Talk on HRT and Breast Cancer with Kate Panter

Panel discussion on Breast Cancer, Menopause and HRT

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Leading Clinicians Collaborate in an In-depth Panel Discussion on the link between Breast Cancer, Menopause and HRT

As we close Breast Cancer Awareness Month (October 22) a group of leading clinicians took part in a panel to discuss Breast Cancer, Menopause and HRT, (Hormone Replacement Therapy) tackling some of the myths associated with the subject whilst championing the emergence of a pioneering screening process and existing innovative diagnostic procedures available to patients offering greater precision in the treatment of breast cancer. (Click here to watch) or see below under media.

Between 1 in 7 women in the western world will get breast cancer in their lifetime. Many women now understand that if they are asymptomatic, but carry a BRCA mutation they are at a high lifetime risk of developing cancer.

Professor Zoe Winters, Senior London Consultant Breast Cancer Surgeon at New Victoria Hospital contributed to the discussion by sharing news that HRT produces huge overall health benefits that particularly derive from Oestrogen replacement at the time of perimenopausal symptoms. Safest forms of Oestrogen comprise transdermal administrations that don’t significantly raise risks of breast cancer in the long-term. It is Progesterone long-term that does this, where it is required in women with an intact uterus to reduce unopposed oestrogen effects on the uterine lining.

All women should be aware that we are not all at the same risks for breast cancer within the general population. We are currently guided by predicted averages in the general population. Based on a recent UK randomised trial, including European guidelines, we recommend commencing mammograms at 40 years of age annually. Fifty-year olds may safely undergo 2 yearly mammograms indefinitely.

A mammogram is performed to assess both breasts in total and by comparing it to previous mammograms. One key finding to communicate with each woman is “What is your breast tissue density?” This is quantified by the radiologist assessing the ratio of breast duct tissues that appear “white” compared to fatty tissues that appear “darker” on the mammogram. Breast tissue density is a strong predictor of one’s breast cancer risks, where very dense breast tissues raise your risks by 4-6-fold compared to very fatty breasts. Very dense breast tissues may also reduce the sensitivity of mammograms, and we may miss detecting 20% of breast cancers. However, this guides how frequently we recommend mammograms, and whether we include bilateral breast ultrasounds or breast magnetic resonance imaging or MRIs.

Dr Kate Panter, Obstetrician and Gynaecologist at New Victoria Hospital, Consultant Gynaecologist and a specialist at the British Menopause Society went on to discuss the taboos around both menopause and taking HRT. While she feels the peri-menopause itself can still be considered taboo since many women struggle to even admit they are experiencing symptoms, she explains: “The taboo around taking HRT has in large part, come from the way the media talks about breast cancer risks associated with HRT. They portray HRT as the only risk for breast cancer, and a huge risk at that, when in fact there are other more significant lifestyle factors, such as obesity for example that can put you at risk of breast cancer. “

Professor Barbara McGowan, an Endocrinologist agreed by saying that many women have been too scared to take HRT because the link between HRT and breast cancer has been greatly distorted by the media over the past 20 years. She went on to explain: “There are recent publications that suggest a slight increased risk of breast cancer with taking HRT but that it will depend on the type of preparation. Never- the- less that risk remains reasonably low, and, after stopping HRT that risk tends to regress in time”.

There is often confusion from a woman’s perspective about the various types of HRT available and knowing what would suit them best.

Dr Panter talked about the different administrations of HRT. She explained: “When a woman is peri-menopausal, or going through the menopause, within a year of reaching menopause, or immediately post-menopausal, the time when you are no longer menstruating, you need to take cyclical HRT.

This means taking Oestrogen throughout the month and progesterone for the second half of the month. If your periods have stopped, for approximately a year – then we can give you what we call continuous combined or no-bleed HRT, where we give you a little bit of oestrogen and a little progesterone every day.”

There are various ways to take HRT, options include taking HRT orally or transdermally (through the skin, like gel or patches) or a combination, oestrogen gel applied to the skin and progesterone tablets.

Dr Panter discussed the benefits of taking transdermal HRT: “HRT used to be given orally, but that’s no longer the case, now we prefer to give oestrogen through the skin, as it doesn’t have to withstand digestion and so we can give an exact copy of your hormone, a bio-identical form of HRT, one that more closely represents our body’s own hormones, so there are benefits to transdermal administration. A natural copy of progesterone, Utrogestan, can be taken orally. There are also synthetic progestogens to be taken orally and they are much stronger than the hormones our bodies produce.”

There are alternatives if women decide they don’t want to use HRT or can’t take HRT for example if they have had hormonal cancers, these include vaginal lubricants and non-hormonal vaginal moisturisers as the vaginal area can be dry during menopause and Selective Serotonin Reuptake Inhibitors (SSRIs) anti- depression drugs which are effective for night sweats and CBT or Cognitive Behavioural Therapy for anxiety.

Dr Panter explained: “By the time most women come to someone like me they have already tried to manage their symptoms, they’ve visited the health shop, tried Magnesium, Red Clover, spent a lot of time and effort on diet and exercise and are very often at the end of their tether. One of the things I do recommend, is a self-help guide to Managing Hot Flushes and Night Sweats: A cognitive behavioural self-help guide to the menopause written by Melanie Smith and Myra Hunter a professor from King’s College London, which I think is helpful for women to work through as it helps to think about our symptoms differently and CBT is incredibly effective at managing depression and anxiety. “

Professor Winters spoke about symptoms that women should be aware of before visiting a one-stop-clinic such as New Victoria Hospital for a triple assessment to determine if they have breast cancer:

A discrete or a perceived lump in the breast, that can be differentiated from the surrounding firm but normal dense breast tissues, and the intervening soft fatty tissues. The one-stop breast clinic assessment requires careful clinical examinations and explanations alongside complimentary breast imaging interpreted by expert consultant radiologists. She explained that over 95.5% of breast pain is benign and rarely related to breast cancer.

Other key symptoms to be aware of are any bloody nipple discharge or ongoing nipple discharge that could also be exacerbated by HRT, however, any sustained inflammatory changes to the breast skin or nipple skin should be investigated.

Professor Winters explained: “In a one-stop setting, we are teaching women how to examine their breasts and trying to be very clear about what a lump constitutes, compared to what normal breast tissues feel like.”

On the topic of how long to take HRT and when or of to stop taking it, Dr Panter said if you are going to take HRT the maximum benefit and the fewest risks are to start it early, so around the time of your menopause to derive the most benefit and least risk, particularly if you start it early, where there is no benefit on holding out.”

Dr McGowan reiterated during the session that the benefits far outweigh the risks and urged women not to be scared to use HRT if it’s appropriate in their case. Dr Panter explained that HRT will help our lifestyles and more holistically will help us to sleep, to be calmer and to cope at work and at home. Professor Winters said she looked forward to a more personalised and finessed breast screening processes as breast cancer care evolves in the future.

Biographies: Contributing Guests –

Professor Zoe Winters – Breast  Cancer Consultant Surgeon & Breast Specialist

Professor Barbara McGowan – Endocrinologist

Dr Kate Panter – Consultant Gynaecologist at the New Victoria Hospital

With thanks to New Victoria Hospital and JFPR Consulting for putting this together.

