Our Specialist Breast Clinics aim to provide easy-access clinics for patients with symptoms of breast cancer. We cannot provide a general breast health clinic with our available resources.

For the benefit of all our patients and to keep the waiting times to under 2 weeks, your support in referring the appropriate patients would be appreciated.

Many breast complaints can be treated and followed up at the primary care level without the need to be seen at a specialist breast clinic.

• A breast lump in patients > 20 years
• Skin changes (Peau de orange, skin nodules, fungating breast lesion)
• New onset nipple retraction
• Pathological nipple discharge (Unilateral, spontaneous bloody nipple discharge)
• Inflammatory conditions not responding to antibiotic treatment and follow up
• Enlarged axillary nodes

 

Please Note: Breast pain in isolation is not a symptom of breast cancer

 ROUTINE MAMMOGRAMS

Please Note:

• “Screening mammograms” are not offered to asymptomatic individuals without a specific indication
• Mammograms are only done on patients over 40 years unless there is a history of previous breast cancer, or other family members had their cancers at a very young age.
• Patients under 40 receive a point-of-care ultrasound in the breast clinic if they present with a breast lump.
• There is no indication to repeat a routine mammogram if the patient had a normal mammogram in the last year, unless there are new concerning symptoms.
• Routine mammograms are not done on patients with symptoms of breast cancer; these patients need to be referred to a diagnostic breast clinic. There are 2 clinics in metro West at Groote Schuur Hospital and Mitchells Plain Hospital.

 
INDICATIONS FOR ROUTINE MAMMOGRAMS

Patients with no previous breast cancer

1. A lifetime risk score of > 25% on the IBIS breast risk assessment tool. These patients should have a yearly mammogram, starting at the age of five years before the youngest family member’s age at diagnosis. Ideally, patients with an IBIS lifetime risk of > 25% should be referred and followed up in a high-risk breast clinic.
2. Hormone Replacement Therapy (HRT), these patients should have a mammogram before starting and every 2-3 years while on treatment.
3. Patients older than 50 years with isolated unilateral focal breast pain that is not responding to a trial of NSAIDS after 3-6 months of follow-up.

Patients with previous breast cancer

1. Breast-conserving treatment initially
   
   • Mammogram yearly for 5 years in all patients
   • Stop after 5 years if there is no family history of breast cancer, or the patient is older than 70.
   • Continue 2 yearly if there is a family history of breast cancer. A first-degree (mother, sister, daughter)  or 2 second-degree family members (aunt, grandmother)
   • In young patients, especially if they had their first cancer before 40 years, continue with 2 yearly mammograms until 70, even if there is no family history.
2. Mastectomy initially
   • Mammogram of the contralateral breast every 2 years x 3
   • Stop after 5 years if there is no family history of breast cancer, or the patient is older than 70.
   • Continue 2 yearly if there is a family history of breast cancer. A first-degree (mother, sister, daughter)  or 2 second-degree family members (aunt, grandmother)
   • In young patients, especially if they had their first cancer before 40 years, continue with 2 yearly mammograms until 70, even if there is no family history.

 

Routine Mammogram Referral

To refer to the Groote Schuur Breast Mammogram Service use this link: Groote Schuur Hospital Mammogram 

Patients over 20 years of age

All patients with a lump in the breast over the age of 20, regardless of the size of the lump, need to be referred to a breast clinic

To refer to the Groote Schuur Breast clinic use this link: Groote Schuur Hospital Breast Clinic

To refer to the Mitchells Plain breast clinic use this link: Mitchells Plain Hospital Breast Clinic

 

Patients under 20 years of age

If your patient is younger than 20 you can refer your patient to our clinics if the lump is more than 4cm in size (golf ball size) or if there are any other symptoms of breast cancer. Remember breast cancer is almost unheard of in teenagers and it is completely acceptable to reassure and follow up young patients if their lumps are small.

If you want to make a booking for a teenager in our clinics please email us at breastsurgendo@gmail.com

 Paget's disease of the nipple

Pagets's Disease of the nipple presents as an excoriation / non-healing wound on the nipple. The nipple is almost always involved, which often distinguishes it from eczema of the nipple-areola complex, where the nipple is often not involved. Paget's disease requires a punch biopsy of the nipple to make a diagnosis and needs to be referred to the a specialist breast clinic. If possible the punch biopsy should be performed at primary health care level as this is not considered a specialist investigation.

 

Eczema of the nipple-areola complex

Eczema of the nipple-areola complex is common and needs to be distinguished from Paget's disease of the nipple. The nipple is usually spared, and patients present with a "wheeping" rash. Patients should be told not to use any soap on the affected skin. They should wear a bra made of 100% cotton. Bras made with nylon and polyester should be avoided (the tag on the bra should show the composition of the material). Betamethasone 0.05% ointment daily should be the first-line treatment. This can be followed by Hydrocortizone 1% once better for a lasting result. If there is suspicion of Paget's disease or no response to treatment the patient should be referred.

