Benign Breast Disorders -------Hormone Replacement Therapy (HRT)
Ductal Carcinoma in Situ (DCIS)
Lobular Carcinoma in Situ (LCIS)
Your doctor will already have explained to you that your condition is non-cancerous. He/she would have explained in some detail what your condition is. This leaflet has been designed to help you understand a little further and that you may wish to read this over again from time to time.
Our Breast Care Nurses Jane Barker and Lesley Jones are available to talk to you if you wish to return again. A message may be left with the receptionist at the Breast Care Centre, telephone number 0117 9753 752.
Discharge of fluid from the nipple is a common complaint that is rarely a sign of any serious disease.
The fluid may appear to look like breast milk, but is not actual milk secretion. This is caused by swelling (inflammation) of the milk ducts and is called Duct ectasia. This is not uncommon in women over 40, as the ducts in the breast become wider, particularly if you smoke. It is more common that fluid discharge comes from several ducts in one or both breasts. This fluid may be creamy, green, yellow/brown, black or a combination of colours.
Doctors only operate on multiple duct discharges if they persist and are troublesome. A blood stained discharge from a nipple may suggest an early breast cancer. The tests you have under gone at the Breast Care Centre will have excluded this.
Lumpy breasts can be perfectly normal. Breast tissue is glandular and responds to your sex hormones during your monthly cycle. This will vary and often appear worse before a period. There is more glandular tissue in the upper, outer part of the breast, so this area is especially prone to lumpiness.
HRT will have the same effect. Although you may feel a lump yourself, tests at the Breast Care Centre may not show an actual lump, but an area of thickening as previously described (diffuse nodularity).
However, just because your tests have not shown an actual lump, do not assume if you discover another lump that it is the same problem. If you notice a new lump that does not go away, you should see your GP. He/she will then decided if you need to return to the Breast Care Centre.
Cysts are fluid filled sacs that appear quite quickly in the breast. They are often painful and can reoccur. This condition tends to happen in women in their 40,s and 50's. There may be several in one or both breasts and can disperse and be absorbed easily into your breast, with no effect on you. However, a cyst, if large and painful, may be drawn off (aspirated) by your GP or specialist. This will be done using a hypodermic needle, this may be slightly painful, but there is instant relief from pain from the cyst once it has been aspirated.
Fibroadenomas (benign breast lump) are commonly found in women under 30. These also occur during puberty when the breast is developing. It is caused by an over-development of the milk gland (lobule). Although these lumps occur when you are younger, they do not usually become noticeable for many years when the breast becomes softer and less dense. The fibroadenomas are harmless and do not turn into cancer. The tests you have had at the Breast Care Centre will have confirmed your lump is a fibroadenoma. These are not generally removed unless they are painful or become larger. current evidence suggests that fewer than 5% increase in size.
Breast pain (mastalgia) is very common, but like headache, is rarely a sign of anything serious. 2 out of 3 women suffer from breast pain at some stage. During the reproductive years and often for several years afterwards, the breasts are stimulated by your hormones. No-one really knows what causes breast pain. It may be that the breast becomes more sensitive to the changing hormone levels. Because of this, you may notice that your pain becomes worse leading up to your period and your breasts may feel lumpier than usual, tender or swollen. This then settles when your period starts or stops. This is called cyclical pain. Pain in the breast can vary from day to day. Pain may occur at any time during the month, come and go and vary in severity. this is called non-cyclical pain.
As breast pain from time to time, settles and starts at various times throughout the month, it is difficult to tell if a particular treatment has helped.
Now that have attended the Breast Care Centre and have been informed that it is not a serious problem not requiring an operation, simple self help measures may be all that is necessary.
We advise you wear a well fitting supportive bra with the correct cup size. If bras are tight this will increase breast pain. Always wear a properly fitted sports bra for any planned serious exercise.
At night many women find wearing a light supporting sleep bra helps when the pain is particularly bad. Simple painkillers may help and be necessary from time to time. Water tablets (diuretics) and antibiotics are of no value in the treatment of breast pain. Reducing the amount of animal fat in your diet, especially saturated fat, can be of help. This is because fatty acids, present in the fats and oils we eat, can effect the way the body responds to its hormones. A remedy that is effective for up to 70% of women is GamoLenic Acid. This helps the body convert fat and reduces breast pain. The dose required is 360 mg per day of Gamolenic acid (GLA). This is found in evening primrose capsules. The drug can be bought over the counter from all leading chemists. Prices vary, so shop around! This may take up to 3 months to reach its full effect. Side effects are rare in evening primrose oil; occasionally nausea (sickness) may occur, however you should not take it if you suffer from epilepsy or are on tablets to control epilepsy. More information may be obtained from the chemist.
