Breast cancer has become a leading health concern in the United Kingdom. For a British woman, the life time risk of being diagnosed with breast cancer is 1 in 9. (1 in 7, USA)

Risk Factors:

Age: The risk of breast cancer shows a linear increase with age.

Family History: Any positive family history increases a woman's risk of breast cancer. (See details under Familial Breast Cancer section.)

Age of Menarche: Women who have regular ovulatory cycles before age 13 have a fourfold greater risk than those whose menarche has occurred after 13 years.

Age of Menopause: Women who experience menopause after 55 years have a 2 fold risk of breast cancer compared to women who experience menopause before age 44.

Incidence of breast cancer correlates well with life time exposure to oestrogen. Thus a woman with early menarche and late menopause will have a higher risk of developing breast cancer.

Age at first birth: Women who have had their child before age 19 have half the risk compared to a woman who has not given birth (nulliparous), while women who have had their first child between 30-34 years have the same risk as nulliparous women. Child birth after 35 years has a even greater risk than nulliparous women.

Oral Contraceptive pills: The potential of exogenous hormones to increase a woman's risk of breast cancer remains controversial. Some studies show prolonged use of oral contraceptives (greater than 10 years) may be associated with an increased risk of breast cancer.

Obesity: Potential risk factor especially in post menopausal women.

Alcohol: contributing factor.

Exposure to ionising radiation: for treatment of Hodgkin's disease has been associated with increased risk if the exposure was before age 30 years.

How do I know that I may be having breast cancer?

Breast cancer commonly presents as a painless firm lump in the breast. This lump may be associated with enlarged glands in the arm pit. (axillary lymph nodes.) The lump may involve the overlying skin and can present in the form of ulceration, thickening and/ or orange peel like appearance of the overlying skin and skin nodules. Breast lump may get adherent to the underlying muscle (pectoralis major) or the underlying chest wall. Breast cancer may rarely present as blood stained nipple discharge. There could be in drawing of the nipple with destruction of the nipple in some cases. If you feel you have any of the above findings while you examine your breasts, then you need to contact your G.P urgently.

What do I do next?

If you have any of the findings as mentioned above, you need to get in touch with your GP urgently. The GP will in turn refer you to the One Stop Breast Clinic.

FORMAT OF ONE STOP CLINIC

If the tumour is proven to be malignant, then you need to undergo appropriate treatment depending on the stage of the cancer.

Is my breast cancer in the early stage?

Broadly, breast cancers can be divided into 4 stages:

Early Stage Breast Cancer (ESBC), Stage 1: in simple words means cancer is confined to the breast and has not spread to other sites in the body. Generally the cancer is less than 5 cms. across, free from the underlying muscle (pectoralis major) and chest wall and no skin involvement. The glands in the armpit are not enlarged.

Locally Advanced Breast Cancer (LABC), Stage2, 3: means a cancer that is more than 5 cms. across OR a cancer of any size that has grown into the skin or the underlying muscle or chest wall. The lymph glands in the armpit may be enlarged and involved with cancer.

Metastatic Breast Cancer (MBC) Stage 4: cancer of any size with spread to distant organs, i.e.: liver, lungs, bones, or to lymph glands in the opposite armpit.

Although, early stage breast cancers have less than 2% chance of spreading to the distant organs, investigations to rule out distant spread (metastases) could be asked for depending on the findings in individual patients.

Locally Advanced breast cancer have a higher chance of spreading to the distant organs, and most of the times investigations to rule out distant spread will be asked for.

What are the investigations done to rule out distant spread?

Ultrasound scan / CT scan of the abdomen: to rule out spread to liver, ovaries.
X-ray Chest / CT scan of the chest: to rule out spread to the lungs.
CT scan of the neck: to rule out involvement of the lymph glands in the neck.
Radionuclide Bone Scan: to rule out spread to bones.

What treatment will be offered if I have early stage breast cancer?

Early stage breast cancer can be operated primarily and you would not require chemotherapy before surgery.

