Download Breast Screening Terminology

BREAST SCREENING TERMINOLOGY
A
ABS at BASO
Abbreviated title of the Association of Breast Surgery at BASO (the British
Association of Surgical Oncology). ABS publishes guidelines relating to the
management of breast disease, including breast cancers diagnosed through the
breast screening programme. Breast screening units take part in the provision of
data for the annual BASO audit. See http://www.baso.org.uk/content/Default.asp.
Acceptability/ uptake
Women who have attended for screening mammography following invitation. These
figures are monitored and are expressed as a percentage of those invited in a given
time period. This figure is derived from the KC62.
Adenocarcinoma
Adenocarcinomas are cancers that can be found in many parts of the body. In the
breast, they arise in the epithelial lining of ducts. Ductal and lobular carcinomas of
the breast are types of adenocarcinoma.
Adjuvant
Additional treatment used to optimise the response to initial treatment or the cure
rate. An example is the addition of chemotherapy after surgery to improve the
likelihood of controlling the cancer.
Adjuvant chemotherapy/ hormone therapy
The use of either chemotherapy or hormone therapy after initial treatment by surgery
or radiotherapy. The aim of adjuvant therapy is to destroy any cancer that has
spread from the original site; it should not be recommended to women whose breast
cancer does not express hormone receptor protein. However tumours that lack
hormone receptor protein but contain progesterone should be considered for
adjuvant hormone therapy. (See also neoadjuvant therapy.)
Areola
The pigmented skin around the nipple.
Assessment clinics
Clinics specifically set up for the purpose of assessing women who have an
abnormal screening mammogram (breast x-ray). Further examinations can be
carried out at these clinics in order to diagnose whether a women has a breast
cancer. Procedures such as further x-ray view, ultrasound, fine needle aspiration
cytology (FNA), core biopsy (wide bore needle) or clinical examination may be
carried out. The interval between screening mammography and assessment
appointment should be no longer than one week after the decision that further
investigation is required and within three weeks of the attendance for screening
mammogram. (Minimum standard 90%; target 100%.)
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Asymmetry
A term used in reporting mammograms to describe the structures of the breast. It
may refer to asymmetry in the duct pattern, the shape of the breast, or the density of
55 the breast. These are common features and are almost always normal.
Occasionally, however, asymmetry of duct shape or density can be an indicator of
breast cancer.
Asymptomatic
Having no symptoms.
Atypia
Atypia means not normal or typical. The term is used by cytologists to describe cells
that are not entirely normal but are not sufficiently abnormal to prompt a diagnosis of
cancer. For example, cells produced by infection or inflammation often show atypia
but are not caused by cancer.
Atypical Ductal Hyperplasia (ADH)
A condition in which there are more epithelial cells than normal in the lining of breast
ducts and they look abnormal under a microscope. Although ADH is non-cancerous,
it shares some features with ductal carcinoma in situ and its presence may indicate
increased risk of breast cancer.
Augmentation
‘Making bigger.’ An augmentation mammoplasty is a surgical procedure that
involves placing implants in the breast to enlarge them.
Axilla
The armpit. This is a common route for breast cancer to spread to other parts of the
body and the absence or presence of cancer cells in the axillary lymph nodes
(located under the arm) is an important indicator of breast cancer. Assessing the
axillary nodes normally involves a process called axillary dissection. (See below.)
Axillary dissection/ clearance
Axillary dissection is the removal from the armpit of the nodes and tissues most likely
to be affected by breast cancer. Clearance can be complete or partial. There are
three levels of axillary lymph nodes
• Level I is the bottom level, below the lower edge of the pectoralis minor muscle
• Level II lies under the pectoralis minor muscle
• Level III is above the pectoralis minor muscle
A traditional axillary lymph node dissection usually removes nodes in levels I and II.
For women with invasive breast cancer, this procedure accompanies a mastectomy.
It may be done at the same time as, or after, a lumpectomy.
B
Batch
A defined group of eligible women within a specific GP practice who are to be taken
through the screening process. Each batch of women will be given a unique
identifying number.
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Benign
A growth or lump that is not cancerous. A benign lump may still cause a problem if it
interferes with function or causes pain. Benign lumps do not metastasise (spread)
and are usually removed by surgery.
Bilateral
A term that means ‘on both sides’, ie in both breasts.
Biopsy
Removal of a sample of cell tissue to assist in the diagnosis of disease.
BRCA1/ BRCA2/ TP53
These are the names given to three human genes that help to suppress the tumours
and uncontrolled cell growth associated with cancer. Harmful mutations in these
highly penetrant genes have been linked with breast cancer and carriers are at
increased risk of developing it at some stage in their lifetime.
