How can I treat breast pain?

A comfortable support bra may provide relief. There may be particular stimuli for pain to avoid, such as caffeine or chocolate. Evening primrose oil, a natural source of gamolenic acid (GLA), can reduce pain and nodularity (dose of 300 mg daily). If that fails, there are other drugs that can be used, but they tend to have significant side effects, and are held in reserve.

Do breast cysts increase my chance of breast cancer?

The cancer risk associated with benign breast disease is in general very low. There appears to be a slightly increased risk (1.5 – 2 the general population risk) in women with a history of fibrocystic breast disease. If the diagnosis of atypical epithelial hyperplasia has been made, the risk is higher (4 – 5), increasing still further if there is also a family history (up to 9 the risk). Cystic breast disease alone is not an indication for routine mammographic screening, outside of the National Breast Screening Programme.

I have completed my treatment for cancer  –  am I cured?

Everything has been done at this time to prevent the cancer coming back. However, despite this, there is a chance of the cancer returning. The probability of this depends on the characteristics of your cancer. There is no test that can be done at this time to say that all the abnormal cancer cells have gone and that you have been cured. Two-thirds of all recurrences occur within the first 5 years after treatment. Thereafter, the probability of recurrence decreases exponentially with time, although late recurrences may still occur. It is important to have initial yearly imaging with mammograms following treatment, looking for local recurrence or problems in the other breast. Alternative imaging techniques may be used for certain clinical indications. Whole body scans or bone scans have no role in breast cancer follow-up, unless there are particular symptoms requiring further investigation.

I had breast cancer when I was 50 years of age. Is my daughter at increased risk?

Only a very small number (5 – 10%) of all breast cancers are associated with an identifiable genetic abnormality. It is important to obtain an accurate family history, not only of breast cancer but also of ovarian cancer and other epithelial malignancies such as prostate and bowel cancer in male family members. If there is no other family history, then the lifetime risk of your daughter having breast cancer will be no different to the general population. Your daughter should be “breast aware”, and enter the National Breast Screening Programme at an appropriate age. If there is a strong family history, then you should be referred to a family history clinic/genetic clinic for further assessment, counselling, and the opportunity to take part in screening or prevention studies.

I have a strong family history of breast cancer, can I prevent breast cancer?

The NSABP-P1 prevention study (13 388 women) randomized women at high risk of developing breast cancer into receiving tamoxifen or not. The study was halted early due to a 45% reduction in the incidence of breast cancer in the tamoxifen arm (85 cases in the tamoxifen arm versus 154 cases in the placebo arm) and the FDA has approved tamoxifen for prevention. However, there was also a significant incidence of toxic side effects of tamoxifen such as endometrial carcinoma (33 in tamoxifen group, 14 in placebo) and thromboembolic complications (17 cases of pulmonary embolism, 6 in the placebo), in addition to quality of life issues. The majority of side effects occurred in patients more than 50 years old, who also experience the most benefit. A British and Italian study of women at high risk (mainly due to family history rather than age) failed to demonstrate significant reduction in breast cancer incidence with tamoxifen. There is evidence that women at increased risk due to genetic mutation are less likely to benefit from tamoxifen because their tumours are more likely to be hormone insensitive. For some women it is an alternative to prophylactic mastectomy or a watch and wait policy, but the jury is still out as to the overall benefit. The use of tamoxifen should be an individual decision, balancing probability of benefit and potential side effects of treatment.

Does tamoxifen cause me to go into the menopause?

Menopausal symptoms may occur during the treatment for breast cancer and can be due to a variety of factors:

  • You may have reached the menopause naturally at about the same time as you developed breast cancer.
  • You may have stopped taking hormone replacement therapy at the time of diagnosis, bringing on the symptoms.
  • Chemotherapy treatment may cause your ovaries to stop working, causing an early menopause. Sometimes the ovaries start working again, depending on your age and other factors.
  • Tamoxifen can cause similar symptoms to the menopause, such as hot flushes and night sweats. It does not cause the menopause to occur  –  indeed, tamoxifen was developed initially as a fertility agent.

Will I still be able to have a successful pregnancy following chemotherapy?

