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um, thank you. The most common age of breast cancer would be between 50 and 60 years. Uh, and that's somewhat of a anomaly. Now we know that death rates from breast cancer are reducing over the age of 50 but the incidence is increasing in all age groups, particularly in the latter half of the 20th century. So why is that? We know that if you look across the world, the areas in which breast cancer is the most reduced would be in Africa, Asia and the middle part of the world, where, as in the Netherlands, the States and Northwest Times, which is where we are, we have the highest risk of breast cancer in the world. If you move from one country to another, um, the that movement facilitates a change in breast cancer risk because of lifestyle modification, so that in two generations we would see a change. Um, now, if if you take a population, for example, um, Ethiopian Jews were airlifted to Israel and Operation Moses and um, this was in the nineties, we would expect within two generations of they're arriving in Israel that they would have an increased risk of breast cancer because of their change in lifestyle before they left, they would be nomadic, have large families, be breastfeeding. We're going to look at all of that when we think about breast cancer Risk. If you're looking at the age at which you are exposed to estrogen, obviously from the menarche, when you start having periods to your menopause, when you stop having periods and when you look at the age of monarchy in the UK that's been reducing over the 21st century, so it's now around 12 or 13, although it can be perfectly normal to start having periods at 16 or 17, Um, and in China that age would still be 16 or 17 years. And that's probably to do with good nutrition. If a person conceives that pregnancy will reduce their individual risk, whatever that is of breast cancer by about 25% and the more babies one has, the more the risk is reduced. Now. I'm not advocating that everyone has to have five babies because risk would have reduced by 50%. Um, but what I'm saying is that in current modern society, where families tend to be smaller with better nutrition, with immunization um, good water supply, then pregnancy is not as protective as it was the age at which one has the first pregnancy really matters. So, um, if you go through medical school and you come out at the other end and maybe you start working in your jobs and you do a PhD, you're coming out when you're 30. And if you defer having your first pregnancy, Um, from the age of 22/35 whatever your risk of breast cancer is, that's increased by 30%. I'm not advocating that everyone has to get pregnant. What I'm saying is that if you are weighing up your risks, where do you sit with that? And for each year that you delay, then the risk of breast cancer increases by 3%. We know that, as I've said, the risks which are pertaining to breast cancer are late menopause now, early monarchy, limited duration of breastfeeding, fewer Children, um, and and all of those things impact on breast cancer risk. Um, what I'm going to do now is talk about wet nurses. So these were women who, um, in the Middle Ages in Britain. If if you had a baby and your next door neighbor had a baby. And perhaps you, uh your baby died after childbirth, either from sepsis or bleeding. And your next door neighbor died herself. From those two things, you might take that baby, and you might feed it. And for each year, that a woman's breast Hello? For each that a woman, breastfeeds. Um then, um, their risk is reduced. Produced by 4%. Now, the average maternity leave up until recently in our country was about six months. Um and so, um, you know, we're trying to lengthen that, um, and certainly when I was a school medical officer, we would have teachers coming into express milk. Leave that for whoever was looking after their child. So although you might not physically be in the room feeding your baby, that reduces your individual breast cancer risk. Now, obviously, breast feeding is not just about reducing breast cancer risk for the mother. It's also about the benefits to the baby. And I'm sure all of you know that within the breast milk, there is protection against all of the infections that the mother has had apart from chicken pox, including coated. Um, so that with exposure. Um, there are antibodies in the milk which would help and also protective against gastroenteritis. Breastfeeding also prevents, um, to a large extent cot death. So these are sudden deaths in the first year of the baby's life. Nothing to do with misadventure or infection. Baby just dies of no reason. And if one is breastfeeding, then that is hugely helpful. Additionally, Um, when one is breastfeeding, the feed tends to take a long time, and that length of time means that there's focus on the baby both from the mother and also from other members of the family. The baby's awake for much longer, and we know intellectually that that has huge benefit to babies who are breastfed. At some point, um, women