Breast clinic referral

To refer to the Groote Schuur Breast clinic use this link: Groote Schuur Hospital Breast Clinic

To refer to the Mitchells Plain breast clinic use this link: Mitchells Plain Hospital Breast Clinic

 

Remember teenagers are not routinely seen at our clinic. If you want to make a booking for a teenager in our clinics please email us at breastsurgendo@gmail.com

 

 

 

Any new onset skin or nipple distortion or nipple retraction is considered o symptom of breast cancer and needs to be referred to the breast clinic.

Breast clinic referral

To refer to the Groote Schuur Breast clinic use this link: Groote Schuur Hospital Breast Clinic

To refer to the Mitchells Plain breast clinic use this link: Mitchells Plain Hospital Breast Clinic

 

Remember teenagers are not routinely seen at our clinic. If you want to make a booking for a teenager in our clinics please email us at breastsurgendo@gmail.com

 

 

Premenopausal 

The nodularity needs reassessment 7 days after the patients next menstrual cycle if the nodularity persists, then she needs to be referred to our clinic. Please do not refer these patients without follow up.

 

Postmenopausal

All postmenopausal patients with asymmetrical nodularity need to be referred to our clinic

Breast clinic referral

To refer to the Groote Schuur Breast clinic use this link: Groote Schuur Hospital Breast Clinic

To refer to the Mitchells Plain breast clinic use this link: Mitchells Plain Hospital Breast Clinic

 

Remember teenagers are not routinely seen at our clinic. If you want to make a booking for a teenager in our clinics please email us at breastsurgendo@gmail.com

 

 

Please note:

Only pathological nipple discharges should be referred to our clinic.

 

What is a pathological nipple discharge?

A pathological nipple discharge should meet the following criteria:

1. It should be spontaneous and not expressed
2. It should be coming from a single duct
3. It should be bloody or a copious clear discharge

 

What if the discharge does not meet these criteria?

If the discharge does not meet these criteria, there is no need to refer the patient. You can reassure your patient that the discharge is physiological. She should refrain from squeezing their nipple, and she can be discharged.

Breast clinic referral

To refer to the Groote Schuur Breast clinic use this link: Groote Schuur Hospital Breast Clinic

To refer to the Mitchells Plain breast clinic use this link: Mitchells Plain Hospital Breast Clinic

 

Remember teenagers are not routinely seen at our clinic. If you want to make a booking for a teenager in our clinics please email us at breastsurgendo@gmail.com

 

 

Mastitis is common and a distinction is made between lactating and non-lactating breast infections

 

Lactating breast infections

These infections occur in breastfeeding mothers. The most common organism is Staph Aureus, and the antibiotic of choice is Flucloxacillin. Start the patient on Flucloxcacillin and follow her up in 5 to 7 days. If there is no response or worsening of the infection, she will need a referral for assessment. If there is a large abscess in the breast, the patient needs to be referred to the nearest acute surgical facility and not the breast clinic.

 

Non lactating breast infections

These infections occur in women with no history of current or recent breastfeeding. The first choice of antibiotic is Co-amoxiclav. Start the patient on Co-amoxiclav and follow her up in 5 to 7 days. If there is no response or worsening of the infection, she will need a referral for assessment. If there is a large abscess in the breast, the patient needs to be referred to the nearest acute surgical facility and not the breast clinic.

Breast clinic referral

To refer to the Groote Schuur Breast clinic use this link: Groote Schuur Hospital Breast Clinic

To refer to the Mitchells Plain breast clinic use this link: Mitchells Plain Hospital Breast Clinic

 

Remember teenagers are not routinely seen at our clinic. If you want to make a booking for a teenager in our clinics please email us at breastsurgendo@gmail.com

 

 

 

Patients with a breast abscess should not be referred to the breast clinic. Please refer your patient to your nearest facility where the abscess can be drained. This is usually the same facility where other acute surgical patients are referred to in your drainage area.

If you feel your patient should be seen because of concern, please contact us by email at breastsurgendo@gmail.com  

Breast Pain (Mastalgia) 

Patients with breast pain as their only symptom are not seen at a specialist Breast Clinic. They can be treated by their primary healthcare provider. The treatment is not complex, and these patients do not require any special investigations. Mastalgia on its own is not a symptom of breast cancer. Mastalgia is not an indication for a mammogram.

Most women (up to 7 in 10 women) develop breast pain at some stage in life develop breast pain at some stage in their life.

In about 2 in 3 women the pain develops in the days just before a period - cyclical breast pain.

In the remainder, the pain is not related to periods - non-cyclical.

 

 What are the treatment options for breast pain?

The value of reassurance cannot be overstated. Patients are worried that they have breast cancer. This is not the case in patients with isolated mastalgia, and they should be reassured. This is often all that is needed. Breast pain is as common as a headache, and just as not every headache needs to be seen by a neurologsist, not every mastalgia needs to be seen by a breast specialist. If there are no "red flag" symptoms of breast cancer the patient can be managed in the primary healthcare environment.

No treatment may be needed if the symptoms are mild. 

