Breast Care Service

If you have been referred to the Breast Clinic by your GP, your first appointment will be in one of our New Patient Clinics.

At this appointment you will be seen and examined by one of the breast surgeons or by one of the junior doctors working in their team, helped by our team of clinic nurses who will help put you at ease during your visit and explain the clinic process. If needed, you will be offered appropriate imaging of your breasts, which will happen the same day. This is usually a mammogram and/or an ultrasound scan.

The mammogram/scans are reported while you wait and any tissue biopsy test that is needed can be performed at the same time. If you need a biopsy you will need to come back to clinic the following week for the results. In some cases we may be able to write to you with your results.

As there is a lot happening at these busy clinics it can often take a few hours to have all your examinations and investigations completed and reported, so please come prepared to be at the clinic for most of the morning. There is a drinks machine in the unit and a café in Noble’s providing hot drinks, snacks and sandwiches. If all your investigations are normal or show a benign (harmless) cause not needing a biopsy, you can often be discharged from the clinic on the same day.

If you need a biopsy that is guided by an MRI scan this will be arranged for a different date.

If you are diagnosed with breast cancer our caring and professional specialist breast cancer nurses will be with you every step of the way.

You will have a named Breast Care Nurse, who will be there to summarise your diagnosis and treatment plan again after your initial results appointment and make sure you understand everything that has been discussed.

You will receive a Breast Cancer Information Pack, where details of your diagnosis and treatment will be written down so that you can refer to them in the future should you wish. You will also be given a telephone number that you can ring if you have any questions or concerns regarding your treatment. If you call and your named Breast Care Nurse is not available, one of the other nurses in the team may be able to answer your question, or if not, they will take a message for your Breast Care Nurse to ring you back.

Your Breast Care Nurse will also be there when you receive your results, and will be able to go through the information your surgeon has told you again, either directly after the consultation or at a later date if you prefer. Even after your diagnosis and treatments are completed, you will still have access to breast care nursing support and we would encourage you to contact them with any questions or concerns that you have during your follow-up period.

Breast surgery and treatment can affect you dramatically, both physically and emotionally. Our nurses are here to help you to get the support you need to improve your health and start enjoying life again as soon as possible. Some of the services we offer include support, dressing clinic, breast reconstruction advice and prosthesis fitting.

Breast Prosthetic Service

We offer a Breast Prosthetic Service in the Manx Breast Unit. Here, your breast care nurse will give you individual advice about wearing a prosthesis and guidance on correctly fitting bras. You can also be referred to the service from GPs, Consultants and Nurse Specialists.

Contact Macmillan Breast Care Specialist Nurse

Telephone: 01624 650194

If a tissue biopsy is needed it will often be carried out with the help of a mammogram or ultrasound scan, with local anaesthetic to accurately target the area of concern.

If you are attending a new patient clinic, the biopsy will be performed the same day.  If you are attending a follow-up appointment, the biopsy will be arranged for a date in the near future.

The imaging services we offer are:

• Mammography
• Ultrasound scanning
• Breast tomosynthesis
• MRI scanning
• Image-guided tissue biopsy
• Fine needle aspiration
• Core biopsy
• Vacuum assisted biopsy
• Breast Radiology

After your imaging, we will be in touch with your results either by post or at a scheduled follow-up appointment with your Consultant’s team.

What is a mammogram?

A mammogram is a specialised X-Ray of the breast. It is the same procedure that is used in the NHS Breast Screening Programme. The breast tissue is positioned between X-ray plates and then “squashed” to get the best picture possible. This happens in two different directions for each breast and the pictures are then read by members of our team of expert breast radiologists. Mammograms are only offered if you are older than 35, as younger women have breast tissue that is too dense to accurately see things within. All our mammograms are stored digitally.

What is an Ultrasound Scan (USS)?

An Ultrasound scan does not use X-rays. It is uses the same type of sound-wave equipment that ladies are offered to monitor their babies during pregnancy. It is the main type of imaging that you will be offered if you are under 35. If you are older and you have come to clinic after feeling a lump, you may be offered a mammogram plus an ultrasound scan. Thick clear jelly will be used between the probe and your skin to help produce a clearer image. You will be able to wipe this jelly off at the end of the examination. If a biopsy test is needed this can often be done at the same time.

What is Tomosynthesis?

