It’s the most common type of cancer in women, with 1 in 8 being diagnosed across Victoria alone. It’s time to talk seriously about breast awareness and cancer care.
We caught up with specialist Breast Cancer surgeon Dr Chantel and breast care nurse Sarah Morrison to talk about all things breast cancer and breast health.
Dr Chantel Thornton is a specialist breast cancer surgeon specialising in the treatment of benign and malignant breast conditions.
Sarah is an Epworth breast care nurse. She supports women from diagnosis right through to survivor-ship, through their surgical treatment, and then their medical treatment, right through to getting them back to some form of normality after having a cancer diagnosis.
What is breast cancer?
CT: Breast cancer is basically when the breast cell starts growing outside its normal boundaries. So, normally cells in the body if they start to grow wildly or bizarrely there are special checkpoints or mediators that will recognise that and they’ll switch off and destroy the cell.
What happens in all cancers is the individuals’ cells start to grow wildly and abnormally and those checkpoints, or those big brother cells that would normally be watching to turn off or switch off the abnormality in the cell, don’t work, and therefore the breast cell then grows abnormally. Breast cancer itself comes in a few forms, but the most common is ductal breast cancer (where) it comes from the milk ducts. You can also have lobular breast cancer, and then there are multiple other sub-types.
Do some people have a higher risk of being diagnosed with breast cancer?
CT: Yes, they do. Women that have a strong family history of breast cancer, and we’re talking about women that have more than three relatives, (especially) first or second degree relatives on the same side of the family. Women who have a history or a family history of ovarian cancer. Women who have had a male in their family with breast cancer, or women that carry a genetic mutation or an Ashkenazi Jewish background have an increased risk.
Then from a community perspective we know that women, particularly those in a post-menopausal setting that are overweight, women that have had prolonged exposure to estrogen therapy, women who may have had imasiation radiation therapy to the breast, and treatments of Hodgkin and lymphoma and the like. Then obviously just being female, increase in age etc. Mostly actually it’s nothing that women have done, it’s just being a woman and being in the Australian community. It’s a very very common disease.
Is there any way you can reduce your risk?
CT: Yes, having lots of babies, and having them before the age of 30. Breastfeeding longer than six months, exercising (regularly) 240 minutes a week looking at 120 minutes of aerobic style exercise, and then the rest of that core body conditioning style exercise, reducing your alcohol consumption, increasing fresh fruit and vegetables in your diet, keeping your body weight in a healthy weight range, reducing your exposure to estrogen and not taking hormone replacement therapies for a prolonged period of time.
When should we start checking our breasts?
SM: I would suggest probably from a teenage girl.
Sometimes just doing a breast check and feeling isn’t sort of the direction we hope to go in, it’s more about changes and dimpling and/or changes in size, anything different to what you normally see from puberty onward.
What symptoms should you be looking out for & when should you go & see your doctor?
CT: Normally what we’re talking about is breast awareness. We’re looking, for example, for a lump or thickening or (change in) contour or size and/or shape of the breast that last longer than a menstrual cycle. That’s exactly what Sarah is saying. It’s being aware of the normal changes in your breast and knowing what’s normal for you and if you have a symptom like nipple discharge, changes in the skin, so a thickening or crusting of the skin over the nipple, a lump in the breast tissue or just something that just doesn’t feel quite right and that lasts longer than one menstrual cycle and it continues to be there then you should see your doctor. Or, pain in the breast is also a very common finding. Although pain in the breast is also uncommonly associated with breast cancer.
How often should you have a mammogram & what does a mammogram feel like?
SM: Well, you should have a mammogram every couple of years. A mammogram can be uncomfortable, but it’s not painful. It’s done through radiology and it’s a machine where you put your breasts into the machine and the machine squashes it down so it gets a lovely picture of the breast top to bottom and side to side. Those images are then reviewed by the radiologist and then if there’s any concerns a GP will refer you on to a breast surgeon to review anything that may be, hopefully, benign. So it’s uncomfortable, but at the same time I think it depends on the size of your breasts.
CT: At Epworth now we have this beautiful machine which combines time synthesis and mammogram and so it not only increases the sensitivity of the investigation but it also reduces the amount of compression required, and really that’s what ladies find most uncomfortable.
Now with this thing called CT time synthesis that we combine with a routine mammogram the compression required is a lot less. We also get not only those 2D images of the head to toe and side to side view that Sarah was talking about, but we also get this fabulous 3D image that goes through the breast that the radiologist can see to improve the sensitivity, in particularly in ladies who have dense breasts.
