What is the triple assessment for breast cancer?

Triple Assessment for Breast Cancer

The triple assessment for breast cancer consists of clinical examination, imaging (mammography and ultrasound), and pathological assessment through core needle biopsy, which together provide a highly accurate diagnostic approach with nearly 100% sensitivity when used in combination. 1, 2

Components of Triple Assessment

1. Clinical Examination

• Bimanual palpation of breasts and regional lymph nodes
• Assessment for distant metastases (bones, liver, lungs)
• Evaluation of any palpable abnormalities including size, shape, consistency, and mobility

2. Imaging

• Mammography: Bilateral mammography is the primary imaging modality

  • Two views of each breast should be performed in screening programs 3
  • Digital breast tomosynthesis (3D mammography) may improve diagnostic accuracy, especially in women with dense breasts 3

• Ultrasound:

  • Essential complementary imaging to mammography
  • Particularly valuable for younger women, dense breasts, and evaluating palpable masses
  • Should be performed even with negative mammography if there is a discrete clinical mass 3
  • Used for guiding tissue sampling procedures

• MRI (not routinely part of triple assessment):

  • Reserved for specific situations such as:
    • Familial breast cancer with BRCA mutations
    • Lobular cancers
    • Dense breasts
    • Suspected multifocality/multicentricity
    • Discrepancies between conventional imaging and clinical examination
    • Before neoadjuvant therapy 3

3. Pathological Assessment

• Core needle biopsy: Preferred method for tissue diagnosis

  • Preferably obtained by ultrasound or stereotactic guidance 3
  • Allows for histological diagnosis and determination of biomarkers (ER, PR, HER2, Ki67)
  • More reliable than fine needle aspiration cytology (FNAC) with diagnostic rates of 95.5% 1

• Fine needle aspiration cytology (FNAC):

  • May be used but has lower sensitivity (73.2%) compared to core biopsy 1
  • Cannot reliably distinguish between invasive and in-situ carcinoma

Diagnostic Performance

The combined triple assessment approach significantly outperforms any single modality:

• When all three components are positive for malignancy, the positive predictive value is 100% 1
• When all three components are negative, the negative predictive value is 100% 4
• Overall accuracy of 99.3% when all modalities are used together 2, 5

Clinical Implementation

1. Initial Assessment:

   • Complete clinical breast examination
   • Bilateral mammography and ultrasound of breast and regional lymph nodes
   • Core biopsy of suspicious lesions (preferably image-guided)

2. Interpretation:

   • Triple assessment is considered positive if any component suggests malignancy
   • Triple assessment is negative only if all components are negative 2
   • Discordant results require further investigation, usually with open biopsy

3. Multidisciplinary Discussion:

   • Diagnostic findings should be discussed by a multidisciplinary team 3
   • When imaging raises sufficient suspicion, histological verification should be performed using interventional breast diagnostic techniques

Important Considerations

• Early recall for repeat mammography is not recommended and should never substitute for adequate assessment 3
• For impalpable lesions, radiological-pathological correlation is essential 3
• A marker (surgical clip, carbon) should be placed into the tumor at biopsy to ensure correct surgical resection site 3
• In cases of DCIS, lobular carcinoma in situ, or atypical hyperplasia on needle biopsy, confirmation with surgical excision is recommended 3

Pitfalls to Avoid

• Relying on a single assessment modality can lead to missed diagnoses
• Failing to correlate radiological and pathological findings
• Performing unnecessary biopsies when triple assessment is concordantly benign
• Recent research suggests that clinical core biopsies may not be necessary for non-suspicious palpable lesions (S3) with normal imaging (R1/R2) 6
• Accepting poor quality mammograms that don't meet diagnostic standards 3

The triple assessment approach has revolutionized breast cancer diagnosis by providing a highly accurate, minimally invasive diagnostic pathway that can often be completed within 24-72 hours 5, allowing for prompt treatment planning and reducing unnecessary surgical biopsies.