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3. Symptoms, screening and investigations

BREAST AWARENESS

The Department of Health (DH) of the most developed countries recommends that instead of examining your breasts every month, you should become breast aware. Being breast aware means getting to know what is normal for your breasts and knowing what changes to look out for, because this means you will be more likely to notice anything unusual more quickly. Generally the sooner breast cancer is diagnosed and treated, the better the prognosis (outcome). So to help people report symptoms quickly, the (DHs) suggests using the following five-point code.

1. Know what is normal for you everyone’s breasts are a different shape and size, and some people naturally have one breast bigger than the other, so try to become familiar with your normal shape. Remember this will change as you get older, have children and go through the menopause.

2. Know what changes to look and feel for most people know that lumps are a possible symptom of breast cancer, but there are other changes that you should report to your doctor without delay.

3. Look and feel get in to the habit of looking at and feeling your breasts from time to time. Look at your breasts in the mirror and feel them, perhaps when you are in the shower, putting on body lotion or just getting dressed or undressed.

4. Report any changes to your family doctor without delay. Your doctor can then reassure you or send you to a breast clinic for more detailed investigations. It is reassuring to know that more than 90% of people referred to a hospital with breast symptoms do not have cancer. Attend routine breast screening if you are 50 years of age or over. The rest of this course covers the signs and symptoms of breast cancer, gives details about the “Breast Screening Programme” and describes some of the more common tests used to confirm or to exclude a diagnosis of breast cancer.

3.1 SIGNS AND SYMPTOMS

Question: What symptoms of breast cancer should I look out for?

Answer: If you have any of the symptoms listed below, tell your family doctor about them as soon as possible. If you put off going, you will only worry about it. The chances are there is nothing wrong, but if there is a problem you need to find out quickly. In the less likely event it is breast cancer, the sooner it can be treated the better. The following are examples of the types of changes which you should report to your family doctor without delay:

• A change in the size or shape of the breasts – maybe one has got larger or smaller or one seems to be ‘pulling’ in a different direction;

• Changes to the nipple – maybe one is inverted (pulling inwards) or has a rash around it, or there is a discharge leaking from the nipple which might show as a stain in your bra;

• Swelling in the armpit area;

• A thickening or lump in the breast that feels different from your usual breast tissue;

• A puckering or dimpling appearance on the skin surface;

• Unresolved pain in one part of the breast (rather than all over).

Also, if you have a friend or relative who is worried about any of these things, encourage them to go to the doctor.

Question: I don’t like to bother the doctor with something so trivial. They will think I’m just being silly, won’t they?

 Answer: If you notice a breast change that worries you, it is not trivial. The DHs recommends that you report breast symptoms without delay. Most doctors are very sympathetic and will listen to what you say, examine you and either set your mind at rest immediately or refer you to a breast clinic for more detailed tests, usually within two weeks. Your doctor has national guidelines about who to refer to a specialist based on their age and the symptoms they have. All people referred urgently (because the family doctor believes there is a higher chance of it being breast cancer) are seen at the hospital within 10 working days or two calendar weeks (this is called the ‘two-week rule’). People referred non-urgently may have to wait longer to be seen but it is still important to have any symptoms checked out just in case.

Question: My friend had breast cancer last year. Since then I keep imagining I’ve got breast cancer every time I get an ache in my breast. Have I got a cancer phobia?

Answer: One of the most common fears people have whenever they notice something unusual in the breast is that they have cancer. This doesn’t mean you’ve got an irrational fear about cancer. Most of you worry about getting ill and are scared of changes you can’t explain. Go and talk to your practice nurse or family doctor. If you don’t have any symptoms but are still worried, you may be able to talk with a counselor, who will help you talk about your fears. Remember to keep being breast aware. You might also find it helpful to speak to an anonymous person, maybe from a cancer support organization.

 3.2 SCREENING

Question: My mother had a letter from the doctor which mentioned the “Breast Screening Programme”. Does that mean she could have cancer?

Answer: No it doesn’t. It is a free check-up offered to women over 50 every three years. The “Breast Screening Programme” was set up as a way of detecting breast cancer at a very early stage because the sooner it is diagnosed the more likely treatment will be successful.

Research shows that breast screening saves around 1400 lives every year in each of the most developed countries of European Union (EU) and, for example, that of every 500 women screened, one life will be saved. Your mother has been invited for breast screening, which involves having a mammogram (a breast X-ray) which can detect abnormal changes in the breast that are too small to be felt by the hand. When you have a mammogram you need to undress to the waist and stand in front of an X-ray machine. Each breast is X-rayed in turn by placing it between two X-ray plates. Two views of each breast are taken, one from above and one from the side (diagonally across the breast). Some people find mammograms uncomfortable or even painful but this should pass quickly as soon as the X-ray plates are removed. The “Breast Screening Programme” currently offers a free mammogram every three years to all women in same of the most developed countries of EU aged 50 years and over. Screening services are all staffed entirely by women.

Question: I am 44 now so why don’t I get called for breast screening?

