Cancer Lumps Symptoms

hello, i'm helen zorbas and it's my pleasure to welcome you to this breast cancer education series produced by national breast &ovarian cancer centre in collaboration withthe rural health education foundation. we're delighted to have you, as health professionals in ruraland remote areas of australia, joining us for this programfocusing on breast cancer care. in australia, approximately 30% of womendiagnosed with breast cancer

live outside a major metropolitan city. as well as their cancer diagnosis, these women face additional challenges, including geographic isolation and limited contactwith specialist health care workers. as rural health professionals, you have a vital role to playin both the provision of information and the delivery of best practice,clinical and supportive carefor rural women with breast cancer.

we hope that, through this series, we improve your accessto evidence-based information and, ultimately, benefit the womenwith breast cancer in your care. the program has been developed to bespecifically relevant to rural practice and i would like to thankour facilitator, doctor norman swan, and the breast cancer expertsand rural health professionals who have contributed their timeand expertise to this broadcast. i hope you enjoy the program. hello, i'm norman swan,

welcome to this programon ductal carcinoma in situ. is it cancer, doctor? hope to answer that question for youin a moment or two. this program is a joint initiative of the national breast& ovarian cancer centre and the rural health educationfoundation and is a project ofthe supporting women in rural areas diagnosed with breast cancer program,funded by the australian government. ductal carcinoma in situ or dcis

is a non-invasive tumour arising from and contained entirelywithin a breast duct. the incidents of dcis has risenin the last 15 years, primarily due to the introductionof screening mammography. women diagnosed with dcisare actually four times more likely to develop invasive breast canceras women of similar age. so we're going to coverthe early detection of dcis, current thinking about treatment,management and follow-up. you'll find a number of useful resourcesavailable

at both the national breast& ovarian cancer website, and that's the nbocc.org.au, and on the rural health educationfoundation's website - rhef.com.au. our panel -brendon coventry is a surgeon working at the royal adelaide hospital with a special interest in breastsurgery and breast reconstruction. - welcome, brendon.- hello, norman. hello, viewers. warwick lee is the state radiologistfor breastscreen new south wales. he's not wearing his uniform,but i'm sure he's got one.

associate professor of medical radiationsciences at university of sydney. - welcome, warwick.- norman. jenny mayis a rural general practitioner based at the university of newcastle and the department of rural healthin tamworth and is an academic rural gp. - welcome, jenny.- thank you, norman. lee millard-newton is employedby the north coast area health service as a specialist breast nurse

and the north coast cancer instituteand breastscreen north coast at coffs harbour health campus. - welcome, lee.- norman, thank you. chris milross is headof radiation oncology at the sydney cancer centre,royal prince alfred hospital, and is also an associate professorat the central clinical school of the university of sydney.welcome to you all. so, brendon, the definition,i gave a rough definition in my intro, how do you defineductal carcinoma in situ?

well, ductal carcinoma in situ is, uh, carcinoma of the breast,cytologically, but it's confined... norman: so it is cancer, doctor?- it is, yes. it's cytologically cancer.that's the diagnosis. but it's confined to inside the duct. it's bounded by the basement membranearound the breast duct. so it hasn't yet escaped outside and become invasive breast cancer. - but it can be quite extensive.- yes, it can.

it can involve the whole breastpotentially. in most cases, though,it's confined to areas of the breast, or at least one area of the breast. warwick, how oftenis it just one area of the breast? the majority of the time,it would be just one area of the breast, but it has potential to be confinedto a segment of the breast. so if it is widespread,it is usually segmental disease in the upper-outer quadrant,upper-inner quadrant... so it's a segmental disease,that's how it grows and goes...

and if you've got it in one segment, what's the chances you've got itin another segment? i'm sorry, i don't know the figures,norman, but it's unlikely. it's less likely,as it's a segmental disease. it's usually a continuous disease. but there's a pretty wide variationthere. i think that demonstratesthe imprecise knowledge we have about the progression of dcis. we know that there is a very significantproportion of women with dcis

that progress to invasive disease. but by the same token, there's a certainnumber of women that don't progress. the problem that we have iswe don't know which women they are that do not progress. what's the incidence doing with dcis,brendon? well, dcis, currently, there's about 1,600 women a yeardiagnosed with dcis in australia and that sits at around about

14 per 100,000 women per population and, uh... the incidencesremained fairly static over the last five years or so. it increased quite rapidlyover the previous ten years or so due to the introduction progressivelyof mammographic screening. norman: and that's the graphthat we're seeing there. uh, most... cases of dcis are now diagnosedwithin a screening program. detected by a calcificationin an asymptomatic woman

having a screening mammogram. but dcis was around prior to screening, probably made up of 2% of cancerprior to the screening. now it makes up roughly 18-20%of all cancers diagnosed. so that demonstrates the influencethat mammography has on the diagnosis. so... warwick, do all... is this the polyp... the bowel polyp of breast cancer? in other words, invasive canceralways starts as dcis or not?

uh, most invasive cancer starts as dcis. the usual invasive ductand invasive lobular carcinoma starts as dcis - yes. uh, but that's not to say, conversely, that all dcis ends upas invasive cancer. and do we knowwhat the predictive factors are? we can't confidently predict100% of women who are going to progress but there are features, aren't there? not reliable enoughto determine treatment of dcis.