Tomosynthesis is a new breast diagnostic procedure and we are one of only a few units in the country that are able to offer this at the moment. This procedure is similar to a mammogram but is able to produce 3D images of the breast. It uses X-rays taken in many angles to produce multiple images of the breast tissue. These thin slices are then put together using a computer and the Radiologist is able to “look through” the breast tissue on a computer screen. This test may be used if there is some uncertainty as to what has been seen on standard mammograms to help reach a diagnosis.

What is an MRI scan?

Only some patients will need an MRI scan, it is not routinely used for breast assessment. If you need an MRI scan the reasons for this will be discussed with you in clinic. It does not use X-rays, but strong magnets. If you need an MRI scan an appointment will be sent out to you for a different day, and the procedure is performed in the main part of the hospital. Biopsies of breast tissue can be taken using the MRI scan if needed. More detailed information would be given to you when you attend for the scan. You will be asked to return to the clinic in the next few weeks after your scan for your results.

If you need a biopsy, these will often be done on the same day as your first appointment. They can either be performed with the help of a mammogram or ultrasound scan machine or by the doctor feeling the lump.

If you need a biopsy that is guided by an MRI scan this will be arranged for a different date.

There are three main types of biopsy:

Fine Needle Aspiration (FNA)

This is where a needle similar to a blood-taking needle is used to collect a sample of cells from the breast. No local anaesthetic is needed (the same as if you had a blood test) and the whole procedure is over in less than a minute.

Core Biopsy

This is the most common type of biopsy taken in our breast clinics. During this procedure you will have a local anaesthetic injection to numb the skin and breast tissue, and a biopsy needle is passed into the area of concern to take samples of breast tissue to be looked at under the microscope. A number of samples are taken to make sure that enough tissue is present to make a diagnosis. You can get some bruising of the skin after this procedure, and the nurse or radiographer present will press on the area after the biopsy is performed to help minimise this. You then will have some paper stitches (Steristrips) placed over the site where the needle went through the skin, with a dressing placed over the top. More detailed instructions will also be given to you for what to expect after the procedure. You normally return to the clinic the following week for the results.

A Vacuum Assisted Biopsy (VAB)

This procedure is performed after a local anaesthetic injection to numb the skin and breast tissue and is done using a mammogram or USS machine to help target the area. A needle is passed to the area of concern and slightly larger samples of breast tissue are taken than are obtained in a core biopsy. You can get some bruising of the skin after this procedure, and the nurse or radiographer present will press on the area after the biopsy is performed to help minimise this. You then will have some paper stitches (Steristrips) placed over the site where the needle went through the skin, with a dressing placed over the top.

More detailed instructions will also be given to you for what to expect after the procedure. This procedure is sometimes used if your first biopsy has not been able to give us a clear result to be able to tell you the diagnosis. You will usually need to come back to the Manx Breast Unit on a different day if you need this procedure. You normally will be asked to return to clinic the week after your test, for the results.

The majority of people that come to our breast clinic are, after appropriate investigations, able to be reassured that there is a harmless cause for the breast changes they have noticed.

You may be told that the area is normal dense breast tissue, that you have a fluid filled cyst which can be drained in the same day with a small needle or have a harmless lump, often something called a Fibroadenoma. Even if your examination and mammogram/ultrasound scan all look benign (harmless) a needle biopsy test may be performed for confirmation, either using a mammogram or ultrasound scan machine, or by the doctor feeling the area of the lump. If you have a benign diagnosis more information will be given to you by the team regarding this, including information leaflets. Often no more follow-up is needed and you can be discharged from the clinic either the same day or after your biopsy results.

Our Breast Surgeons perform a full range of breast conserving and mastectomy procedures, implant-based immediate and delayed breast reconstructions.

Every patient with a diagnosis of breast cancer will receive an individualised treatment plan.

Therefore, if you know someone else who has had breast cancer the treatment you are offered may be different from the care they received. Usually treatment will consist of surgery, which may be a lumpectomy (also known as a wide local excision/breast conserving surgery).  This removes the breast cancer and a margin of normal tissue around the outside of it. Or it might be recommended that you consider having a mastectomy (this removes all of the breast tissue on the side that has breast cancer). It is also likely that surgery to the armpit glands will be discussed.

Sometimes additional scans or biopsy tests are needed before the final surgical plan is made and you may be asked to come back to the clinic on a further occasion for the results of these. Our breast surgeons are able to offer a full range of surgical options for both breast conserving surgery and mastectomy with or without a reconstruction, although not all breast reconstructive surgery is performed on the Island.