are going to be asked if they would like some hormones. Okay, so this could be as contraception. It could be, um, to improve. Their polycystic over is it could be to help with their heavy periods and menorrhagia. And we need to have a conversation about that because if you give the combined pills that we're talking here about an estrogen and progesterone containing pill, um, if you give that pill for two years. There's a slightly increased risk of breast cancer now in young women. Um, at the age of 20 to 30 the risk of breast cancer is about one in 1000. So if you're slightly increasing that risk, then okay, that's that's slight. But if you give the pill the combined pill for four years, it is protective against ovarian cancer during that time and for the following 15 years. And we're going to see a group of people for whom that is incredibly important. If cancers arise, um, and women are taking the combined pill. They tend to be less advanced and because generally we're teaching those women how to, uh, examine themselves and and we're seeing them and checking them regularly. Um, I think it's really important when you're counseling somebody about contraception or hormones that this is explained, particularly in the context of family history, which will come on two. But I think it's really important that whatever you're offering that person and that you're offering it to them, um, with all of the medical situation of that person taken into account, so whatever their clinical needs are plus family history, plus, um, their their risk we're going to talk a little bit now about weight. Now, I said to you that breast cancer is predominantly in the 50 to 60 year old age group. So why would that be when what I've been talking about up until now is estrogen? Now we know that if women are obese after the menopause, then that fatty tissue is converted to estrogen and that has a stimulatory effect both on the breast tissue and also on the uterus. Um, such that you can develop, you're trying and also, uh, also breast cancers. And so what one would aim for is to not carry too much weight. Um, the video that I would now play is actually a video of Liverpool Street station with a flash mob dance. And, um, when we go into schools and universities, it's terribly common. That exercise during their program is not something that they want to take up. And what we're advocating is that there should be three hours of vigorous exercise does during the week, which has a massive 30% reduction in their individual risk. Now, if you were just walking to and from your place of study or work for half an hour each day. You've probably done that amount of exercise rather than taking any transport. But I think that at an age where people are starting to plan their own lives and taking responsibility for what they're doing, I think it's really key to build in some form of exercise that's preferable to them, which will be beneficial in reducing breast cancer and other cancer risks. So three hours a week is key. Um, we're showing a picture of a man in this series because alcohol is an issue. Now if a woman drinks any alcohol, it's an age where people are going off to university, planning their lives for them so Selves. And we know that at that age from our studies, about 10% already binge drinking in the week. We know that for each unit that a woman regularly consume, so every day a unit would be a glass of wine or half a pint of beer that increases their breast cancer risk, whatever that is, by 7%. So we would suggest booze or bust. We would suggest alcohol is not the way to go. We know it's going to happen in a student population, but we're trying to avoid that. Um, obviously, um, smoking is something that we would talk about in relation to cancer, but it's not related to breast cancer. So at this point, obviously remember wherever the tar from your spliff or your PSA cigarette ends up, whether it's in your cheeks or your tongue, your larynx, your esophagus, your stomach, your lungs, your bladder and, importantly, your cervix. There's an increased risk of cancers in those areas from the inhaled tar. Um, in this country, we have a chat called Jamie Oliver. Um, he writes great recipe books, but he also did a fantastic teaching program on healthy eating. And what he was particularly advocating, um, in schools was less saturated fats. So these are facts from animals. Now we know that it's incredibly important that we maintain calcium in the skeleton both for this generation and for the next generation. But if you were going to have any beef in your diet, we would prefer that you, um, Stuart rather than barbecue it, because the carcinogenic particles of all those burnt bits are the bits that increases cancer. Um, so I think calcium is really important. Um, it can be from other types of milk. So not milks. Soya oh, milk. But I think very carefully about how much, uh, animal fat there is in the diet, because that's carcinogenic. So we say, Reduce your intake and Stewart, don't barbecue it. Um, there's a picture we show