Breast cancer
There are many different types of breast cancer: some can be cured, but the most
aggressive types are usually incurable. Cancer survival depends chiefly on the size
of the tumour, whether the lymph nodes are affected, and whether the cancer has
spread to (or ‘invaded’) another part of the body.
Non-invasive breast cancer is confined to the normal duct structures and has not
spread into the surrounding tissue and around the body. Invasive breast cancer has
spread outside the duct structures into the surrounding breast tissue and it may also
have spread via the blood stream and lymphatic channels into the rest of the body.
Non-invasive breast cancer can usually be cured by surgical excision. Invasive
breast cancer often requires more extensive and systemic (whole body) treatment.
C
Carcinoma
The name given to any cancer that starts in the lining of body organs such as the
breast, prostate, lung or bowel. It is a malignant uncontrolled overgrowth of abnormal
cells that destroy the surrounding structures. In the very early stages of breast
cancer, before a carcinoma has had time to spread beyond the ducts, it is known as
a ductal carcinoma in situ or DCIS. (‘In situ’ is a Latin term meaning ‘in the original
place’.)
Care Quality Commission
Established by the Health and Social Care Act 2008 to regulate the quality of health
and social care and look after the interests of people detained under the Mental
Health Act. On 1 April 2009 it took on the responsibilities previously covered by the
Commission for Social Care Inspection, the Healthcare Commission and the Mental
Health Act Commission.
Ceased
Used to describe a woman who is no longer included in the breast screening
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programme, but is still within the eligible population. A woman should be ‘ceased’
from the programme only if she has had a bilateral mastectomy or if she has
expressed a wish not to receive invitations. In the second case, a withdrawal letter
57 should be signed by the woman and retained at the Screening Office and the
Authority. Provided she remains within the eligible population she can ask to rejoin
the screening programme at any time.
Chemotherapy
Drug or chemical treatment administered to destroy cancer cells. Combination
chemotherapy uses two or more chemotherapy drugs at the same time to treat
cancer; they are usually chosen because they fight the cancer cells in different ways.
Clinical governance
NHS organisations have a statutory duty to improve quality at local level. Clinical
governance supports them by providing a quality assurance framework for this
process. The framework includes a range of activities designed to ensure that
standards of clinical care are maintained and improved and that the NHS
organisation and its systems are fully accountable to patients.
Comedo
An overgrowth of epithelial cells forming a solid mass within a duct. This leads to
eventual necrosis (dead cells) in the central part which may be squeezed from the
duct like toothpaste. When necrosis is associated with cancer, it often means that
the cancer is able to grow quickly. Comedo type DCIS (or comedocarcinoma) tends
to be more aggressive than other types such as cribriform carcinoma.
Consent
Patient consent is paramount in the provision of a successful screening service. For
patients to make an informed decision and therefore give valid consent they should
be provided with sufficient support and information about the screening process. All
women invited for screening must receive a copy of the ‘NHS Breast Screening’
leaflet with their invitation letter which explains the risks and benefits of screening.
(See Consent to Cancer Screening. National Cancer Screening Programmes, 2009
(NHS CSP Publication No 4.)
Core biopsies with wide bore needles
This involves taking a small core tissue sample for diagnosis rather than a small cell
sample. It requires a larger needle than is used for fine needle aspiration cytology.
Trucut is a leading make of needle used to take this kind of specimen. Vacuum
assisted core biopsy uses a similar technique, normally with larger gauge cores.
Coverage
This indicates how many of women invited do attend for screening and thus how
effectively a service is screening its eligible population. Coverage is expressed as
the percentage of women screened divided by the total eligible population in a three
year period. This information is obtained from the KC63 statistical tables.
Cranio-caudal view
One of the two standard projections for mammograms. The cranio-caudal view is
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taken with the client facing the machine and the breast support table horizontally
under the breast. The breast is compressed from above. This view should
demonstrate the medial border and as much of the lateral border as possible, along
with the central part of the breast. (See also Medio-lateral oblique view and Paddle
view.)
Cribriform
An overgrowth of epithelial cells filling a duct in the breast. Unlike the
comedocarcinoma their growth is not solid but forms mucin-containing spaces that
give it a sieve-like appearance. (Cribriform means ‘shaped like a sieve’) The
absence of necrosis means that that a cribriform carcinoma is less likely to become
invasive. However, it is often seen alongside the more aggressive comedo type.
Cytology
The study of individual cells, their size, structure and abnormalities, in order to make
a diagnosis to guide treatment.
Cytopathologist
A doctor who examines tissues and fluids at the cellular level with a microscope to
make a diagnosis and help to guide treatment.
D
DCIS
The abbreviation for ductal carcinoma in situ. (See Carcinoma and Breast cancer
above.)
Density
On mammograms soft tissue structures produce a white density on the image.