Surgery could be in the form of:

Wide excision of the lump with axillary lymph node dissection( WLE+ ALND):
In this procedure, the breast is preserved and only the lump is widely excised along with the lymph glands in the armpit. All patients undergoing this procedure will need radiotherapy to the breast 4-6 weeks after surgery.
Not all patients can have their breasts preserved. If the cancer involves a significant proportion of the breast or appears to have more than one focus, then the breast cannot be preserved.

Modified Radical Mastectomy (MRM): The entire breast tissue along with the draining lymph glands in the armpit is excised, preserving the underlying muscle (pectoralis major).
Post operative radiotherapy depends on the number of involved lymph glands in the arm pit.

Will I be given Chemotherapy after surgery?

This will depend on the size of the tumour and the number of lymph glands involved with tumour.
Chemotherapy is generally started 3-4 weeks after surgery. It is in the form of intravenous injections and infusions and 4-6 cycles are given 3 weekly.

Will I be given Tamoxifen (Hormonal therapy)?

All the tumours that are removed surgically are send for histo-pathological examination.
Special studies are performed to detect the presence of Oestrogen receptors.

All pre-menopausal ladies with oestrogen receptor positive tumours will receive tablet Tamoxifen(20mg) daily for 5 years.

All postmenopausal ladies, irrespective of their tumour oestrogen receptor status will receive tablet Tamoxifen(20mg) for 5 years.

What treatment will be offered if I have locally advanced breast cancer?

Locally advanced breast cancers cannot be operated upon primarily and need pre-operative chemotherapy to shrink the tumour size.
The response to chemotherapy can be:
Complete: more than 75% of the tumour shrinks.
Partial: less than or 50% of the tumour shrinks.
Static: no response
Progression: increases in size on chemotherapy.
Response to chemotherapy will be assessed before every cycle by the treating doctors.

Surgery could be in the form of WLE + ALND or MRM depending on the tumour response to chemotherapy.

All patients with locally advanced breast cancer will need postoperative radiotherapy.

Patient will generally get 6 cycles of chemotherapy at 3 weeks interval. If they have received 3 cycles of chemotherapy before surgery, then the next three cycles would be started 10-15 days after the surgery, once the surgical wound has healed.

All pre-menopausal ladies with oestrogen receptor positive tumours will receive tablet Tamoxifen(20mg) daily for 5 years.

All postmenopausal ladies, irrespective of their tumour oestrogen receptor status will receive tablet Tamoxifen(20mg) for 5 years.

What treatment will be offered if I have metastatic breast cancer?

Metastatic breast cancers are generally treated with a combination of chemotherapy, hormonal therapy and or radiotherapy depending on the site of distant spread.

Surgery is only indicated if the breast tumour is fungating or bleeding.

Will removing the entire breast (Mastectomy) be better than a breast preserving surgery?

It has been proven beyond doubt, that breast preserving surgery followed by postoperative radiotherapy has similar recurrence and long term survival rates as compared to a Mastectomy.

Does that mean all patients with breast cancer can opt for breast preserving surgery?

No, unfortunately all patients cannot be offered breast preserving surgery.
Contraindications for breast preserving surgery:
If the cancer has more than one focus in the breast.
Satisfactory cosmesis is unlikely.
Pregnant ladies (especially in the 1st and 2nd trimester of pregnancy). This is because all patients undergoing breast preserving surgery would need postoperative radiotherapy which can cause harmful effects on the growing foetus.

Once operated will I have to come for regular follow up or further treatment in the Breast clinic?

You would have to come for follow up to the breast clinic every 3 months for the first two years and then every 6 months for the next 3 years.
Mammograms would be done every 18 months after your surgery.

As mentioned earlier, most women will be recommended to have some further treatment after surgery to minimise the risk of the cancer recurring. We work closely with the cancer centre at Charing Cross Hospital, and following your surgery, you will usually be given an appointment to see the specialist team. The type of treatment will vary according to individual circumstances. If there is any thing you do not understand or are unsure about, please do ask.