Images of dense breast

Breast Density Updated 24/04/2026- By Prof Zoe Winters

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Dense breasts and what this means for women undergoing breast screening

Updates on breast screening in women with dense breast tissues 24/04/2026

Three different supplemental imaging techniques have been compared in a UK randomised clinical trial called the BRAID UK trial https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)00582-3/fulltext

The level 1 or highest quality evidence shows that when compared to standard mammograms combined with ultrasound:

  1. Contrast-enhanced mammogram (CEM)
    Or
  2. Abbreviated breast MRI

Are: 

Equally effective in detecting new breast cancers

Detect 3 times as many invasive cancers 

Detect earlier stage cancers half the size; and may influence / improve survival outcomes

Frequently asked questions:

1. Does having dense breasts increase my risk of breast cancer?
  • Increased breast density (C or D) increases risks of developing breast cancer compared with predominantly fatty breasts
  • Increased risk is moderate and requires consideration alongside other risk factors: family history, prior biopsies, and genetic predisposition
2. Should all women with dense breasts have supplemental screening?
  • Supplemental imaging should be discussed as part of shared decision-making
3. What are the main supplemental imaging options?
  • Contrast-enhanced breast MRI (Full MRI or “abbreviated/fast” MRI)

  • Abbreviated MRI takes 15 minutes and is equally effective and less costly

  • Contrast-enhanced mammography

  • Automated breast ultrasound aided by a machine rather than hand-held is less effective compared to MRI or contrast mammogram
4. How do I know if I personally should have supplemental imaging?
  • Shared-decisions are best guided by your 5-year risks of developing breast cancer described as High risk (greater than 1.66% and less than 6%) or Very High risk (greater than and equal to 6% at 5 years) 

  • You and your Consultant Breast Cancer Surgeon should weigh potential benefits (earlier detection) against harms (false positives which means “over detection” where a lesion that enhances is not a cancer; including potential increases in anxiety; and in costs to clients and providers) 

What is a Contrast-Enhanced Mammogram or CEM?

This is a mammogram done after injecting an iodine-based contrast dye into a vein, so that the scan can highlight areas with increased blood flow, such as many cancers 

It uses the same X-ray exam as a standard mammogram, but takes paired low energy and high energy images and then combines them to create an iodine-only image that shows enhancing areas more clearly.

CEM can help detect cancers that are harder to see on a standard mammogram, especially in dense breasts (C or D). It can also be used in circumstances to assess the extent or true size of a known cancer, to check symptoms or to assess the response to upfront medical treatments like chemotherapy or endocrine treatments like Letrozole. 

Practical point:

It is not the same as a 3-D mammogram which is called Tomosynthesis. It is the contrast that adds the extra information.

How does it compare with breast MRI?

Neither is universally “better”

Diagnostic performance:

CEM has a higher specificity (77%) which means fewer recalls and false positive biopsies than MRI

CEM has a lower sensitivity and cancer detection of 61% versus 100% for MRI

SO there is a slightly better overall discrimination for MRI (higher diagnostic odds ratio)

MRI is still preferred for: 

  • High-risk screening (High risk genes like BRCA; TP53; PALB2)

  • Detailed local staging like:

  • Multifocal / multicentric cancers 

  • Contralateral occult cancer which means cancers not seen on mammogram, like invasive lobular cancers (ILC) or non-calcified DCIS or ductal cancer in situ which is defined as intraductal or microscopic pre-invasive breast cancer cells 

  • Implants and lesions close to chest wall / axillary tail (upper outer breast tissue that extends into the axilla / armpit)

Practical points and patient-centred factors:

  • CEM is cheaper, quicker and easier to implement in mammography units where MRI may not be readily accessible

  • Women report a preference for CEM as there is no tunnel, and they feel less claustrophobic

Safety and contraindications:

  • CEM uses iodinated contrast plus iodinated radiation 

  • It is not advised where there is a significant iodine allergy; untreated overactive thyroid called hyperthyroidism; requires caution where there is renal / kidney impairment 

  • It is generally avoided for high-risk mutation carriers as a primary screening tool because of radiation

    *End of update*

June 2022

General importance

The density of breast tissues relates to the amounts or relative proportions of normal breast duct tissues that appear as the white component on an X-Ray or mammogram. This breast duct tissue is referred to as fibroglandular that means breast ducts surrounded by fibrous or connective tissues (collagen, fibrinogen). Connective tissues give structure and support to the breast ducts. It is the fibroglandular tissues that are assessed for any abnormal changes on mammograms.

Fibroglandular tissues absorb X-Rays and project as “white” on the mammogram. This is referred to as “dense” tissue. The amounts of fibroglandular tissue are compared to the amounts of fatty tissue that projects as “dark” on the mammogram as fat cells are mostly liquid, and are not dense like fibroglandular tissues. The amounts of fibroglandular tissue are largely genetically determined, and also depend on hormonal stimulations such as the oral contraceptive pill, the intrauterine Mirena coil and hormone replacement treatment (HRT).

Most cancers absorb X-rays to a similar extent as fibroglandular tissues, and therefore they also appear as white “masses” on a mammogram. Dense “white” tissues can therefore hide similar dense “white” cancers. (It’s like looking for a white ball in a snowstorm). This means that mammographically dense breasts have a reduced sensitivity (reduced detection of breast cancers) when relying on a mammogram only to detect breast cancers. In these cases, it is crucial to recommend additional screening using bilateral breast ultrasounds or breast MRI (Magnetic Resonance Imaging).

Assessments

A mammogram is the international standard for breast screening by “taking a picture” of each breast as a whole. The mammogram measures the amounts of fibroglandular tissues. The principle of an X-ray is to identify the “white” from the “dark” areas to calculate the ratio of how much “white” to “dark” areas there are in both breasts.

It is not possible to assess overall breast density using breast ultrasounds. The latter is operator-dependent and doesn’t take a picture of the whole breast, and is used to focus on a particular lesion seen on the mammogram. Ultrasound can’t report overall fibroglandular density in the breasts.

Below is a picture that shows how a cancer would present on a mammogram in each of the breast density categories.

In a fatty breast (A or B) a small cancer is easily seen, compared to a dense breast (C or D), whereby a large cancer is difficult to see.

Definition and measurements

Mammographic breast tissue density is classified into 4 categories by the ACR American College of Radiology and BI-RADS Breast Imaging – Reporting and Data Systems as follows:

Breast tissue density is reported from A to D by the Consultant Radiologist as follows:

A

The breasts are almost entirely fatty

about 10% of the screening population

B

Scattered areas of fibroglandular density

about 42% of the screening population

C

heterogeneously dense, that may obscure small masses

about 40% of the screening population

D

extremely dense, that lowers the sensitivity of mammography

about 8% of the screening population

Picture of category A, B, C, or D of breast density

ACR BIRADS C and D are clinically regarded as dense breasts

Radiologists measure the breast density on mammograms using different methods. Most commonly the Radiologist “eye-balls” the films and visually quantitates proportionate areas of “white” compared to “dark” tissues. Alternative methods use different automated computer programs potentially reducing variabilities in the reporting by Radiologists.

Implications

Dense breasts are a strong independent risk factor in all women and are currently used for breast cancer risk prediction. Dense breasts (ACR-C and D) raise breast cancer risks two fold above the current risks of 1 in 7- 8 women developing breast
cancer. This rate equals that of having a first degree relative such as either a mother or sister having breast cancer. Dense breasts account for 26% of cancers in post-menopausal women.

Extremely dense breasts (ACR-D) raise breast cancer risks by 4 to 6 fold compared to extremely fatty breasts (ACR-A).

A personal breast cancer risk test called MammoRisk uses an Artificial Intelligence (AI) – developed algorithm to assess breast cancer risks at 5 years. Breast density is one of the strongest prognostic factors for increasing breast cancer risks that is integrated into the MammoRisk test.

Recommendations by the European Society of Breast Imaging (EUSOBI)

X-ray based imaging techniques are all significantly affected by dense breast tissues leading to an under-diagnosis of breast cancers. The diagnostic sensitivity (optimal breast cancer detections) of mammograms is highest in women with fatty breasts (ACR-A) at 86- 89%, compared to women with dense breasts where the detection of breast cancers falls to 62-68%.

