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Science
RADIO 4 SCIENCE TRANSCRIPTS
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CHECK UP
Thursday 19 August 2004 3.00-3.30pm
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BRITISH BROADCASTING CORPORATION  

RADIO SCIENCE UNIT 

CHECK UP - No. 3 - Benign Breast Disease  

RADIO 4 

THURSDAY 19/08/04 1500-1530 

PRESENTER:
BARBARA MYERS 


CONTRIBUTORS:
ROB CARPENTER 


PRODUCER:
ELISABETH TUOHY
   

 
NOT CHECKED AS BROADCAST


MYERS
Hello. Lumpy painful breasts used to be diagnosed as fibrocystic disease but these symptoms are so common that they're probably better described as a normal, if rather unfortunate, part of the menstrual cycle for many women. Which is not to say that you have to put up with the discomfort and you should never ignore new or suspicious lumps - they could be cancerous. But how do you know the difference? Does breast self-examination help? When should you get your breasts checked out by a doctor? And what sort of treatments are available, even when the lumps turn out to be harmless? 

If this is something that affects you and you've found a good treatment, for example, let us know. If you're still struggling then call us now with your questions and put them to our breast specialist. The number to ring - 08700 100 444. You can e-mail of course, that's checkup@bbc.co.uk. And joining me in the studio is Rob Carpenter, he's a breast specialist at Bart's and the London Hospital. 

Rob, just how lumpy can lumpy be in some women's breasts? 

CARPENTER
Well they can be very lumpy Barbara and the truth is that sometimes it's very difficult to tell the difference between a lumpy area in one part of the breast and a true breast lump. In some women this is a particular problem and for sure if I have difficulty telling the difference between a lumpy area in one part of the breast and a true lump I wouldn't expect my patients to be able to tell the difference either. 

MYERS
Well let's see what questions we get from our callers about their lumps and bumps. Samantha is on the line now, she's in Brighton, Samantha your question please for Rob Carpenter. 

SAMANTHA
Yes, is there an increased risk of developing cancer if you have a tendency for cysts and should I go for a check up every time I find one? 

MYERS
Okay, so you've got these breast cysts have you? 

SAMANTHA
Yes, I've been getting them since I was a teenager. 

MYERS
Okay and just help us understand - we've been talking lumps, you call them cysts, what do they feel or look like to you? 

SAMANTHA
Well they don't look like anything, I can't actually see anything on the surface but you can feel them underneath the skin and they're quite tender and painful. 

MYERS
And they've been diagnosed as cysts have they? 

SAMANTHA
Yes.

MYERS
Okay, does that mean that they've got liquid in them? 

SAMANTHA
I believe so, yes. 

MYERS
Okay and the concern though is if you have them is there a relationship with developing cancer, which must be a worry I guess. 

SAMANTHA
Yeah very worrying yeah. 

MYERS
Rob, help us with this - is there any connection between cysts and cancer? 

CARPENTER
Okay, well I think the simple answer to that Barbara is no. Very, very rarely are cysts a precursor or a prelude to cancer. Of course breast cancer is common in this country, one in nine women in their lifetime will develop breast cancer and cysts are very common also, particularly in the 40-50 year old age group. And so not surprisingly cysts and breast cancer can co-exist. But I think to all intents and purposes cysts don't become breast cancer. Nevertheless, cysts present as a lump in the breast, just like breast cancer presents as a lump in the breast. A cyst actually is a fluid filled lump whereas a breast cancer is a solid lump, if you like. 

MYERS
Well the fact that Samantha knows she's got cysts does that mean that she can afford to sort of live with that and know that any of these lumps are also cysts - I mean that's also the concern you were expressing - I mean how would you know then whether a new lump is actually just another cyst or could be the start of a cancerous growth? 

CARPENTER
Well this is an important point and Samantha in the past has been investigated and she's confident she has cysts and effectively what that means is she will have had a mammogram or probably an ultrasound as well and a fine needle will have been put into the cyst and all of the fluid aspirated so that when she left the clinic, for example, there won't be any lumps in the breast. And Samantha if you develop another lump you should treat it exactly as you treated the first lump. It's likely to be a cyst but we can't be sure of that until you've had the relevant tests. Often if the second lump comes up quite quickly after the first cyst has been diagnosed that will just be to put another fine needle in and aspirate the fluid, if it's after, say, a period of nine months or a year then more mammograms or ultrasounds will be necessary. So whilst any lump, Samantha, that you develop in the future is likely to be a cyst you really can't be sure, if you're sure that you have a breast lump then I would recommend that you have it investigated properly every time. 

