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Dr. Michael Michell: Who is the leader of the pack?

The traditional surgeon-led organisation and structure of the diagnostic breast clinic has recently been challenged. This is due to many things, including, changes in the natures of the population of patients presenting to the clinic, radical improvements in many of the diagnostic techniques employed and the expectation of the public that an accurate diagnosis will be achieved with minimum delay.

Greater public awareness of breast disease and emphasis on early diagnosis of malignancy has resulted in increased numbers of women presenting with minor symptoms and signs and a lower proportion of patients with malignancy. Patients with breast cancer may present with minimal non-specific signs such as change in texture or lumpiness and interpretation of such signs is difficult and unreliable.

Accurate diagnosis of both benign and malignant breast lesions relies on the wellestablished triple diagnostic method. There are many developments in imaging. These include the implementation of digital mammography, high resolution ultrasound and the widespread use of image guided sampling techniques which have led to improved diagnostic accuracy – diagnostic surgical excision is now rarely required. Further improvements (due in particular to the introduction of advanced applications of digital imaging such as tomosynthesis) are anticipated. It is essential in both the private and public healthcare systems that such new and expensive technology is used efficiently.

The traditional model of initial clinical assessment by a surgeon is no longer appropriate and has already been abandoned by a third of such clinics in the UK. Several different models of delivery are currently under evaluation. Appropriate diagnostic pathways are developed according to the patients age, and presenting symptoms and signs.

Effective leadership of the diagnostic breast service is essential to ensure that modern technology and the clinical skills and knowledge of all members of the multidisciplinary team are used most efficiently and effectively. Such leadership requires specialist clinical experience and knowledge of breast disease together with expert negotiation, communication and management skills.