Current European recommendations are to perform bilateral synchronous ultrasounds with the potential to increase the overall imaging sensitivity from 77% to 91% in women aged from 40-49 years. Overall, however, ultrasound may be limited compared to performing contrast enhanced breast MRI. Supplemental MRI in addition to mammograms detected an additional 16.5 cancers per 1000 screening episodes.

Breast MRI assesses increases in tissue blood flow where cancers that comprise faster growing cells “light up” significantly more than normal or benign tissues like cysts or fibroadenomas. Results of a Dutch clinical trial called the DENSE trial ultimately concluded that a potentially more cost effective screening strategy in women with dense breasts would be to recommend 2 yearly mammograms and MRI that saves 8.6 lives per 1000 screened women. This is an evolving field and “we should watch this space”.

Sharing information with women

All women with dense breasts should have the advantages and disadvantages of enhanced breast screening using combined mammograms and MRI 2 yearly explained to them.

Advantages of enhanced breast screening:

Two yearly MRI leads to early cancer detection in about 10% of women and reduces the risk of dying from breast cancer to a little over 3%, providing a mortality reduction by about 40 %. A woman gains on average 15 years in good health, before she dies of another cause.

Disadvantages of enhanced breast screening:

Enhanced screening with breast MRI in particular will increase the chance that she will at least once experience the situation of a ‘false alarm’, i.e. receive a positive screening test which, after appropriate assessment, turns out to be a harmless finding. Of all positive (abnormal) screening findings, only about 30% are really cancerous; this value is similar for mammography and for MRI.

All women should be made aware of the clinical implications and importance of each mammogram report classifying their individual breast tissue density score labelled from A to D. This is now a mandatory requirement to all screening mammogram reports.

Breast tissue density informs future screening recommendations such as bilateral breast ultrasounds and or breast MRIs at every screening round. This approach is preventative in women and will save lives.

Updated 25/09/2025

Click on the DenseBreast-info logo below for more medically-sourced resources that was developed by health care professionals for both providers and patients, to advance the education on the screening and risk implications of dense breast tissue.

Logo for dense breast organisation with link

                             

                                                            …TIME TO EDUCATE THE WORLD…
                    CLICK THE PICTURE BELOW FOR GREAT RESOURCES ABOUT BREAST DENSITY

World dense breast day logo the last Wednesday in September with link to information

     World Dense Breast Day last Wednesday in September, sponsored by DenseBreast-info.co

Darling magazine article

Breast Screening and latest care – By Professor Zoe Winters

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 Professor Zoe Winters – Talks About The Very Latest In Breast Cancer Screening And Care

Professor Zoe Winters is a Consultant Breast Cancer Surgeon and Breast Specialist
I am delighted and honoured to share my passion and short story and how I got to where I am now in my career. My early passions in medical school related to acquiring as much knowledge as I could where I felt that “ knowledge is power” and can embolden how we present complex cases of breast cancer in the context of a fascinating expansion in the field of understanding different types of breast cancers, what causes breast cancer and how they might have arisen.

Professor Winters in theatre with female colleagues

In my current full time private practice in London, we talk a lot about gene mutations that occur at the time of the “egg and sperm” recombination to produce what are known as germline mutations. These account for the minority of breast cancer (8-10%), however the ability to test extended gene panels beyond BRCA1 and BRCA2 have changed our abilities to perform young onset breast cancer screening using tests like breast MRI including 3D mammograms and ultrasounds. These include genes like PALB2, CHEK2 and ATM whereby young age commencement of breast screening from 30 years using breast MRI can reduce breast cancer deaths by 56% to 60%.

LET’S LOOK AT THE GENES

On the other hand, we are passionate about talking about how spontaneous breast cancers occur through what we refer to as multiple functional changes in background genes that effectively act like the “body machinery”. We can assess multiple functional changes in 76 or more low risk genes to assess the changes in a “big gene dataset” using a validated personal breast cancer risk test called MammoRisk. This can allow us to predict personal breast cancer risks at 5 years and allows us to recommend the frequency of screening mammograms in all women from 40 years of age and older. This means we can personalise how often we recommend each individual woman’s mammograms with or without synchronous breast ultrasounds depending on their mammogram assessments of breast tissue density.

My passion is trying to deliver “state of the art knowledge” to my patients in a One-Stop rapid diagnosis breast clinic on all aspects of breast health and breast cancer symptoms that allows each individual to understand basic mechanisms that help to explain what we do and why.

MEDICINE IS MY PASSION

“Medicine is my absolute passion and I try to share my excitement and knowledge in each patient interaction”.

“I want women to feel empowered and comfortably reassured that we are working in a multidisciplinary team of experts ranging from Radiologists, to Pathologists and Breast Surgery that also encompasses more complex plastic surgery breast reconstructions and breast reductions and is always supported by clarifying surgery options and explaining the pros and cons of each type of surgery”.

“We share every medical report with each patient and place the patient at the centre of each decision-making step”.

“Breast Surgery has changed dramatically and is now synonymous with targeted personalised approaches based on each patient’s particular breast cancer biology. The aims of modern breast cancer surgery are to de-escalate the extent of surgery by combining the latest medical treatments such as chemotherapy and endocrine treatments (drugs that block the oestrogen and progesterone receptors in breast cancer) only when they are needed based on the cancer genes that can be measured in each cancer”. The patient’s age and cancer biology can also determine whether we give post surgery radiotherapy and how much we give”.

“We offer the latest techniques in localising small cancers using a Magnetic Seed, the size of a grain of rice”. The cancer is then detected using a Magnetic probe during surgery. We perform localisation of the axillary predictor lymph nodes using a liquid containing magnetic iron filings called Magtrace, that also allows us to perform diagnostic excisions of small numbers of sentinel lymph nodes”. The latter represent the key predominant draining lymph nodes that we would like to test diagnostically and determine whether we treat the axilla using axillary lymph node dissection that causes most of the side effects or whether we can treat the axilla using radiotherapy that causes half the numbers of side effects.

“We combine targeted cancer surgery with the latest breast remodelling techniques that are called” Therapeutic Mammoplasty” or “Therapeutic Breast Reduction” that are techniques that allow us to remove one or multiple cancers and optimally save the breast taking cognisance of the overall cosmetic results”.

SHE’S STILL ONE OF THE VERY FEW WOMEN LEADING IN THIS FIELD

“One of the highlights of my career was becoming a Professor of Breast Surgery which took 17 years and unfortunately numbers very few women in the UK. This pinnacle was the culmination of decades of work and dedication, but also pure “sweat and tears” in the context of a climate of patriarchal attitudes and discrimination at all levels of clinical and academic medicine”.

“I have used all of my experiences to power on because no one can snuff out passion and determination, and today I am thrilled to be part of the London Clinical fraternity of breast cancer surgery and breast health”. I truly work with some of the leading and top colleagues in London and Surrey”.

“One of my other passions is mentoring the future generation of surgeons so they can attain their full potential based on each individual’s talents. It was a privilege and honour to be able to do postgraduate research in molecular biology at Oxford University. I found it fascinating and that it underpins major advances in past and future drug developments and in garnering some understanding into mechanisms of breast cancer development and growth”.

BIOGRAPHY:

Professor Zoe Winters became a Professor of Breast Surgery in 2017 through University College London. She is an experienced, Senior London Consultant Breast Cancer Surgeon and Breast Specialist, specialising in the diagnosis, treatment and management of breast diseases, breast cancer and all benign breast problems. She is a nationally and internationally recognised senior breast surgeon, with clinical excellence awards through iWantGreatCare in 2018, 2019, 2021 and 2022. Zoe also received the London Prestige Health award for Top Breast Surgeon of the year in 2021 and 2022. Professor Winters trained in Johannesburg and Cape Town (South Africa) and completed her Doctor of Philosophy degree at the University of Oxford by receiving the prestigious Oxford Nuffield Senior Research Fellowship.