Our Breast Surgeons will be able to discuss whether reconstruction is a suitable option with you and they can refer you to the Plastic Surgery Team in Liverpool for some forms of reconstruction if needed. After surgery, further treatments such as radiotherapy, chemotherapy and endocrine tablet treatment may be discussed. In some cases chemotherapy before surgery may be discussed (neo-adjuvant chemotherapy). The specific treatment options recommended will be individualised to your breast cancer.

Our Breast Surgeons perform breast conserving and mastectomy procedures, implant-based immediate and delayed breast reconstructions. If an autologous (using your own tissue) reconstruction is your preferred option, they will refer you to one of the Plastic Surgeons in Liverpool for a further consultation and subsequent surgery if you wish to proceed.

The type of surgery you may need will depend on the kind of cancer you have, the size of the tumour and the size of your breasts. Our surgeons carry out three main types of surgery:

Lumpectomy

This is also known as breast conserving surgery / wide local excision.  This is removal of just the cancer and an area of normal surrounding tissue, leaving the rest of your breast. This may not be recommended for you if you have a larger breast cancer, more than one cancer in the breast, or have had previous radiotherapy treatment in the same area.

Mastectomy

With or without a reconstruction – to remove the whole breast, often including the nipple. This is recommended for larger cancers, when there are multiple cancers in the breast, if you have previously had radiotherapy to the area, or if it is your preference to have a mastectomy. This may be a simple mastectomy, where no reconstruction is performed and a prosthesis is worn in the bra to re-create a breast shape through clothes. It will also be discussed whether an immediate breast reconstruction at the time of the mastectomy is appropriate for you.

Lymph Node Surgery

If you have been diagnosed with an invasive breast cancer you will be offered lymph node surgery at the same time as your breast procedure. All axillary surgery has a lifelong risk of causing arm swelling (lymphoedema) and your surgeon and breast care nurse will explain this risk and ways to prevent it in more detail. There are two main types of lymph node surgery:-

v A sentinel node biopsy – This is the procedure that you will be offered if an ultrasound scan of your armpit glands is normal, or if you have needed a biopsy of your armpit glands and the biopsy has come back normal. This procedure involves having an injection of a liquid that is mildly radioactive beside the nipple of the breast that has the cancer.

v Axillary Clearance – If the ultrasound scan of your armpit glands show abnormal looking cells these will then be biopsied. If the biopsy then shows that the armpit glands have some cancer cells within them, you will be offered an axillary node clearance. This removes all the armpit glands. If this operation is needed your surgeon and breast.

The vast majority of our breast cancer surgery is performed as a day case. This means that as long as there is a responsible adult that is able to stay with you overnight on the day of your operation, you can often go home the same day as your surgery.

We have a dedicated Breast Physiotherapist who will see you before and after your surgery with the correct exercises advice and details of rehabilitation exercise classes you can attend.

In some cases, if an elderly patient has been diagnosed with breast cancer, has a lot of other medical problems and is not fit for surgery, anti-hormone tablet therapy alone may be discussed if the breast cancer is hormone sensitive (Oestrogen receptor (ER) positive). This treatment does not cure or get rid of the cancer, but can keep it under control. It is not a first-line treatment option and is only usually considered if surgery is not possible on medical grounds.

Breast Physiotherapy

Physiotherapy - Breast Care page

A breast reconstruction can take place either at the same time as your mastectomy (immediate reconstruction) or later on, after the rest of your treatment is complete (delayed reconstruction).

If you need a mastectomy you may be suitable for a breast reconstruction

A breast reconstruction can take place either at the same time as your mastectomy (immediate reconstruction) or later on, after the rest of your treatment is complete (delayed reconstruction). The surgery uses either a high-quality breast implant, or tissue from another part of your body to create a new breast shape. Your surgeon will discuss options for reconstruction with you.

It will also be discussed whether an immediate breast reconstruction at the time of the mastectomy is appropriate for you. This decision is made on an individual patient basis and will be determined by factors such as whether you want to consider any form of reconstruction, your general health and fitness, the type of breast cancer that you have, the need for other treatments such as chemotherapy and radiotherapy and whether you are a smoker. Sometimes it is recommended that the reconstruction be done as a delayed procedure after the rest of your cancer treatment has finished. If you remain fit and suitable for a breast reconstruction there is no time limit after your surgery that this has to be done by – it can be many years later if this is what you wish.

