the nature and site of the abnormality.
Radiological evaluation:
Radiological evaluation includes imaging tests to assess and find the cause of the breast symptoms, usually by using mammography and ultrasound.
Mammography:
In mammography, the breasts are examined using low dose x-ray. For the mammography, the patient will be asked to undress till the waist and stand in front of the mammography machine. A female x-ray expert (mammographer) will ask you to rest the breast on the x-ray machine. The breast is then gently and firmly compressed by a perspex plate in order to keep it still and get a clear and complete picture. Two or more images of each breast will be taken to view the breast tissue from different angles.
One must inform the mammographer if they are pregnant or think that they are pregnant, or if they have breast implants.
Ultrasound:
An ultrasound scan uses high-frequency sound waves to produce an image of the breast tissue. This method is painless and can be done usually in a few minutes. The patient will be asked to undress till the waist and lie down with arm above the head. A lubricating gel will be spread over the area of the breast. The expert will move a hand-held scanning probe (called a transducer) over the breast.
Ultrasound is usually preferred for women younger than 35 years and for pregnant or lactating women. It provides very accurate results when clinically guided or directed to an identified abnormality.
The radiological tests recommended depend on the woman’s age. Women older than 35 years are recommended to undergo both mammogram and ultrasound. For women younger than 35 years, first and ultrasound is performed, and if further information is needed, a mammogram is used.
Mammography and ultrasound are usually used in a complementary capacity in the evaluation of breast abnormalities due to their limitations. Their combination will correctly identify about 95% of breast cancers in symptomatic women. A small proportion of breast cancers, which will not be diagnosed on imaging alone, require clinical opinion to determine whether further testing such as biopsy is needed.
Pathological evaluation:
Pathological evaluation involves fine needle aspiration (FNA) cytology and core biopsy. Both have high specificity and sensitivity when used for palpable and impalpable breast lesions.
Fine needle aspiration biopsy:
In this test, a small sample of cells is drawn from a lump or any other abnormality, using a thing needle. This test rarely requires a local anaesthetic. If the lump cannot be felt easily, ultrasound or mammography may be used to guide the needle into the right area.
Core biopsy:
In this test, a very small cut is made in the woman’s skin under a local anaesthetic. Through the cut, several samples of tissue are removed from the lump using a spring-loaded core biopsy device. This test provides a piece of breast tissue instead of individual cells, making it easier for the pathologist to identify any changes.
FNA or core biopsy can be performed freehand by the breast surgeon. There are no absolute factors determining when FNA cytology or core biopsy is preferred over the other. When FNA cytology fails to correlate with imaging studies or clinical findings, core biopsy can be used.
How are the results interpreted?
A positive result on any component of the triple assessment indicates breast cancer; the likelihood of cancer increases if more than one component of the assessment is positive. This requires further investigation and a specialist referral.
A negative result on all the three components of the triple assessment suggests that breast cancer is unlikely and further investigation is not required. However, if the symptoms persist, or there are risk factors such as previous personal history or strong family history of breast cancer, or the woman is still concerned, a specialist opinion may be necessary.
What after the tests?
Most women do not show any signs of cancer in any components of the triple assessment. The small percentage of women who show possible signs of breast cancer in one or more of component of the test will be advised to undergo further investigations. These investigations may include excisional biopsies to obtain more information about the cancer. Based on the results of these investigations, the doctor will make a treatment plan. The patient may also be referred to a surgeon, who will study the case thoroughly and decide whether surgery is required; if yes, he/she will develop a surgical plan.
References:
- Jan M, Mattoo JA, Salroo NA, Ahangar S. Triple assessment in the diagnosis of breast cancer in Kashmir. Indian J Surg. 2010;72(2):97-103.
- The investigation of a new breast symptom a guide for General Practitioners. Australian Government Cancer Australia. https://www.canceraustralia.gov.au/sites/default/files/publications/ibs-investigation-of-new-breast-symptoms_50ac43dbc9a16.pdf. Accessed on 23rd March 2021.
- NHS Breast Screening Programme. Public Health England. https://associationofbreastsurgery.org.uk/media/1414/nhs-bsp-clinical-guidance-for-breast-cancer-screening-assessment.pdf.
- Breast Cancer: An Atlas of Investigation and Management. https://hemonc.mhmedical.com/content.aspx?bookid=2339§ionid=182113932.
- D Saispandana, C Sree Harsha, S V S Rao. Triple Assessment in Evaluation of Breast Lump. JMSCR Vol 08 Issue 01 Page 653-657 January 2020.
- D Yue, C Swinson, D Ravichandran. Triple assessment is not necessary in most young women referred with breast symptoms. Ann R Coll Surg Engl 2015; 97: 466–468
- M Jan, J A Mattoo, N A Salroo, S Ahangar. Triple assessment in the diagnosis of breast cancer in Kashmir. Indian J Surg (March–April 2010) 72:97–103
- Karim MO, Khan KA, Khan AJ, Javed A, Fazid S, Aslam MI. Triple Assessment of Breast Lump: Should We Perform Core Biopsy for Every Patient?. Cureus. 2020;12(3):e7479. Published 2020 Mar 30.
- Khoda L, Kapa B, Singh KG, Gojendra T, Singh LR, Sharma KL. Evaluation of modified triple test (clinical breast examination, ultrasonography, and fine-needle aspiration cytology) in the diagnosis of palpable breast lumps. J Med Soc 2015;29:26-30
- M Nigam, B Nigam. Triple Assessment of Breast – Gold Standard in Mass Screening for Breast Cancer Diagnosis. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861. Volume 7, Issue 3 (May.- Jun. 2013), PP 01-07
- Dr. Pragnya Chigurupati
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