Professor Winters works closely with Oncologists, Geneticists, Plastic Surgeons and Psychiatrists at the Royal Marsden NHS Foundation Trust. Zoe has received many awards for her clinical research, including the King James IV Professorship for surgery research from the Royal College of Surgeons of Edinburgh. She has also led two world first randomised trials in breast surgery and has validated the first European Patient Reported Quality of Life questionnaire in breast reconstruction after cancer surgery that has been used internationally. Zoe now teaches post-graduate surgeons in the latest aspects of breast cancer and breast cancer surgery, including breast reconstructions.

You can find out more at the following sites:

Darling Magazine UK

New Victoria Private Hospital

HCA – Chelsea Outpatient Centre

OneWelbeck Women’s Health

iWantGreatcare
Doctify

You may also enjoy reading Michelle’s breast cancer journey under Professor Winters’ care

Breast pain

HRT and Breast Cancer: What you need to know – By Prof Zoe Winters & Miss Jeannie Yoon

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The mere mention of HRT can spark fears of breast cancer, but should it? Breast surgeon Professor Zoe Winters and Consultant Gynaecologist Jeannie Yoon set the record straight.

Navigating the Menopause can be a huge challenge for many women. It can be a strange and isolating time for some as despite being well informed, there remains a taboo about acknowledging it and discussing it openly. 

Approximately 95% of women will go through the Menopause between the ages of 45 and 55 years with an average age of 51 years. The symptoms can range from minor to debilitating and include hot flushes, night sweats, joint and muscle pain, ‘brain fog’ often described as ‘word salad’, poor concentration, disturbed sleep, low mood, anxiety, vaginal dryness, a reduction in libido and bone fractures in later life. These Menopausal symptoms typically continue for 5 years after the last period and for around 10% of these women, they can last up to 12 years. 

It is important to remember that each woman will experience this journey differently. For many this natural transition can be relatively seamless, but for 25%, their personal and professional lives can be significantly affected. 

In the past, clinicians approached women with menopausal symptoms with a rather fixed approach of ‘one size fits all’, but we now know that an integrated approach based on the individual woman’s needs works best. 

A healthy lifestyle can minimise the effects of the menopause and certain complementary and alternative therapies may help. The most widely used and effective treatment for menopausal symptoms is Hormone Replacement Therapy (HRT) but only around 1 million women in the UK are currently using this.  

“…there is now a generation of women who have been denied the opportunity of an improved quality of life during their menopausal years…” 

HRT was first available in the 1940s before becoming widely used in the 1960s when it revolutionised the management of the menopausal woman. However, in 2002 and 2003 the results of the USA Women’s Health Initiative (WHI) and the UK Million Women Study (MWS) were published and their findings raised concerns about the safety of HRT, including the risk of Breast Cancer.  There was widespread publicity which resulted in panic amongst clinicians and users. The number of women taking HRT fell by around 60%, and that has not changed significantly in the intervening years. 

As a result there is now a generation of women who have been denied the opportunity of an improved quality of life during their menopausal years. 

breast mammogram harley street emporium

It is important to note that the WHI study had flaws. It demonstrated adverse effects of HRT in the older postmenopausal women (over the age of 60 years) but this is not the age group of women that presents with the new onset of menopausal symptoms that occur mainly in the late 40s to 50s. 

“…other factors like lifestyle issues, obesity, alcohol consumption and smoking can have a greater effect on Breast Cancer risk than HRT…”

When advising women in the 40-50 age group, their age specific risk needs to be taken into consideration and the data suggests that the overall risk benefit profile is more favourable for women ages 50 to 59 years. Of course a full medical history is vital when assessing suitability for HRT as other factors like lifestyle issues, obesity, alcohol consumption and smoking can have a greater effect on Breast Cancer risk than HRT. According to NICE, obese women have a 6 times higher risk of developing Breast Cancer than the extra risk associated with combined HRT. 

The current consensus is that HRT taken for less than 5 years does not significantly increase the risk of Breast Cancer, but studies have shown that after 5 years of use, a small increase in risk is possible. Once HRT has been stopped, this risk appears to return back to baseline, suggesting that HRT may promote the growth of Breast Cancer cells that are already present if HRT is taken for more than 5 years after the age of 50 years. In some women, however, there is no evidence that HRT causes Breast Cancer.  

In 2019 the highly reputable journal, The Lancet, published a large meta-analysis looking at women with a normal body mass index who started HRT in their 40’s-50’s. It confirmed that different types of HRT are associated with different risk for women who started HRT in their 40’s-50’s.   

womens health concern breast cancer risk

Oestrogen-only HRT does not appear to increase the risk of breast cancer (1 in 200 women), while there appears to be a small increased risk with long-term (>5 years) use of combined HRT (oestrogen and progesterone) preparations (1 in 50 women), compared to the general population of women at 50-69 years of age who have never taken HRT ( 1 in 16). Consequently, breast surgeons recommend more frequent (annual versus 2 yearly) mammograms plus ultrasound in individual cases based on perceived increased risks of breast cancer.  

The type of HRT and the ways it’s taken or used can influence risks too and should be discussed in detail with your expert clinician. For example, the safest form of HRT is oestrogen only versus combination oestrogen and progesterone recommended in women with an intact uterus. Transdermal or topical oestrogen is safer than oral administration, as the former bypasses being metabolised through the liver, thus avoiding the less safer liver metabolites of oestrogen. The type of progesterone is also thought to play a role. 

“…Women now live longer in the post-menopausal period than in their reproductive phase and it is therefore of paramount importance that we focus not just on extending their lives, but to ensure that they have a quality of life that they duly deserve…”

Another important factor to note is the fact that if HRT is commenced at an earlier age due to Premature Ovarian Failure, the use of HRT up to the age of 50 years does not increase the breast cancer risk any more than in women who continue to have periods up to the age of 50 years. The additional risk from HRT only applies if it is then taken for more than 5 years after the age of 50 years. 

This does not, however, mean that you have to stop taking HRT after the age of 50.

Women are often told that after 5 years or after the age of 60 that they should stop too, but this is not the case. If you are aware of the risks and benefits and your health is closely monitored you can opt to continue.

mammogram-harley-street-emporium

There are numerous health benefits derived from HRT in women who are symptomatic with the earlier timely recommended use of HRT being the most beneficial. Exposure to long term, or longer than 5 years of uninterrupted oestrogen and progesterone is just one of a number of breast cancer risk factors that may also increase breast density. Other breast cancer risk factors comprise family history, gene mutations and atypia (slightly abnormal appearing cells) on tissue biopsies, and finally common gene variants involving population or background genes called single nucleotide polymorphisms or SNPs.  

Currently, there are exciting possibilities to offer all women over 40 years of age access to testing of their individual Breast Cancer Risk Score whereby if they are high risk, we would recommend annual clinical examination and breast mammogram screening.  In women with prohibitively dense breasts, we can include focused ultrasound and breast MRI. There are two large high-quality studies in the USA and Europe evaluating the benefits of women selecting mammography based on personalised risk. We can now offer this testing in private care. 

As a Clinician in modern times, we are aware that women now live longer in the post-menopausal period than in their reproductive phase and it is therefore of paramount importance that we focus not just on extending their lives, but to ensure that they have a quality of life that they duly deserve. It is therefore essential that we work together in an integrated fashion to empower women with accurate and appropriate information for them to make the right choices for themselves and to treat them as individuals. 

