The Triple Assessment

The breast triple assessment is a hospital-based assessment clinic that allows for the early and rapid detection of breast cancer. Women (and men) can be referred to this ‘one stop’ clinic by their GP if they have signs or symptoms that meet the breast cancer “2 week wait” referral criteria, or if there has been a suspicious finding on their routine breast cancer screening mammography. The triple assessment aims to provide a quick and simple outpatient approach to diagnosis and allow for the early intervention in the treatment of breast cancer.

History and Examination

A detailed history and examination are performed by a breast surgeon or associate specialist. In the history, further to the clinical details of their presenting complaint, any potential risk factors are identified, including family history and current medications. The full breast examination is described here, however predominantly focuses around breast palpation and assessment of the axillary nodes.

Imaging

The mainstay of imaging during the triple assessment is based around either mammography or ultrasound investigations:

  • Mammography involves compression views of the breast across two views (oblique and craniocaudal), allowing for the detection mass lesions or microcalcifications.
  • Ultrasound scanning is more useful in women <35 years and in men, due to the density of the breast tissue in identifying anomalies. This form of imaging is also routinely used during core biopsies.

MRI imaging is not used in the mainstay of triple assessment however can be useful in the assessment of lobular breast cancers (and in assessing response to neoadjuvant therapy); whilst it has high sensitivity, it has a low specificity.

Histology

A biopsy is required of any suspicious mass or lesion presenting to the clinic, most commonly obtained via core biopsy. A core biopsy provides full histology (as opposed to fine needle aspiration (FNA) which only provides cytology), allowing differentiation between invasive and in-situ carcinoma.

The test can generate important information about tumour grading and staging, and has a higher sensitivity and specificity than FNA for detecting breast cancer. If a woman has recurrent cystic disease (and the lesion is clinically a cyst), this can be aspirated using FNA at this stage for cytology and to relieve symptoms.


Differential Diagnosis

At each stage of the triple assessment, the suspicion for malignancy is graded to create an overall risk index, as discussed below. The key here is to establish whether this is likely a benign lesion or whether the patient should go onto have more definitive biopsy and further intervention.

Examination Score Imaging Score (Mammography (M), Ultrasound (U)) Histology Score
P1 – Normal M1 / U1 – Normal B1 – Normal
P2 – Benign M2 / U2 – Benign B2 – Benign
P3 – Uncertain/likely benign M3 / U3 – Uncertain/likely benign B3 – Uncertain, probably benign
P4 – Suspicious of malignancy M4 / U4 – Suspicious of malignancy B4 – Suspicious of malignancy
P5 – Malignant M5 / U5 – Malignant B5 – Malignant

 


Management

From the clinical, radiological and pathological information gained about a breast lump at the Triple Assessment, a diagnosis of breast cancer can be made. The individual case will then be discussed at a Multi-Disciplinary Team (MDT) meeting where a treatment plan will be developed. The majority of women will go onto have breast surgery and assessment of their axilla at some stage to treat their breast cancer, with chemotherapy and / or radiotherapy offered if appropriate.

Key Points

  • The triple assessment comprises of the history + examination, imaging, and histology
  • Each part of the assessment is combined for a case-by-case evaluation to the likely diagnosis
  • Cases suspicious for breast cancer are discussed by the MDT to create a suitable treatment plan

Quiz

Question 1 / 3
A 25yr old lady with a suspicious breast lump is referred to breast clinic for triple assessment. By what imaging modality would be best used as first line?

Quiz

Question 2 / 3
A 42yr old lady is referred to breast clinic due to a solid lesion in her R breast. What method is best to obtain the histology from this mass?

Quiz

Question 3 / 3
A patient is scored grade P4 following examination of their lump, what does this correlate to?

Results

Further Reading

Investigation of suspected breast cancer
Britton P et al., The BMJ

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