Answer: Breast cancer is much more common in women over the age of 49 years. In fact 80% of breast cancers occur in older women so it makes sense to screen this age group as this is where most breast cancers will be found. Mammograms are actually less effective in premenopausal women under the age of 50. This is because breast tissue is denser in younger a woman which makes it more difficult to clearly see any abnormal areas. After the menopause breast tissue contains more fatty tissue which is clearer on a mammogram.

Younger women who are not eligible for routine screening but who have symptoms can still be referred to a hospital for tests and these might include a mammogram or an ultrasound scan.

Question: If I’m the right age for screening, will I be called to have a mammogram?

Answer: Women aged between 50 and 70 years, identified via family doctor records, are routinely invited for breast screening. Therefore if you are not registered with an NHS family doctor you will not receive an invitation. You may not receive your invitation as soon as you reach 50 years because people from different family doctors practices are invited in turn, but you will receive it before your 53rd birthday. Depending on where you live, you will go to a special screening unit, a hospital or a mobile unit (for example in a shopping centre) for your mammogram. After the age of 70, you are still eligible for free mammograms every three years but you will need to ask for it and make an appointment: you will not receive an automatic invitation after this time. The government has said that screening ages will be extended in the future, to women aged 47–73 years.

Question: How do I find out if my X-ray is normal?

Answer: The results of your mammogram will be sent to you and your family doctor within two weeks.

Question: If I’m called back for a repeat mammogram, does it mean I’ve got breast cancer?

Answer: Only about 5% of women are recalled and of these only around one in eight will be found to have cancer. Most abnormalities seen on a mammogram are benign (or non-cancerous) lumps, such as cysts (fluid-filled lumps). Sometimes a repeat X-ray is needed because there was a technical problem and the picture is not clear. It is important that you attend your second appointment so this can be checked. If further investigations (such as a clinical examination, ultrasound scan or more mammograms at different angles) are necessary these will be carried out as soon as possible.

Question: If my family doctor or screening doctor sends me to the hospital breast clinic, how will they tell if I have breast cancer?

Answer: At the hospital breast clinic you will usually have a combination of tests known as ‘triple assessment’.

1. They will take your medical history and examine the breasts, axillae (armpits) and collarbone area.

2. They will do a mammogram and/or an ultrasound scan to ‘look’ inside the breast. Ultrasound scans use sound waves to build up pictures of the inside of the breast. You will need to lie down whilst gel is spread on the breast and a probe is passed over the surface of your skin. It is painless and takes a few minutes to do. Ultrasound scans can be useful in younger women, whose breasts are too dense for a clear mammogram and to identify certain types of lumps, such as cysts.

3. If necessary, they will remove some cells or tissue for analysis, either by “Fine Needle Aspiration Cytology (FNAC)” which uses a needle to draw off some cells for laboratory analysis, or by core biopsy that uses a bigger needle to take out a sliver (small piece) of tissue under a local anaesthetic, which numbs the area.

Some hospitals can give you most of your results on the same day, but others will call you back for them between one and two weeks later. The core biopsy result will take five to seven days.

Question: What happens if the hospital says I have breast cancer?

Answer: If the tests show you have breast cancer, your case will then be discussed by the breast unit team. They will be a team made up of breast surgeons, oncologists (cancer drug specialists and radio - therapists), radiologists (X-ray specialists), pathologists (tissue specialists), breast care nurses and others. Together they form a multidisciplinary

team (MDT), and they can determine the best course of treatment for you. Possible treatments will then be discussed with you at another appointment. You should meet a breast care nurse at this time. She will be there to give you emotional support and to help

answer your questions. You may need some other investigations. The important thing is that you should understand what a test involves and why it is being done. If you don’t understand, or you don’t remember what you were told the first time, ask again.

Question: Why might I have blood tests?

 Answer: Blood samples may be taken to assess your general health and how well certain organs in your body, such as liver or kidneys, are functioning. Blood tests are not used to detect the breast cancer itself, and are most commonly done before an operation or before

chemotherapy (drug treatment).

 3.3 SCANS AND TESTS

 Question: I am booked in for an MRI scan. What does that involve?

Answer: An MRI scan uses a magnetic field to build up extremely detailed pictures of the body. The full name for this investigation is magnetic resonance imaging. Computers and radio waves are also used but no radioactive substances. There is usually no special preparation. Not everyone can have this type of scan, for example it isn’t suitable for people who have metal in their body such as a heart pacemaker. You cannot take things like keys and watches into the scanning room. Before you come for the scan you may be asked to wear clothes which don’t have zips or other metal fastenings, or you might be asked to change into a gown when you arrive.

The scan is not harmful or painful but you will have to lie still for about an hour, usually face down on your tummy, which may be uncomfortable. The table you lie on moves into the scanning machine and so you may feel closed in temporarily. The scanner can be quite noisy at first, but this reduces to tapping sounds later. You may also have an injection of ‘contrast’ (dye) into a vein in your arm or hand.

You should feel no effects from this. The purpose of the contrast is to provide clearer images of certain organs.

Question: Does everyone with breast cancer have an MRI scan?