Very occasionally the pain is so bad that prescription drugs may be considered. These block the hormone cycle and are usually associated with more side effects, e.g. weight gain, acne and hirsuitism (facial hair) nausea and dizziness. The drugs can only be taken by women not taking the oral contraceptive pill. Wherever possible it is best to try simple remedies and let nature take its course.
We also see many women with pain in the chest wall and occasionally localised areas in the breast known as trigger spots. Treatments include injecting the tender areas with steroid injection (like tennis elbow), wearing a firm supportive bra and non-steroidal anti-inflammatory drugs. Surgery is not generally recommended for women with breast pain as this has no benefit.
1. Lie flat on your back with your head on a pillow. Put a folded
towel under the shoulder on the side of the breast you are
checking. This helps to spread the tissue so that it is easier to feel.
2. Put the hand on the same side as the breast that you are going to
examine under your head.
3. With your other hand flat and fingers together, use the flats of your
fingers to feel around the breast in small circular movements, in an
anticlockwise direction.
4. Cover the whole breast including the nipple.
5. Check your armpit for lumps in the same way, starting in the
hollow and moving down towards the breast.
Now examine the other breast in the same way.
If you think you have found something, feel the same area on the opposite breast. If they are the same it's probably just your shape, but if you are worried, do visit your doctor. Taking care of your breasts involves a simple monthly examination. by following a few easy steps you will soon become to know what is normal for you and you will be aware of any changes.
HOW TO LOOK FOR CHANGES
Stand up straight in front of a mirror with your arms loosely by your sides. raise your arms above your head and move from side to side so you can see your breasts in the mirror from different angles.
WHAT TO LOOK FOR
A change in the size of either breast. A change in the shape or position of either nipple. Bleeding or discharge from the nipples. Unusual dimpling or puckering.
The Breast Care Team acknowledge that leading up to this appointment may have been an anxious time for you. Now that you have been informed that the condition is not a serious one you will probably start to feel better in yourself.
The Breast Care Nurse, Jane Barker, will be happy to see you at any time for any further information you may wish regarding your diagnosis. You may also wish to meet with her to talk over the anxious time you have been through.
If you wish to meet with Jane please ring the Breast Care Centre, tel ; 0117 9753 752, for an appointment.
You do not have to examine your breasts more frequently from today. Once per month, following your period (or on the same day each month if you do not have periods), is recommended. This leaflet will help you. you can contact the centre if you wish to be shown how to examine your breasts. A breast form can be used to demonstrate this.
Once again, please feel free to contact Jane if you have any concerns or questions following today's visit.
The epidemiological evidence has shown that the incidence of breast cancer correlates with dietary factors, life style factors such as exercise and obesity, together with hormonal factors predominantly related to the menstrual cycles of the woman. The evidence suggests that all these factors may operate through a promoting effect of oestrogen during the menstrual cycles that a woman’s breasts are exposed to. The onset of the periods and the age at menopause have a significant effect on the incidence of breast cancer. Most significant amongst this data is the reduction in risk resulting from a premature menopause. The important question is does oestrogen replacement therapy after the menopause effect the incidence of breast cancer?
Women who develop breast cancer on hormone replacement therapy have tumours detected at an earlier stage with fewer lymph node metastases and a better overall survival. This is due to the accelerated growth that oestrogen dependent tumours undergo when exposed to HRT. Those patients who develop breast cancer on HRT should be told that the HRT has not caused the tumour but has merely accelerated the growth of something that would have developed inevitably through the promoting effect of oestrogen. By accelerating its growth the lump is more rapidly detected by the patient and hence diagnosed at an earlier stage.
10% of patients breasts do become denser after exposure to HRT which may impair the ability of mammograms to detect breast cancers through mammographic screening programmes. This effect is small and its significance unproven.
There is no long term evidence to suggest that HRT when given to breast cancer survivors with menopausal symptoms has a detrimental effect on their survival. Prospective randomised trials are shortly to begin to address this important clinical problem. Until we have the answers from these studies patients should be told that whilst there is no evidence they may be doing themselves harm we as yet do not know with certainty the safety of hormone replacement therapy for breast cancer survivors. This is a question that should be addressed by the specialist with information from the oestrogen receptor status of the tumour which may be useful.
The evidence suggests that women who are at increased risk because of a family history should be reassured that they take HRT without exposing themselves to an increased risk above the normal general population. Women who are interested in helping prevent breast cancer may be interested in taking part in the UKCCR IBIS trial which is a randomised trial of Tamoxifen versus placebo. Telephone Mrs. Ruth Illingworth. IBIS Co-ordinator, Frenchay Breast Care Centre - 0117 9753809 for details. Patients in this study are allowed to take HRT together with the trial drug. This trial will answer not only the important question as to whether Tamoxifen can prevent breast cancer but also can Tamoxifen and HRT together protect the breast and help menopausal symptoms.