I normally recommend that women get breast imaging on a bi-annual basis as Sarah said, from age forty. Breast Screen Australia will allow women to enrol from age forty, but they would have to self-remind and self-refer until they turn fifty. Then from fifty onward they would remind the patient. Now the caveat to that is that unfortunately Breast Screen only have digital imaging and so it’s not the, I suppose, most sensitive imaging. They don’t have imaging with time synthesis unless of course a patient gets a callback and then they will be sent to a centre where there is time synthesis. So, in ladies that are young or that have dense breasts or have a strong family history they’re now having their imaging done through the private sector.
How is screening different for someone with dense breasts?
CT: So that means the breasts are full of ducts and lobules! So when you’ve got very dense breast tissue what you have is a lot of ducts and lobules which means that when you do the mammogram it won’t be very see-through. The mammogram will be white and so when we’re looking for a breast cancer on monography we’re looking for a little white dot. So when you’ve got lots of ducts and lobules it camouflages the problem and makes it more difficult for things to be seen on imaging. Secondly, it makes it more difficult for you to examine your breasts because your breasts will often feel very dense, very nodular, very lumpy. And thirdly, we know that breast density is an independent risk factor not just merely due to the fact that there’s a camouflage or a false negative effect with the imaging. So we always tell women about their breast density so that they can be aware that their monogram is going to be more difficult, their clinical exam is going to be more difficult, and that they need to be obviously more vigilant in their breast imaging and their breast examinations.
How is breast cancer diagnosed?
CT: About 50% of breast cancer is actually diagnosed through Breast Screen. It’s totally asymptomatic. The other 50% may present with a symptom, the most common being a small lump or an area of thickening in the breast.
How is it treated?
CT: Treatment will mainly involve the surgical side, the removal of the cancer, which will either be in its entirety, i.e the entire breast with an immediate breast reconstruction at the lady’s wish, or just a mastectomy if they don’t wish to have a reconstruction up front, or removing the actual cancer with a surrounding margin normal tissue called a lumpectomy.
Whenever we do a cancer operation we also sample the lymph nodes under the armpit and the most commonly performed procedure now is called a centennial lymph node biopsy, and that’s really just to make sure and to determine how aggressive the cancer is and to see whether or not the cancer cells have the ability to spread from the breast to the armpit to determine further treatment. And then further treatment could involve chemotherapy, radiotherapy, or drug treatment and that’s where Sarah will talk about her side of things. Sarah not only works as a breast care nurse but she also works at Epworth in the oncology ward. So she gets the added benefit that she sees the patients in the rooms with me when we diagnose the patient, when we take the little biopsy to make the diagnosis, and then she’s able to follow them through their journey to support them when they go through their chemotherapy- if they need chemotherapy. Not every lady needs chemotherapy.
SM: So quite often when you ask how breast cancer is diagnosed, it all starts with in this room. When we get the images Chantel will then biopsy and send for more scans and do much more thorough investigations. The woman is told of course and then treatment options start from there. It’s like a big recipe book and it’s just a matter of which recipe suits that person. The treatment options can range from chemotherapy, radiotherapy, and hormone therapy. Now, what’s becoming more and more popular are the immunotherapies which are making a lot of headway in the breast cancer field.
The patients are then referred on to other specialists; mainly medical oncologists and radio oncologists. They will take over the systemic care of the patient, so the hormone therapy. Hopefully they don’t have to have too much therapy afterwards but it’s one of those cancers that doesn’t get treated and then finished within six months, it can be ten years; and then it’s constant surveillance down the track. It’s a long time. They’re not sick all that time, often they’re living a very well and healthy life, but it’s a chronic disease.
CT: I think it’s important to also touch on the fact that we have a very highly skilled multidisciplinary team and it’s very important for ladies to know, particularly women who might be living in rural and country areas, that it’s very important that your case is discussed in a multidisciplinary team meeting. So while I say I diagnose the breast cancer, I take the patient to the operating theatre and I remove the cancer, none of that is done before the case is discussed in a multidisciplinary team meeting with all of the specialists involved.
We’re going off at lunchtime today to talk about our cases from last week. We talk about the patients in the meeting, we review their pathology under the microscope with pathologists, we review all their imaging before we make any decision to operate on the patient. It’s very important that everything is discussed in that team meeting because we know that improves on survival of the patients. So that the oncologists will already know the story about the patient, they’ve already seen the pathology under the microscope and then I’ll say my plan is ‘this’ and they’ll say great, then I’ll catch up with the patient on the ward after you’ve finished surgery, then we’ll take it from there. Then we’ll go back once we’ve done the operation and we’ll review the pathology, we’ll review the imaging and we’ll say okay what did we find, do we need to do further surgery or do we now move on to further specialist treatment.
