Prophylactic Mastectomy – how much does it really help?

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Being diagnosed with breast cancer and undergoing mastectomy can be a traumatic experience, and surgeons are often consulted about “prophylactic” mastectomy – a procedure to remove the healthy breast along with the cancer-affected breast in the hope of avoiding a recurrence of breast cancer at a later stage. Researchers at the University of Minnesota have found that the “survival benefit” for this procedure is less than 1% at 20 years post-surgery – at least, for patients who do not have the BRCA gene mutation.  According to Medscape, their findings were presented recently at the American College of Surgeons 2013 Annual Clinical Congress. The increasing demand for the procedure is surprising in itself, given that not so long ago most patients dreaded the removal of a breast and would not wish to consider the loss of both breasts if one, at least, was healthy. Now, it seems that as many as one in five women are undergoing double mastectomies despite having a normal lifetime risk and a healthy other breast. What has changed? It’s not entirely clear but may have to do with the increasing recognition and awareness of breast cancer in society as well as publicity around public figures who opt to have prophylactic mastectomies earlier in 2013. Film star Angelina Jolie is a case in point, whose life chances have been substantially improved because she was found to have the BRCA mutation after two close female relatives developed breast cancer. In cases like Angelina’s, prophylactic mastectomy is worthwhile, even though no cancer has yet been diagnosed. Women are also aware that surgical management of the breast has improved dramatically in the past couple of decades and that cosmetic outcomes are often very acceptable with modern reconstruction techniques. However, the new computer model which predicts the likelihood of long term survival of patients who have had breast cancer but do not have the high-risk BRCA mutation suggests that for most patients there is little to be gained in terms of risk reduction, by removing the healthy breast. The research compared risks for breast cancer occurring in the other breast, and chances of survival with and without prophylactic mastectomy, in women aged between 40 and 60 who had been diagnosed with early-stage breast cancer but were without the BRCA mutation. The analysis also took into account age, how much the original breast tumour had grown before diagnosis (Stage I or II), and also the extent of oestrogen receptor involvement. According to this model, a person at the lowest risk for recurrence of breast cancer (i.e. younger, with a Stage I tumour, and oestrogen-receptor negative), might hope (on average) to gain an approximate extra 6 months of life. An older patient...

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More on mammograms and breast cancer risk

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Kudos to Cape Town doctor Martinique Stilwell, for tackling the controversial and sticky subject of breast cancer risk in last week’s Mail & Guardian. Her article is a breath of fresh air – and not least because she reminds us, here in South Africa, that very often less can be more. South African women are still very much in need of clinic services near to their homes where they can talk to, and be examined by, well trained, caring community nurses. Meanwhile, the debate about how much screening should be offered to women under 50 – aside from those with particularly high risk due to BRCA mutations – rages on. Here at Bay Breast Care we don’t recommend that you postpone mammogram screening until over 50, especially if you have “dense” breasts – firm breasts are always popular, but the density of breast tissue vs fatty tissue makes this breast more difficult to visualise on a mammogram. Patients at high risk may need additional ultrasound screening and perhaps even Magnetic Resonance Imagery (MRI). Radiologist Dr Sandra Basson, who trained in Germany, says that high-risk women there have scans on a six monthly basis, alternating MRI scanning with mammography to keep the mammo exposure to a minumum whilst still providing good and frequent screening that would be able to catch even a fast growing cancer in an early stage. The good news is that for Medical Aid patients, there is more acceptance these days of other methods, including the notoriously expensive MRI procedure, and this means a better service for those who need it. On the other hand, if your risk is average, keep things simple – you neither need nor want to have expensive, uncomfortable procedures that don’t add to either your peace of mind or your span of healthy life. Martinique Stilwell’s article is a timely reminder to women to become aware of our true breast cancer risk. Those who over-estimate their risk experience needless anxiety whilst those who under-estimate can be too blasé about the need for regular screening and a healthy lifestyle. To calculate your risk, use a breast cancer risk calculator. The first part gives you the basic risk, the second part refines that with a few more details on lifestyle. A word of warning: for some women, the calculations aren’t accurate. The risk will come out too low if you have a BRCA mutation, and it may be too high for women who consume large amounts of phyto-oestrogens on a regular basis – for example, soya beans and soy products. More research is needed on that. However for most of us the calculator will work well and give a much better result than a...