The main types of breast reconstruction are:

Implant-Based

In this procedure a breast implant is placed either on top of or underneath the pectoralis major chest wall muscle to re-create a breast shape. It will be discussed with you whether an additional internal sling or hammock is needed to give a better breast shape. Sometimes it is possible to use some of your own skin to create the internal hammock (dermal sling) or else the internal hammock suggested may be specially processed tissue that has come from an animal source (Acellular Collagen Matrix), although synthetic hammocks are also available. Your breast surgeon will advise you if this is possible. The implant that is used may be a permanent silicone implant or a water filled bag (expander) that can be adjusted in volume at clinic appointments after your procedure, and switched to a permanent implant at a later stage.

Free Flap Based

For this operation you would be referred to the plastic surgeons. An area of fat and overlying skin is taken often from the tummy, but sometimes from the inner thigh or gluteal (bottom) region and re-plumbed into blood vessels in your chest wall. This donated area of fat and skin is used to recreate a breast shape, no implant is usually used in these procedures. Only certain people are suitable for this operation and it has a long recovery period. Your surgeon will be able to make an assessment as to whether you would be suitable for this procedure and explain it in more detail.

Pedicle Flap Based

A pedicle flap reconstruction is where part of your own tissue – often a large muscle from your back called the Latissimus Dorsi(LD) is lifted up with an area of overlying back skin which is then passed through a tunnel in your armpit to create a new breast shape. This is often done in combination with a breast implant underneath, but sometimes, if you were to have enough back tissue, an implant may not be needed.

If you are considering either immediate or delayed breast reconstruction you will have the opportunity to discuss all these techniques and your suitability for them with your surgeon and breast care nurse. Your breast care nurse will also be able to arrange for you to talk to other ladies who have had similar procedures to help you make a decision as to the best type of reconstruction for you.

For further information about breast reconstruction, speak to your Consultant or Breast Care Nurse.

Cancer Research Patient information on breast reconstruction

BAPRAS information for ladies considering breast reconstruction

ABS Patient Information on Breast Practice in Oncoplastic Breast Surgery

Association of Breast Surgery UK - Patients

Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) –
what we know and what we don't know

Association of Breast Surgery UK - Advice regarding Breast Implant safety

Referral Process for Reconstructive Breast Surgery

Reconstructive breast surgery for patients with breast cancer

Assessment and diagnosis of breast disease is undertaken at the Manx Breast Unit and a plan for management of the breast disease is drawn up by the specialist multidisciplinary team and then discussed with the patient. In some cases a cancer is removed and breast reconstruction will be performed at the same time (immediate breast reconstruction). On other occasions, a cancer is removed and reconstruction is performed at a later date (delayed breast reconstruction). Your breast team will advise you on the most appropriate option for your condition and help you to make this decision.

Our service provides a comprehensive service using modern surgical techniques, including therapeutic mammoplasty, implant based reconstruction, lipofilling, nipple reconstruction and nipple areola complex tattooing. Autologous (using your own tissue) reconstructions such as DIEP and TUG free flaps are undertaken in Liverpool and we can refer you to discuss these options with the breast plastic surgeons. Following reconstruction, additional procedures are occasionally necessary, such as nipple reconstruction and surgery for symmetry.

Referrals

Patients seeking delayed breast reconstruction following cancer surgery are referred to the breast surgeons at Noble’s Hospital to discuss their options.

Reconstructive breast surgery for patients with non-cancer issues

Breast Augmentation surgery is NOT routinely funded.

Revision of Breast Augmentation surgery is NOT routinely funded.

The appearance and feel of breast implants deteriorates over time due to changes in the surrounding breast tissue and/or in the implant itself. These changes are predictable and you should have been warned of the risk at the time of operation.

NHS funding will be available for implant removal where the implant is affected by Grade IV capsular contracture (the breast is hard, painful to touch and appears abnormal). To avoid creating asymmetry, the unaffected implant may be removed at the same time. Replacement implants will not be funded.

Breast Reduction procedures will only be funded where ALL the following criteria are met:

• The individual’s breast development is considered to be complete
• The patient has a BMI of 27 or below which has been stable for two years prior to referral
• If the patient claims back or neck pain related to the size of the breasts, there must be a documented plausible association (e.g. a record of visible grooving from bra straps), the pain must be significant (documented record of analgesia use and impact on activities) and the pain has not resolved with physiotherapy
• Evidence of a clinically significant history of intertrigo or ulceration which has not responded to treatment and has been documented in the clinical notes.