MYERS
So is that helpful for you, I mean obviously you know quite a bit about the state of your breasts if you've had this for a length of time, are you comfortable with the situation that you find yourself in? 

SAMANTHA
Well I just find that I've become increasingly complacent about them, I find another lump and think oh it's just another lump, so I don't really want to go through the procedure again but I do know that I really should go and get it checked again. 

MYERS
And this procedure, as Rob was talking about, having them aspirated with a fine needle is that quite an uncomfortable procedure? 

SAMANTHA
Yes it's very painful, yeah. 

MYERS
So obviously you would want to avoid that if possible. So there's some reassurance that there's no necessary connection between being - having cystic breasts and the possibility of cancer but nonetheless not to be complacent. 

CARPENTER
Absolutely and I'm sorry you've found it a painful exercise Samantha because most often it isn't or just associated with a little bit of discomfit. Perhaps next time you might ask, whoever's doing this for you, to use a little bit of local anaesthetic and it might not be as off-putting for you. 

MYERS
Okay, we'll move on to another caller if we may but thank you very much for that. Well in fact I'd like to mention an e-mail I've had from Jody in Cardiff and she tells us that she's 26 with a strong family history of breast cancer but, she says, I suffer from very sore breasts just before her period, in fact they get bigger by a whole cup size, and that's exacerbated by exercise and so she's asking, very directly, is there anything she can do to relieve the pain - that's the first thing - and again, is there any link between her breast condition, the change in their size, and the dreaded breast cancer? So first, anything she can do to relieve the pain of the swollen breasts? 

CARPENTER
This is quite a difficult area and quite often the thing that most concerns my patients is that the pain might be associated with underlying breast cancer and most often it isn't. The sort of pain that's Jody's talking about is called cyclical pain and we differentiate that from non-cyclical pain, so if the pain is there for the week leading up to the period and then it gets a little bit better afterwards that's almost certainly related to the hormonal changes that occur during normal periods, during normal cycles. If the pain is quite separate from that, if it just occurs at any time and often it's worse with pressure, for example, on the breast, it's almost always under those circumstances due to a muscular skeletal cause - mild arthritis in the ribs or something like this. So it's important to differentiate the two. It does sound as if Jody's is related to her cycle. Traditionally gentle drugs like evening primrose oil have been used and some people think that this brings about relief from the discomfort. If it happens, if the relief occurs, it's usually only after continuous use and only after about two or three cycles. Having said, and if I sound sceptical I may well be here, because there's no real evidence that's been disclosed to support the use of evening primrose oil. Having said this it is a very gentle treatment, there are virtually no, if any, side effects. 

MYERS
Is there any evidence then for using perhaps other vitamins or any kind of ointments or anything that you could put on - apply topically to help with the discomfort? 

CARPENTER
Nothing that I know. 

MYERS
Let's see if our callers might have some suggestions, it is always very interesting to see what people have to say actually works for them but I hear what you're saying - there isn't really much in the literature to prove or disprove any of this supplements. 

CARPENTER
No indeed. And obviously this sort of pain stops at the menopause when the cycles stop. You can use drugs that modify the cycle or stop the cycle, which will stop the pain, but I've never actually found a patient who would want that. There are other drugs that can help but have quite distressing side effects. Masculinising, if you like, or [indistinct word] side effects. And again I find most of my patients really don't want that and after a reasonable explanation about what's happening and having the tests and reassurance from me that this isn't breast cancer I find most of my patients are prepared to simply see how things go. 

MYERS
And you are saying then that we're talking about these cysts and lumps that come up cyclically - perhaps you feel it more during the run up to your period - then it's a hormonal influence that we're describing is it? 