You can find out more about the authors of this article here:

Miss Jeannie Yoon – Consultant Gynaecologist and Obstetrician  

Professor Zoe Winters – Consultant Breast Surgeon and Breast Specialist  

London Breast Health

Harley Street Emporium

Patient story

The Story Of One Woman’s Breast Cancer Journey

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When the COVID-19 pandemic kicked off in 2020, no one knew how far reaching the repercussions would be. Now, over a year in, we are beginning to understand. Macmillan estimates that due to the huge strain put on hospitals across the UK, there could now be up to 50,000 missing cancer diagnoses in the UK but, as anyone who has been impacted by cancer will know, the people tackling the disease are more than just a number. This Breast Cancer Awareness Month in October, we follow one woman’s journey with breast cancer from diagnosis to recovery with the help of private, charity-run medical facility New Victoria Hospital.

DISCOVERY

Receiving a cancer diagnosis in the middle of a pandemic lockdown with a teen child in need of home-schooling may sound like a nightmare, but this is exactly what happened to personal assistant Michelle Tatarczuk, 42, who found a lump in her right breast back in May 2020.

Obviously worried, she was keen to get it checked as soon as possible, but due to the COVID restrictions that were in place at the time she had to wait for a mammogram. Michelle adds, “I felt slightly concerned about the lump, but thought it would be ok as the GP said it felt benign and also because I have no history of breast cancer in my family.”

It wasn’t until October that Michelle was able to attend an annual health assessment. From there, she was quickly referred to Professor of Breast Surgery, Zoe Winters.

DIAGNOSIS

A nationally and internationally recognised breast surgeon, Professor Winters is one of the top breast consultants at New Victoria Hospital and has won several clinical excellence awards. Also awarded for her clinical research, she has led two world-first randomised trials in breast surgery. As such, Michelle knew she was in safe hands.

Professor Zoe Winter says, “Surgery is both an art and a science where wisdom is required to consider the latest thinking and innovations in treatment inspired by these concepts to impact positively on women’s lives”

It was through a mammogram, ultrasound, biopsy and MRI pathway at New Victoria Hospital that she received her complete diagnosis – a Grade II Pleomorphic Invasive Lobular Cancer in the right breast.

Professor Winters adds, “clinically there were no obvious abnormalities, but mammogram and ultrasound detected an atypical lump measuring 6 mm that biopsy confirmed was a small cancer. Breast MRI showed further small nodules that allowed conserving surgery”

Michelle recalls, “Nothing was picked up on my mammogram, only during my ultrasound. I am forever thankful to the sonographer who saw the shadow and did the biopsies. It could easily have been missed. It was a big shock to find out I had breast cancer, as I don’t have a history of this type in my family,” Michelle continues “and attending the consultations was a bit overwhelming at first as there was so much information to take in.”

This, she says, was made easier by the expertise and care of Professor Winters, who explained the results to her scans and the best course of treatment in a way that was easy to understand. “She was always very patient, reassuring and positive and following our consultations and she sent me lots of information to read through in my own time, which was very helpful.”

For cancer patients – particularly those who have a long and difficult journey to recovery – working alongside a medical team that treats you as humanely as possible is a top priority. Thankfully, Michelle found this in Prof. Winters. ”I truly feel that she really cares about her patients and makes you feel that you are not just a number. I very much enjoyed my consultations with her. She really is an amazing surgeon.”

During this period, Michelle also found the added touches that New Victoria provided particularly helpful considering the ongoing situation with the pandemic. “The facilities were great, the environment was very welcoming and COVID regulations were followed. There was always parking available (free of charge) and I never had to wait too long to be seen for my scans and appointments.”

Michelle in Hospital recovering from surgery

TREATMENT

Michelle was recommended surgery, radiotherapy and injections as part of her treatment plan, with her operation taking place in December 2020 – two months after being diagnosed with breast cancer. Her Lumpectomy included a right wire guided local incision and dual localisation sentinel node removal.

Professor Winter says, “New localisation techniques allow the surgeon to remove very small cancers that can’t be felt. Likewise dye localisation of lymphatic draining lymph nodes allows simultaneous diagnosis and treatment of predictor lymph nodes called a sentinel lymph node biopsy. Early cancer detection predicts significantly improves clinical outcomes and ensures potential cures”.

Michelle was then given time to recover before starting on ten sessions of Radiotherapy.

RECOVERY

As anyone who has dealt with cancer knows, the road to recovery is rarely smooth sailing – particularly if it involves other challenging factors. For Michelle, the initial recovery from surgery took 8 weeks, which then had to be followed up with Radiotherapy, and a cocktail of daily and monthly injections – both of which she will need to continue for at least 5 years.

“The whole process – surgery and radiotherapy – was extremely difficult as I had to go to all consultations and treatment by myself and couldn’t see any of our family as we were in lockdown,” Michelle explains. “My husband spent a lot of time waiting for me in car parks!”

Speaking of the immediate surgery recovery, she said: “I was physically very sore and tired immediately following and was unable to do anything too physical for 8 weeks. I found this very difficult as I am a very active person.”

HEALING HURDLES

Cancer patients often find there are small hurdles to overcome on their road to healing – ones that are worth taking, but challenging nonetheless. Michelle experienced some muscle tightness in her arm and shoulder following her surgery and Radiotherapy, for which she underwent physiotherapy. She also had a slight skin lymphedema (a fluid build-up) and medication-induced menopause, causing hot flashes.

THANKFULNESS

Despite the huge challenge that Michelle’s breast cancer journey has presented for her, she is thankful for the time and health it’s afforded her. “These difficulties, as well as the lack of sleep they caused, did affect me physically and psychologically but are far better than the alternative.

“The treatment has removed all the cancer from my body. It saved my life.”
Early detection of breast cancer is vital as it increases the chance of successful treatment. For more information on the services provided by Professor Zoe Winters and New Victoria Hospital’s specialist breast clinic, head to the website here: New Victoria Hosptial.co.uk

Darling Magazine UK

Read Michelle’s story also in the Mirror

You may also like to read Darling Magazine Editor, Karine’s Cancer Journey

You may also like to read other cancer patient stories here

Close up of Genes

Genetic testing and what it means – By Prof Zoe Winters

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Personalised genetic testing in breast cancer patients and what it means.

Hereditary breast cancer – inherited germline mutations 

This means the abnormally functioning genes we inherit that predict a high lifetime risk for developing breast cancer ranging from 35-80% by 80 years of age. Inherited breast cancer is rare and causes only 5% of all breast cancers. Currently the guidelines for testing high risk genes has expanded with lowered thresholds for genetic testing of the following genes: BRCA1, BRCA2, PALB2, CHD1, P53 and PTEN. We test different numbers of genes based on family history of breast and ovarian cancer or other cancers that indicate the need for syndromic testing. These other cancers include: prostate; pancreatic; colonic; stomach; thyroid; and uterine cancer amongst others. We use established algorithms on which to base referring you to a specialist geneticist. 

In the last 5 years, we have tested women presenting with early breast cancer who are: <45 years of age; have a triple negative (negative for oestrogen, progesterone and HER2) breast cancer <70 years of age; and bilateral breast cancer <60 of age. 

Hereditary gene testing focuses treatment recommendations on: risk-reducing breast and ovarian surgery, including high-risk breast screening and biological risk-reducing chemoprevention using drugs like Tamoxifen or Aromatase Inhibitors (AIs) for 5 years. Importantly, we should also check for hereditary genes in advanced breast cancer where the cancer has returned or spread to other body sites. 