That’s really done as a joint decision- with multiple specialists, and that’s what really has significantly improved survival of ladies with breast cancer.
How common is breast cancer?
CT: It’s extremely common. Victorian figures show it’s about 1 in 8; it’s the most common cancer in females. 1 in 8 women will at some stage in their life get breast cancer. That 1 in 8 figure though really is in the ladies in the older age group. So, you know, women in their eighties and the likes. Women in their earlier ages do not need to feel alarmed by that but as we said just being breast aware is very important, and knowing your family history is important too. All the other stuff that we talked about isn’t rocket science, I mean, live a healthy lifestyle.
What advice do you have for managing fear of cancer re-occurrence?
SM: I think one of the biggest things, and it’s probably the most prominent question that I get asked as a breast care nurse from patients is, years and years later after they’ve had their diagnosis, they’ve been treated for breast cancer. It’s an absolutely normal question, and it’s a normal feeling to have. Quite often I just say to ladies ‘you’re being constantly surveyed, you’re more aware, you’re hyper vigilant that you’re checking, and from your diagnosis you’ll be constantly checked. You’ll be checking in with your surgeon, your oncologist, you’re having that constant checkup compared to your friend that hasn’t had breast cancer who probably isn’t being checked up, or hasn’t been as proactive as what you are. If something does pop up later on, which cross our fingers and toes that doesn’t happen, then we’re on to it pretty early. Quite often women are on hormone therapy for up to ten years now so they do feel like they’re having a bit of an insurance policy with having that done. It does relieve their anxiety.
CT: 70% of all breast cancers will have receptors on them (for estrogen and progesterone) which means that if we block estrogen and progesterone in the body, which is what Sarah is talking about, is hormone therapy, an anti-hormone which lowers the estrogen and progesterone in the body to prevent the cancer growing or reoccurring. We actually sometimes advise that ladies take these anti-estrogen, or these estrogen-lowering tablets for up to ten years. They’re taking a tablet every day to reduce a risk of re-occurrence. It’s important to make ladies understand what their actual treatment is doing, and the fact is, there are many other therapies that we have available to treat ladies with recurrent breast cancer.
We talk about breast cancer much more as a chronic disease now because we know that it’s a type of cancer that can come back ten, fifteen, twenty years later. But, women are living long and active lives with metastatic breast cancer. Many of them will not die of breast cancer, they’ll die of some other cause which isn’t associated with breast cancer. The second thing I should say is that for us, we’re actually quite lucky because we’re dealing with a cancer that has one of the highest survival rates of all cancers. 94% of all ladies that are diagnosed with breast cancer will live a very long time.
So from our perspective, it makes our job quite rewarding because we get to see our patients for many, many years. We give them very aggressive treatment options up front because we expect that they’re going to live to their eighties and we want to give them absolutely everything; world class, gold standard.
What would be your advice for looking after your mind, body & spirit if you’re diagnosed with breast cancer?
SM: That’s a really important part of the whole breast cancer journey. The mind does funny things, it can play tricks on people and given a cancer diagnosis, particularly breast, it’s very much hormonal driven, and so women can be very emotional based on the very fact that they’ve got breast cancer. So, we always highly recommend support groups, support networks within their families or within their group of friends.
We also have a support group here at Epworth called Boob Club which is for women under the age of 45, which is Chantel’s demographic. Women anywhere, they don’t have to be Epworth patients, but they can join the club and it’s really good for them to be able to talk to each other. There’s lots and lots of support groups, and there are lots of support organisations; Think Pink, Counterpart, The Otis Foundation, who support primarily women with breast cancer, it has a lot of community support. Body - definitely it’s about keeping fit and healthy. Exercise has shown to be valuable, as Chantel said, over 3-4 sessions a week. We have to think about our bones as we get older and weight limits. Lots of meditation and yoga is also really important, and a healthy diet. Making sure that we keep our BMI down and our exercise up. I think a lot of it is to do with having a healthy mind that can make a big difference.
CT: Epworth have a fabulous survivor-ship program which Sarah also helps to collaborate and facilitate, and that’s an incredible program for women who have finished their immediate surgical treatment to help them with this exact thing, the pscyho-social processes. In particular, women who have lost their breast, their femininity, sexuality, the psychology, particularly if they haven’t had children, or if they’ve got children, fertility issues etc. We have dedicated psychologists and dedicated exercise physiologists that help our patients because it’s a very stressful time.
I think it’s about knowing from a women’s perspective that the support is there, and that they’re not going to be feeling like this forever, and that they’re going to get better. It’s often quite difficult during the immediate management so it’s sort of just about getting them through to get back on with their life and getting back into the community doing things that they love to do.
05 July 2019
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