CARPENTER
It's a little bit more complicated than that Barbara, probably it's not the fact that different levels of hormones are being secreted by the ovaries but rather that the cells in the breast have a different response with age or different times in the cycle to the hormones that are being secreted. There's usually no underlying endocrine disturbance but for some reason the receptiveness of the breast or their ability to change to respond to the hormone changes in different parts of the breast and different times in life. 

MYERS
And you can - yes - you can expect some respite after the menopause, which must be one consolation. 

CARPENTER
You can't have cyclical pain after the menopause unless you're taking a cyclical form of HRT. 

MYERS
Lets go back to the calls and we've got Juliet Fleming who's in Cambridgeshire, hello Juliet your question please. 

FLEMING
My mother died of breast cancer in her mid-40s and I'm now 44 and would be very glad to have a mammogram but I'm still breast-feeding my son, who's currently three and a half, and my breasts are not as they were when I was first breast-feeding - I can go for days without breast feeding him - but I do occasionally breast-feed. Two organisations I called to have breast screening - mammogram - done advised me that it couldn't be done while still breast feeding and I was just wondering whether that is indeed the case and whether it takes into account women such as myself who breast-feed over many years - are we really precluded from having mammograms? 

MYERS
Rob. 

CARPENTER
I think you're bringing up several very interesting points there Juliet. The first thing to say is that having a mammogram under the age of 50 isn't an absolute safe way of excluding breast cancer. The area is really full of controversy and there are trials running for women, just like yourself, who are at higher risk of developing breast cancer because of their family history to see if mammograms in fact are going to be effective under the age of 40. So the first thing is there's no absolute need for you to have a mammogram. The second thing to say is that I would also advise you not to have a mammogram while you're breast-feeding and that's because the breasts are very different while they're producing milk from when they're, what we call, involutional, which is the period after you stop breast-feeding, and it'll take about six months really for the tissue that's producing milk in your breast to regress back to the way you were before you were pregnant. So my advice would be to avoid a mammogram until you've stopped breast-feeding for about six months really. Although I'd also say that before simply having a mammogram I'd discuss it a little bit more fully with a breast expert just to see - so that you understand what the pros and cons are and also that you understand that if the mammogram's negative it doesn't mean it's an absolute surety that there's no problem. 

MYERS
Does that help Juliet? 

FLEMING
Yes thank you. 

MYERS
Thank you very much. I guess Juliet at least is doing the right thing by breast-feeding, is it the case that that is protective against the development of breast cancer or is that a bit simplistic? 

CARPENTER
Well overall yes if you look at it. But to get the most out of the protection in fact you have to be very young when you breast-feed and that means actually probably in the early 20s or even before 20. And in fact breast-feeding later on and unfortunately that means closer to my age is associated with a slightly higher risk. But overall breast-feeding is protective, not many women in our country would breast-feed before the age of 20 of course to get the maximum benefit. 

MYERS
And we talked of course there about mammograms, I mean are there any other useful tests that if you are worried, at whatever age, particularly if there is a familial history of breast cancer, I mean is there anything else that you could be looking at? 

CARPENTER
Well there are two other imaging modalities if you like. Ultrasound is one, which has never been shown to be particularly useful to screen breasts, it's very useful if there's a lump you can focus it on but in terms of just screening all parts of the breast it's never been shown to be very useful. And MRI scanning - magnetic resonance imaging scanning - is being looked at experimentally in clinical trials to see if this is going to be useful in younger women, particularly those with a strong family history. It's unlikely it'll ever be used to screen the population though because it's quite an uncomfortable procedure to go through, it takes up to an hour and therefore it's not going to ever be practical. 

MYERS
So then you come back, I suppose, to breast self-awareness, perhaps breast self-examination and there's a bit of a debate about whether that's very useful in picking up lumps. I mean would you advise women to keep a check on their own breasts and the development of any possible lumps? 

CARPENTER
Yes I would and I think there's a difference here between sort of scientific controversy, in other words has breast self-examination ever been shown to provide you with a benefit should you develop a breast cancer, that's one argument where there's controversy. But really I'd advise women to be breast aware, in other words not to obsessionally examine on a weekly basis but perhaps on a monthly basis, maybe two weeks after the last period when the breasts usually are least lumpy, to just be aware of how the breasts look and feel so that should there be any changes you'll pick them up early and get a specialist referral. 

