Breast cancer

1. What are the statistics for recurrence of breast cancer at 5 and 10 years?

Almost 90 out of every 100 women (almost 90%) will survive their cancer for 5 years or more after diagnosis.

Almost 80 out of every 100 women (almost 80%) will survive their cancer for 10 years or more after diagnosis.

2. What is the management guidance of a malignant breast lump (small) in a patient with implants who will not agree to them (implants) being removed?

The treatment for breast cancer in women who previously had implant augmentation is the same as in those without. If possible breast conservation will be done with the implant left in place. If a mastectomy is required the implant can either be left in place, a new implant reconstruction performed or a reconstruction can be done using the patient’s own tissue. Some women prefer not to have a reconstruction and have the old implant removed.

The approach will depend on the characteristics of cancer the treatment required and the woman’s wishes. If radiotherapy is needed, the scar tissue around the implant often becomes prominent (capsular contracture) leading to discomfort and reduced cosmesis.

3. What is the guidance on managing uncertainty with lumps and bumps?

NICE guidelines state that people should be referred using a suspected cancer pathway referral (for appointment within 2 weeks) for breast cancer if they are:

  • aged 30 and over and have an unexplained breast lump with or without pain, or
  • aged 50 and over with any of the following symptoms in one nipple only: discharge; retraction; other changes of concern [new 2015].

A suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer should also be considered in people:

  • with skin changes that suggest breast cancer, or
  • aged 30 and over with an unexplained lump in the axilla [new 2015].

4. What is the guidance on referral for a patient reporting breast pain?

1 in 5 women seen in breast clinic have breast pain. In the absence of any other symptoms or signs, breast pain is not a sign of cancer. If examination is normal, no further investigation is required in women under 40. Those aged over 40 are offered opportunistic mammogram.

As a GP you could:

  • provide reassurance
  • prescribe NSAIDS to relieve pain, reduce inflammation and bring down a high temperature
  • recommend a supportive bra
  • encourage a reduction in caffeine and red wine intake, if high
  • suggest a trial of evening primrose oil (EPO) to relieve pain.

If the breast pain is persistent and premenopausal, a change in the patient’s oral contraceptive pill, to regulate hormones, could be trialled.

5. Which factors give a better long-term health outcome for breast cancer patients?

Long-term risk is most affected by tumour size, nodal involvement, grade and receptor status. As a rule, Grade 1 or 2, less than 2cm, no nodes involved and ER/PgR positive will indicate a low-risk tumour – although this assumes compliance with treatment. Generally, 5 years of endocrine treatment is considered sufficient in these cases.

Cases of triple negative cancer tend to recur within the first 2-3 years if they are going to, although this is a generalisation. Women can protect themselves by increasing activity and keeping body weight within healthy BMI range.

6. What can you offer women post breast cancer if they request HRT?

We would advise that symptoms are treated individually and with non-hormonal agents in the first instance if the woman had an ER positive cancer. There is growing evidence of efficacy of exercise, acupuncture, diet and mindfulness/meditation/CBT.

If none of this is effective and the woman is struggling, then it becomes a discussion about risk and what they are happy to accept. Referral to a menopause clinic may be helpful for newer interventions.

A woman with an ER negative cancer can have HRT although it still increases her risk of a new cancer with long-term use.

7. What is the guidance on DEXA and osteoporosis treatment post breast cancer?

  • Women who had menopaused early or are on an AI should have a baseline DEXA to assess bone density.
  • If osteopenic, offer lifestyle advice and ADCAL, and re-check in 2 years. A t-score of <-2 and on an AI would indicate a need to start an oral bisphosphonate as well.
  • If osteoporotic, then bisphosphonate and continue AI advised. If unable to tolerate, then to consider the risk - switch to tamoxifen if lower risk or consider IV bisphosphonate or referral to rheumatology team to interrogate further. Generally there is no need to re-check if tolerating bisphosphonate as on maximum treatment, although we often do.
  • Continuity between DEX scans is advised – so do try and have in same hospital.
  • Lifestyle advice of weight-bearing exercise, dietary calcium , stopping smoking and weight management.

Head and neck cancers

What is the guidance on referring neck lumps?

It is important that suspected cancer is referred promptly via the local 2-week-wait (2WW) referral pathway.

As per NICE guidelines (2015):

Laryngeal cancer

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with:

  • persistent unexplained hoarseness, or
  • an unexplained lump in the neck.   

Oral cancer

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:

  • unexplained ulceration in the oral cavity lasting for more than 3 weeks, or
  • a persistent and unexplained lump in the neck.  

Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:

  • a lump on the lip or in the oral cavity, or
  • a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.  

Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) for oral cancer in people when assessed by a dentist as having either:

  • a lump on the lip or in the oral cavity consistent with oral cancer, or
  • a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.  

Thyroid cancer

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump.

What are the red flag symptoms associated with oral cavity lumps?

ALWAYS consider if the presentation may represent mouth cancer. It is important that suspected cancer is referred promptly via the local 2-week-wait (2WW) referral pathway.

High-risk sites for cancer include:

  • Floor of mouth
  • Ventrolateral tongue (especially posteriorly along with adjacent lingual alveolus)
  • Oropharynx

Red flag symptoms:

  • Ulceration – recurrent or persistent. The ulcer may have a raised edge and may discharge blood, but may not be painful.
  • Red and/or white lesions with an irregular surface texture on palpation or appearance – focal or widespread.
  • Unusual lumps or swellings in the mouth, head or neck area.
  • Unexplained numbness or persistent pain in the mouth.
  • Difficulty moving the jaw.
  • Difficulty swallowing.
  • Swelling of the tongue add/or speech problems.
  • Persistent unexplained dry mouth or halitosis.

Register for a GP Education Day

Our free interactive seminars cover aspects of cancer diagnosis, treatment and care, relevant to you as a GP.

Read more