and it's really in the research areaof trying to select out those women that we can - with dcis - that may not progress toinvasive carcinoma. but in the current state of knowledge, we cannot reliably predict those women. so we get back to the initial question -is it cancer, doctor? yes, it is cancer. radiotherapy is almost universal,isn't it? yeah, it's as common as surgery.

um, it can be treatedusing all of these methods. - normally...norman: so i asked the question badly? normally, surgery... not at all! normally, surgery is the mainstayof treatment of dcis. surgical excision, complete surgicalexcision of the area of dcis. um, radiotherapy is added in in the majority of women particularly thosewith higher risk dcis. and that's really defined as, uh...removing the women of low risk

and they are dcisthat is in a small area, uh... very well differentiated and with low,with no necrosis being present... ..and also in a breastcapable of being treated adequately withcomplete surgical excision. so with an adequate marginof normal breast around it. this is an area of confusion for gps,isn't it, jenny? jenny: it certainly is, norman. and certainly not only is itan area of confusion for gps

but obviously for the womenwho come to us trying to, um... sort out what the diagnosis means, because, for many women,the diagnosis of dcis sounds awfully likethat of invasive cancer that their next-door neighbouror one of their relatives has. i guess it's trying to weave your waythrough that discussion and help them to make, you know,good informed decisions about the best way forward.

lee, what questions do women ask you when they get this diagnosis? uh, they come looking, i guess... the breast nurse is one resource person where they can go to to tryand tease out the pathology results and offer some explanationof what is going on and lead the women to resources that they might be able tobetter utilise, to understand what is going onwith their disease,

what dcis actually is in comparisonto what an invasive cancer is. what do you think the core areasof confusion are? i think the treatment sounds awfullylike the treatment for breast cancer and the fact that, once you're treated,you still retain an ongoing, recurrent risk of breast cancer,sounds awfully like breast cancer. i think the difference, the importantkey difference to tease out is that dcis has a very low rateof systemic or, um, regional diseaseremoved from the breast. so it's a more local issue.

but as i said, for many women, this is a difficult discussion to have. the best analogy thati think we can come up for is a pipe - and whilst the cells are cancerous, they're retained within the pipeor within the duct of the breast, and whilst everit stays within the pipe, then that's not invasion, that's not cancer going more distantly,i guess. what is the recurrence rate,chris milross?

the recurrence rate after surgery aloneis in the 20% ballpark. perhaps 20-30%. we know that the additionof radiotherapy to breast conserving surgery reduces the risk of recurrencedown to less than 10%, so the 5-10% level. the occurrences that occurafter breast conserving surgery for dcis are about half and half, invasive and/or a further episodeof dcis.

untreated with radiotherapy, the recurrence rate's the sameas invasive cancer, then? chris: yeah, it's in the same ballpark. interesting. but you can reallydramatically reduce that. of course, with invasive breast cancer, that's after you've had your adjuvantchemotherapy and radiotherapy is the recurrence rate. so, in fact, untreated invasivewould be much higher than that. um... no.

untreated after breast conservingsurgery, the recurrence rate's about 20%,20-30%, let's say. right. so... there's a pressure here,and people talk about over... in other words,whether we're overtreating or not. what's your answer to a woman, warwick, who says, 'can't i just wait and see?' there's two problemswith waiting and see. the first, i've already mentioned ita couple of times,

we cannot predict the women, with dcis, who are going to progressto invasive disease. so that's the first part,once we have the diagnosis of dcis. the second part is that most womenthat are newly diagnosed with dcis are diagnosed on a needle core biopsy. uh, the needle core biopsy may show dcis in that area that's been biopsied. it doesn't tell uswhether the lady also has, the woman also has invasive carcinoma,

which has not been sampledby the needle biopsy. which, yes, can coexist with the dcis. norman: so the surgery's diagnostic,as well, brendon? brendon: mmm, absolutely. with the core biopsy, you're restricted to the areasyou sample. so, uh... what you're faced with is potentially a sampling error. at least with surgical removal,

you can sample a large section of it and prove that you've completelyexcised the area. norman: lee, you've seen some bad storieswith women who've waited, watched and waited... i think it's, um...it's really important that women have that discussionwith their treating team to ascertain the significanceand importance of the pathology result and weighing that up against, um...

whether they're going to have treatmentor not rather than making that decisionthemselves. i think that needs to be based upon... ..informed decision-making. so i don't think that can be something that the women just makea decision on their own. sure. got a couple of questionscoming in. question from kerry in queensland, 'is the use of vaginal oestrogen creamscontraindicated for women with dcis?'

chris, do you know? the short answer to that question is no. there is some systemic absorptionof oestrogen from vaginal creams but, generally,it's considered to be safe. or, at least, there's no evidenceof it causing an increase in the recurrenceof any oestrogen-sensitive cancers. do you bother doing the er status, oestrogen-receptor status of, um...dcis? um, it's not routinely performed.

pathologically, it doesn't typicallymake a great deal of difference to the treatmentthat we subsequently recommend. in any case, my understandingis that the oestrogen receptor positivity rates are high for dcis. so there's a little theoretical reasonfor being concerned about oestrogen. but in practice, probably no. - jenny, you want to add to that?- no. a question from a general practitionerin canberra, we've answered that. 'is dcis the precursorof all adenocarcinomas of the breast?'