MYERS
And not just women, we've got John on the line next who has found something on examination, John tell us about your experience then. 

JOHN
Hello. 

MYERS
Hello John. 

JOHN
Hi, I'm 46 and about four months ago I noticed a pain in my right breast and over the four months I developed a lump under my right nipple and the nipple started to retract. So I went to the doctor's and I got the ultrasound and the mammogram and basically was told that it's normal breast tissue and they're waiting to discover why the growth should occur. And I just wonder if there's any ideas that you might come up with that might cause this breast growth in a man - sort of middle aged man. 

MYERS
So you've been given reassurance but nonetheless you'd like to know why you've got this. 

JOHN
Yes, I was told by the doctor there's nothing to worry about, there's no - she said there's nothing to worry about, there's no hard lumps or bumps, it's just breast growth. 

MYERS
Okay, so if John had turned up in your breast clinic then, Rob, you would have been - you would have been able to reassure him as well? 

CARPENTER
I hope so. I think it's important to remember that whilst most usually if a man gets a breast swelling it's a condition called gynaecomastia, which is a generalised swelling of the breast. Men can also get breast lumps, just like women, and men can also get breast cancer, although usually very rarely. And so in examining John I would have first of all found if there might be any risk, for example, of why he might develop breasts and that could be related, for example, to some drugs that people take. Amongst other things he'd get a general exam as well as a very specific exam of the breast and I'd be trying to find out whether this was a generalised swelling or a definite lump. We use exactly the same tests for men as for women and so a mammogram and an ultrasound would be usual. And if there was a lump then we would take some cells to look at under the microscope as well. It sounds as if John's problem is a generalised swelling and if that's the case I would very firmly have reassured him and it's interesting that his concern persists. Is there anything special that worries you at the moment? 

JOHN
It's just still a little bit painful... 

CARPENTER
Okay. 

JOHN
... it's under the nipple, the nipple's a little bit sore. 

CARPENTER
Okay. Has anybody discussed with you the fact that this might just disappear, that the swelling might go away of its own accord, or perhaps even offered you some surgery to get rid of it if it's causing you a particular problem? 

JOHN
Not at the moment, I mean I went to the - had the mammogram two weeks ago and they're going to contact me again to - for a further consultation. 

CARPENTER
Okay, well I think you would like to know whether this discomfit's in some way going to be relieved and how that might occur. 

MYERS
I guess, tell us whether there is any real relationship between pain, whether it's in a man's breast or a woman's, and the possibility of something nasty going on - my understanding is almost an inverse relationship - the more painful it is the less likely it is to be sinister - is that true? 

CARPENTER
Well it's my experience as well. Breast cancer is usually very unlikely to present itself as pain and the converse, I suppose, is that breast pain is very common. So I wouldn't be deterred though if I found a breast lump that wasn't painful, if I knew that was a breast lump I would go along and see my GP immediately. The fact it wasn't painful wouldn't stop me. 

MYERS
Alright, thank you very much John and now to Anne, she's in Hampshire, and your question please. 

ANNE
About five months ago I got an inverted nipple and I've been and had a mammogram done and then I had a fast check, had ultrasound and saw the doctor and he said oh it was milk duct but I'm still quite worried about this inverted nipple - it pops in and pops out. At the moment I've got really like a dull ache under the arm and down the arm and I feel a bit concerned really, should I go and have another mammogram done or what? 

MYERS
Right, okay well you've got an expert here to ask those questions to, so Rob what would you say? 

CARPENTER
Okay, well just a few clarifying points first of all. The nipple's changed shape? 

ANNE
No it hasn't changed shape, it has a line across it when it dips in. 

CARPENTER
Right, will that come out? 

ANNE
Yes it comes out. 

CARPENTER
Okay, well it's highly unlikely to be a major problem then in that case. We always say that if the nipple changes shape it could be a sign of breast cancer but that's usually a permanent change of shape, so if that little slit comes out when you manipulate the area then it's highly unlikely to be due to a problem underneath. But was there a nipple discharge as well did you say? 

ANNE
No I've not had nipple discharge but I do have a supernumerary which does discharge and it's discharged ever since I've had children. 

MYERS
Is that a spare nipple? 

ANNE
It is. 

MYERS
Right, okay. And has that also gone inverted? 