It is possible to have a successful pregnancy following chemotherapy. However, chemotherapy does affect ovarian function and may cause permanent ovarian failure and early menopause. The older you are, the more likely this is to occur, and infertility may be a consequence of treatment. Once chemotherapy has started, periods may stop or be irregular. It may be possible to become pregnant, even if experiencing menopausal symptoms. Therefore it is important to continue using contraception, particularly as chemotherapy agents could damage the fetus. It is best to avoid pregnancy for a period of time (2 years usually recommended) following treatment. The oral contraceptive pill is typically avoided. Periods may still return many months following breast cancer treatment. Ovarian storage is highly experimental, and there is no evidence that it can overcome ovarian failure and result in successful pregnancy.

What are the side effects of early menopause?

Menopause causes a reduction in oestrogen levels, which can in the long term have adverse effects on bone density and cholesterol control. Tamoxifen slows bone loss in postmenopausal women, and other drugs may be used to reduce the risk of osteoporosis. A bone density study should be performed to assess baseline bone characteristics and family history should also be taken into account. Weight-bearing exercise such as walking can help prevent bone loss. Other drugs, for example, the selective oestrogen receptor modulators (e.g. raloxifene), may have a role in preventing osteoporosis, if you are not on tamoxifen. hormone replacement therapy prevents the long-term complications of early menopause, but is not recommended routinely in breast cancer patients.

Can I use hormone replacement therapy for my menopausal symptoms, if I have had breast cancer?

Because breast cancer is, in the majority of cases, a hormone-sensitive disease, the administration of hormone replacement therapy for the relief of menopausal symptoms and prevention of other medical complications of menopause, such as osteoporosis, is controversial. In general, hormone replacement therapy is not recommended. However, for some women, the magnitude of their symptoms is such that they are willing to accept a possible increase in breast cancer recurrence for the potential benefits of the treatment. It may also be that the risk is not increased in hormone-negative tumours. There are recent non-randomized studies that have shown hormone replacement therapy can be used without adverse effects on breast cancer recurrence rates. hormone replacement therapy may be prescribed, if the patient is fully aware that complete data are still outstanding as to the risk – benefit ratio. Randomized controlled trials addressing these questions are underway and hope to give us more information as to whether it is safe to prescribe hormone replacement therapy to breast cancer patients.

What can I do about hot flushes on tamoxifen?

The majority of women experience hot flushes on treatment, which can be very debilitating. Sometimes changing the brand of tamoxifen can help or taking 10 mg twice daily. A variety of agents have been used to treat these symptoms in clinical trials. Vitamin E (800 IU/day) is a reasonable first-line therapy, as it is safe and inexpensive, with demonstrated benefit. Clonidine has traditionally been used, but is generally not well tolerated. Venlafaxine (37.5 mg/day), one of the new antidepressants, has been shown in clinical trials to alleviate hot flushes in about 40% of patients (compared with 27% in placebo). Finally, a progestational agent such as megestrol acetate can be used (40 mg/day for one month, decreasing to 20 mg/day thereafter). Traditional hormone replacement therapy is the most effective treatment, but there remains concern over its use following breast cancer (see above).

Can I take complementary medicine with my treatment?

Women who have tried complementary approaches have found them helpful, although in most cases there is no evidence from clinical trials that they work. It is important to go to a recognized, qualified practitioner for advice if you wish to do this. Complementary therapies such as aromatherapy, relaxation therapy, and acupuncture may help with coping with chemotherapy or menopausal symptoms. There is little clinical evidence for homeopathy or traditional Chinese medicines, although there are anecdotal reports of their use in controlling menopausal symptoms. It is important to tell your specialist if you are taking additional herbal remedies, in case there may be a recognized interaction with the treatment you are having.

I have completed my treatment  –  what follow-up will I have following treatment and how do I know my cancer hasn’t come back?

Follow-up will depend on the local services, and there is no clear follow-up strategy that is “the best”. It is increasingly recognized that many hospital visits can increase anxiety regarding the diagnosis, and regular follow-up does not appear to affect overall survival if a recurrence does occur. Some centres will see you regularly following treatment for a period of time. It is important to have regular mammographic follow-up, to detect local problems within the treated breast or contralateral breast problems. Sometimes the general practitioner will see you on a regular basis, or you will be given written information as to symptoms or signs that you should see your general practitioner or specialist about.

The initial period following completion of treatment can often be a difficult time, as the “active treatment” is over with. It is often the time to adjust to having had a potentially life-threatening illness, with no guarantees possible as to the future outcome. It is important to talk about these fears and anxieties, either to your breast care nurse, general practitioner, self-help groups, or others who support you.

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