Key learning points:
– All women can be made aware of breast symptoms
– Eligible women should be encouraged to attend a free NHS breast screening mammogram
– Breast cancer is now very treatable and curable if diagnosed at an early stage
Breast cancer is very common among women in this country – figures show that 49,000 women were diagnosed with breast cancer in 2011, which is more than 130 every day.1 The lifetime risk of developing breast cancer is one-in-eight, however, more women are surviving, being cured and living to their expected age. Breast cancer treatments are now very successful. The treatment may be a combination of medical and surgical depending on the stage of the cancer at diagnosis. Therefore, it is so important that breast cancer is diagnosed at an early stage to potentially minimise the amount of treatment necessary. Conversely, sometimes an early breast cancer can require extensive surgery, but this can cure the patient of their disease. With modern surgical techniques even if a mastectomy is needed, many patients are offered an immediate reconstruction to rebuild the breast. This should be standard practice across the country.
Symptoms of breast cancer
Breast cancer can present in some obvious ways, and others not so evident, so anyone presenting with intractable breast problems should be assessed at a specialist breast clinic with access to specialist imaging. Some of the more unseen signs are early and curable.
1. A lump– any lump that doesn’t go away or get smaller must be investigated. Most lumps are benign, but any lump that a patient is concerned about should be referred to a specialist. On examination it is sometimes very difficult to establish the difference between a benign and a cancerous lump, therefore, further investigation by a specialist with access to imaging is reassuring for patients.
2. Skin changes –when looking at the breasts, some changes to the skin or contour of the outline may be obvious when the arms are lifted above head height. This may indicate that a lump is present beneath the skin and tethering the lump to the overlying skin. If there is peau d’orange (in other words literally orange skin) where the skin appears pitted and oedematous or red and hardened, this can be a sign of an inflammatory cancer or a locally advanced cancer.
3. Nipple discharge –white or colourless discharge is very common. It can either originate from a single duct or multiple ducts. If a woman needs to squeeze their nipple to elicit a discharge, then they should be told to desist from squeezing, and the discharge will stop. However, a single duct discharge that is brown or bloody in colour and spontaneous must be investigated further, as this can be a sign of early changes within the breast.
4. Inverted nipple –a nipple that has always been inverted is not a concern, neither is one that will evert on manipulation. But a nipple that becomes inverted and cannot be drawn out can sometimes mean the ducts beneath have become shortened by something (often a cancer) within the ducts, and needs investigation.
Less common symptoms
1. Changes to the nipple –a rash or itch can sometimes be associated with a rare form of cancer know as Paget’s disease, which looks like an eczema to the nipple itself – not the areola. It may also be diagnosed with an underlying area of ductal carcinoma in situ (DCIS). Traditionally this was treated with a mastectomy, but there are much better oncoplastic operations to treat this with the most cosmetically pleasing being a Grisotti flap.
1. Mammographic changes – if patients attend for NHS screening mammograms, or have mammograms performed there is an opportunity to notice breast cancer. This is because sometimes very early changes can be picked up on mammograms alone and no changes can be detected clinically. Mammograms can identify areas of microcalcification – tiny dots of a chalk like substance, which to a trained radiologist can be a warning sign of early breast cancer (DCIS). This is sometimes the most difficult aspect to explain to patients, as there may be nothing to feel, but the mammographic changes could be extensive, and may necessitate a mastectomy to cure the disease. If diagnosed with microcalcification on a mammogram, then biopsies are needed to confirm suspicions. Further investigation may be with a magnetic resonance imaging (MRI) scan. However, microcalcification can also be completely benign, which may be apparent to radiologists.
Mammograms can also pick up impalpable areas – benign or malignant that need further investigation. The reason for the NHS breast screening programme is to pick up tiny abnormal areas within the breast, that if diagnosed as malignant can be treated with minimal management. For every 200 women who attend screening mammograms between the age of 50-70, only 15 will be diagnosed with breast cancer, 12 of whom will then survive. That means that 185 are told they are normal.2 There is a fear that by diagnosing a small breast cancer on mammograms, this may never have caused any problems to the patient, and they may have been over treated, though there is no way to know which breast cancer could cause problems and which wouldn’t.
2.There are some benign appearing lumps (phyllodes tumours) that need to be excised, because when they are looked at pathologically, they can have malignant potential. These are extremely rare and are usually treated with surgery to the breast alone, and will not often need other treatments such as radiotherapy or chemotherapy.
3.Patients who have had previous radiotherapy either for an earlier breast cancer or for lymphoma treatment (mantle radiotherapy) are more at risk of developing angiosarcoma – a radiation induced cancer, which is seen on occasion in the breast. It can present as skin changes that can be extensive and rapidly growing.
4.Other benign changes seen on mammograms include radial scars, atypical ductal or lobular hyperplasia and lobular carcinoma in situ. This again can be seen as early warning signs of breast cancer, and usually requires an excision of the abnormal area on the mammogram in order to possibly prevent breast cancer occurring in the future.
Support and encouragement for patients
The best method that is widely available for the detection of breast cancers at this time is mammograms. Other investigations are useful, but not for mass screening. MRI scans are used mainly for patients who have a diagnosis of breast cancer, and there are insufficient machines to undertake widespread screening. Breast ultrasounds are useful if a patient can feel a lump, but again not suitable or informative for looking at the whole breast or both breasts. Patients seen in a symptomatic breast clinic will undergo triple assessment – clinical history and examination, breast imaging with mammogram and/or ultrasound and fine needle aspiration or core biopsy if necessary.
Patients attending one stop clinics for triple assessment will usually only have mammograms if they are over the age of 40, as breast tissue is too dense to show anything in younger women.
Women should have been called for their first NHS screening mammogram by the time they are 50 years of age, and these will continue with regular invitations every three years until they reach 70. Women can continue to be screened after this age – but need to ‘opt in’ by requesting this through GP practices/practice managers.
What practice nurses can do
Practice nurses should encourage all patients of eligible age to attend for their routine NHS breast screening – uptake of these invitations vary across the country, and in inner cities the uptake is very poor. Every woman seen in primary care should be urged to check their breasts regularly, once a month after a period is sufficient. Many women don’t know what to look for. Breast Cancer Care have produced some excellent leaflets that are free to download and can also be ordered, this information is also available in all different languages (see Resources for more information).3
If patients are concerned about breast symptoms, a referral to a one stop/rapid access clinic should be made. All symptomatic referrals – whether for a suspected cancer or for symptomatic (non cancer) reasons will be seen within two weeks. Reassurance can be offered to patients that this may not be because of clinical concerns, but because of guidelines and targets many patients become frightened when they are offered appointments so quickly.
Many women think they don’t need to be aware of their breasts and don’t need to know possible symptoms. All women who have not had a mastectomy have breast tissue and therefore must be made aware of the need to be responsible for their own health. If each practice nurse can direct one concerned woman to have an investigation into her breast health, and enthuse women to be motivated to look at and touch their own breasts. If this is done then the breast units around the country may diagnose women with much smaller, more easily treatable and ultimately curable breast cancers.
Breast Cancer Care –
1. Cancer research UK. Breast cancer statistics. cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer#heading-Zero (accessed 3 August 2015).
2. Breast Cancer Now. Breast screening facts. breastscreeningfacts.org/ (accessed 6 August 2015).
3. Breast Cancer Care. Taking care of your breasts. breastcancercare.org.uk/information-support/publications/browse-order?category=155 (accessed 1 August 2015).