’Localised density’ is a term often used to describe a mass in the breast. Another
often used in this context is ‘opacity’. The two terms are often used interchangeably.
DNA
The abbreviation for ‘did not attend’, used when women fail to attend their screening
appointment. Units are obliged to follow up these women and attempt to encourage
attendance in the future.
Duct ectasia
Particularly in pre- or perimenopausal women (age 40 – 50), milk ducts may become
swollen and clogged, and may dilate (swell), leading to inflammation and, in some
cases, nipple discharge. This is a benign, non-cancerous, condition.
E
Echogenicity
The echo pattern of a structure on ultrasound.
Eligible population
A group of individuals within the health community who are entitled to services if they
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meet specific criteria. Within the breast screening programme the eligible population
consists of women aged 50–70 (expanding by 2012 to 47–73). Women over the
specified age range may request an appointment on their own behalf.
End code
The computer code used to describe the closure of a screening episode for a woman
who has been invited for screening. The end code describes the outcome of each
screening episode.
Episode
The period of time during which all screening activity associated with an eligible
woman takes place. From invitation, through attendance/ non-attendance to
outcome, an episode should be completed within six months. An open episode is an
episode without an end code and therefore incomplete.
Epithelial cell
A type of cell which covers or lines structures in the body. The ducts within the
breast where milk is formed are lined with epithelial cells and it is abnormalities in
these cells that give rise to breast disease and breast cancer.
Epithelial proliferation with and without atypia
Epithelial cells sometimes grow and the ducts can become lined with cells several
layers thick. If these cells are normal (ie if they are the same size and shape as the
normal single layer of epithelial cells) this is called epithelial proliferation without
atypia. If the proliferating cells differ in either shape or size, however, this is termed
epithelial proliferation with atypia. Epithelial proliferation maybe either ductal (within
ducts) or lobular (within lobules). This proliferation is one stage in the progression
from normal epithelium through to cancer which can be summarised as follows
• Normal epithelium
• Epithelial proliferation without atypia
• Epithelial proliferation with atypia
• Carcinoma in situ
• Invasive carcinoma
Excision biopsy/ open biopsy
A surgical excision required to make a tissue diagnosis.
An open biopsy is a surgical procedure in which the skin is incised to obtain tissue.
In a closed biopsy, by contrast, the abnormality is biopsied by means of a needle,
such as fine needle aspiration or core biopsy. (See Core biopsies above.)
In an excision biopsy the entire abnormality is excised by the surgeon. This is usually
done when the abnormality is small and can be successfully excised without causing
too much distortion of the breast.
Exeter system
See NHAIS system.
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F
Failsafe batches
A screening batch created with the specific intention of inviting women who may
have been missed routine screening. The failsafe batch is created at quarterly
intervals and the parameters are set to ensure that women without a screening
outcome on the Health Authority system for that screening interval are selected and
invited.
False negative result
When a woman’s initial screening result is recorded as normal but she is later found
to have breast cancer.
False positive result
When a woman’s initial screening result is recorded as abnormal but she is later
found not to have breast cancer.
Fat necrosis
Small areas of degenerate fat in the breast, often presenting as a hard lump. (See
Comedo above and Necrosis below.)
Fibroadenoma
A benign tumour of the breast. It consists of normal breast tissue aggregated to form
a lump which, if large enough, may be palpable. It is particularly common in younger
women (age 20–30). Many are small and cannot be felt but are frequently seen in
women attending for screening. They do not need to be excised as they have no
potential to become malignant.
Fibroadenosis
This is best explained by dividing the word into its components: ‘fibro’ relates to the
fibrous tissue; ‘aden’ refers to gland; ‘osis’ means abnormal condition. Fibroadenosis
describes the benign overproliferation of fibrous and glandular tissue in the breast. It
can be either localised or diffused throughout the breast.
Fibrocystic changes
An abnormal process which involves a proliferation of fibrous tissue and the
formation of cystic spaces in which fluid can collect, forming (usually microscopic,
but sometimes much larger) cysts in the breast.
Fine needle aspiration (FNA)
FNA/ FNAC stands for fine needle aspiration cytology, in which a fine needle is
inserted into the tissue to aspirate cells (remove them by suction) for cytological
examination.
G
GP referral
When a woman is referred for screening by her General Practitioner rather than
being selected as part of a normal screening batch.
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H
Healthcare Commission
See Care Quality Commission above.
Histological calcification
Calcification is an aggregation of calcium molecules. Because calcium stops x-rays,
calcification appears on a mammogram as an area of white density. Histological
calcification is a term used to describe much smaller particles of calcium which are
only visible under the microscope.
Histology
A branch of biology (the study of living organisms) in which cells and tissues are
examined under the microscope. Performed by a histologist.