Mutations or abnormal function of the BRCA1/2 genes means that cancer cells cannot detect damages to their genetic material or DNA, and also cannot repair their damaged DNA. This is why cancers occur at such high rates in these patients. This genetic deficiency can be used as a treatment advantage when combined with drugs that block sensors of DNA damage and repair. These drugs are called PARP inhibitors and they effectively kill BRCA1/2 abnormal cancer cells where the BRCA genes aren’t functioning. The PARP inhibitors sensitise BRCA cancers to the DNA damaging effects of chemotherapy and radiotherapy. 

The platinum types of chemotherapy like Carboplatin are also particularly effective in killing BRCA mutated breast cancers. 

These drugs are also highly effective in treating triple negative breast cancers (no expression of oestrogen, progesterone or the HER2 gene) that carry mutations of the BRCA 1 (70%) or BRCA2 (20%) genes. 

The abnormal DNA repair pathways conferred by these gene mutations can be used for treatment advantages. 

The more recent testing of the PALB2 gene (Partner and Localiser of Breast Cancer 2 (BRCA2)) functions together with the BRCA2 gene and serves as an additional drug-able target for cancer treatments. All women previously undergoing BRCA testing before 2014 should be referred for retesting of BRCA1/2 and PALB2.

Women with advanced breast cancer that carried BRCA mutations were treated with PARP inhibitors in two breast cancer trials called OLYMPIAD and EMBRACA. They both showed a significant improvement in cancer-free survival. 

Currently, there are many breast cancer trials evaluating PARP inhibitors either at the pre-surgery (neoadjuvant) or post-surgery (adjuvant) stages of treatments in women with BRCA abnormal genes. 

Genomic gene expression signatures in early oestrogen (ER+) positive breast cancer to guide chemotherapy 

A number of commercial assays are used to quantitate levels of 10 -100 different gene expressions using messenger RNA in what is known as a “transcriptome”. This is not the same as a germline mutation that occurs in hereditary breast cancers or advanced breast cancers (described above). Until now, we have relied on cancer histological grade and proliferation index (ki67), but the transcriptome profile provides us with much more prognostic/predictive information on the full spectrum of breast cancers over and above routine breast cancer staging.

The transcriptome predicts 10-year overall survival in women with early stage oestrogen positive (ER+) lymph node negative disease evaluated in the TAILORX trial. The 21-Gene OncotypeDx recurrence score identifies those women who will benefit from chemotherapy after surgery, and allows us to recommend personalised treatments. 

Another trial called MINDACT has also shown that the 70 gene MammaPrint assay determines when chemotherapy is beneficial for increasing survival in addition to ER+ endocrine treatment. Young age <50 years is a key factor when interpreting the gene recurrence scores, with greater benefits of chemotherapy in younger women compared to those >50 years. This may be due to a chemotherapy-induced menopause. OncotypeDx can also be used to predict recurrence scores in lymph node positive patients, who may avoid chemotherapy without compromising cancer outcomes. 

Other genomic assays such as the 12-gene EndoPredict and the PAM-50 have not been as fully evaluated in studies comparing chemotherapy versus no chemotherapy. It is possible that gene assays may also predict when to extend or prolong endocrine treatments such as Tamoxifen or aromatase inhibitors from 5 to 10 years, however there are no high-quality studies validating this at present.  

Genomic sequencing in advanced breast cancer to increase drug treatments 

Testing acquired or somatic mutations of 200-600 genes is based on the relatively frequent mutations that occur between the primary breast cancer and the subsequent recurrence or relapse of breast cancer. Testing can be done by sequencing genes in the cancer tissue or the circulating free cancer DNA (ctDNA), where cancer cells release their DNA into the circulation when they die. The gene testing of ctDNA correlates well with that of the cancer tissues and should be evaluated first. Levels of ctDNA can be used to predict worse cancers that are progressing, and are not responding to treatments after only two weeks. 

Acquired mutations as cancers evolve or that occur after treatments have been shown in ER+ cancers to involve the oestrogen resistance gene (ESR 1) that confers resistance to aromatase inhibitors, which means these drugs cease to be effective. The commonest mutations in 40% of ER+ cancers also affect the PI3 kinase pathway that can be targeted by specific drugs. 

Germline testing of BRCA1/2 selects patients who will benefit from PARP inhibitors and carboplatin chemotherapy. Triple negative cancers may also harbour mutations in the PIK3 kinase pathway that can be used as drug-able targets.

Molecular testing of breast cancer is a rapidly evolving field and is here to stay! 

References:

Litton JK, Burstein HJ, Turner NC. Molecular Testing in Breast Cancer. Am Soc Clin Oncol Educ Book. 2019 Jan; 39: e1-e7. doi: 10.1200/EDBK_237715.

More information:

Family history and breast cancer – Breast Cancer Now

NVH news and articles/breast health and genetic testing

Breast pain

A guide to Breast Pain – By Professor Zoe Winters

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A breast surgeon’s guide to Breast Pain (BP) – the second commonest One-Stop breast problem

 

I see many women in the UK with breast pain (BP) and over the years, my medical understanding of how to explain its rationale and treatment has evolved. My key aims in a One-Stop breast clinic are to communicate clearly and reassure based on the current medical evidence.

Breast pain (BP) is like the “common cold”. It affects 70-80% of women in the One-Stop breast clinic, but rarely are we able to attribute it to a specific cause. That’s because it is multifactorial. We do not know about genes predisposing to benign conditions, but there are likely to be other female members of one’s family who have suffered from this syndrome.

BP is not a risk factor for breast cancer and is very rarely associated, occurring in about 

0.4 – 0.8% of cases. Breast density (increased amounts of breast tissue) is a risk factor for breast cancer, and may be linked to persistent BP extending over 3 to 8 years. Larger breast volume is also a contributing factor with “increased strain” on connective tissue ligaments.

The onset of BP can be sudden in women in their 30’s or 40’s with only 15% occurring in post-menopausal women. 

 

Overall Breast Pain is a benign condition without an obvious single cause, however it still requires assessment by a healthcare professional. 

 

Cyclical BP – 70% of women (onset in 30’s) 

This is described as “coming and going” (cyclical) and an indicator for recurring BP later in life until one reaches menopause. It tends to be widespread in the breast occurring in more than one location. We attribute this type of BP to the increased hormonal sensitivity of normal breast tissue of unknown causes. Blood hormone levels are normal and there is no evidence of breast disease. 

Possible contributing factors are:

  • Medications: Antidepressants such as Selective Serotonin Uptake Inhibitors 

Up to 20% of BP will resolve within 3 months, and 60% of BP will recur within 3 years.

Older onset BP – 25% of women (onset in 40’s)

This is more constant and is localised to a “trigger spot” or a single area particularly in the central nipple region and in the lower inner breast. 

This type of BP is more likely to be “inflammatory” which isn’t due to a  bacterial infection, but rather to a “chemical phenomenon” that occurs in the ageing breast ducts where the walls of the hollow breast ducts (milk ducts) become thin causing duct dilatation called “duct ectasia”. A chemical inflammation occurs due to stagnant breast duct secretions and can cause local BP. 

Constant BP usually isn’t hormonal, and 50% resolves spontaneously. 

Why should BP occur in only one breast?

Embryology (development of the human embryo) explains this because it provides a logical explanation. We develop in two potentially symmetrical halves from the spine behind, extending to the front of our bodies to join in the midline. Therefore, none of us are totally symmetrical! This applies to face, hands, feet or breasts!

Each milk duct line is developmentally separate extending from the armpit to the groin on the right and on the left, respectively. So our breasts aren’t  symmetrical in shape, size or in the amounts of breast tissue they contain and in biochemical responses to particular triggers.