now, which is one of mine is beautiful sunsets. So there's beautiful sunlight over trees in the middle of France in the early part of the last century, and we remind students that, as with plants who make their own food in the presence of sunlight and chlorophyll, we make vitamin D and vitamin D obviously has all kinds of protective effects, particularly with glandular fever and M s, for example, but also is cancer protective for 20 minutes in the sun. Now we're not advocating that everyone sits in some bathes. What we're saying is that if the early part of the day you can walk with your sleeves role or expose your face, and obviously there are people who are very covered up. We have long sleeves, and it's incredibly important for those people that we maintain, uh, some skin exposure and then slip slip into the shade slap slap on a hat and some sun block, as the Australians would tell us to prevent skin cancers. Those of you who are intending to be doctors on the estrogen of programs to Mars are going to have their work cut out because nine months they're nine months back and nine months in on Mars exposed to radiation without the protection of the nerve. Mhm. There is a problem we know from studies when Concord used to fly. So this was an aircraft that would get you from London to Paris in about 3.5 hours that they develop more breast cancer than other air hostesses. Um and, um so it's terribly important that one reduces ones radiation exposure. So when you're advocating X rays for patients, how much exposure if they had to the torso that is going to engender breast cancer? We're talking here really only about cancerous lumps. We're not talking about innocent benign lumps at all. Um, and we can send you leaflets that have a summary of all of these lifestyle measures. Um, explaining, um, as an aide memoir, their their risk. What I'm going to move on to you now is the genetic risk. Now, even if one is a gene carrier, Uh, for a gene that predisposes to breast cancer, if one modifies lifestyle, then that stabilizes the genes. So lifestyle is still very important for this group of patients. So the the music that you've just heard is part of the video that we've produced, which basically says breast cancer is hereditary. So no, your genes. Now, um, when we're talking about genetics and breast cancer, we are particularly talking about gene genes which are heritable from both sides of the family, from your father and your mother's. And when we do this presentation, which is now at schools and universities in 26 different institutions in the UK um, repeatedly, um, people will ask me, but But what if my dad had cancer? Does that make a difference? Yes, it really does. And I think it's really important to explain to patients, um, that your hair it inherited characteristics are from both of your parents. Now, um, one. If one has a first degree relative to your mother or your sister with breast cancer that doubles your risk of breast cancer and the more first degree relatives one has with breast cancer, the more the risk. Having said that, 85% of women who do have a first degree relative will not get breast cancer, possibly because of lifestyle or possibly that. It's just a mutation in that individual that's not passed on. Okay, so, um, there are breast cancer genes. These are called braca genes, which we all have. And, um, there was a development of mutation in these jeans now in the Ashkenazi Jewish population. So these are Jews who have had a migration experience from the land of Israel. At the time of the first Temple, the temple was destroyed by the Babylonians. They were taken to Babylon, and about 10,000 went back to the land of Israel. But the majority went on into Middle Europe because through the Middle Ages, and obviously later, um, there was an anti Semitism, and those populations were kept in relative isolation in the pair of Russia or in ghettos. Those genes have become propagated in the population. This is a dominant genes. Okay, So that means, as you know, that if either of your parents carry this gene, then it's past to the next generation and gives risk. Um, now, if you carry, um, if in Ashkenazi Jews. So these are Jews from that that migration. Um, there's a 1.5 times risk of breast cancer. Now, this I told you before that the majority of breast cancers are postmenopausal, um, and some 20% of premenopausal. But in Ashkenazi Jews, that risk is increased both in premenopausal and post menopausal Jews. And that means that by 1.5 times, if you take 100 Ashkenazi Jews, about 2.45% of them will have these mutations without any family history. And if there is a family history, 10% will carry these mutations. Um, so it's very important to know that if you've got someone with Ashkenazi Jewish ancestry in front of you, they may not have family history, and they can still be a carrier of Bracha. Um, Now, because of the Holocaust, lots of people don't know they're family history. They may have one side of the family who are not aware at all of their family history, and I think that it's