- the answer is probably most.brendon: yeah, look, i think so. we know this... although there's little direct evidence, what we can say is that,in about two thirds of cases, invasive cancers are associatedwith areas of adjacent dcis. so that's very suggestivethat it's arising from there. and, uh... dcis itself goes on to invasive cancerin about two thirds of cases. so, uh... you know,

there's a very, very close associationbetween these diseases and we know that, with a lot of cancers, there seemsto be this progression through from atypical cells to in situ tumourand then, finally, invasive tumours. so this is seenwith the large variety of cancers, there's no reason to believeit would be any different with breast. let's go to our first case study -susan's 54, mother of two, lives in a small ruraltown and works at the local council. she's had the same gp, jenny,for many years

and attends breastscreenevery two years. so she's probably had her third visit. on her third visit to breastscreen, she was recalled for further assessment. do you ever see people after? i mean, are they in a state of panic in between breastscreen and going backfor their further assessment? indeed, norman, and it is a very anxiety-provokingsituation to be recalled.

now, obviously,the letters that breastscreen sends are very comfortingand reassuring letters and there are lots of technicaland other reasons why people are recalledto assessment centres but the majority of my patients would immediately thinkthat this is going to be the... where they're going to geta diagnosis of cancer confirmed ..and are very anxious. norman: lee?- i would agree with that.

i think the role of the breast nursecounsellor at a breastscreen assessment clinic is to talk the patient through or walk the patient through the processthat she's going to undertake on the day and when she leavesthe assessment clinic, is to ensurethat she has an understanding of what's gone on during the day, if she has had a biopsy, to ensurethat she has a timely follow-up with her gp for those results

and giving clear informationabout what that means. i'd agree with that,i think there's a lot we can't get through to the patient,to be honest. i think that we can explain thingsin a medical sense. usually, it takes a little bit of timefor things to sink in and to have the breast care nursefollow that up with the ability for further questioning and answers to be given, reiteration of a lot of the points

that we've madeduring the initial assessment. i think it's very important. vital. so... warwick,how is the diagnosis made? - so the woman comes back for...warwick: yes. and these days, in most jurisdictions,we're talking about digital mammography? that's correct.so the routine screening mammography, as i'm sure most people know, will be the two-view mammography. roughly in between 5-10% of womenare recalled for additional views,

additional mammographic views,ultrasound, and possibly percutaneous biopsyand needle biopsy. with, uh... calcification, which is the way that, um, ductalcarcinoma in situ most often presents, uh, there will be the mammography,ultrasound, and almost certainlya series of tactical mammographically guided percutaneousbiopsy or needle biopsy. norman: so here is the mammogramof, um... susan. warwick: uh, yes.

the image on the left-hand sideof the screen is the craniocaudal view of the breast and the calcification is so small you can't see it there. so we have the magnification view. and that's typical calcification of higher grade ductal carcinoma in situ. it's conforming to the line of a duct... ..in a linear distribution.

the calcification is linearand branching, forming a cast of the duct. norman: so when you say high grade,you mean highly differentiated? warwick: no, high grade.- high grade. so...? higher grade ductal carcinoma in situ,a higher grade cancer. - right, so that's the mammogram.- that's the mammogram. so you find that, what's next? it's important that the gps knowwhat's going to happen. it's really important, 'cause thenwe can inform people appropriately.

uh, the next will bean ultrasound examination of that breast. ductal carcinoma in situis usually not seen well on ultrasound but if there is coexisting invasivecarcinoma, it may be visible on ultrasoundand not visible on mammography. you may see just pure dcis on ultrasound and that may aidultrasound-guided biopsy but, usually, it will be negative and the next step will bemammographic-guided stereotactic biopsy.

norman: we'll show a picture of itin a moment. the, um...how often, jenny, do you see...? have you ever seen paget's diseaseof the nipple? i've seen paget's disease once and i think many gps would have seen it,extremely rarely, if ever. norman: so here's a picture of it. brendon, do you want to talk us through paget's disease of the nipple? brendon: well, uh, it most often looks

like dermatitis of the nipple. there can be destruction of the nipple completely and i've had a couple of women come in with complete destruction of the nipple. but, fortunately, you have the other side to compare it to. so, really, any distortion or... ..cutaneous...

particularly the areola region of the nipple, around the areola, dermatitis or, um... obvious abnormality means biopsy. norman: so is the dcis in the nipple? what's the story here? is that where the dcis is? uh, no, paget's disease was, of course,initially described by paget

and he put his name to the cells,paget cells, which are clear cells in the epidermis. so these are, uh...a particular histologic type of cell that the pathologistrecognised in the epidermis. now, what that was originally supposedto signify was a underlying carcinomasomewhere in the breast and it was thought originallythat these were invasive cancers and i think figures initiallywill put it around 80%, historically.

but it's nowhere near that. but what it can signifynow that we've got mammography is underlying dcis as well. so it might be invasiveor it might be dcis or it can be both associated with paget's disease,or it might be paget's on its own. so it's a marker. but, jenny, if you see this,you don't send them to breastscreenif you see paget's disease? jenny: no, this is time to refer...norman: for a diagnostic testing.