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Fret or forget? Digging for answers with Fair Lady in Breast Cancer Month

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Kudos to Fair Lady (October 2013) for kicking off Breast Cancer Awareness Month in style! They asked Cape Town breast cancer specialist Jenny Edge to share the latest evidence. What should we worry about? What shouldn’t we worry about? What should we do or not do to improve our chances of avoiding breast cancer? Dr Edge says that the evidence is there for alcohol, hormone replacement therapy and (not) breast-feeding. There is a common element in these factors: the hormone oestrogen which has a close association with breast cancer. We’re going to review some of her comments for you – with a few of our own. Alcohol alters oestrogen levels in the body – to break down oestrogens you need a fully functioning liver, not one that is battling to de-tox the alcohol you consume! More than two drinks a day for men or one for women, and your liver will have reduced capacity for other work. So any alcohol at all increases breast cancer risk, though not by much. According to Dr Edge in Fair Lady, one daily drink will raise your “absolute risk” by 7% – everyone has an ‘absolute risk’ which varies depending on our family history, age, number of children we have, and lifestyle. So if your ‘absolute risk’ is 1%, and you drink one drink per day, the overall risk goes up to 1.07%. Hormone Replacement Therapy (HRT) lost its sparkle with the publication of a huge British study showing a definite increase in breast cancer risk for women who used HRT. “Combination” HRT (with both progesterone and oestrogen components) was seen as more harmful based on these results, whereas oestrogen-only HRT increased the risk while women were using it but only after several years. However, here at Bay Breast Care, we’re wondering if the news on HRT isn’t quite so bad. The results of this study have recently been re-analysed, raising doubts amongst experts – because even the biggest study can still come up with misleading results if there is bias present, and it’s not easy to control for all possible biases. Professor Ian Fraser, Gynaecologist at the University of Sydney, wrote in the British Medical Journal last year: “The epidemiologists have managed to raise fear among women in the general community about use of hormone replacement preparations, yet these therapies have an enormous impact on many aspects of well-being, such that the benefit-risk ratio for most individual women is very positive. I would really like to show the epidemiologists I know (who do not see any patients) the dramatic impact which this therapy can have on the quality of the lives of many menopausal women” (BMJ 2012;344:e513). So although the link between HRT...

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Breast Cancer: Reducing your lifetime risk – the evidence

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As awareness of breast cancer increases, interest is growing around ways to prevent it. Breast cancer survivors are especially likely to make risk reduction a priority. Yet there is so much misunderstanding about “risk” which in public health is not merely an emotive word, but a statistical concept with a precise meaning. Some known risks cannot easily be controlled – such as your genes, the age at which you begin menstrual cycles, and the age at which you reach menopause. It is believed that inherited risk accounts for around 10% of all breast cancers. Other known risk factors such as the timing of pregnancy, birth and breastfeeding, often involve choice but – realistically – are not likely to shift in respect of what amounts to a relatively small improvement in lifetime breast cancer risk. On the other hand, information claiming to be authoritative about cancer prevention is often promoted to the public, despite offering little solid scientific support for interventions that may not only be inconvenient but also – often – quite costly. There is a clear need for researchers to sort through the facts, the myths and the concerns, for everyone’s sake. Research of this nature is difficult and expensive; large samples of women must be followed for long periods of time, after giving accurate, detailed accounts of health behaviours or environmental exposures. Nonetheless, the research is being done and the results are being made available. In 2011, the Institute of Medicine in the USA reviewed the evidence base for environmental risk factors associated with breast cancer. The entire report can be downloaded here. Six risk factors The following six risk factors emerged with strong research support from this review. 1. Ionising radiation. This radiation is involved in X-rays and CT scans. Ionising radiation separates electrons from their atoms, creating an intra-cellular electrical charge which is capable of breaking DNA, the machinery of cellular reproduction. Cells damaged in this way will mostly die or be repaired by the body’s own defence mechanisms, but some may continue to reproduce forming a cancer growth. Until recently, it was assumed that normal X-rays were not a significant source of radiation exposure, but researchers have found that the “dose effect” is to some extent cumulative. So a few X-rays done when really necessary are not of concern, but repeated X-ray imaging should be avoided. CT scans (Computerised Tomography) which build up a picture using multiple X-rays involve large doses of ionising radiation and are definitely cause for concern, especially in children – though despite the increased cancer risk the use of a CT scan may still be safer than alternatives such as exploratory surgery. The US Food and Drug Administration provides detailed...