really important that people may not identify as being astronauts the Jewish, um, in terms of their religion. But in terms of their ancestry, we're doing a study at the moment across. All of the presentations that we're doing is looking just that topic because we know that people have maybe one grandparent who's Ashkenazi Jewish, and they are not practicing Jews themselves. But coming through the generations, that gene may propagate itself. Um, an example of this is Angelina Jolie. So she is a women's ambassador for the U. N. And obviously an actress, and she has Ashkenazi Jewish ancestry. Her mother had ovarian cancer. Now Braca genes code not only for breast cancer but also for breast ovary, prostate cancer in men, male breast cancer, some melanomas, colon cancer, Hodgkin's disease, pancreatic cancer if I have not already said that and her mother had ovarian cancer, so she knew her mother was a bracket carrier. And, um, if if one is a bracket carrier, there is between 50 and 80% chance in the lifetime of that individual of getting breast cancer. So when she was screened, what she decided to do was initially to have her family. Now she may well have taken the combined pill. I don't know that would have reduced her risk after taking it for four years, giving her a 15 year window during which to have her family breast feeding and pregnancy. As we've discussed reduced risk even if you're a carrier of a gene, and she then decided that what she would do would be to have a new for ectomy. And obviously, if there's less estrogen around, then that reduces risk. And she also had a risk reducing surgery to the breast. So she had all her breast tissue removed, after which time one could take HRT. And that's that's fairly common practice amongst our practice population. Um, what I would say is that if one does carry a mutation, um, such as Bracha, then because of the difference in the tissue, it offers a target for treatment. So there are some treatments, for example, pump inhibitors, which are offered to Bracha patients when they do develop cancers. And there's a lot of discussion. We are partners to genetics who there's a link to on our leaflets. Um, they offer something called the Genius Project looking at recessive genes, and we're just about to start Bracha gene testing as well. So in the UK, the government has just agreed to test all Ashkenazi Jews in the new year for breakfast status. And I think that that coming from the Ukraine, it's likely that you have huge Ashkenazi residual populations, perhaps who have intermittent into the population or just not aware of their ancestry. We're going to move on a little bit now, too. Screening. Now we've talked about genetics. We've talked about lifestyle, and now we're talking about what our patients are exposed to in the way of trying to pick up cancers. I've explained to you that within the Ashkenazi population, these cancers are 21.5 times as much, and both in the pre menopause or post menopausal populations. And screening in the UK currently has just been reverted back to over 50. We had a trial going on for women under for over 47 to have mammography unless there is a strong family history or their Ashkenazy, in which case there are different possibilities for screening. So what we want to advocate is for people to be breast aware. So what we teach is we show a section through the breast showing the milk ducts, the breast tissue, the fatty tissue and the the ribs underneath and allied to that is a picture of a mammogram. We try to explain that you know, the mammogram has to be read by somebody who's skilled a radiologist, um, and that that's a week X ray that's done in this country every three years after the age of 50. But under that age group, we would offer ultrasound or MRI because of the density of the breast. We talk about particularly the changes during the menstrual cycle. So you're all of you. I'm sure you're familiar with the menstrual cycle and the thickening of the uterine tissue and changes in hormones throughout the cycle. But actually those those tissue changes are going on for the same reasons within the breast. So if you have someone who comes to see you and says, You know I've got this this pain in my breast or I've got this thickening in my breast and they're just about to menstruate, then it's worth getting them back after a period and seeing if all of those changes have resolved and often they have. But if they're not resolving, those are the changes that we need to be aware of so in particular, we want people to be aware for themselves now rest. Self examination is not particularly advocated for older women because mammography is more effective, although it's terribly helpful and we pick up breast cancers that are not only picked up by women but also by their partners. But I think it's really important, for example, when you have an opportunity to teach at when you're giving contraception when you're doing a postnatal, when you when you're doing antenatal, um, to teach women how to look at themselves because they're in an