BREAST CANCERS

The information outlined below on the most common breast cancer symptoms, conditions and treatments is provided as a guide only and it is not intended to be comprehensive.

What is ductal carcinoma in situ (DCIS)?

DCIS is an early and non-invasive form of breast cancer, where very abnormal cells have developed within the milk ducts but are unable to invade tissue locally and therefore cannot spread to other sites within the body. As a result of being confined to the breast ducts, a diagnosis of DCIS has an excellent outlook or prognosis following treatment.

What are the symptoms of DCIS?

DCIS often has no accompanying symptoms and it is usually identified incidentally on a mammogram as small white flecks or calcifications. A small number of patients may notice a change in the breast such as a lump, discharge from the nipple or skin change involving the nipple (called Paget’s disease).

How is DCIS diagnosed?

If the radiologist who looks at your mammogram suspects you have DCIS they will arrange for you to have an X-ray guided (stereotactic) biopsy. The biopsy report will follow within a few days and be discussed within the breast cancer MDT.

What is the treatment for DCIS?

The current national treatment recommendations for DCIS involve surgical removal and sometimes radiotherapy to the breast afterwards.

• Wide Local excision with radiation therapy. For small areas of DCIS, removal of the affected breast tissue with breast conserving surgery and post-operative radiotherapy offers safe and successful treatment.

• Mastectomy. For women who have more extensive areas of DCIS, or DCIS involving more than one area of the breast, then a mastectomy may be necessary. This will depend upon the size of the area affected, the size of the patients breast and wherever possible the preference of the patient. This would normally be carried out with an axillary sentinel lymph node biopsy at the same time. Patients who undergo a mastectomy for DCIS are very unlikely to require radiotherapy afterwards, and are very likely to be able to have a breast reconstruction carried out at the same time if they wish (immediate reconstruction).

• Chemotherapy. Chemotherapy is not needed in the treatment DCIS.

• Anti-hormonal therapy. Anti-hormonal therapy is sometimes discussed for individual patients, but is not currently recommended in national guidance.

What is the prognosis for DCIS?

Women with DCIS have an excellent prognosis, but patients treated for DCIS will be offered post treatment surveillance with mammograms to both the treated and non-treated breast following completion of treatment.

Breast cancer is very common and will affect one in eight women in the UK over the course of their lifetime. In 2015 there were 55,000 new patients diagnosed.

What are the symptoms of invasive breast cancer?

Patients may identify a change in their breast (below) or may be asymptomatic and have their breast cancer diagnosed as a result of undergoing a screening mammogram. The following are possible signs of breast cancer that a patient may notice and should cause you to arrange an appointment with your GP:

• Lump in the breast
• Thickening of the breast skin
• Rash or redness of the breast
• Swelling in one breast
• New pain in one breast
• Nipple turning inward (inversion)
• Nipple discharge
• Lumps in the underarm area
• Skin tethering or distortion on raising arm above head

How is invasive breast cancer diagnosed?

During a clinic appointment, you will be asked all about the breast change or symptom you have noticed, and a full medical history and clinical examination should be carried out. It is very likely that further tests will be arranged on the basis of your symptoms and examination and may include:

• Mammograms (X-ray)
• Breast ultrasound
• Breast MRI
• Breast biopsy

What is the treatment for invasive breast cancer?

Treatment for all patients with breast cancer should be discussed by your breast surgeon at the local breast cancer multidisciplinary team (MDT). This is a weekly meeting with many breast cancer specialists present to ensure that there is agreement on investigations, diagnosis and that the correct form of treatment is being offered to the patient.

There are many types of treatment available for breast cancer, and may include

• Breast surgery (breast conservation, mastectomy)
• Lymph node surgery (sentinel node biopsy, axillary node dissection)
• Breast reconstruction
• Radiotherapy
• Chemotherapy
• Anti-hormonal therapy
• Targeted Biological therapy
• Bisphosphonate therapy

For most patients, surgery will be the first part of their treatment for breast cancer, but there may be situations where patients are offered either chemotherapy or anti-hormonal tablets before their surgical treatment (neo-adjuvant medical therapy). The reasons for this can vary and should always be thoroughly discussed with the patient before she makes a decision about her treatment.

What is the prognosis for invasive ductal carcinoma?

This will depend on numerous factors including:

• Tumour sensitivity and response to different types of treatment (Oestrogen and Herceptin)
• Disease stage (confined to the breast / spread to lymph nodes / distant spread)
• Fitness of the patient to undergo certain types of treatment

Despite this, breast cancer remains a very treatable type of cancer, with survival rates considerably higher than for many other common types of cancers even for patients with more advanced patterns of disease at diagnosis.

Invasive Lobular Carcinoma (ILC) is the second most common form of breast cancer diagnosed, representing approximately 15% of invasive breast cancers. This type of cancer is sometimes more difficult to feel on self-examination or see on standard types of breast imaging, and rather than forming a lump may cause more subtle changes in the breast like tethering of the skin or a change in the shape of the breast.

This type of breast cancer is not necessarily any more difficult to treat by comparison to invasive ductal cancer of the breast, but due to difficulties if being able to feel it in the breast by self-examination may be larger than other types of breast cancer when the diagnosis is made.

How is invasive lobular carcinoma (ILC) diagnosed?

Similar to invasive ductal cancer, lobular breast cancer is diagnosed by imaging with mammograms and ultrasound and a breast biopsy. It is not uncommon to investigate this type of breast cancer with a breast MRI scan as well, as it often gives the most accurate information about the size of this type of cancer by comparison to mammogram and ultrasound.

Steps of diagnosis include:

• Digital mammography
• Ultrasound
• Biopsy
• MRI

What is the treatment for invasive lobular carcinoma?