The development of new selective oestrogen agonists which stimulate the bone and protect the cardiovascular system against atherosclerosis but yet do not stimulate the breast are eagerly awaited. These may be combined with selective blockers which specifically block just oestrogen receptors on the breast and endometrium, thus producing the desired effect of protection from endometrial and breast cancer but oestrogen stimulation of the bone, cardiovascular system and receptors in the brain.
After the menopause dietary factors play a much more important role in promoting breast cancer than oestrogen. In Japan the incidence of breast cancer rapidly falls off after the menopause whereas in the West it continues to rise. These dietary factors are therefore considerably more important than the small effect that a low dose of oestrogen replacement has on the incidence of breast cancer. Women should be encouraged to take HRT even if they have a strong family history of breast cancer as they are much less likely to die from any cause whilst taking it compared to those who do not, and should not be concerned about the small increased risk of breast cancer in women who take HRT for more than 10 years.
A Factsheet
What is DCIS?
DCIS stands for Ductal Carcinoma in Situ. It is important to say right at the beginning that it is NOT cancer, but can turn into cancer if left alone i.e. it is a pre-cancerous change.
What has happened is that some of the cells of the lining of the milk ducts within the breast have developed some cancerous changes. However they are still only within these ducts and have not spread into the surrounding breast tissue. This type of spread is called invasion and only when this happens can we call it cancer.
When does it turn into Cancer?
We don’t know how long it takes for DCIS to turn into cancer In some cases it may have already started to do so by the time it has been found, in others it may never turn into cancer. There is no doubt however, that there is a very high risk of it doing so and leaving it alone is not a sensible option.
How is it Found?
DCIS is becoming much more common. The reason for this, is that in the vast majority of cases, it is found on a mammogram (X-ray of the breast). These have been done much more frequently over the last ten years or so because of the National Breast Screening Programme, where all women between the ages of 50 and 64 are invited to have mammograms every three years.
It shows up on the mammogram as little white specks of calcium which has been deposited in the milk ducts by the abnormal cells (microcalcification). However it is important to realise, that most microcalcification on a mammogram is not due to DCIS, but often due to minor infection in the past. It also usually possible to tell the difference by looking at the calcium specks closely.
Occasionally DCIS causes symptoms such as a lump or discharge from the nipple, but this is unusual.
How is DCIS Diagnosed?
First of all we have to make sure that the suspicious area is DCIS and not either innocent microcalcification or DCIS which has turned into cancer. This is done in a variety of ways. Either using a small needle to take some cells out of the area for examination under the microscope (Fine Needle Aspiration or FNA), or using a larger needle with local anaesthetic to remove a small piece of tissue (Core Biopsy) or to do an operation to remove the suspect area (Biopsy).
If there is no lump to feel then these methods may have to be used whilst having a mammogram so that the needle can be guided into the correct position. Sometimes we arrange for this to be done with specialist equipment at the Avon Breast Screening Unit at Tower Hill in the centre of Bristol.
What is the Treatment for DCIS?
The aim of treatment is to cure the disease by removing all the affected tissue before it can turn into cancer. This is different to actual cancer where even when all the known affected tissue has been removed, it can never be said to be cured as it may have spread to other parts of the body already.
In the past the usual recommendation was to remove the whole breast (mastectomy), but we now know that this is not always necessary. In most cases we can just remove the affected tissue with a small amount of normal tissue around it, to make sure that it has all been removed. This is called a Wide Local Excision (WLE) and in most cases would not affect the shape of the breast.
We may however still advise a mastectomy if for example the area of DCIS in your breast was large or if there were several areas of DCIS throughout your breast. If this was the case we would discuss with you whether you would want the breast built up again (reconstruction). This could be done at the same time as the mastectomy or at any time afterwards.
We would not normally need to remove the glands (Lymph Nodes) from your armpit whichever operation you have.
After your operation the pathologist will examine the removed tissue very carefully and a week after the operation we will see you and discuss the findings. If you have had a wide local excision, we may then discuss whether you might need radiotherapy. This would be just in case there were a few undetectable pre-cancerous cells elsewhere in the breast which have started to change. We may also recommend a tablet called tamoxifen, which is an anti-hormone tablet used for treating certain kinds of breast cancer, as there is some evidence that this may stop any undetected pre-cancerous cells from progressing into cancer.
What about Follow up?
After your treatment has been completed, you do have a slightly higher risk of the DCIS coming back than someone who had never had it.
For this reason we will keep a close eye on you by seeing you and examining you yearly for at least 5 years and by doing regular mammograms.
A Factsheet
What is LCIS?
LCIS stands for Lobular Carcinoma in Situ.