age group, which is not going to be screened. So what is any change in size, Any change in shape? Are there cyclical changes which are resolving, or is everything not resolving? What is normal for you? Okay, it's really important. There's a picture from Modigliani who painted a fabulous painting of a woman with one breast bigger than the other. And if that is normal for that individual, if that person has one breast bigger than the other, and that's always been how it is reassure, please, that that's okay. If one nipple has always been inverted and it's not changed, that's fine. But if a nipple has become inverted. If there's any crusting, if there's any discharge, women come with the coloration on their on their bra. For example, is there any dimpling of the skin, which might show that there's a tumor underlying the skin? Or is there any rash? So I had a patient recently with a rash over the breast, which she had been told was a fungal infection. She had metastatic breast cancer, and I think it's incredibly important not to be dismissive of changes on the breast, because you can't be sure unless you check. Rembrandt had a mistress. He painted her very faithfully with her left breast with a big wedge shadow on it. And if you look online, you can see that painting. He didn't know he was painting her with with Code Orange. This is changes in the breast skin that looked like orange peel, and that's indicative often of breast cancer. Underneath. It can be for other reasons, but you do have to refer. I'm going to play you the sounds of video. Now, as you know, breast come in all shapes and sizes. We ones, big ones, three kids later ones. But I want to tell you about breast like these with pimples. Skin like orange peel, crusty only king nipples or a nipple has become turned in. Most women know that if you've got a lump in your breast, you need to get it looked at straight away. But it's not just lumps. That can be a sign of breast cancer. If you notice any changes in your breasts, however small, you need to see a doctor even if you've been for a screening recently. Breast cancer is much more treatable these days, and the earlier it's found, the easier it is to treat one in nine. Women in Scotland will develop breast cancer at some point in their life, so don't get scared. Get checked. Okay, so that was a health policy from the BBC Rich Broadcasting Corporation to women in Scotland, just indicating various changes in in the breasts. There's also another campaign called What Breast cancer can Look and feel like No, your lemons, and this is an egg box containing lots of different lemons. Some of them are squeezing juice out. Some of them have got little dimples. Some of them have got discoloration of the skin or sort of orange, purely type skin, or some have little lumps just under the skin. And basically, it's saying these are the changes that you might anticipate, meaning that there is something that needs to be investigated to exclude breast cancer. It's terribly important if you're looking at five year survival, the most recent charts that we have from 2009, but it's basically a trend, so we know that if your life expectancy at 80 to 99 is about a year and a half, we expect that your relative survival at that age would be lower compared with middle aged women. We know that cure is spoken of for breast cancer, which presents early and certainly over 90% survival for five years, um, in the 50 to 69 age group, but in young women, so these are 15 to 39. Although I said that the incidence of breast cancer was about one in 1000 relative, survival is less, and the reason for that is late presentation, so they don't know that pain might be a reason for presenting. They don't know that rash might be a reason, Um, and these lumps go undetected for a long period of time. It's terribly important that these women are taught. Um, we have to remember that the natural history of breast cancer is not always dire, although there is a steady decline if untreated. And so we do want to get these women early. So the message that we have is befriend your boobs, make it your lifetime mission that you will be regularly checking yourself your patients. Okay, Um, we had a medical student amongst our team who the first day she was in casualty with her friend, having never examined patient other than in our general practice in her BSC year and the doctor on call. So I'm really busy. Can you just take a history and examine the patient? And all she knew how to do was examine that woman's breasts, and she picked up her first breast cancer on the first day. Um, two, which the team said, Actually, we wouldn't have examined her breast and casualty, So wow, um, so I think always remember that there is an opportunity for you to make that diagnosis with symptoms that are not necessarily straightforward. So can you please get your patients do yourselves. Stand in front of the mirror, lift your arms up and look at the breast. See how they do. They moved symmetrically. Are they doing what they normally do or is one moving in