ANNE
No, no that's just normal. 

CARPENTER
Okay well this is known, it's not surprising really that if you can develop an extra nipple it's not surprising that there'll be some normal breast tissue underneath it sometimes and that's going to be stimulated just like in normal breasts should you be pregnant. The answer is really does this bother - the question is does it bother you? 

ANNE
No it doesn't bother me at all but I'm just worried about this nipple kind of dips in and dips out or should I just forget it? 

CARPENTER
Really I'd keep an eye on it but I wouldn't be too worried if it corrects itself. The nipple inversion or the nipple change that we worry about is one that is new, it wasn't there before, and it's permanent, it doesn't ... 

ANNE
Doesn't come out. 

CARPENTER
Ah ha. 

ANNE
Right, okay, fine, thanks very much that's really reassuring. 

MYERS
Well that's what we're here to try and offer reassurance where it's appropriate and it sounds as though you're okay with that - the case of the disappearing nipple, inverting nipple. Okay we'll go to another Anne, if we may, this time she's waiting to speak to us in Oxford. Hello Anne and your question please. Are you with us Anne? Not for the minute. Let me then mention an e-mail because we have one from Sarah who says she has a right breast which feels heavier and more sensitive than the left. Her doctor has examined her, he suggests that because there are no lumps that perhaps the breasts have always been lopsided, to put it like that, different in size and she hasn't noticed before. But she thinks that actually her breasts might have changed. So yes feeling a little bit heavy on one side and feeling this has happened relatively recently - she's 32 years old. Any ideas Rob? 

CARPENTER
Well breasts are asymmetrical usually, so Sarah's GP's quite right. 

MYERS
So it's generally true is it - most people would have one a little bit heavier than the other? 

CARPENTER
Oh yes and sometimes it can be quite significant and quite obvious, most usually it isn't. The - I think the important thing here is whether - and Sarah's suggesting this in the e-mail - that it's happened quite recently, so there's been a change, as opposed to something that you've always had obviously. So I'd suggest that it probably would be sensible for Sarah to be seen at her breast unit. 

MYERS
So this is where she'd move on from the doctor's examination - competent though I'm sure it was - and actually seek a second opinion in a specialist clinic? 

CARPENTER
Well it wouldn't be a second opinion as such, I mean the GP would refer in for a specialist opinion - that would be the first specialist opinion, as opposed to the GP's opinion. Just very rarely instead of breast cancer presenting as a lump it can present as a sort of a diffuse enlargement of the breast. Now Sarah's in an age, in her early 30s, where it's very unlikely to be breast cancer but nonetheless if it's changed recently and become large recently I think it would be sensible to go along to the unit. 

MYERS
Is age quite important when you are dealing in the round with a patient who might come through to a specialist clinic, that whatever you might feel or indeed what other diagnostic tests you might run there is a sense in which a lot of this is age related - the younger you are the less likely it is to be breast cancer, for example, if there is a lump that you might feel? 

CARPENTER
Yeah and this is very important, under the age of 30, for example, it's highly unlikely that a breast lump's going to be breast cancer but over the age of 70 it most always is breast cancer and it's as related to age as that. Of course in between you have a mixture of women who have benign and malignant breast lumps but age is crucially important. 

MYERS
Okay thank you very much and we'll take, I think, what is a final e-mail, I think it's an e-mail. A 16 year old boy who had lumps in each breast for a year and is now going to see a specialist, how worried should he and his mother be? So that's - give us a 30 second answer on that one if you will Rob. 

CARPENTER
Well at 16 and with both breasts enlarged it's likely to be a pubertal normal development and as long as there are no underlying causes for this, which could be found in a simple check up, then it's highly likely this will settle with time. Embarrassing as it is my advice would be to simply wait and see how things go on. 

MYERS
Okay we leave it at that, our time is out, I'm sorry we had to leave in Anne in Oxford waiting on the line there, along with Denise and Kathy and various other people but my thanks very much to all who rang in today and e-mailed and in particular my thanks to Rob Carpenter from Bart's and the London. More information can be had on our free and confidential help line - 0800 044 044. And you can go on to the website of course and follow the trail to Check Up. And next week we're dealing with travel health. 

ENDS


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