I'm a breast cancer surgeon. AMAZING

[Gincision]

What the thread title says. I've been a consultant for nearly 2 years. Open for questions...

How do you feel about breast screening? I’ve been offered a chance to be part of a trial to screen women of a lower age. The patient information sheet is not overly reassuring about the number of false positives from a mammogram.

Hi OP, I also think you're amazing :)

I know family history is a risk factor, my paternal grandmother had breast cancer in her early sixties, is that enough to put me at an increased risk?

@freyanna you should be getting a dexa scan every 2 years while you're on an aromatase inhibitor. So if it's more than that since you had one it is worth asking.

Surfnterf lovely to hear that your treatment has been successful and your able to watch your little boys grow up.

Sharpand I’m a psychologist who works in cancer services. If you are still in the thick of treatment I’d suggest asking your team about future risks. Your oncologist will have all the information and be able to talk it over with you.
Risk and probability is so difficult. What sounds good to one person will sound awful to someone else.
Sorry to interrupt Gin

@SoftlyCatchyMonkey1

How do you deal with the emotional side of your job?
I feel very privileged that I get to share the darkest moments of people's lives with them. I'm sure I don't always get it right because what different people need can vary hugely but I certainly think that how you are with people during this time can make a huge difference to how they cope. I hope that the majority of the time the fact that I really care about my patients comes across and helps them. As to how I copied with my own emotions, mostly I go home, hug my husband and children, and feel thankful for our current good health. Certain people get to me though, usually those who I can relate to in some way. I've cried on more than one occasion about particular patients (I've welled up in front of some but never actually cried) but ultimately I need to be able to detach in some way so I can do the best for them.

Does it affect the way you are with some patients if they're particularly anxious?
Funnily enough I find people who are openly anxious or scared easier to deal with than those who internalise everything. Probably because that's more my own personality and I can relate to it more. I try and read what they want and talk as much or as little as they need. Some want hugs, I am comfortable with this if they instigate it but I wouldn't instigate it myself.

Did you get training into how you deal with patient fear and dread?
Not formally. I spent a lot of my early training observing others do this and learnt from both the good and bad consultations. I have been observed by my bosses then who gave me pointers. Now I ask my breast care nurses for feedback from time to time, both positive and negative, to make sure I do the best I can.

And questions with answers that can't be sugar coated?
This can be hard. But I think you have to be honest. I'll look them in the eye and speak clearly, in language they will understand (based on what they have asked and what they know already). You're right that there are some things that cannot be sugar coated but usually people don't ask questions when they are not ready for the answer. Usually people value honesty, and as long as you deliver the news with sensitivity it's better not to shy away from difficult discussions

@Ledkr sorry to hear about everything you've been through but glad to hear your treatment has been successful and that you feel it's been a positive step to have preventative surgery.

Re your daughter I think she would need to wait until she is at least 18 to really think about what she wants. For most people knowledge is power, but others prefer not to know. If she treated positive usually oophrectomies wouldn't be recommended until her family was complete (assuming she wants children). As you'll know risk reducing surgery for breast cancer is a long process, which is necessary to ensure that you have all the time you need to make sure it's the right decision for you. So there should be no rush to do anything even if she was also positive. You'll know your dd but most 16 year olds wouldn't have the maturity to process all of this. Some 18 year olds wouldn't either. Sorry for the waffly answer, to summarise when you and she think she has the maturity to deal with a positive result.

@SockQueen I don't routinely use blue dye anyway, because of this risk. I use radioisotope and as long as I get a good signal I'll rely on this. If I don't I'll use the dye. I tell patients as part of the consent process about the risk of anaphylaxis if I use it. Although using single agent is against current NICE guidance, the guidance is very out of date and this is standard practice among most breast surgeons I know

@Mamia15 and @ranoutofquinoaandprosecco it's a very personal thing. Some ladies are horrified at the thought of losing a breast or assymetry / poor cosmesis after breast conservation. Others really don't care. Most are somewhere between the 2. If you are not bothered about reconstruction then that's totally fine, and you would still have the option in the future if it turns out you are more bothered than you thought.

Mamia glad you had a good result!

Ranoutofquinoa I think it's really normal to worry about being put to sleep (in fact I think it would be a bit odd to not be worried!) Talk to your anaesthetist as there may be something they can give you to help with the anxiety if you find it overwhelming.