The main factors influencing the selection of treatments are:
· the type and size of cancer,
· the extent of surgery performed,
· the presence/absence of cancer cells in the lymph nodes under the arm,
· whether or not the patient has been through the menopause.
· whether or not the cancer has hormone receptors
· signs of spread to other parts of the body

The following treatments are the ones most commonly recommended:

Radiotherapy:
Radiotherapy will usually be recommended to treat the remaining breast tissue when patients have had an operation which removes only part of the breast.
Radiotherapy is treatment with high energy rays accurately directed to the breast tissue with the intention of eradicating any abnormal cells. The treatment is carried out at Charing Cross Hospital. This involves an initial appointment for the planning and simulation of treatment when X rays and measurements will be taken as the treatment is 'set up'. It is important to have regained reasonable arm movement to enable you to be comfortable in the treatment position. The course of treatment usually starts a couple of weeks later and then you will need to attend daily, Monday to Friday each week for a period of about 6 weeks. The treatment can cause some tiredness, but otherwise the side effects are local to the area being treated. The skin may become red during treatment and very occasionally 'weepy'. This will improve once treatment is completed.

Tamoxifen:
Tamoxifen is frequently used in post menopausal women, but may also be of benefit to some pre menopausal women.
Tamoxifen is one of the most commonly used hormone therapies. It works by blocking the stimulating effects that oestogen has on tumour cells. It is taken as a tablet, once a day and maybe continued for up to five years. There may possibly be some side effects which can include hot flushes, weight gain, vaginal discharge or bleeding. Occasionally nausea or skin rash may occur. Many of these effects settle after a time and generally the drug is well tolerated. Pre menopausal patients may experience changes in the menstrual cycle. Care should be taken to avoid the risk of pregnancy by using barrier methods of birth control.
Repeat prescriptions are available from your own G.P.

Chemotherapy:
Chemotherapy is most commonly used for pre menopausal women who have cancer cells identified in the lymph glands. It may also be recommended in other instances; in either pre or post menopausal women if there are indications to suggest that chemotherapy would be of benefit or where Tamoxifen is not suitable.

Chemotherapy is treatment with a special group of drugs (cytotoxics) which have a destructive effect on dividing cells in the body. There are several different combinations of drugs which have been shown to be effective against breast cancer.
Treatment is usually given either as a course of injections into a vein or as a combination of injections and tablets. Each course will be repeated every 3-4 weeks for up to six months. This is usually done on an outpatient basis at Charing Cross Hospital.
Chemotherapy will have an effect on some of the normal cells of the body and this may cause side effects during treatment which will pass as the cells recover.
The blood cells are affected and regular blood tests will be carried out to monitor this. You will be given specific advice about this and also about symptoms which need attention.
The cells of the ovaries may be affected and menstrual periods can become irregular or stop during treatment. They may then return but this is very individual. Future fertility may be affected and this should be discussed fully prior to commencing treatment.
Generally for a few days after the treatment you may feel 'under the weather'. Other side effects may include nausea, sore mouth, diarrhorea, thinning or loss of hair; but will vary depending on the different drugs used. The potential side effects will be explained to you in relation to your plan of treatment and where possible you will be given advice and medication to help minimise these effects.

The above treatments are the ones which are recommended in the majority of cases, but in some instances other alternatives may be offered.

Charing Cross Cancer Centre is actively involved in research for breast cancer. By studying groups of women undergoing specific treatments, important information can be gained to help the future treatment of breast cancer. For this reason you may be asked to enter into a clinical trial. This will be fully discussed with you and you will be allowed time to make a decision. You are under no obligation to participate.

We aim to provide information appropriate to each patient by individual discussion in addition to this general information. Please do let us know if you have any uncertainties or queries and we will try our best to help. You may find it helpful to write down any particular points that you would like to discuss.

If you require further advice or information please contact the
Macmillan Breast Care Nurses, Hazel Ricard and Hilary Rickwood on 020 8565 5885