If the pain is more severe, or for the times when it may flare up worse than usual, treatment options include the following:

1. Support the breasts. A well-supporting bra should be worn. Some women find that wearing a supporting bra 24 hours a day for the week before a period is helpful. It is best to avoid underwired bras. Wear a sports bra during exercise.
2. Painkillers such as paracetamol or ibuprofen. Take regularly on the days when the breasts are painful.
3. Topical ('rub-on') anti-inflammatory cream. For example, topical diclofenac or topical ibuprofen (Voltaren Gel).
4. Evening primrose oil is often recommended as a treatment for breast pain. A dose of 1-3gms (2-6 tablets) of Evening Primrose oil each day for a period of 6 weeks is required before the benefit can be assessed. Improvement in the severity of cyclical and non-cyclical mastalgia is 58% and 38% respectively. If symptoms improve, continue these tablets.

Most lumps and swellings in men are not a sign of cancer. They are usually caused by something fairly harmless, such as gynecomastia, a lipoma or a cyst. Breast cancer in male patients, although rare, does exist. Any patient with a symptom of breast cancer needs a referral. The symptoms of male breast cancer are exactly the same as for female breast cancer

 

Gynecomastia 

Gynaecomastia can vary from a small, firm enlargement of breast tissue just behind the nipple to a larger, more female-looking breast. Gynaecomastia can affect one or both breasts. The area can be tender to touch or painful.

 

Which patients do not need a referral?

• Adolescents with physiological gynecomastia
• Elderly men with senile gynecomastia
• Drug-related cause
• Fatty pseudo-gynecomastia

 

Which patients need a referral?

• Eccentric hard mass (Refer to the Breast Clinic for biopsy)
• Rapid enlargement (Refer to the appropriate clinic if abnormal blood tests otherwise, Breast Clinic)
• Recent onset in lean >20 yr old (Refer to the appropriate clinic if abnormal blood tests otherwise, Breast Clinic)
• Persistent painful gynecomastia (Refer to the appropriate clinic if abnormal blood tests otherwise, Breast Clinic)
• Adolescents with massive gynecomastia (Refer to the appropriate clinic if abnormal blood tests otherwise, Plastic Surgery Clinic)
• Adolescents with gynecomastia persisting > 18-24 months (Refer to the appropriate clinic if abnormal blood tests otherwise, Plastic Surgery Clinic)

 

What blood tests need to be done for patients with gynecomastia?

Patients that meet the referral criteria above need the following blood tests before referral 

• 9am Testosterone (If abnormal, refer to Medical endocrine clinic via VULA app)
• Thyroid function (If abnormal, refer to Medical endocrine clinic via VULA app)
• Liver function (If abnormal, refer to Liver clinic via VULA app)

• B-HCG (If abnormal, refer to Urology Clinic)
• Alfa-fetoprotein (If abnormal, refer to Urology Clinic)

Breast clinic referral

To refer to the Groote Schuur Breast clinic use this link: Groote Schuur Hospital Breast Clinic

To refer to the Mitchells Plain breast clinic use this link: Mitchells Plain Hospital Breast Clinic

 

Remember teenagers are not routinely seen at our clinic. If you want to make a booking for a teenager in our clinics please email us at breastsurgendo@gmail.com

 

 

Benign Conditions

Bilateral macromastia is a benign condition not seen in the breast clinic. Please refer to the link below for more information regarding the referral of patients for a breast reduction

 

Criteria and referral process for breast reduction at Groote Schuur Hospital

 

 

Patients known with breast cancer and symptoms of distal metastasis need to be referred to Oncology at LE 33

Please contact 021 4044267 to arrange an appointment directly with the Breast Oncology Department

Please do not send these patients to the breast cancer, they will not be seen

 

 

These patients need to be referred to the breast clinic for a biopsy

Breast clinic referral

To refer to the Groote Schuur Breast clinic use this link: Groote Schuur Hospital Breast Clinic

To refer to the Mitchells Plain breast clinic use this link: Mitchells Plain Hospital Breast Clinic

 

Remember teenagers are not routinely seen at our clinic. If you want to make a booking for a teenager in our clinics please email us at breastsurgendo@gmail.com

 

 

All patients with enlarged axillary nodes need to be referred to the breast clinic

Breast clinic referral

To refer to the Groote Schuur Breast clinic use this link: Groote Schuur Hospital Breast Clinic

To refer to the Mitchells Plain breast clinic use this link: Mitchells Plain Hospital Breast Clinic

 

Remember teenagers are not routinely seen at our clinic. If you want to make a booking for a teenager in our clinics please email us at breastsurgendo@gmail.com

 

 

Please note:

These patients need to be referred to a Friday Breast clinic at Groote Schuur Hospital

If your patient lives in the Mitchells Plain Hospital drainage area, please email us to breastsurgendo@gmail.com to facilitate a referral to the Groote Schuur Breast Clinic.

The reason for this is that oncology see all new patients on a Friday at the Groote Schuur Hospital Breast Clinic.

 

Breast clinic referral

To refer to the Groote Schuur Breast clinic use this link: Groote Schuur Hospital Breast Clinic