@weebarra recovery time after reconstruction is variable depending on whether you have 1 or 2 stage reconstruction (have your skin stretched first with an expandable implant which is out in at the first operation then a second operation to replace this with an implant or your own tissue or straight to final reconstruction which is only possible with your own tissue)

Implant reconstruction would have to be 2 stage to get enough skin to make space for an implant. But you can bring skin from elsewhere on your body if you use your own tissue meaning that it is possible to do as a single operation although the cosmesis often isn't as good.

Recovery 6 weeks to 3 months depending on type of reconstruction.

Do you have reconstruction nurse specialists at your hospital? If you wanted you could ask to meet with them to go through it in more detail as you might not be suitable for all of these options depending on what other treatment you've had. Then you'd be able to decide if this was something you were interested in or not.

@Hangingaroundtheportal nothing to worry about for you at all. The report is about the risk of anaphylaxis at the time the dye is injected, the blue stain after is nothing to worry about

I had a DCIS of around 1cm (low/medium grade) cut out at age 44, discovered while removing a papilloma.

I had another lumpectomy afterwards with clear margins and was advised against radiotherapy/further treatment.

Is this normal not to require radiotherapy and are my chances of the cancer reappearing higher?

Many thanks

My maternal aunt had breast cancer very young (early 30s). Had a mastectomy and then died of ovarian cancer.

I asked my GP about early mammograms and he agreed. I went for one and then got called back to the hospital a week later. I never went. That was ten years ago. Do they normally call people back? Haven’t had a mammogram since.

Oh and my mother is now terminally ill with ovarian cancer. Do you think I ought to ask about gene testing?

@freddiemercury

what's the likelihood of it returning so quickly
It would be unusual assuming the surgical margins were fine, but not impossible which is why it's important to stay vigilant. I agree it's hard to know what is normal after all the treatment but your team should be happy to see you if there is anything you're concerned about. I'd rather see hundreds of ladies with lumpy scars to put their mind at ease than have them worrying at home when it's relatively easy to help you feel better by checking and arranging a scan if necessary. I'm not worried about your pain as it can be normal for this to persist after surgery and radiotherapy but equally if it's getting worse and you're concerned there is no harm in flagging that up either.

Also...tamoxifen..I have hardly any side effects...is it definitely working?
Plenty of people don't have side effects, it will definitely be working

my bone scan they did barely an hour after I'd been injected....would it still have been accurate?
This will be fine. If your around are getting worse though there is no harm in also flagging this up with your team.

Basically, anything you're worried about call your breast nurse. That's what they are there for and they'll always be happy to answer your worries and arrange for you to be seen if necessary

@Slartybartfast some male patients. Usually men with gynaecomastia but I've seen a couple of men with breast cancer. Not since I've been a consultant though, only 1 in 100 breast cancers occur in men

@Oscha most 'lumps':I see in the breast clinic are just bits of prominent breast tissue. I would always take someone seriously regarding a lump they've found as although I'm a breast expert they're the expert in their own breasts so if they've found something new I'd investigate it. Remember though that the people I see have already been seen by their GP who is also worried enough to send them and watching to see what happens over a couple of weeks is very normal.

As to how you know, the only answer really is experience. However if you feel the rest of your breasts concentrating more on the texture, if the lump you've find has a similar texture it could just be a bit of breast tissue. Definitely go back though if you're still worried, at the end of the day it's difficult to be totally sure without a mammogram/scan.

I am hoping to do graduate entry medicine in the next few years. Would you recommend medicine as a career?
What made you choose surgery?

I frequently get small red lumps which 'pop' if I squeeze them and white gunk comes out - sometimes mixed with blood if it's a larger one. I've had them on and off all my adult life so I just ignore them. Should I stop ignoring them?

@Fattygettingthin in the clinic you'll get a full triple assessment. That means an examination by a doctor or nurse specialist, an ultrasound scan of the breast (not normally a mammogram as they are not very useful in ladies under 40 years as their breasts are too dense for it to be reliable) and possibly the armpit, and a biopsy if they can see anything abnormal on the scan. They might also do a biopsy if the scan is normal but they can feel something on examination. The while process can take a few hours but by the end you'll have the results of the scan and good idea what's causing this, although biopsies will take a week or so to come back so you'd need a separate appointment for those results. Your GP is totally right to refer you in with those symptoms although there are other reasons for this other than cancer (for example an infection). Your family history would also warrant investigation as to whether you have a genetic abnormality in your family that might make you more likely to get breast and possibly ovarian cancer. Some of the ladies on this thread have been through this. If you would want to know if this was the case for you then ask about this at your appointment as they could refer you for further assessment and tests.