Where the above criteria apply, funding authorisation must be obtained by the GP before referral to the breast surgeon.

The team of surgeons on the Isle of Man or in Liverpool see and treat a range of non-cancer developmental breast abnormalities including breast asymmetry, tuberous breasts (sometimes called constricted breasts), lack of breast growth (amastia or hypomastia), excessively large breasts, and enlarged male breasts (gynaecomastia).

Gynaecomastia surgery is NOT routinely funded. (Referrals for endocrine assessment or exclusion of malignancy for appropriate individuals with gynaecomastia are NOT restricted by this policy).

Surgical correction of inverted nipple is NOT routinely funded.

Mastopexy (breast lift) is NOT routinely funded.

These procedures require approval of an individual funding requestpanel. Your GP will be familiar with the rules for these funding requests and it often saves time to go through this process first, as neither our breast surgeons nor the breast plastic surgeons are involved in the application or appeals process.

Referrals

Patients seeking correction of non-cancerous breast problems are referred to Noble’s Hospital by their GP but only once individual funding request has been approved.

DHSC Clinical Commissioning Policy on Aesthetic Breast Surgery

Individual Funding Request Panel (IRFP)

Useful Websites

Association of Breast Surgery - Patients information and resources

Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) –
what we know and what we don't know

Joint statement from ABS, BAAPS and BAPRAS - Advice regarding Breast Implant safety

American Society of Plastic Surgeons - Patient Safety

Recovery following breast surgery is different for every patient. Following your surgery, you will be seen back in clinic at the Manx Breast Unit after approximately two weeks for the results.

Your results will have been discussed at a Multidisciplinary Team Meeting (MDT) prior to your appointment, to discuss whether additional treatments are necessary.

This meeting is attended by Breast Surgeons, Radiologists, Pathologists, Breast Care Nurses and Oncologists (from Clatterbridge Cancer Centre) who will agree on a management plan specifically for you.

At your results appointment you will find out if further surgery is necessary and what additional treatments are recommended. If you require radiotherapy or chemotherapy, our team will be in contact with staff at Clatterbridge Cancer Centre and your GP to make sure you are getting the best and most joined-up cancer treatment possible. You will still come to the Manx Breast Unit for after-care following treatment.

If you have a hormone sensitive breast cancer (a breast cancer that is oestrogen receptor (ER) positive), anti-hormone (endocrine) therapy will be discussed with you. The type of tablet that you are offered will differ depending on whether you have gone through the menopause (‘the change’) or not. If you are still pre-menopausal (having periods) the drug Tamoxifen will be discussed with you. If you are post-menopausal a medication called an Aromatase Inhibitor will be discussed (Letrozole, Anastrazole, Exemestane) as well as Tamoxifen, the possible side effects of these medications will be explained to you by your surgeon and breast care nurse.

Follow-up usually consists of clinical examination and mammograms once a year for 5 years to your remaining breast tissue (if you have had a mastectomy, with or without reconstruction, the other breast will be examined). If you have had bilateral mastectomy (both breasts removed), mammograms will not be necessary.

After 5 years you can be discharged back to having mammograms every 2 years with the NHS Breast Screening Programme.

If you are still younger than the lower age limit of the National Breast Screening Programme at the end of this 5-year time frame, you will continue to receive mammograms every year until you are screening age.

You will have access to your Breast Care Nurse at any point and at all times during your follow-up; and we encourage you to contact us with any worries or questions you may have. Our nurses will be there for you to answer your concerns and support you in dealing with the psychological effects of breast surgery. They also provide the Breast Prosthetic Service, which can assess you after your surgery if you have had a mastectomy with no reconstruction; and give individual advice about wearing your prosthesis and correctly fitting bras, if needed.

Mr Elfatih Eltahir (Consultant Breast Surgeon)

Dr Rebecca Miller (Consultant Breast Radiologist)

Mr El-Rasheed Abdalla (Associate Specialist General/Breast Surgeon)

Mr Muhammad Salman (SAS Breast and General Surgery)

Ms Niamh Gelder (Superintendent Breast Radiographer)

Ms Alison Crebbin (Breast Radiographer)

Ms Helen Mylchreest (Breast Care Clinical Nurse Specialist)

Edith Van Genuchten (Breast Physiotherapist)

Ms Helen Alder/Ms Elizabeth Parrington (Secretaries)

Rosie Boardman (MDT co-ordinator)