Histopathology
A branch of pathology (the study of disease) in which tissue is examined under the
microscope to identify changes associated with disease. This examination will inform
the medical team’s diagnosis of whether a patient has cancer and, if so, which type.
Performed by a histopathologist,
Hormone therapy
Treatment with hormones. Used as adjuvant or back-up to primary (usually surgical)
treatment of breast cancer.
I
Impalpable
Used to describe a lesion that cannot be felt.
Incident screen
Second and subsequent attendance for mammography following previous successful
mammography. (See also Prevalent screen.)
Interval cancers
Cancers presenting between three yearly screening examinations.
Invasive
Cancer that begins in one area and then spreads deeper into the tissues of that
area.
K
KC62
The computer generated report of activity and outcomes for every screening episode
in each screening unit over a six month period. The KC62 is passed to the regional
Quality Assurance Officer for collation with data from other centres and from there to
the Department of Health. KC62 data are the basis of the UK Annual Screening
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Report.
KC63
The return submitted annually to the Department of Health by every Health Authority
in England. The KC63 reports breast screening activity within the health provider
area. Coverage statistics are derived from the statistical report.
Kv
Kv stands for Kilovoltage and indicates the voltage at which x-ray machines operate.
For standard x-rays, such as a chest x-ray, this is in the range of 120–130 Kv. For a
variety of reasons mammography equipment works at a much lower energy level, in
the 27–28 Kv range. At this lower level the contrast between soft tissues is more
clearly seen.
L
Latissimus dorsi flap (LD Flap)
Breast reconstruction technique that uses muscle, fat and skin taken from the back
to rebuild the breast. May be used with or without a silicone implant.
Lesion
A localised abnormality of a tissue or structure.
Lipoma
A benign tumour composed chiefly of fat cells.
Lobular carcinoma in situ (LCIS)
LCIS is not a cancer, but its presence indicates a small increase in the risk of
developing breast cancer later in life. Despite this, most women with LCIS do not
develop breast cancer. (See also Breast cancer and Carcinoma.) LCIS is not
visible on a mammogram and is usually discovered by chance after a woman has
had a breast biopsy or a breast lump removed.
In the past LCIS was sometimes treated with surgery to remove the breast
(mastectomy). As most women with LCIS will not go on to develop breast cancer,
this is now thought to be unnecessary. Today women diagnosed with LCIS are
normally given 6–12 monthly breast examinations and a mammogram every 1–2
years. In this way, any changes in the breast can be identified at the earliest stage
and treated if appropriate. Rarely, a woman with LCIS may make a personal decision
to have both breasts removed (bilateral mastectomy). This tends to happen where
there is a strong family history of breast cancer, or the woman is extremely anxious
about her risk of developing breast cancer.
Local recurrence
The reappearance of cancer cells after treatment in the place where they were
originally found. This is different to metastasis, where cancer cells are found away
from the original site.
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Localisation biopsy
Diagnostic biopsy of an impalpable lesion.
Locally advanced
Used to describe a cancer that has grown but has not spread or metastasised.
Lumpectomy
Surgical removal of a cancerous lump or tumour in the breast, along with a small
margin of surrounding tissue. Also known as breast-conserving surgery. (See also
Segmentectomy.)
Lymphadenopathy
Persistent abnormal enlargement of the lymph nodes. Lymphadenopathy is seen
when breast cancer spreads to the lymph glands in the axilla. It is not always
associated with cancer, however, and is quite commonly seen with infections.
Lymph nodes
As well as veins and arteries the body has another transport network, called the
lymphatic system. This carries a watery clear fluid, lymph, through a network of
organs, ducts, and nodes. This fluid distributes immune cells (lymphocytes) that
protect the body against antigens such as viruses and bacteria. The lymphatic
system also helps to drain fluid from cells and tissues, filters it, and returns it to the
blood stream.
A lymph node is one of 300 small, bean-shaped organs clustered mostly in the neck,
armpit and groin. They are filled with the lymphocytes that filter the lymph fluid before
it re-enters the blood stream. This filtering process traps bacteria, viruses and other
foreign substances such as cancer cells. Swollen lymph nodes (lymphadenopathy)
indicate a high level of activity, as is the case when the body is fighting cancers.
Cancer cells often break away from one another and can pass into the lymphatic
system. When they do, there are usually trapped by the lymph node ‘filters’, where
they may continue to grow, giving rise to lymph node metastases (secondary cancer
in the lymph nodes). In the breast these usually occur in the armpit or axilla). Some
cancer cells are able to spread to other parts of the body via the lymph channels.
M
Macroscopic
Large enough to be seen with the eye.
Magnetic Resonance Imaging (MRI)
A test using an MRI scanner to look inside the body, particularly at the soft tissues. It
uses a large magnet to create an image of the internal organs.
