BREAST CANCERS

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 patient’s 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 likely to be able to have a breast reconstruction carried out at the same time if they wish (immediate reconstruction).
• Anti-hormonal therapy. Anti-hormonal therapy is sometimes discussed for individual patients, with oestrogen sensitive DCIS
• Chemotherapy. Chemotherapy is not needed in the treatment DCIS.

What is the prognosis for DCIS?

Women with DCIS have an excellent prognosis, but patients treated for DCIS will be offered at least 5 years of surveillance with annual mammograms 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. There are 2 main types. Invasive ductal carcinoma of the breast (IDC) makes up over 80% of cases and invasive lobular carcinoma of the breast (ILC) accounts for about 15% of cases. The word “invasive” just means that this is a cancer, not that is has any additional aggressive features.

What are the symptoms of invasive breast cancer?

Patients may identify a change in their breast (below) or may have no symptoms and have their breast cancer diagnosed as a result of undergoing a routine screening mammogram. The following are possible signs of breast cancer that you 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
• Nipple turning inward (inversion)
• Nipple discharge
• Lumps in the underarm area
• Skin tethering or distortion on raising arm above head
• New localised pain in one breast

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 will 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?

All breast cancers will be assessed for grade, the presence or absence of important cell surface receptors (oestrogen and herceptin) and the characteristics of the lymph nodes in the armpit before treatment begins in order to work out the best treatment plan for you.

Rachel will discuss each step in the treatment pathway at the local breast cancer multidisciplinary team meeting (MDT). This is a weekly meeting with many breast cancer specialists present to ensure that there is agreement on investigations, diagnosis and the best treatment options.

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

• Breast surgery (breast conservation, mastectomy)
• Lymph node surgery (sentinel node biopsy, axillary node dissection)
• Breast reconstruction
• Radiotherapy
• Chemotherapy
• Anti-hormonal therapy in oestrogen sensitive breast cancers
• Targeted Biological therapy in Her 2 receptor positive breast cancers
• Bisphosphonate therapy in ladies who have gone through the menopause with higher risk breast cancers

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 breast cancer?

This will depend on numerous factors including:

• Disease stage (confined to the breast / spread to lymph nodes / distant spread)
• Tumour sensitivity and response to different types of treatment (such as chemotherapy, hormone blocking drugs and herceptin)
• Fitness of the patient to undergo certain types of treatment

It is important to remember that breast cancer is generally 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.

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.

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

Because ILC can sometimes be harder to size on standard mammograms it is common to recommend a breast MRI scan as well, as it often gives the most accurate information about the size and shape of this type of cancer.

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 assessment 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 a possible increased breast cancer risk in the future, 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 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 more regularly than is used in the national screening programme.

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 of the nipple?

• 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
• Burning and/or itching of the nipple/areola

How is Paget’s disease diagnosed?

During your clinic appointment, you will be asked all about the breast change or symptom you have noticed, and a full medical history and clinical examination will 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
• NIpple biopsy

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 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 often 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 similar to the treatments outlined above for patients being treated for an invasive breast cancer.

What is the prognosis for Paget’s disease?

The outlook depends upon the associated disease within the breast. If DCIS is the only abnormality identified then the outlook following treatment is excellent. If there is an associated cancer the outlook depends on that. It is important that you are able to discuss this with your surgeon.

Following completion of treatment for Paget’s disease you will be offered at least 5 years of surveillance with annual mammograms.

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). It is most often considered for women who require a full mastectomy. Nationally, about a third of women having a mastectomy choose to have an immediate reconstruction and a further smaller group choose to have a delayed reconstruction.

Partial breast reconstruction or breast reshaping ( using breast reduction techniques) can also be useful in women who are able to preserve some of their own breast tissue but where there will be a noticeable change in volume or shape after the cancer surgery.

Types of Breast Reconstruction after Mastectomy.

There are 2 main types of reconstruction

1. Techniques that depend on a breast implant to recreate the volume of the missing breast

This is the commonest type of reconstruction for patients having an immediate breast reconstruction. Much of the skin of the breast is preserved and a cohesive silicone breast implant is placed inside the space left after the mastectomy.

Sometimes the nipple can also be preserved if the cancer is small and not close to the nipple and there is no extensive DCIS associated with it.

The implant can be placed under the chest wall muscle or on top of it and the choice often depends on the shape and size of the breast and the amount of overlying fatty tissue for implant coverage.

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

It is now common to combine an implant reconstruction with a biological mesh wrapped around the implant for an additional internal support.

2. Techniques that use a ‘flap’ of your own tissues from elsewhere ( “autologous” reconstruction)

In recent years, own tissue or ‘autologous’ reconstructions have become more and more popular with patients because the breast can appear more natural looking. Tissue is usually taken from the tummy or back, but sometimes the buttocks or thighs, and 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 initial recovery period.

Reconstruction after Breast Conservation

1. Therapeutic mammoplasty. This technique uses a breast reduction technique to remove a larger breast cancer while leaving a good shape breast
2. Fat transfer. This may be used to “fill in” dips in the breast after breast cancer surgery and radiotherapy

The decision to undergo any reconstructive surgery is a very personal one, and there are advantages and disadvantages of this type of surgery and the techniques used are specific to your individual situation and needs. Rachel will be happy to talk to you in more detail about the pros and cons of all these techniques.