and how often, warwick,is it diagnosed a palpable lump? well, less than five...less than 5% presents clinically. probably closer to 2%,it will present as clinically. of those clinically,the most common clinical presentation will be a palpable lumpor a nipple discharge. rarely paget's disease. um... but all those presentationsare uncommon for dcis. by far and awaythe most common presentation of dcis is in an asymptomatic womanwith a screening mammogram.

i think we've got a pictureof a core biopsy somewhere. we might get that up on the screen. there it is there. do you wantto talk us through that, warwick? warwick: uh, well, this shows the duct which is filled with malignant cells. there is some amorphous calcification there which corresponds to the calcification that we see on the mammogram,

as the tumour and the calcification is forming a cast of that duct. norman: so that's... warwick: the other important thing is it has normal surrounding tissue there, there's no invasion out of the duct. norman: brendon, want to comment?- no, no further. lucy from ashmontin new south wales at charles sturt university -

'do you think any new molecularprofiling studies have progressed our knowledgeof progression of dcis? chris? chris: outside my area of expertise,i'm sorry. it's certainly not my area of expertise but that is certainly one of the waysof research at the moment - trying to select womenwho have percutaneous biopsy, percutaneous diagnosis of dcis, uh, looking at the molecular markers, to select the womenwho perhaps will not progress,

perhaps will not need further treatment, perhaps will not need excision. - but at the moment, it's research.norman: not reliable. it's a good question, it was outlinedby the nih consensus statement and what they were trying to dois nail down which women might not need such aggressive surgicaland radiotherapeutic treatment. the difficulty at the momentis we don't have the tools to be able to select those women out,

so that we can save them ofthe burden of that treatment. at the moment,we have to essentially treat them all in order to capture the onesthat are going to go on and develop invasive malignancyand other problems. warwick: but the researchis being done now. uh, a complimentfrom another gp in canberra. 'i like jenny's analogy - the pipe. but did i hear right? 20% get furtherdisease after treatment?' that's not what we said there, was it?

it's down at 5%, is that right, chris? yes, following a combinationof breast conserving surgery and then post-surgery radiotherapyto the breast. and elizabeth... ..has asked, 'how dependableor accurate are needle biopsies?' it's a pharmacist asking. uh, they're very... norman: if you're doing them,they're fantastic. to answer that question,we can go back 15-20 years.

most women who had breast cancerwere diagnosed after an open biopsy. the ratio might have been... and the ratio of benign diseaseof cancer may have been eight benign disease to two cancers. it's been turned around completely now. so the... well over 80%,probably closer to 90% of women had a pre-operative diagnosis of cancer,both invasive and dcis.

i think that indicates how reliableneedle biopsy can be in both dcis and invasive cancer. norman: so you're not missing manyis what you're saying? not with... well, you have to take itwith all triple assessment. i think that's key with... we're talking about dcis, which is mostoften detected with mammography, but, really, we're talking aboutmanagement of cancer in women whether they're screeningor symptomatic. we have to take triple assessment.

- so we don't take one tool.norman: chris? i think there's one importantadditional point there and that is that the combination of the imaging evidence and the biopsy, uh, allows for careful planning of the definitive surgery. there's also a good measure of clinicalsuspicion that's tied in there as well. you know, if you think that it's dcis on mammographic grounds,

and the needle samplecomes back as negative, then, of course, it might mean repeatingthe needle sample. the core sampleobviously gives you more histology which the pathologist is morecomfortable with than a needle sample but... you know, a good cytologist can give you a lot of information about the cytologic malignancyof the lesion. so we're already getting the flavourof a multi-disciplinary team here. we've got lee as the breast nurse,

we've got a pathologist who's involvedsomewhere, who's not on the panel, there's a radiologist,come interventional radiologist... where does the gp sit in all thisfrom breastscreen? so you've done the biopsy,she doesn't get it there and then, it's got to go off to the pathologist.how long does it take on average? uh, 48 hours is what i usually tellthe ladies i do biopsies on. norman: and who gives the news? um, it's the team. it's usually, though, to the gpand the gp is key in all the steps.

norman: so the gp breaks the news?- generally, generally. although, because it's an mdt,and a lot of us are involved, we all have to be preparedto talk about the subject. the final results of the biopsyare often given by the gp. but in a diagnosticor screening setting, the women are asking you questions and so you have to be in that teamworkto supply the answers. norman: is that your experience, jenny? exactly. i think women comewell prepared to hear the news.

it would be very surprising for a womanto have undergone an assessment, spoken to lee and the other membersof the team at the assessment centre and not have any ideathat there's a diagnosis of either cancer or dcis coming. so it is, i think, somethingwhere it's a matter of preparation at a number of points along the way. often, it is the general practitionerwho will put the words on it and read the pathology to the patient and actually show them.

but, again,just like we were saying earlier, often, patients aren't listeningto a lot of what you've got to say at that particular visit and it is something where, i think... it's something that you grow intoand grow along, i guess, on a journey. who makes the referral to the surgeon? the general practitioner, particularlywhen we're thinking rurally. so if you live in a town where thereis no breast surgeon down the road, then the decision about where you go

will be one takenin consultation with the patient about where their relatives are,what their capacity to travel is, and what their inclinations are in terms of the sorts of surgerythat they may wish to contemplate. so tell me how you decidewho's going to do the surgery? - what's your criteria in your head?jenny: well, my criteria? my criteria is i have a bookthat was put out a few years ago which actually has a listof accredited breast surgeons and i pull out the bookif they're asking to go somewhere

where i'm not familiar. obviously, you know,within any regional area, you will be well awareof your local breast surgeons, your local surgeonswho do breast surgery, and in consultation with a woman, then they may well go downthose sorts of tracks. what's your advice for gpswho may not see very many women in their careers with breast cancer, how to deal with this,what are the sorts of questions to ask.