The breast tissue within each breast is not equivalent. Most breast tissue is located in the upper outer breast, central breast and where the breast attaches to the chest wall, called the infra-mammary fold. This means that each breast has its own potential to develop cyclical or constant BP. 

In fact, most BP is one-sided in 76% and affects both breasts in 24% of patients. 

Treatments 

A comprehensive overview of all randomised trials looking at treatments for BP have provided clear evidence for the following recommendations:

First line treatment for BP:  Topical Voltarol gel which is a non-steroidal anti-inflammatory where there is far greater benefit compared to unwanted side-effects. There is one randomised clinical trial. The magnitude of the benefit on BP from a number of studies showed a 70-92% reduction in pain. 

Second line treatment: Selective Oestrogen Receptor Modulators (SERMS). 

Raloxifene was shown in trials to prevent breast cancer and to treat osteoporosis. It acts by selectively blocking the oestrogen receptor The recommended dose for treating BP is recommended at half the dose routinely used in preventing osteoporosis (30 mg orally daily) for 6 months. It can reduce BP up to 92%.

The other SERM option is Tamoxifen, the drug we use to treat breast cancer patients, that can be used at half the dose (10 mg orally daily) for 6 months. Tamoxifen is however less effective than Raloxifene in reducing BP (45% versus 92%) and has more side-effects.

Neither Raloxifene nor Tamoxifen are registered for BP treatment despite having been shown to be effective in randomised clinical trials. Raloxifene is a preferred second-line choice for severe BP as it is associated with fewer side effects than Tamoxifen. 

Both above treatments should only be used under the supervision of your surgeon and ONLY in those women where Voltarol gel is ineffective, or their BP is severe and is affecting a woman’s quality of life. 

You should still get your breast pain assessed by your doctor or another health professional.

Book an appointment here 

References

Goyal A BMJ Clin. Evid. 2011 Jan 17; 2011: 0812.

https://pubmed.ncbi.nlm.nih.gov/21477394/

Jokich P J Am Coll Radiol. 2017 May; 14(5S): S25-S33.

https://pubmed.ncbi.nlm.nih.gov/28473081/

Hafiz SP, Barnes NLP, Kirwan CC. Clinical management of idiopathic mastalgia: a systematic review. J Prim Health Care. 2018 Dec;10(4):312-323.

https://pubmed.ncbi.nlm.nih.gov/31039960/

A diagram of the one-stop process

The benefits of a One-Stop Breast Clinic By Professor Zoe Winters

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According to the current UK guidelines for breast cancer screening, mammography is recommended for all women between 50 and 71 years old, every 3 years. Some areas increase the age range to 47 to 73 years old. Breast cancer risk increases with age, however, it can be useful to speak to a breast specialist at a younger age. Professor Zoe Winters, Consultant Breast Surgeon, talks about the importance of early diagnosis and the benefits of a One-Stop Breast Clinic.

The importance of breast cancer prevention

Breast cancer prevention is a goal that all doctors and nurse practitioners in the field aspire towards. It starts with clear communication on personal breast awareness and breast self-examination and is also based on how soon and how often women should have mammograms and /or ultrasound (US).

We now have the benefits of digitally enhanced mammograms, including 3-D tomosynthesis. Doppler-assisted breast ultrasound (US) that measures increased blood flow in a specific lump or area of the breast may also increase interpretative accuracy. US is
used to guide needle tissue biopsies, to accurately confirm the correct diagnosis of any breast lump.

When is it a good time to have mammograms?

There is no consensus worldwide on how soon and how often women should have mammograms.

The benefits of mammogram screening in women in their forties have recently been reported by the UK Age trial. The study randomly invited women from 39/40 to 48 years of age to have yearly screening mammograms (group of 53,000). This test group was compared to a standard care group undergoing mammograms from 50 years of age and repeated every 3 years (group of 162,000).

At 10 years, there were less breast cancer deaths in the early screening mammogram test group (83), compared to 219 in the standard of care 50-year-old plus group. This amounted to a significant or 25% reduction in breast cancer deaths.

Other European countries and the USA have practised screening mammograms from either 40 or 45-years of age every year.

Why UK guidelines recommend breast cancer screening for women over 50 only?

In the UK, the National Screening Committee and the NHSBSP Publication No 49 set the national Breast Cancer screening guidelines.

Breast cancer incidence peaks between 50 and 70 years of age. The wider the age range, the greater the chances to incur an over diagnosis, where women are more likely to be diagnosed with benign, harmless forms of cancer.

High-intensity international screening programs showed that after 25 years of follow-up, >50% of mammogram-detected small cancers were over-diagnosed. This means an early diagnosis of a cancer that would not otherwise have shortened that woman’s survival.

However, could these improved breast cancer death rates be the results of much improved current breast cancer medical/drug treatments rather than early mammogram screening?

Over diagnosis can have a negative impact on women’s mental wellbeing and potentially discourage them from participating in further screenings in the future.
Although it is important to know that breast imaging examination can’t distinguish between harmful and benign types of cancer, this is the only and most efficient tool for early diagnosis.

Knowing your breasts is the first step towards early diagnosis

The Breast Cancer Now online publications website is an excellent source of patient information that clarifies key changes that every woman should be aware of and alerted to when examining their breasts.

Breast cancer symptoms you should pay attention to

Women should be aware of any changes to either of their breasts, however small it may seem. This may be a change in the shape or size of the breast and/or the nipple. Any concern about a persistent lump is important.

Many of these concerns do not automatically mean that there is breast disease, but the latter can only be ruled out through a specialist examination and breast imaging such as mammograms and/or ultrasound.

Other concerns that should be investigated are:

  • breast pain
  • nipple discharge
  • nipple rashes
  • permanent nipple indentation
  • breast skin dimpling

Not all the changes are a sign of cancer

The breasts develop from two separate milk duct lines, and therefore a “normal asymmetry” is possible in terms of their shape, size and amounts of breast tissue.

Most breast lumps are not disease, but relate to normal breast tissue that is asymmetrical with unequal distributions of breast tissue that is not “a smooth surface under the skin”.
The latter results in the sense of a lump, whereby you may be feeling normal tissue.

Neither cysts, nor breast pain are risk factors for breast cancer in over 95% of cases but should still be investigated at a One -Stop Breast Clinic.

How does the One-Stop A diagram of the one-stop process Breast Clinic work?

Most normal lumps are fluid-filled cavities called cysts that occur based on normal ageing of the breast milk ducts or tubules draining the breast milk sacs or terminal lobules.
Any solid breast lump usually requires a tissue biopsy to determine its diagnosis.

Women of any age who are concerned about their breasts can contact our One-Stop rapid diagnosis Breast Clinic.
This is how the One-Stop Breast Clinic works:

  • Step 1 – Specialist Consultation

If you are concerned about any changes in your breasts or have risk factors, you can book an Outpatient appointment with a Breast Surgeon at New Victoria Hospital. The specialist will listen to your concerns, ask questions about your lifestyle, family history, and assess your case.

  • Step 2 – Appropriate examination

After a clinical breast exam, if there is any suspicion of tissue abnormalities, these cases are acted upon immediately. Your Consultant Breast Surgeon will book the appropriate Imaging exams to further investigate your case.

  • Step 3 – Tissue biopsy

On the same day of your Imaging examination, you can be offered a tissue biopsy. This is a non-invasive procedure to collect a sample of your breast tissue with a needle, for a precise diagnosis.

  • Step 4 – Results

Results from a tissue biopsy may take up to 72 hours as they are discussed within a dedicated multi-disciplinary team meeting, comprising radiologists, pathologists, surgeons, and oncologists. You will be reassured and guided
through the treatment options.

The benefits of the One-Stop Breast Clinic

Many women find One-Stop Breast Clinics very beneficial.