ILC can be treated with either a wide local excision (lumpectomy) or mastectomy depending on the size and location of the tumour and wherever possible patient preference. Surgery will also be recommended to remove some lymph nodes at the same time as the tumour, similar to the treatment for invasive ductal cancer. The type of surgery to the lymph nodes will depend upon their appearance in pre-operative tests.

In addition, your oncologist may recommend other treatments such as radiotherapy, chemotherapy and/or anti-hormonal tablet therapy, but will offer you a consultation to discuss the advantages and disadvantages of any additional treatment.

What is the prognosis for invasive lobular carcinoma?

As with all types of breast cancer, this will depend on whether the disease is localised to the breast or has been able to spread to the lymph nodes under your arm or elsewhere in your body. This information will be available to patients as a result of information we get back following the surgical part of your treatment, or if additional body scans (CT) are organised for you during your investigation and treatment.

While lobular carcinoma in situ (LCIS) sounds like a type of breast cancer, it is probably more accurate to say that it is an abnormal finding which suggests that the patient is at an additional risk of developing breast cancer in the future.

It is often asymptomatic, and may be found as a result of a patient undergoing mammograms for unrelated reasons such as breast pain, or through the national NHS breast screening programme.

What can I do if I have LCIS cells in my breast?

Part of your initial imaging will be to ensure that there is not an invasive breast cancer associated with the area of LCIS identified, at which point we will be able to reassure you that you do not require any form of treatment at that time.

Whilst a diagnosis of LCIS is significant, it is important not to panic. Whilst it does predict an increased breast cancer risk for the affected patient, it does not mean that such a diagnosis is inevitable or that you will have to undergo radical risk reduction surgery like a mastectomy.

We can discuss the lifestyle modifications which you can make in order to reduce your risk of breast cancer generally. We can also discuss future surveillance of your breasts with the use of breast imaging such as mammograms carried out on an annual basis, more regularly than is used in the national screening programme. This would be to ensure that we are able to detect any changes which may (or may not) occur following the identification of LCIS in your breast.

Paget’s disease is a relatively uncommon type of breast cancer that occurs in the mammary ducts adjacent to the nipple and areola skin, and is usually associated with ductal carcinoma in situ (DCIS) within the breast tissue.

What are the symptoms of Paget’s disease?

• Redness and irritation of the nipple and/or areola
• Crusting and scaling of the nipple area
• Bleeding from the nipple/areola
• Oozing from the nipple/areola
• Burning and/or itching of the nipple/areola

How is Paget’s disease diagnosed?

Patients who present to a specialist with symptoms or signs of Paget’s disease will be offered investigations with mammograms and ultrasound, and a tissue biopsy to make the diagnosis. The biopsy is normally done under local anaesthetic in the outpatient clinic, and will send a small sample of the affected skin away to be examined under the microscope to make the diagnosis.

What is the treatment for Paget’s disease?

If Paget’s disease is localised to the central part of the breast in the milk ducts around the nipple and areola, then a wide local excision can be offered with surgical removal of the nipple and areola and a margin of healthy tissue around the edge of the disease. Radiotherapy to the breast may be offered to the patient following surgery depending on the size of the affected area found.

If any associated DCIS is more widespread within the breast then a mastectomy may be necessary, but could be combined with an immediate breast reconstruction.

If any small areas of invasive breast cancer are identified within the tissue removed, then additional treatment may be offered to the patient, similar to what would be offered for patients being treated for an invasive breast cancer.

What is the prognosis for Paget’s disease?

If DCIS is the only abnormality identified then the prognosis or outlook following treatment is excellent. Other areas of disease identified within any tissue removed may also have an impact on this however, and it is important that you are able to discuss this with your surgeon.

Following treatment for Paget’s disease you will be offered annual mammograms to both breasts to ensure that no further abnormalities occur after treatment.

Breast reconstruction is now widely available to patients who undergo surgical treatment for breast cancer, and is known to improve the quality of life for women treated for this disease. It can occur at the same time as treatment for breast cancer (immediate breast reconstruction) or may be undertaken following completion of surgical treatment, sometimes after many years (delayed breast reconstruction).

Types of Breast Reconstruction

Implant Based Reconstruction

This is the commonest type of reconstruction for patients having an immediate breast reconstruction. The skin and nipple of the breast are preserved and a cohesive silicone breast implant is placed inside the space left after the mastectomy. This is sometimes placed under the pectoral chest wall muscle, and sometimes on top of it. Often, the implant used is “teardrop” in shape in order to create as natural a shape to the reconstructed breast as possible.

Sometimes a tissue-expander implant may need to be used, either to change the size of the reconstructed breast or if the patient has medical conditions which might put them at higher risks of wound healing problems (and therefore implant infection and loss).

Tissue-flap Based Reconstruction

This type of reconstruction uses the patient’s own tissue to recreate the breast following mastectomy, and can be done as either an immediate or delayed reconstruction. The common sites used to donate tissue for breast reconstruction include the back, the lower abdominal tissue, the inner thighs and the gluteal / buttock area.

Unlike an implant based procedure, once surgery is complete a flap will not need to be replaced in the future. This type of surgery will necessitate scars on other parts of your body where the tissue-flap is taken from and will often entail a longer recovery.

The decision to undergo reconstructive surgery is a very personal one, and there are advantages and disadvantages of this type of surgery and the technique used specific to your individual situation and needs.

I am experienced in all aspects of immediate and delayed breast reconstruction and will be happy to discuss the options open to you before you decide if it is the right thing for you or not.

Discussion with Mr McIntosh is important to answer any questions that you may have. For information about any additional conditions not featured within the site, please contact us for more information.

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