if you're feeling anxious about it. i think it's to arm yourselfwith the tools that you might be ableto assist the woman. the nbocc has a great resource that helps in that consultation. - so this is the decision-making aid...?- decision-making tool. we've got a picture. that allows the gpand indeed, the surgeon, to follow a track,giving women their choices? and that becomes an information resource

that the woman can actually movebetween her surgeon and her gp so that she can actually discussthose treatment decisions with her surgeon,once she's had that referral and goes along to the surgeonand they can talk about the tumour size, the tumour type, um, in comparison to breast size, what might be the best typeof surgery for her, whether radiotherapy would be indicated, the indications for a mastectomy

as opposed to conservationof the breast. all of those decision-making toolsare built into that... it allows all the members of the teamto go through that, not just waitingtill the surgeon sees her. you start with the gp and have thatconversation with the gp with that tool. that's the national breast& ovarian cancer centre where they have this decision aid toolwhich you can find on their website and get a hold of one.we had a picture of it. there it is there.

the decision-making aid,available from the nbocc. brendon, what do you thinkthe criteria gps should use, apart from maybe the book? i don't think that book's availablein all jurisdictions. it's in new south wales,not sure it's available in others. what criteria should go throughyour head as a general practitioner about the right surgeon to refer to? well, i think the key elementis really access to good surgical facilities

and that includes goodlocalisation techniques. in other words,the ability to be able to... because, often,these are non-palpable lesions, so they need some form of localisation - either carbon localisationor needle localisation - in order to be able to excise the areacompetently and completely. so that's on the surgical side. also, uh, the access toexcellent pathology services, to excellent specimenradiology services...

norman: how would a gp know that? well, gps, you know,often get a bit of a feel for where these centres arethat can provide these services. norman: if you're a country surgeon, with an interest in breast surgery,how do you...? they would normally have access to that. there's plentyof good country surgeons around that will be able to have accessto these facilities and they'll be able to sendthe pathology to the right places,

to the breast pathologist, to get the... but you want to get a feel, they're hooked into the right networkto be confident. it's not hard surgerybut it's everything that goes around it. that's right.it's the support services predominantly that actually, uh, add to the... norman: this is a team game.- exactly. brendon: yes, exactly. and how to include the gp in that?

it's notoriously hardto bring the gp with you. yes, and it's extremely easy for themto be left out of the loop if communication lapses for any reason. so what breastscreen often does, and it depends on the jurisdiction,that's granted, but, uh... what often happens is a fax goes throughalmost immediately, containing information concerning, uh,the woman's basic history, the radiological findings,

the, uh, pathology that was performedand if there's a result, then the result can be incorporatedin that if it's available immediately, which it sometimes is in some centres,particularly city centres, and also, a surgical assessment as well. now, that may end upbeing a different surgeon that performs the surgery, ultimately,depending on the location and, uh... the general practitioner'spreferences, but if all of that information at leastgoes back to the general practitioner, which is usually the case,

then the general practitioneris fully armed, then, for the woman to come in the door anddiscuss this at a proper community level which is really what's needed. often the woman has been recalled backto the mammographic screening service and it's that that often alertsthe woman to the fact that there's something going on here and that it's being looked atmore intensely. usually, they start asking questionsof the screening services. - right?warwick: yes.

so some information is alreadygoing back to the woman to say, 'listen,i get the feeling that something's...' norman: but you can't leave her hanging. she's got to be supportedall the way through this. this is a very scary time, probably muchscarier not knowing what's going on than actually getting the news. very much so. chris, what's the treatment goal? the treatment goal is, uh... the riskof recurrence in the breast,

both invasive and in situ. norman: so it's preventive.- yep. prevention of further disease, either in situ diseaseor invasive disease. um, what are the chances...? elizabeth from new south wales again. 'what are the chances of womenaged over 70 presenting with dcis?' do we know? brendon: the rate drops down.

about half of the women with dcislie between 50 and 59 years of age. norman: so peri- and post-menopause? yeah, now some of that may flow fromthe fact that screening's predominantly done in that age groupand it tends to drop off after 70. so... the rate of pick-upis probably more a reflection of the rate of mammographic screening. - is that right?- correct. and, uh... so there's a bitof a catch 22 in there, but the relative riskappears to decrease.

and the risk factors are the same?if you see increased breast density, that's a risk factor and so on? - yes.- alcohol... the usual story? yep, that's correct. it mirrors... well, we've spoken about it before -invasive carcinoma comes from dcis, so the risk factors for dcisare the same as for invasive carcinoma. i have a question from the act. 'what's the place of magnetic resonanceimaging?' i mean, with dcis? the, uh... that's a very good question.

it hasn't finally been worked out -it's still a project under development. it was initially thought that mriwas relatively insensitive for dcis, but with today's modern scanners -with the high-resolution scanners and good contrast administration -it's actually very sensitive for dcis. it hasn't, however, come to, uh... ..been yet shownthat routinely doing mri... first of all -i'll backtrack a little bit - it's not a screening tool for dcis... norman:it's for diagnostics or surveillance.

yes. well... yes. no, surveillanceonly in the high-risk women - the bracket ones and bracket twos...norman: they're at risk of dcis? they're at risk of dcisas invasive carcinoma. so, the next questionfor mri scanning is 'should the women have a pre-operativework-up with mri scanning after the diagnosis of dcis?' well, the answer is 'at this stage, no -not on a routine basis'. but perhaps in selected women, perhapsin women who've got widespread dcis...