A new randomised trial in the USA called the WISDOM study that stands for “Women Informed to Screen Depending on Measures of Risk” is a study that is often shared with many women in One-Stop Breast Clinics.

This trial uses a personalised breast cancer risk score in the past 5 years. This score is based on age, race, affected first degree relatives, prior breast biopsies, proliferative breast conditions with atypia (abnormal cells), breast density score assessed using a BI-RADS and genomics (high/moderate penetrance genes) and 96 polygenic risk score (lower risk common genetic variants).

The rapid diagnosis One-Stop Breast Clinic aims to provide results at the same time as the consult in over 95% of patients.

The One-Stop Breast Clinic:

  • facilitates a referral to a specialist consultant clinical geneticist
  • provides you detailed information sheets on “Genes and Families” (Breast Cancer Now publications, ref 4) that gives you a clearer idea on gene risk factors
  • gives you peace of mind sooner with a fast diagnosis process

When you should have your breast checked by a specialist

Although the current UK guidelines suggest mammography screening for women over 50, there are many cases where a breast examination either through a Consultation, an ultrasound scan or mammography can give you peace of mind.

You should consider visiting the One-Stop Breast Clinic if:

  • You have a family history of breast cancer and/or ovarian cancer
  • You are concerned about a change in the skin or tissue texture of your breasts
  • You have done a genetic test before 2014, as more in-depth, specific gene testing is available
  • You want to avoid long waiting times for your results

The benefits of the One-Stop clinic – News at New Victoria Hospital

Patients experience of the One-Stop Breast Clinic

One-Stop Breast Clinic Locations

Patient bakes a cake for raffle

Breast cancer patient stories

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Patient empowerment is essential both as a process and outcome. Breast patients, Mona and Andrea share their experience at New Victoria Hospital One-Stop Breast Clinic, highlighting the importance of making informed decisions.

Breast cancer affects 1 in 7 women in the UK. For Breast Cancer Awareness Month, we’ve spoken about the importance of cancer screening and prevention and the benefits of New Victoria Hospital One-Stop Breast Clinic in our previous blog article.

Today we would like to share with you the story of Mona and Andrea, two women who attended NVH One-Stop Breast Clinic and received very attentive care thanks to our multidisciplinary approach and fast track access to consultation and diagnosis.

Mona: the One-Stop Breast Clinic is my idea of less stress

“Before Covid, I was not aware of belonging to the 70+ group.

Unfortunately, I also was not aware, I should have had a yearly Mammogram test after the age of 70.

I detected the abnormality in my large breast by pure chance. After seeing my GP, I began my treatment under the NHS. I then decided to have a double Mastectomy at New Victoria Hospital under Prof Zoe Winters and her team.

It was a very successful experience. I like my new shape. The knowledgeable, trustworthy and caring treatment at NVH with its tasteful facilities made my recovery so easy.

I wish I had known about New Victoria’s One-Stop Breast Clinic earlier in order to have the choice to get the complete cancer treatment there.

Their Self Pay option is comfortable, and I didn’t have to worry about additional fees as it was an all-inclusive package.

Having the One-Stop Breast Clinic is my idea of less stress to resolve and treat the problem, more efficiently and quicker”.

Andrea: Maintaining control into a chaotic process

Andrea Knowles-Jones raising funds for Breast Cancer

“I have just turned 49 years old. I live in Surrey with my husband Andy and daughter Holly who will be 7 in November. I work for a large pharmaceutical wholesaler and am sole breadwinner, whilst Andy is a wonderful full-time parent doing the most important job of looking after Holly.

My business is extremely high pressured. I usually run at a million mph, and anything less than 100% just doesn’t cut it. Our colleagues are classed as key workers given that we deliver life-saving medication and essential healthcare products to the NHS, pharmacies and hospitals across the UK on a twice-daily basis and so when the Covid pandemic hit, we went into full crisis mode.

My annual screening mammogram came round in March.

I have yearly scans as my mother had breast cancer twice and then sadly passed away due to ovarian cancer. I was concerned when I was told I had pinky brown discharge coming out from my left nipple.

I was reassured that most likely nothing and indeed when I got the results a couple of weeks later, I got the standard ‘all OK, see you next year’ one-liner letter. I promptly pushed any worries to the back of my mind and continued focusing on work and the craziness that was ensuing in a Covid world.

A month or so later, however, I started noticing some pinky-brown spotting on bras and other clothing. I also found a small lump by my nipple. My breasts were feeling heavy and aching specifically on the left side, which was displaying symptoms.

Considering the recent clear mammogram result, I wasn’t overly panicky. I spoke to my GP who got me quickly referred back to the breast team who sent me for further tests.

The night before that appointment, I noticed a large hard area on the side of my breast, not a lump as such, but definitely noticeable. Not sure how I hadn’t picked up on it before. Again though nothing showed up on the mammogram, but the doctor was concerned about the hard area when she did the ultrasound and took biopsies there and then.

Two weeks later, I had a telephone consultation, and I was absolutely shocked to receive a diagnosis of DCIS intermediate level in my left breast. I honestly was not expecting it but went straight into pragmatic, action crisis mode. I pressed on with organising MRI and other tests so we could confirm the extent of disease and work out a treatment plan.

This was all done initially through an NHS consultant, but I am lucky to have medical insurance which when we got as far as we could with investigations being progressed on the NHS, I triggered.

As a result of the pandemic, local private hospitals were under the jurisdiction of the NHS, and so I had to look further afield to find a suitable consultant to look after me. This turned out to be a godsend and actually the silver lining of the Coronavirus situation as I was lucky enough to go under the care of Professor Winters.

KNOWLEDGE IS POWER

Obviously, trust is key, but you also need a level of chemistry with your consultant who you are going to be discussing and sharing some very intimate and often distressing situations with.

For me, knowledge is also power and I found the ‘being out of control’ aspect of my diagnosis incredibly challenging as in my personal and professional life I have to juggle a lot of responsibility and being organised, planned and in control is how I cope.

From my initial chat with Jenny, Prof Zoe’s practice manager to the moment I met Zoe in clinic at the New Victoria Hospital (the first clinician I had actually met face to face since my diagnosis), I knew I had made the right choice and was in the best hands.

Professor Winters was to me the perfect blend of providing informative and expert consultation taking the time to talk through all aspects of tests, scans, biopsies, results etc to ensure I understood everything. She showed empathy and understanding of what I was going through.

As a lover of detail myself, Zoe left no stone unturned and was beyond thorough to ensure we made informed decisions on my surgery and treatment plan. She gave me back my power and control and I will be forever grateful for that and cannot thank Professor Zoe enough.

I was so assured that whatever additional help and counsel was required, Professor Zoe will recruit and bring the very best experts on to the team to look after me. I really had and still have the best of the best on my side.

I still struggle with acceptance of everything that has been happening to me as at each appointment, things seem to worsen, and I had to take in more and more bad news to get my head around.

I have had a skin-sparing mastectomy of my left breast with immediate reconstruction and post pathology results revealed a large area of invasive cancer as well, which was a shock.

But we got it in time, and I am now doing all possible to prevent it coming back which has included radiotherapy and now hormone therapy which has required me to have medically induced menopause. I have more surgery ahead to help me ‘get my body’ back, but I have a top, first-class plastic surgery caring for me, thanks to Zoe.

I often think about what the situation could have been if I had just left things and not persisted with checks. What if I had left it because I was too busy and didn’t get round to it until next year’s annual check. Thankfully, I didn’t, and my clear message is that YOU know your body better than anyone else or any machine and so trust your gut instinct and if in doubt, check it out. It might be nothing, which is great but if it is something, you can get it early and do something about it.”

Andrea’s story in The Times