Magnification view
An x-ray technique that enables structures in the breast to be magnified. It is
normally used where microcalcification is suspected.
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Malignancy
In general, this means progressive and resistant to treatment and tending to cause
death. A malignant tumour is one that grows, that can invade nearby tissue, and that
may spread to other parts of the body. Malignant cells are able to push their way
through and between normal cells and, as they divide and multiply, they damage
surrounding tissue. Some malignant cells penetrate small blood vessels, enter the
bloodstream, and are able to produce secondary tumours (metastases) in other
areas of the body. Others metastasise via the lymphatic system. (See Lymph
nodes.)
Mammography
The technique of producing a picture of the structure of the breast by compressing
the breast and passing an x-ray beam through it.
Mass/ opacity
A localised density seen on a mammogram that could represent a tumour.
mAs
mAs is a measure of energy (current), an abbreviation of milliamps per second.
Mastectomy
Surgical removal of the whole breast.
Medio-lateral oblique view
One of the two standard projections for mammograms. For the oblique view the
machine is angled at approximately 45° with the breast support table under the
breast and angled into the axilla. The medio-lateral oblique view should demonstrate
the pectoral muscle down to nipple level wherever possible and include the nipple in
profile with the inframammary angle clearly visible. (See also Cranio-caudal view
and Paddle view.)
Metastasis
The spread of cancer cells from one part of the body to another. The original site
where a cancer develops is called a primary tumour. Malignant tumours may spread
to other parts of the body causing secondary (metastatic) tumours. Cancer cells can
spread via the blood or lymph vessels. (See Lymph nodes, Malignancy and
Micrometastasis.)
Microcalcification
The cells in the gland structure of the breast are designed to produce milk, and milk
contains calcium. When the secretions in the breast are contained in small cystic
spaces the calcium may form tiny aggregates that are visible on the mammogram.
The same thing can happen when the glandular cells do not function properly, as in
several benign processes but also in breast cancer. Microcalcifications within the
ducts and within the tissues of the breast are a sign of abnormal function or
blockages in the ducts. Most calcifications represent benign processes but some are
an early sign of breast cancer.
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Microinvasive carcinoma
Invasive carcinoma less than 1mm in size.
Micrometastasis
Areas where cancer cells have spread but are too small to be detected without a
microscope.
Morbidity
The condition of being diseased. The morbidity rate is the number of cases of a
disease occurring within a particular population.
Mortality
Death rate, usually expressed as the number of people in a defined population who
die within a defined period. Mortality (like incidence) rates are usually presented per
100,000 people.
Multitaxis Scanning System
X-ray imaging system. A reverse geometry source of x-ray (e.g. a raster-scanned
electron beam) and a two-dimensional digital detector are used. The system has
several advantages, including providing direct digital information, and threedimensional radiographs with higher resolution and better contrast.
N
NBSS
The abbreviation for the National Breast Screening (Computer) System
Necrosis
Changes in the cell which indicate that it has died and is being broken down by
enzymes. Necrosis or death of cancer cells can happen as a result of treatment (eg
radiotherapy or chemotherapy) or because a cancer lump has outgrown its blood
supply.
Neoadjuvant
Therapy introduced before the primary medical treatment to increase its
effectiveness. An example is the use of chemotherapy before surgery to increase the
probability of controlling the cancer. (Compare adjuvant therapy, which is given after
the primary treatment.)
Neoplasm
Another name for tumour, meaning aberrant new growth of abnormal cells or tissues.
A neoplasm can be either benign or malignant. Examples of neoplasms include a
fibroadenoma (benign) or a ductal carcinoma (malignant).
NHIAS System
(Also known as the Exeter system.) The health authority computer system that
manages NHS services, patient registration and demographic details for England,
Wales and Northern Ireland. It is managed by Connecting for Health (which is
responsible for all national NHS IT systems) and is based in Exeter. GPs,
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laboratories, pharmacists and other authorised staff can be given access these data
through the ‘Open Exeter’ system.
Node sampling
As well as the lymph nodes in the axilla which drain the breast tissues, there are
some lymph nodes which drain the medial part of the breast. These lie just inside the
chest next to the sternum. Some surgeons sample these nodes at the time of
surgery when the breast tumour they are excising lies in the medial part of the
breast.
Nodal stage (see also Nodal status)
Lymph nodes are graded according to the presence or absence of cancer
A tumour absent from all nodes sampled at all three sites. Score 1
B tumour in low axillary node only, or in an interval mammary node only, or
in fewer than three nodes in an axillary clearance. Score 2
C tumour in apical node, or low axillary plus internal mammary nodes, or in
four or more nodes in axillary clearance. Score 3.
Nodal status (see also Nodal stage)
The presence or absence of cancer in the lymph nodes of the armpit. A woman with
cancer in one or more nodes is node positive (node +ve). A woman with no cancer in
her nodes is node negative (node –ve).