Answer: No, in fact MRI scans are not commonly used in the some countries for people with breast câncer like United Kingdom. They are not a standard part of triple assessment. Possible reasons for having an MRI scan are:

 

  • To find out more about something abnormal seen on a mammogram;
  • To help identify breast cancer in women who have especially dense breast tissue (which can make mammograms hard to read);
  • To screen those people at high risk because of a significant family history;
  • To assist in screening for cancer in women who have implants or scar tissue from previous surgery, as these might affect the accuracy of a mammogram;
  • To determine the integrity of breast implants (looking for ruptures or movement);
  • To distinguish between scar tissue and recurrent breast cancer where the difference between the two is unclear.

 

Question: Will I need a CT scan, and are they like MRI scans?

Answer: CT scans (computerised axial tomography) are not usually needed to diagnose anything in breast tissue, but they can be used to look at other parts of the body (such as the lungs or abdomen) if you have any symptoms that might indicate the breast cancer has spread elsewhere in the body.

The CT scanner is a complicated X-ray machine that uses a computer to produce pictures which resemble ‘slices’ through different parts of your body. You will be asked not to eat or drink for at least a couple of hours before the scan. A CT scan is not harmful or painful but you will have to lie still for up to an hour. The table you lie on can be hard so this may be uncomfortable. The table moves through the X-ray part of the machine as you are being scanned and comes out the other side. So you may feel closed in temporarily. As with an MRI scan, you may have an injection of ‘contrast’ (dye) into a vein in your arm or hand in order to provide clearer images. Again, you should feel no effects from this.

Question: Why is my friend having a bone scan?

Answer: As with MRI and CT scans, bone scans are not routinely done to diagnose breast cancer but can be used either to rule out or confirm a suspicion of breast cancer spreading to the bones, as this is one of the most common places that breast cancer can spread to.

Your friend is being checked to see if her cancer has spread this way.

A bone scan is also called an isotope bone scan. A small amount of a radioactive substance is injected into a vein, and then there is a wait of two to three hours to allow this to circulate around the skeleton before the scan. Abnormal bone absorbs more radioactivity than normal bone, so the radioactive substance is more visible at sites of abnormal activity (referred to as ‘hot spots’). The hot spots could also be caused by arthritis, previous fractures, and so on.

You can go home as soon as the scan has been done, and it is quite safe to have normal contact with people, including children, afterwards.

Question: Why do people with the same diagnosis all have different tests?

Answer: Each person is different and will only need the tests that give the medical team the information they need. Don’t be alarmed if you have some tests and not others, or if you have an investigation that someone else is not having. The doctors may not need certain scans, for example, to confirm a diagnosis of breast cancer or to help plan treatment.

Question: How long do all these tests take?

Answer: The time you may be at the hospital for tests varies. A mammogram or blood test may be over in minutes and a scan may take an hour or more. Occasionally, the preparation for an investigation may take longer than the procedure itself, or you may have to attend more than once during a day – such as for a bone scan. Always ask for details of tests, including the time they take or the time you have to wait. You may wish to take a friend with you, or a book or magazine to read to help pass the time.

Question: How long does it take to get the results of all these tests?

Answer: Some test results can be available almost immediately, for example a simple blood test or a routine chest X-ray. But very often the results take days or a couple of weeks to reach your doctor. In the case of a scan, the technician can identify the parts of your body but the pictures produced must be carefully interpreted by a radiologist (a specialist doctor) who will write a report and send it to your doctor. This may take a few days.

Question: Everyone says the waiting is the worst. Is there anything I can do?

Answer: Many people find this time the most difficult. It’s obviously a time of uncertainty and fear. You may find it helps to talk to your specialist doctors or breast care nurses or to your family doctor. It’s also going to be an anxious time for your family. It may help to discuss your fears and concerns with those close to you. There are also organizations that can provide a listening ear, emotional support and additional information. It may help to talk to people who don’t know you, such as a counsellor or someone on a telephone helpline, or to a person who has been through a similar experience. Organizations which offer such help we listed at the end of the course, some we provide during the course.

Question: What happens when the test results are ready?

Answer: When your specialist team has all the results of your tests, they will be able to advise you about what treatments are available, what alternatives exist and what your best course of action might be. It is important that you understand what is said, what is being offered and that you ask all the questions you want. It can be really helpful to take a friend or relative with you when you go to see your doctor. Make notes and if you want time to think about what has been said, don’t be afraid to ask for it. It’s not uncommon to have difficulty taking in all the information immediately, so don’t feel stupid if you ask about things more than once.

 Question: What treatment will I have?

Answer: Your treatment will be planned individually for you, and will depend on many factors, including the type of breast cancer, its size, ‘grade’ and characteristics and your age. Don’t be concerned if you speak to people who are having similar, but different, treatments. Always ask your doctor or breast care nurse about your individual treatment as they will be able to explain exactly what is planned and why. Ideally, you should be given a written copy of your individual treatment plan, although this may change slightly as time goes on. It can take a little time for treatment to be organised, depending on what treatment you are having first.

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