@WeirdScenesInsideTheGoldmine helpful answer by MissConductUS!

@VanillaSugar there is a link between hrt and breast cancer summarised well here, but it's important to weigh up the risks against the positive effects of hrt, and also be aware that there are other lifestyle choices that have greater impact:
www.cancerresearchuk.org/about-cancer/causes-of-cancer/hormones-and-cancer/hrt-and-cancer

@allaboutculture calcifications on the mammogram are very very common and most have absolutely no relevance. If they are confident they are benign then I wouldn't worry about them. Sometimes they are due to early breast cancer but this usually has a pretty classical pattern. If there was any worry they would have done a biopsy. The calcifications themselves are not associated with an increased risk of breast cancer.

@GhostsToMonsoon MissConductUS is spot on with her answer.

Regarding mastectomies for dcis, standard treatment is surgery to remove it, which would sometime be a mastectomy if the size of the dcisc relative to the size of the breast meant that conserving the breast wasn't possible. This isn't a prophylactic mastectomy but a therapeutic one because dcis is early breast cancer even though it hasn't developed the ability to spread.

There is a trial currently underway though as we don't really know how likely it is for some kinds of dcis to progress to induce breast cancer - see this link:
www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/a-trial-comparing-surgery-with-active-monitoring-for-low-risk-dcis-loris

The problem is that it's pretty difficult to persuade ladies that they want to take part in a trial that might result in them only having observation of something that is still called breast cancer....

@TallulahMazda if you have been assessed as having a moderately increased risk of breast cancer based on your family history then annual mammography (until either 50 or 60 depending on your risk assessment) is sufficient. Some trusts also offer annual examination but there is no evidence that this is necessary.

Moderately increased risk means that your lifetime risk is between 12-30% (low or normal population risk is 12% and high risk over 30%). Because breast cancer is common it's normal to have one or 2 family members with breast cancer end the assessment is mainly based on how close a relative they are and the age they were when they developed cancer. If anyone else is diagnosed with either breast or ovarian cancer that might change the assessment so it would be worth flagging that up if relevant in the future.

Tamoxifen is not normally discussed as a preventative measure until you are high risk.

@Hangingaroundtheportal triple negative breast cancer is more common in brca1 carriers but they can still have hormone receptor positive cancers. And brca2 carriers are not more likely to have triple negative cancer.

@Sharpandshineyteeth it's not possible to say the chance of it recurring without more detail about size, lymph node status and grade of your cancer - you'd be better asking your team this because they'll have all of your specifics as well as knowing what treatment you've had. However, you've done absolutely everything you can to keep the risk as low as possible of it coming back.

Having a mastectomy as a preventative measure (which one of them may or may not have been) reduced your risk by 90-95% because it's not possible to be sure every last tiny bit of breast tissue is removed meaning that it's never zero so it's important to report any new lumps you find in your reconstructed breasts.

Wishing you all the best for the rest of your treatment and the future

@usernamesarerubbish

How do you feel about the Optima trial?
If I'm completely honest, mixed. There is a part of me that feels uncomfortable about ladies who have say, 7 or 8 positive lymph nodes, going into a trial where they might not receive chemotherapy.

However, the trial would not have been approved if there was serious concerns about safety, there is good evidence for other tests similar to the prosigna albeit in lymph node negative patients, and if we hadn't pushed forwards with risks looking at less treatment all ladies would still be having mastectomy and axillary clearance for tiny lymph node negative cancers. I'm certainly convinced that the biology of the cancer is more important than traditional markers of prognosis like size, nodal status and grade.

gintastic THANK YOU...this thread is just so helpful...hugely appreciated.
On a more light hearted note....I think my left armpit (where I had the SNB) is more likely to um get smelly than my other one...could this be true???!! Am I imagining it?!!
And really just thank you. You sound lovely and so caring....my first consultant was just terrible (he wanted to play "I can guess your cup size just by looking" ...told me I had two cancerous lumps and it had spread to my lymphnodes...I had one limp and no spread!!)....needless to say I swapped consultants...my second was truly fantastic...and it makes such a difference. You sound like my second one and your patients are very lucky...