Non-batch referrals
Episodes created by Screening Offices for women outside the normal batch process.
Examples include GP referrals, self requesters, and short term recalls.
Nottingham Prognostic Index (NPI)
This is used to identify the risk of progression of invasive disease. It uses the three
factors which are of the greatest importance in predicting the behaviour of breast
cancer: tumour size, nodal stage, and histological grade.
The NPI is calculated using the following equation: 0.2 x size in mm + lymph node
stage (1-3) + histological (tumour) grade (1-3)
<2.4 = excellent prognosis
<3.4 = good prognosis
<5.4 = moderate prognosis
>5.4 = poor prognosis
O
Occupational standards
Standards have been developed in the NHS breast screening programme to enable
workers and employers to develop skills and experience and encourage skill-mix.
The standards define the competencies for skills at varying level, identify training
needs, contribute to career progression and assist in recruitment. (For more
information see the Skills for Health website, at http://www.skillsforhealth.org.uk
/competences.aspx.) (See also Skill-mix.)
Oestrogen receptor (ER)
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A protein in breast cancer cells that binds oestrogens. Oestrogen receptors are
essential for the oestrogen stimulated growth and proliferation of breast cancer.
However its presence in a tumour indicates that the cancer may respond well to
hormonal therapies.
Oncology
The study and treatment of cancers, and the medical specialty that deals with the
diagnosis and treatment of people with cancer.
One-stop or fast-track clinics
Assessment clinics where tests are carried out and results are given to women on
the same day. Not all sites offer this service.
P
Paddle view
Standard mammogram films/ images are taken with a large compression plate which
compresses the whole breast. A paddle view is an image taken with a small
compression plate which compresses only a small part of the breast.
Sometimes normal structures in the breast overlie one another to produce what
looks like an abnormal shadow on the x-ray image. Paddle views are used to
compress localised areas of the breast to see whether this type of shadow is real or
simply a summation of normal breast structure. (See also Medio-lateral oblique
view and Cranio-caudal view.)
Palpable
A lesion that can be felt.
Papilloma
The localised overgrowth of the epithelial lining in a duct in the breast to produce a
tiny wart-like nodule on a stalk within a duct. Also known as papillary lesion.
Parenchymal deformity
Parenchyma is the tissue that characterises an organ and is essential to it, as
distinct from stroma (an organ’s supportive and connecting tissue). Anything
affecting the structure of parenchymal tissue is referred to as parenchymal deformity
or distortion. These distortions may be caused by previous surgery or other scars but
they are also an important early sign of breast cancer. Because areas of
parenchymal distortion may be visible only in one view, they account for a significant
number of cancers missed by screening radiologists.
Phyllodes tumour
This very rare tumour develops in the connective tissue of the breast. (Compare
carcinomas, which develop in the ducts or lobules.) They are rare but are often large
and require wide surgical excision. Also known as cystosarcoma phyllodes (or
misspelt as phylloides) tumours.
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Prevalent
The first successful attendance for screening mammography. (Compare incident
rounds.) Prevalence is also a term used to describe the frequency with which a
disease occurs. The prevalence of breast cancer is the total number of women who
have breast cancer at any given time: the incidence of breast cancer is the number
of new cases diagnosed in a given year. (The prevalence of a disease is always
greater than its incidence.)
Primary Care Team
Primary care refers to the practice of medicine in the community and the GP practice
is generally considered the ‘primary’ port of call for people who become ill. The
primary care team includes the General Practitioner, practice nurses, the
receptionist, the manager, and community health visitors.
Primary Care Trusts (PCTs)
Primary Care Trusts manage the provision of primary and community care services
in a specific area. These include services provided by doctors surgeries, dental
practices, opticians and pharmacies. NHS walk-in centres and the NHS Direct phone
service are also managed by the local PCT. There are about 152 Primary Care
Trusts in England, each one covering a separate local area. Their overall function is
to improve the health of the population for which they are responsible, develop
primary and community health services, commission secondary care services, and
integrate health and social care locally. They are due to be replaced by other
commissioning bodies in 2011/12.
Prognostic factors
Factors that indicate the probable cause and outcome of a disease, how it is likely to
respond to treatment, and the probability of recovery from it. A prognosis will usually
be based on information from research studies and clinical experience but may be
very difficult to determine with accuracy.
Programme extension/ Age extension
In December 2007, the Department of Health's Cancer Reform Strategy announced
that from 2012 the NHS Breast Screening Programme would be extended to cover
women between the ages of 47 and 73. This means that all women will receive two
extra screening invitations in their lifetime. It also means that all women will have
their first screening invitation before their 50th birthday. This extension is being
introduced as part of a randomised control trial. The trial will run for two screening
rounds and the results of this study are not expected until the early 2020s.