..um... high-grade dcis,dense breasts, um... ..we've mentionedthe strong family history. so, it's in a selected population but certainly not on a routine basisat this stage. brian bowring, a gp in tasmania, asks, 'what percentage of needle biopsiesare false negatives?' uh... norman: you kindaaddressed it earlier. (brendon speaks indistinctly)

the needle biopsies,we can break it down, iwhether it's fine needle biopsies,and we may be going up to... rather than 'false negatives',we'll say 'inadequate result', and you might be looking at,say, 30% of the cytology. if you're going into the core biopsywhere you're getting histology and even more soif we're using vacuum-assisted biopsies with a much wider core - the false negatives on a good samplingwould be very low, less than 5%. now, the way to make sure we don't acton those false negatives incorrectly

is, as i mentioned before...is by having a good triple assessment. so, how are you gonna treat susan? well, what she needs is... it's a relatively small area -2cm or so - of microcalcification, and so she needscomplete excision of that with an adequate marginof normal breast tissue around - surrounding breast tissueto be sure that we clear... - so, it's effectively a lumpectomy?- effectively, yes. and what sort of radiationwould she have?

the radiotherapy treatmenttargets the, um... surgical cavity and the surrounding breast tissueand the remainder of the breast, so it's breast-only radiotherapy and it doesn't targetthe regional lymph nodes in any way, shape or form. and typically, when we doradiotherapy treatment for dcis, we're talking abouta course of treatment given over a five-week period of time,somewhere between four and six weeks. so, what - 20 to 25...?

chris: 25 treatments on average. norman: how sick does the woman getduring that? what are the side effects? speaking as a maleradiation oncologist, i'll go out on a limb and say...norman: your major caveat to begin with. so, no problem at all.it really is falling off a log. these ladies really don't get sick. um... the targetis largely outside the body, and so they do develop a skin reaction although that's typically mild andit can be characterised by itch or heat,

sometimes redness and uncommonly, moist desquamationin the inframammary fold. there's a low incidenceof the general radiotherapy fatigue, and some loss of axillary hair as well,that's targeted, uh... ..with the tangential fieldthat treads across the breast. and all of those things get betterafter the treatment... norman: including lymphoedema? chris: the late effects -or the uncommon side effects - that are listed on the screen are...really quite rare.

lymphoedema of the arm should not occur afterradiotherapy treatment for dcis. having said that, you can getsome oedema in the breast itself - typically in the regionof the surgical cavity when the breast is irradiated. and the other problems that arelisted there are really quite rare. do you do sentinel node biopsyin women with dcis? - yeah, well, in australia...- you don't know when taking it out - whether anything's invasive.- no. and this is part of the problem.

but the tendency in america is to...for a lot of the groups to do... we should explainwhat sentinel node biopsy is. this is finding the first lymph nodethat the drainage goes to, and if that's negative,you can be pretty sure it's not gone to any of the other nodes. yes, so this is tracing outthis single or a couple of nodes that are most likely to bethe first ports of call of tumour spread if it were to occur -so-called sentinel nodes. and the rate of spread of dcisis around 1-2%,

so, i mean, it's extremely low and the morbidity is not inconsiderableof sentinel node biopsy when you compare the risk of spread,so in general, we don't. however, for widespread dcisthat involves a whole breast for which a mastectomymight be the best choice of treatment, then, um... sentinel node biopsymay well be a useful tool. so, it's still a matter of judgementrather than being evidence-based. yes. and with mastectomy of course,you're virtually making incisions into the axilla,so it's not a large undertaking

whereas for a separate areaof the breast where a complete local excisionwas obtained, you might need to makea separate incision in the axilla, so there may be some morbidityin that respect. lee, what about... - and this isan issue for the general practitioner - ..the post-surgical care of a womanwith early breast cancer? the national breast & ovarian cancercentre has been interested in this area and has done surveys. there's a lot of variation aroundaustralia in how much women get...