It is important to say right at the beginning that this is NOT cancer, and probably will never become cancer. When it is found, it is just a sign that you are at higher risk of developing cancer in the future.
What has happened is that some of the cells in the parts of the breast which actually produce milk (the lobules) have developed some cancer-like changes.
You should not confuse it with another condition which you may have heard of called DCIS which is a pre-cancerous condition.
Does LCIS turn into Cancer?
We don’t really know the answer to this but the simple answer is probably: "No it doesn’t". What we do know, is that women who have been found to have LCIS, have an increased risk of developing cancer in the future, and that this risk is to both breasts, not just the one where the LCIS was found.
This risk, of developing cancer, is thought to be about 10% over 10 years and probably more over a longer period or to put it another way; about a 90% chance that you won’t develop cancer over the next 10 years. To put this into context, a woman aged 50 without any risk factors such as LCIS, has about a 2% risk of developing over the next 10 years.
How is it Found?
Most LCIS is found by chance when an operation is done to remove a benign lump and the specimen is examined under the microscope. It is commoner in women who are pre-menopausal and does not show up on mammograms.It is also sometimes found in the surrounding tissue when an operation is done to remove a breast cancer.
What is the Treatment for LCIS
The treatment for LCIS used to be by mastectomy, but as the vast majority of women with LCIS will not develop breast cancer and the risk is to both breasts anyway, having a mastectomy for this would be an extreme measure..
Nowadays therefore, we usually recommend monitoring you closely. This is done by doing an examination and ultrasound examination annually and a mammogram every 18 months. Should a cancer develop, the aim of this is to find it at early stage when it is likely that can be cured.
We may also talk to you about entering a trial of a drug called Tamoxifen to see if this stops cancer from developing. Tamoxifen is widely used in the treatment of breast cancer and there is some evidence to suggest that it may stop cancer from developing in higher risk women. In this trial, which is called the IBIS trial, you would randomly be given either Tamoxifen or a tablet which did nothing (a placebo), for 5 years, and we would monitor you closely in the same way as above.
What if LCIS is found with Breast Cancer?
LCIS is sometimes found around breast cancer when this is removed. Lots of studies have been done, which show that there is no need to treat the cancer any differently i.e. by doing a mastectomy. You would obviously be monitored closely after an operation for cancer anyway.
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| Guidance on the Use of Taxanes
for Breast Cancer May 2000 |
What is NICE Guidance?
The National Institute for Clinical Excellence (NICE) is a part of the NHS. It uses a team of experts who produce guidance for both the NHS and patients on medicines, medical equipment and clinical procedures.
When the Institute evaluates these things, it is called an appraisal. Each appraisal takes around 12 months to complete and involves the manufacturers of the drug or device, professional organisations and patient groups.
NICE was asked to look at the available evidence on Taxanes and provide guidance that would help the NHS decide when Taxanes should be used for treating women with breast cancer.
What is cancer and where do Taxanes fit in?
Cancer is a disease of the body's cells. Normally, all cells divide and reproduce themselves in an orderly and controlled manner. In cancer, the cells multiply without proper control.
Breast cancer is the commonest cause of cancer death in women about 14,000 women die of breast cancer deaths each year in the UK.
The type of treatment given for a cancer depends on many factors. These include:
The Taxanes are a type of anti-cancer drugs known as cytotoxic drugs and they are used during chemotherapy. Chemotherapy is the use of anti-cancer drugs to destroy cancer cells.
Chemotherapy may be used on its own to treat cancer or it may be used with other drugs, with surgery and/or with radiotherapy. In breast cancer it is used:
There are two Taxane drugs available in the UK, docetaxel (Taxotere) and paclitaxel (Taxol). They both cost about £1,500 per course of treatment and each patient may need up to six courses.
When appraising the clinical effectiveness of the Taxanes, NICE looked at a number of factors for each product, including:
What have NICE recommended about the use of Taxanes?
As patients reach the appropriate stage in their treatment for advanced breast cancer, they should be offered either docetaxel (Taxotere) or paclitaxel (Taxol).
The decision as to which product should be used should be taken by the responsible clinician in discussion with the patient. During this discussion they should take into account the information that is listed in full in the NICE Technology Appraisal Guidance – No. 6. Guidance on the Use of Taxanes for Breast Cancer.
The Taxanes are not currently licensed in the UK for adjuvant treatment of early breast cancer or for the first-line treatment of advanced breast cancer. The Institute recommends that the use of the Taxanes for these indications should be limited to a clinical trials setting.
There will be patients undergoing treatment for breast cancer who, at the time this guidance is issued, are not receiving the therapy NICE recommends. These patients should be given the opportunity to discuss with their consultant the benefits of moving to the treatment that is recommended in this guidance or remaining on their existing medication.
Guidance
on Use of Taxanes for Breast Cancer