Prophylactic mastectomy
Removal of the breast to prevent disease.
Q
Quality Assurance Reference Centres (QARCs)
The first point of contact for information about breast screening programmes in their
region. Their role is to establish high quality systems for coordinating and monitoring
all aspects of screening. To do this they work with the local screening centres,
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Primary Care Trusts, laboratories, and other services and personnel contributing to
the NHS Breast Screening Programme. They collect and analyse data on the
performance of local programmes and compare them with national standards,
support local programmes with staff training and guidance on good practice,
implement policy, and arrange formal assessment visits to screening centres.
Quality assurance visit
A visit by the regional quality assurance team to monitor the performance of a
screening service. The process is administered by the regional QARC.
Quality control
Controlling and monitoring processes designed to produce quality systems and
services. In breast screening, quality control facilitates the production of high quality
images with as low a radiation dose as is reasonably possible and minimises the
adverse side-effects of the screening process.
Quality management system
The documented and controlled policy statements, procedures and work instructions
used within a breast screening programme. They are designed to ensure that a high
quality service is available to every woman invited for screening and that staff
working within breast screening are aware of, and comply with, current policy and
practice.
R
Radial scar
These are not really scars, although under a microscope they resemble scars
because of the fibrous tissue that surrounds the central core. They are (mostly
impalpable) benign breast lesions, smaller than 1cm in size. Larger ones are known
as complex sclerosing lesions.
Radiotherapy
Treatment using radiation that is able to target specific areas of the body.
Recall to assessment
A woman will be recalled to assessment if her screening mammogram shows an
area of abnormality that requires further investigation.
Resection margins
The edges of a surgically removed piece of tissue. These should be clear of cancer
cells.
S
Screening round length
The period in which women in the eligible population are called/re-called to attend for
screening mammography (ie 36 months).
Screening round plan
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Each screening unit prepares a screening round plan which documents how, where,
and when all eligible women will be screened by that service over the course of a
three year screening round.
Screening round slippage
The term used when eligible women fall outside the screening round period (ie not
screened before their 53rd birthday) or when their interval between screens exceeds
the 36 month round length.
Segmentectomy
The excision of a segment of the breast. (See also Lumpectomy.)
Self referral/ self request
A woman above the lower age limit (and below the upper limit) who has not been
screened in the previous three years and who requests a return to three-yearly
mammography. Also, a woman above the upper age limit who has not been
screened in the previous three years and asks to be screened.
Sensitivity
The ability of a test to detect accurately when a disease is present: that is, to avoid
false negative results. A sensitivity of 90% will give a positive result in nine out of ten
cases of disease.
Sentinel lymph node biopsy
A sentinel node is the first lymph node to receive lymphatic fluid that has drained
from a tumour. It is thus the first to which cancer cells are likely to spread. Biopsy
involves: (1) identifying the sentinel node by injecting a radioactive substance or blue
dye or both near the tumour; (2) using a scanner to find the sentinel lymph node that
contains the radioactive substance or is stained with the dye; (3) removing the
sentinel nodes to check for the presence of cancer cells.
Short term recall/ early recall
Invitation to re-attend for assessment earlier than the routine three year recall date.
A common short term recall interval is one year.
Skill-mix
1. Introduced into the breast screening programme in response to the staffing
shortfall in radiology, to enable career progression and integration between
roles. In breast screening radiography skill-mix is also known as the ‘four tier
structure’
2. Assistant Practitioners perform radiographic tasks under the supervision of a
State Registered Practitioner
3. State Registered Practitioners are responsible for assessment, for planning
and delivering patient care, and for supervising assistants and other staff
4. Advanced Practitioners are responsible for the same duties as the State
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Registered Practitioners. In addition they are trained to carry out advanced
practice such as image interpretation and core biopsy. They are also required
to demonstrate judgement and decision making skills
5. Consultant Practitioners are recognised experts and strategic, independent,
creative thinkers, advancing research and education for service management.
Specificity
The ability of a test to detect accurately when a disease is not present: that is, to
avoid false positive results.
Specimen radiography
An x-ray of a tissue specimen carried out while the patient is under anaesthetic. The
specimen is x-rayed in a specialist specimen cabinet and the results are available
promptly. The x-ray allows almost immediate assessment of whether a lesion has
been satisfactorily removed and the margins are clear. This method can also be
used for core biopsies.
Spiculation
When it grows, a breast cancer tends to disturb the surrounding normal breast
tissue. This breast tissue reacts by forming a fibrous reaction to the tumour which
often appears as a spicule (or needle shaped object) surrounding the tumour mass.
These spicules are made up of a combination of fibrous reaction from normal breast
tissue and infiltration of the tumour itself into the breast tissue.
