Q&A: Breast cancer
The questions below were raised - and answered by our expert consultants - at one of our regular GP Education Days
What are the main symptoms for breast cancer and when should we be referring?
In reference to the ABS Best Practice guidelines 2010 regarding referral criteria:
Patients with the following symptoms or signs should be referred for assessment. All patients referred to the breast clinic should receive an appointment within two weeks of the date of receipt of the referral.
- Lump, lumpiness, change in texture
At any age:
- Discrete hard lump with fixation +/- skin tethering/dimpling/altered contour
- A lump that enlarges
- A persistent focal area of lumpiness or focal change in breast texture
- Progressive change in breast size with signs of oedema
- Skin distortion
- Previous history of breast cancer with a new lump or suspicious symptoms
- Persistent unexplained axillary swelling
- Spontaneous unilateral blood stained nipple discharge
- Unilateral nipple eczema or nipple change that does not respond to topical treatment
- Recent nipple retraction or distortion
- Over 50 years with unilateral firm subareolar mass +/- nipple discharge or associated skin changes
Women who can be managed at least initially by GP:
- Women under 30 with new breast lump that have not had a period since first noticing it – as long as no other concerning symptoms are present. Refer if it persists.
- Women under 50 years who have nipple discharge that is from multiple ducts or is intermittent and is neither blood stained nor troublesome.
- Patient with minor/moderate degree of breast pain, especially bilateral breast pain, with no discrete palpable abnormality. Refer if the symptoms are persistent.
It’s important to note that bilateral discharge is almost never malignant however it might warrant prolactin (PRL) for prolactinoma. Malignant nipple discharge is usually single duct, and can be blood stained or translucent. Benign nipple discharge is often multiduct, often creamy, but can be green/yellow/brown.
There is also a difference between retraction and inversion. Nipple inversion is usually slit-like, and can be averted. It often results from duct ectasia or fibrosis, and is benign.
Nipple retraction is often when the areola is distorted more than nipple. It can sometimes be circumferential pulling in but the nipple usually visible (unless it is very late stage).
One thing to note is that breast pain is rarely mentioned in the NICE guidelines, and is not usually associated with breast cancer.
Is genetic screening for breast cancer offered?
Women who have breast cancer in their family history or an inherited faulty gene can only have breast screening younger than 50 years old (the starting age for the UK screening programme), if referred to a genetic specialist. There was a study which looked at screening for women aged 40 to 49 with a family history of breast cancer (FH - 01), which found that yearly mammograms for women at an increased risk of breast cancer meant that cancers were diagnosed at an earlier stage.
At The Royal Marsden, we do not offer genetic screening for direct GP referrals as we are not a genetics referral centre. We can see people for family history assessment in order to consider screening from the age of 40. If, on this assessment, they appear to qualify for a genetic test as an unaffected individual i.e. they have not got cancer then we can refer in-house to genetics for a test. Living family members with the disease would be offered the test first however as it is a more effective route.
We do not see women under the age of 40 no matter what their family history as screening does not start until 40. If a women is proven to carry the gene – or their GP already has this knowledge- then their screening is MRI from age 35 and is done by the National Screening Programme.
What are the chances of infertility following breast cancer and what is the feasibility of surrogacy and IVF?
Patients who have experienced breast cancer may have infertility issues. This can be caused by a number of reasons:
- the type of treatment
- type and stage of the cancer at diagnosis
- age of the patient.
Usually, patients who have undergone surgery or radiotherapy for their breast cancer will not have their fertility affected. For those that are treated with chemotherapy, there is a risk of developing premature ovarian failure or very early menopause.
For those women who do experience fertility difficulties, there are options. There is the option of surrogacy through the following routes:
- A frozen embryo is implanted into the surrogate, who carries it to term.
- A frozen egg is fertilised by the partner's sperm and then carried to term by the surrogate.
- A frozen egg is fertilised by donor sperm and then carried to term by the surrogate.
Many women have found surrogates on their own, however it is recommend using an established, reputable centre for the extra reliability.
There is also the option of embryo preservation or IVF. With IVF, the patient takes hormones to stimulate their ovaries to increase egg production. These eggs are removed and fertilised with sperm from a partner or with donor sperm. This embryo can be frozen and stored, and at a later date implanted in the womb. There is some concern that these hormones could stimulate breast cancer cells to grow. IVF may also delay treatment as the patient will need to have egg collection and fertilisation done before they start treatment.
There have been recent studies where eggs have been collected from the ovaries using smaller doses of hormones. Natural IVF has also been looked into where doctors collect eggs during the normal menstrual cycle.