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Medical schemes make screening mammography more accessible

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Good news  for members of medical schemes – certain medical aids are now approving and reimbursing Screening Mammography without requiring a referral from your doctor.  Mammography plays an essential role in detecting breast cancer at an early stage, up to two years before you or your doctor would be able to feel an abnormality in the breast tissue, but it’s taken quite a while for medical aids to allow this. Booking yourself in will simplify the process, especially for busy people who aren’t keen to spend needless time in doctors’ waiting rooms! When you arrive for your Mammo screening, X-Ray Department staff will ask for your doctor’s details (GP or Specialist) so that they can send a report on your X-Ray or scan.  If your X-Ray indicates further management, the medical specialist in the X-Ray department will discuss this with you and explain what you should do – and will contact your doctor to let him or her know what’s happening. By the time you see your own doctor, he or she will have the pictures and the report, and will be ready to help you decide on the next step.  If all is well, your doctor will still get a report from the X-Ray Department and will thus know that everything is in order. By easing the process in this way, medical aids are encouraging their members not to delay their regular Mammo screening (for more information on Screening Mammography and who should be screened, see our article). Port Elizabeth radiology firm Drs Visser, Erasmus, Vawda and Partners  believe that the medical aids have taken “a step in the right direction” with this new provision, because it helps to promote screening mammography and thus the early detection of breast cancer. Here at Bay Breast Care, we agree!  If you have any queries,  check http://www.bayradiology.co.za for contact details of your nearest X-Ray Department. Meanwhile, it’s a good idea to call your medical aid, to find out if they are supporting this pro-screening  initiative. If they are, they deserve a pat on the back; if they aren’t, go right ahead and tell them it’s not good enough. If we women are ready to put our breasts on the table – literally! – then the least we can expect is that our medical aids will help us with an easy and cost effective process. If you’ve never had a mammogram before, check out this video from BUPA in the UK which gives you some idea of what to expect: http://www.youtube.com/watch?v=2t_lW_PICl4...

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What does it mean when I have nipple discharge?

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Although it can be upsetting when a woman who isn’t breastfeeding has fluid coming out of one or both nipples, it’s true to say that this is actually very common and seldom leads to serious concern. The human female breast is a complex and beautiful structure. It is unique in the animal kingdom for combining multiple ducts into one shapely form, with a well designed “bulls-eye” in the middle so that even a newborn baby knows where to find food. We can thank our lucky stars for this, because every foetus starts out with two converging rows of nipples similar to the ones you can see on your pet dog! All but two of these disappear long before birth, though occasionally a child is born with a third nipple – Napoleon was rumoured to have this unusual feature. Most women can press fluid from their nipples if they try – though this is no longer recommended as part of routine self-examination as it’s not likely to do any good. The nipple is a sensitive and erotic zone in which the boundary between pleasurable stimulation (which may also cause discharge) and harmful irritation can be somewhat subjective! The nipple has microscopic openings or pores for milk release which occurs under the influence of hormones.  Discharge from both nipples and from several pores suggests hormonal upset; this is fairly common during peri-menopause whilst some thyroid conditions also affect breasts.  Fluid that looks similar to milk and comes out freely (in the absence of a baby to feed) could indicate a very rare non-cancerous pituitary tumour, for which you may need a blood test followed by MRI scan and specialist advice, as this tiny master-gland lies too deep within the brain for a simple operation.  Although there isn’t always an obvious reason for nipple discharge, medications including certain antidepressants, anti-anxiety treatments, mood stabilizers, blood pressure medicine, ulcer medicine, and long-term psychiatric drugs can cause it. Birth control pills and hormone replacement therapy, by altering hormone levels, are also common culprits, as are some herbal treatments and street drugs especially cannabis. Men can also experience breast problems such as enlargement, pain and discharge. Though often a source of amusement to others it is no laughing matter for the man concerned, who should make no delay to consult his doctor and find out the cause.  It’s fascinating to note that in circumstances of high emotional stress, the nipples can leak bloody fluid – for example, after a public disaster that affects us personally, when children leave home, or when new grandchildren are painfully missed. It seems that women really are mothers of the nation: our breasts can express our love for those “children” and...

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