Standardised cancer detection ratio (SDR)
A measurement of performance which takes into consideration the variable age
distribution. To calculate the SDR, the observed cancers are divided by the expected
cancers. The current target is an SDR of 1.0.
Stellate
A star-shaped tumour that produces deformity of the breast without an obvious mass
of central density.
Stereotactic
In breast screening 50-60% of abnormalities detected at screening are not palpable.
This means that some form of imaging must be used to localise the abnormality for
the surgeon. This can be done in one of two ways. If the abnormality is seen on
ultrasound, then ultrasound can be used to guide needles and to place marker wires.
If an abnormality is not visible on ultrasound then x-ray techniques must be used.
There are a variety of x-ray techniques but the most accurate is called stereotaxis.
For this, the breast is compressed in a special compression plate and two x-ray
films/ images are taken at 30° to one another (hence ‘stereo’). These two views are
used to calculate exactly where in the breast the abnormality is and thus accurately
place a needle or localisation wire.
Strategic Health Authorities
SHAs were created by the government in 2002 to replace Health Authorities and
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manage the local NHS on behalf of the Secretary of State. There were originally 28
SHAs. On July 1 2006, this number was reduced to 10. They are responsible for:
developing plans for improving health services in their local area; making sure local
health services are of a high quality and are performing well; increasing the capacity
of local health services so they can provide more services; making sure national
priorities (for example, programmes for improving cancer services) are integrated
into local health service plans. In the proposed NHS reforms it is expected that these
organisations will be dissolved by 2012–13
Stromal deformity (See also parenchymal deformity)
The parenchyma of the breast or other organ is the tissue responsible for its main
function and usually forms the main part of it. Stroma is the term used for everything
else: connective tissue, blood vessels, nerves and ducts. In a mammogram the
stroma can be seen forming a typical pattern with blood vessels and fibrous tissues
extending out in a regular way through the breast. However, abnormalities of the
breast can cause distortion or deformity of the normal stromal pattern. This may be a
result of surgical scarring or inflammation, but it may also be a sign of breast cancer.
Subcutaneous mastectomy
A surgical procedure in which the breast tissue is removed but the skin and nipple
are left in place. This allows a prosthesis to be used to reconstruct the breast. It
differs from a simple mastectomy in which the breast, the skin, and the nipple are all
removed.
Symptomatic
Showing symptoms. Breast clinics distinguish between asymptomatic women (who
have screen-detected abnormalities of which they were previously unaware) and
symptomatic women (who have abnormalities – such as a lump, pain, indrawing of
the skin or nipple – of which they were already aware).
Systemic treatment
Breast cancer can be either localised (confined to the breast) or systemic (spread
beyond the breast into the rest of the body). Systemic treatment comprises the forms
of drug and hormone therapy used to treat patients whose cancer has spread around
the body.
T
Technical recall examination
When a woman’s screening examination is technically inadequate for reporting she
will be asked to re-attend so that the same mammographic projections may be
repeated.
Technical repeat examination
When an error is identified in a screening examination, the radiographer will arrange
for the same mammographic projection(s)to be repeated.
Tram flap
Breast reconstruction using muscle, fat and tissue from the abdominal wall to
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reconstruct the breast. A silicone implant is not usually required.
Triple approach/ triple assessment
Multi-disciplinary approach to diagnosis, comprising: clinical examination;
radiological assessment (mammography or ultrasound); diagnosis of cell samples
(cytology) or biopsy of core tissue (histology).
U
Ultrasound
An imaging technique for examining the breast and other structures of the body. It
uses very high frequency sound which is passed into the body through a special
probe. The probe then ‘listens’ as the sound bounces back off the tissue structures.
Unlike x-rays, it does not cause tissue damage, and provides an alternative way of
examining breasts in ‘real time’.
Uptake rate
The percentage of women who are sent an invitation to attend for breast screening,
accept it, and undergo mammography.
V
Vacuum assisted biopsy
Large core biopsy undertaken with either ultrasound or stereotactic imaging. It is a
minimally invasive procedure that allows for the removal of multiple tissue samples.
Unlike core needle biopsy (which involves several separate needle insertions to
acquire multiple samples) the special biopsy probe used during vacuum assisted
biopsy is inserted only once into the breast through a small incision made in the skin
of the patient's breast.
Vascular invasion
The invasion of blood or lymphatic vessels in the breast by cancer cells.
W
Wide local excision
Surgery to remove a small cancer. (See also Lumpectomy.) In cases where a
breast cancer is under 3cm in diameter the patient may opt to have only the lump
removed, rather than the whole breast. Wide local excision achieves this by
removing a small localised breast cancer along with a rim of normal tissue around it
to ensure that all the diseased cells have been removed – hence the procedure’s
name.
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