IVF is available for some people on the NHS but not in all parts of the country and the number of treatments a patient can have differs from area to area. IVF can also be paid for.
One thing to note is that the younger the woman, the better her chances of maintaining her fertility. However, if she has an oestrogen dependant tumour, the longevity of the treatment can cause its own problems. Pregnancy should be avoided while on tamoxifen due to the risk of foetal abnormalities.
Are there any particularities to breast cancer treatment in older women as with younger women?
Treatment decisions for breast cancer patients should be based on a variety of factors rather than on age, such as tumour characteristics, patient health, life expectancy, treatment tolerance, estimated absolute benefit, and patient goals and preferences.
Depending on current health, older women can and should be treated with the same standard as younger women. There has been some evidence to suggest that older women have a lower bone marrow reserve, so are at a higher risk of neutropenia when going through chemotherapy, however should still be treated holistically. With regards to surgery, there is the overall risk for general anaesthetic in older people, however it’s usually the first treatment to remove the lump/breast so the decision will be spoken through with the patient and anaesthetist as to whether it could be carried out under local anaesthetic. All women should be offered reconstruction after surgery, however there has been research shown that elderly people do not feel they get the same options as younger women.
Due to the side effects of chemotherapy on fertility chances, some younger women will opt to have surgery and radiotherapy before they consider chemotherapy.
Why is it called triple-negative breast cancer?
Triple-negative breast cancer is when the pathology test shows negative for estrogen receptors (ER-), progesterone receptors (PR-), and HER2 (HER2-). These negative results mean that the growth of the cancer is not affected by the hormones estrogen and progesterone, or by the existence of too many HER2 receptors. This means that triple-negative breast cancer does not respond to hormonal therapy such as tamoxifen, or therapies that target HER2 receptors, such as Herceptin.
Triple-negative breast cancer can still be treated with other methods such as surgery, radiotherapy and chemotherapy, and there is a lot of research being carried out to find new medications that can treat this type of cancer.
What is intraoperative radiotherapy?
Intraoperative radiotherapy is a technique delivering radiotherapy during surgery. The patient remains under anaesthetic in theatre and immediately after their tumour has been removed, low-energy x-rays are directed to the area. There are a number of benefits of this treatment option. One being that the radiation beam does not travel through other parts of the body, so there is less risk of side effects. Secondly, there is no delay between the surgery and delivery of radiotherapy, so it only involves one hospital visit for the patient.
However, there are some risks associated, for example it increases the length of the surgery.
Is there any unified breast cancer management, or is it based purely on NICE guidelines?
Breast cancer management will be determined on a number of factors. The pathology report provides information that will advise the MDT the best treatment choice for the diagnosis. Breast cancer management is based on the size and appearance of the cancer, how quickly it grows and if there are signs of metastasis.
NICE 2016 guidelines state the below for early and locally advanced breast cancer: diagnosis and treatment:
- Preoperative assessment of the breast
- Staging of the axilla
- Surgery to the axilla
- Breast reconstruction
- Adjuvant therapy planning
- Aromatase inhibitors
- Assessment of bone loss
- Primary systemic therapy
- Follow-up imaging
- Clinical follow-up
For more detail, please visit the NICE website.
Can you advise about the use of topical oestrogens (vaginal) in women with breast cancer?
The long-term risks of using topical oestrogen creams after breast cancer are still fairly unknown. Some studies have shown that the use of topical creams after the diagnosis of breast cancer should only be initiated in cases where the patient experiences a high degree of distress, and if it needs to be prescribed then an ultralow dosed formula should be used whenever possible in the first few weeks. Patients also need to be provided with the knowledge of increased risk of recurrence is possible.
There are non-hormonal alternatives that can be prescribed (in the case of vaginal atrophy). Replens MD is a cream applied 2–3 times a week which binds to the vaginal wall and helps rehydrate cells as well as increasing blood flow in the vagina. There is also Hyalofemme that can be applied daily.
Should we be managing male patients differently when they present with breast symptoms?
NICE guidelines notably phrase it to say ‘people who present with’ not specified female.
In males, the symptoms and diagnosis are very similar to women with breast cancer, so should be treated fairly similarly. When it comes to treatment principles, these are generally the same and treatments available are used equally. Male patients can even have reconstruction.
There is a difference in follow up however as mammography is not offered to men.
The most common symptom for men with breast cancer is a lump in the breast area. This is nearly always painless. Other symptoms can include:
- Discharge from the nipple (this may be blood stained)
- An ulcer under the skin of the breast
- Swelling of the breast
- Nipple retraction
- Lumps in the axilla