that in the private sector, they oftendon't get access to breast care nurses and multidisciplinary, team-based care. just what's....what should you be aiming for here? i think in the context of this womanwho's from a rural area, that means that she might betravelling some hours to a larger centre for her surgery... and i think that it's really importantthat if she has contact with a breast care nursein that larger centre and there's no breast care nursein her area,

means that she's well-equippedbefore she leaves, there's good liaison between the breast care nurseat the treating centre. when it's dischargedto a community nurse... it doesn't have to bea breast care nurse. i was just about to say thatit's ensuring there's good liaison, good communicationwith the community nurses. it's also too... it's almost, like,um... empowering the community nurse, having a breast care nursein a folder on their shelf,

so that there's a number of resourcesthat that community nurse can turn to and particularly the ones that areavailable on the nbocc website are very good resources. jenny, how do you follow upa woman with dcis? what the surveillancein your... ? i think surveillance is oneof the most important parts of it because, as chris has said,the goal of the treatment is to reduce recurrence, and so the big thing will beto keep an eye on this woman

and keep her well connectedin terms of follow-up. i think the recommendations are thatfollow-up occurs at least 12-monthly, and certainly for most womenwho've been diagnosed, they will probably seeksome sort of follow-up within the first six months. and certainly that's the wayi'd be heading them, and then probably 12-monthly after that. and that would involve coming,hopefully, to see me as their gp. i would do a clinical examinationand then send them

for appropriate mammographyand/or ultrasound. norman: chris?- i'd agree with that. we need to remember both thetreated breast and the opposite breast, and that's an important partof both the physical examination and the imaging... so, the woman is at increased riskof contralateral disease? chris: yes. and what's the mammographyregime then, for... i mean, if you had a total mastectomy...

..do you still do mammographyon that breast? what's the story?no, just on the contralateral side, but you don't do it on the chest wallor anything like that. i think it's just importantto mention the rate of... ..the risk of recurrence...not recurrence. ..the risk of future breast cancerin the ipsilateral breast or contralateral breast is four timeshigher than the normal population so that's the importance of the... it's still fairly low, isn't it?

i mean, it's 5% at 5 yearsand roughly 10% at 10 years of invasive cancerdeveloping in the... but that's the reasonfor the annual screening... - that's right.- ..and not the usual recommendation of two-yearly screeningin the general population. these ladies need annual screening. so, it's a higher riskand it's interesting that, you know, 90 to 95% of women over a10-year and 5-year period respectively, are not going to get any recurrence.

- mm.- so, it's fairly safe. given this woman'sgonna have five or six... let's say it wasn't susan,and she had disseminated disease in that breastand you did a mastectomy... we underdo breast reconstructionin australia by a vast proportion, is my understanding of the nationalbreast & ovarian cancer centre survey. brendon: fair comment. yes. but let's assume thatshe's offered that opportunity. what's the story herethat you advise women on

in terms of immediate reconstruction versus delayed, given that she'sgoing to have radiotherapy? chris: she won't have radiotherapyafter a mastectomy. lee: no. norman: so if it's a mistake,the problem's solved? she would be an ideal candidatefor immediate reconstruction, and i'd strongly recommend that. she won't have chemoand so there'll be nothing in the way. brendon: and the risk of her recurrenceis extremely low - it's 1% or less,

so it's extremely low. and the reason for no radiotherapyafter mastectomy is that such little tissue's leftthat you consider the risk low of local recurrence? as has just been said,the rate of recurrence is so low after a mastectomy. and is chemo or hormonal therapyever indicated? chemotherapy is never indicatedfor in situ disease. i think the potential roleof hormonal therapy

is somewhat more controversial. if it's used,it's generally restricted to, um... ..those situations with a high riskof recurrent, contralateral disease, and we do start to get intoshaky ground as to whether... norman: the knowledge base is weak?- yeah. um... and clinical trials... are there many clinical trialsrunning at the moment, recruiting in dcis? 'cause given the standard of care

is not just multidisciplinary,team-based care, it's also being offered the chanceto enter a clinical trial. hard for women sometimesin country areas to do that, but you would want themto have access to the latest therapies. what's the storyin terms of current trials? there are clinical trials ongoing, and brendon might like to commenton some of those trials that are attemptingto better define the group who are managedwith breast conserving surgery

where we might more safelyomit the adjuvant radiotherapy. yes, there's a couple that've closed,and we've got some data back on those, looking at... mainly using tamoxifen,aromatase inhibitors and so on, but there's several that are open,and... part of the problem too, is that there's new inhibitors coming ontothe market all the time, and it takes a fair amount of timeto follow these patients up. so... so, there's about seven trialsavailable around the world, some of which are availablein australia,

and of course, those haven't closed yetand the results aren't in. but they're trying a range of differentaromatase inhibitors and, uh... ..and different serms and so forth,and tamoxifen as well. susan comes back to see you, jenny,she's had her radiation therapy, she believes what she's been toldby professor milross that, you know, the chancesof a cure here are really high, that she's really notgonna get disease back, but she just feels lousy,she feels depressed, that's just been a pretty unpleasantexperience for her, she...

..sexual relations with her husbandare not back to normal, she's just feeling low. the scar is a bit biggerthan she expected on her breast even though it wasbreast conserving surgery. how often do you experiencethat sort of conversation? very often, norman. i would think thatthat would be upwards of the norm. for most women, this isan extremely confronting experience and as i said earlier, for those women,

the difference between invasive cancerand dcis is... ..is a pathological one ratherthan one that they've experienced. norman: because for them, it is cancer.- it is cancer. and from susan's point of view,she's undergone mutilating surgery and she's had her life threatened. so, they're bothvery significant adjustments. now, i think the strange thingis that not every woman reports that, and obviously, women deal with someof these issues in very different ways, but i would certainly try and legitimiseand support those feelings

that susan's having and, um... would you wait for her to come to you or are you more proactivein wanting to see women afterwards? there's a debate either way. youcould force a counselling session on her when she doesn't want itor she's not ready to talk about it, so it sounds good to do a follow-upbut she might not want it. what's the story? what do you do? i make myself available but i don't gochasing women, you know? norman: forcing them to talk.- forcing them to.

and nor expecting themto sort of go through, you know, numbness, angerand sort of a process-oriented way, from what is, as i said,a very traumatic experience. i think... i think, lee... and this is where again,one's not operating in isolation. this person will no doubtbe talking to their family, friends and to their breast care nurse. and this is an experiencewidely held in the community - there are many, many womenin that age group

who are survivors of breast cancer, andthey'll be out there talking to susan. norman: giving 17 differentpieces of advice, no doubt. probably. so, lee, what's the approach here interms of helping a woman through this? is talking enough or... what are the techniques thateither nurses or doctors can employ to help a woman through this time? i think talking isa really good starting point because often the women aren'tgoing to raise these issues themselves

and i guess as a breast nurse, it's about contacting these womenand letting them know that you are actually gonnacontact them on... ..maybe in so many weeks timeand so many weeks time after that. and starting the conversation and thenjust being fairly open with questions and low and behold, you do often geta great discussion about, um... ..the issues that they're facing and thedifficulties that they're experiencing. and i think that realisingthat there is somebody who's actually gonna raise those issues

and validate their feelingsis really, really important, and i think what jenny's sayingis very important. it is about liaison,so it's open communication with all members of the treating team and also too,making sure that there are, um... ..support groups the woman can go tobecause it doesn't matter... in country towns, they are available? they are. there's also chat rooms, there's also online groups,there's telephone groups.

norman: we're showing some ofthe places that people can go in terms of cancer council,nbocc and indeed, the breast cancer network of australia. lee: women, um... to them, it's not'oh, i've gotta find a support group where somebody else has had dcis. i've had a cancer diagnosis and i wanna talk to somebody elsewho's had a cancer diagnosis.' - because they don't differentiate.- no. and what about the poor blokes?

lee: the poor blokes. (chuckles)- you know them? - the ones at home.- those support people. i think that they do it really tough too because, um... they don't knowwhat to do or what to say, you know? and men in general,are fixers and doers, so when you start to talk to women,they may be seen in the community... their male partnersmay be seen in the community as not being terribly supportive, but in actual fact, they're doing thingslike mowing the grass or shopping -

those things that they thinkare actually going to help. but i think again, it's ensuring thatyou're able to talk to both of them and raise issues with both of them...or anything. and sometimes it will slip intofrank depression. oh, certainly, and you need to beon the watch for that and intervene where appropriate. most cancer in men - it occupiesabout 1% of all breast cancers - is more advanced, you know? it should be ableto be diagnosed earlier

but it's not -it generally is more advanced. do you get dcis in men? - yes, of course, i'm sure...norman: but you haven't seen it. it's something that i'm sure goes... brendon: i haven't noticed. i mean,have you ever seen mammograms... chris: i've never seen dcis in men. i was talking about menwithout breast cancer who happen to support a womanwith it, but it's a good point. look, that's beena fascinating discussion

and i've learnt a lot about dcis. i've been asking a few stupid questionstonight, but that's my role. what are your take-home messagesfor those watching? chris milross? that the goal of treatment is...reduction in the risk of recurrence of both in situ and perhaps moreimportantly invasive breast cancer. and that secondly,for patients who elect to be treated with breast conserving surgery that radiotherapy is an importantadjunct to that treatment

that is proven to be beneficialand that is well tolerated. norman: lee? i think effective communicationon all levels - the woman, the family,the treatment team - and i think normalising and validatingtheir feelings and concerns. norman: jenny?- it's definitely a team approach, and the other thing i'd like to sayis that it has to happen over time, so the real importanceof continuing surveillance and support, so that women continueto access mammography

and keep the rates of recurrenceas low as they can possibly be. norman: warwick? i'd like toget back to early detection and encourage womenand encourage the gps to ask their women to involvethemselves in breastscreen. - brendon?- i think it's important to emphasise to the womanthat she really has a cancer that has a very good prognosis overall, that the risk - although it's there -is low

and that she needs regular follow-upand regular mammograms and surveillance. also, that if it were to come back, then the overall picture is better thanfor the average cancer, that the rate... - it's almost like a first diagnosis...- yeah, the rate of nodes being positive is only about a third,so two thirds of the cases are going to have negative nodes which puts them ina better prognostic group as well. so, you know, it's not hopeless -that's the message -

and it's very importantto get that through to the woman, at the same time, not to discount itbecause they go through all the trauma that a woman with an invasivebreast cancer goes through, quite often. thank you all very much indeed. i hope you got a lotfrom this program on dcis. our thanks to the national breast& ovarian cancer centre for making the program possible,but thanks to you for taking the time to attend and contributeand ask so many questions. if you're interested inobtaining more information about

the issues or resourceswe've talked about, there are a number availableon the nbocc website, nbocc.org.au. don't forget that decision tool. the rural health education foundationwebsite as well - rhef.com.au. don't forget to completeand send in your evaluation forms to register for cpd points. i'm norman swanand i'll see you next time. captions bycaptioning & subtitling international funded by the australian governmentdepartment of families, housing,

community servicesand indigenous affairs