an erratic way? So one of the cancers I picked up, a woman lifted up her arms and one breasts, one off to one side, and she had a breast cancer. It's really important. Think about the breast, perhaps as a target, like a dart board or as a current bun, and think that you've got to hit every single current in the bun or every single place in the dark board. Now the breast goes from your collarbone to your armpit. Lots of people have breast tissue under their arms, and we're always being asked by particularly pregnant women. You know, I've got a lump under my arm. What they mean is that their their breast tissue is becoming more apparent, and that's absolutely fine as long as it isn't a lump. And it is just breast tissue, which is active. So with a soapy hands, often in the bath. Just feel up into the axilla feel the whole breast systematically planning out, teach your patients to be systematic in their examination. Um, and obviously, um, we are exposed in our presentations to people who are transitioning from one sex to another. There may still be breast tissue, even if they've had what's termed the top job, which is when breast tissue is removed, transitioning from female to mail. There may still be a nipple. There may still be active tissue that needs to be examined, and also we're not sure about the effects of testosterone on future cancers in the breast. So those people need also to be aware and to be managing themselves in the same way. Um, squeeze under the nipple, see if there's any discharge. Obviously, during pregnancy, there may be some milk, but if there is anything else coming out at any other time, that's abnormal. If it's bilateral, it may be, um, under crime onset. But, um, I think it's really important. So the next video that we would have played, basically, so what I want you to do now is actually feel these this model so that you can feel the abnormalities within the breast tissue that's here. So we spoke about making sure that you feel the entire area up into your armpit and also feeling behind the nipple, squeezing the nipple to see if there's any discharge, because normally there's not really a discharge from your nipples, so maybe you have to push hard enough to change your finger color. It doesn't matter how you do it, whether you do it standing up or lying in the bath, but I think that's soapy hands useful. And even if you're really chaotic and you do this all over but firmly and you felt everywhere, that's fine. Or you can be really organized like I am. It just doesn't matter. So why don't you have a feel of that breast and see what you can notice? If you felt it so that it's always there, then it's not because some people's breast tissue is lumpy. So in this breast, how many months are there? Oh, there's one which is a bit more tricky to fill up here, which you need to feel quite deeply, don't you? Okay, so I think when we teach, um, students how to examine, um, often, people are very wary about doing it. People or frightened. Often they need permission to actually look at themselves. So we've had some audiences where, um, students literally have had their hands over their face. They don't want to look at the imagery that were showing. And one of our presentations will stop by the teacher to say, Look, you know, this could save your life. This is really important. You need to be able to look at yourself in the mirror, and I think giving someone permission to check themselves and making them feel safe when you're doing it so that they know what they're doing is incredibly empowering, Um, and very important. The other thing is that I think it's really important when you're when you're teaching young people about this, and even older women is that they disseminate this information. So we're doing a study at the moment looking at whether or not this information is going back to the students families, and we know that it is. And we're very excited about that because anecdotally the families are coming forward either for genetic testing or having examined and found abnormalities. So I think I know that we've We've got a little bit of time left and there are on our leaflets links to websites, which I think would be really helpful to Copperfield being one of them. But I'm going to leave some time for questions. I'd like you to know that we do this presentation, which is copyright in the name of three women. Um, Denise Panic was Children's barrister who develop breast cancer. Nikki Goldfield was a patient of ours who was a teacher. And Harriet Jeffries was a young woman who was a friend of my sons, who didn't realize that there was a fracture in her family and developed breast cancer. Okay, um, are there any questions? Simon, do you want to take the questions? Hello, my, Just having a look. Questions? Can pregnancy alone reduce the risk? Or is breastfeeding the key point pregnancy? Obviously, if you go through sort of nine months of being pregnant, your your hormone levels will change and certainly having more babies. Um, I think at an earlier age is thought to be protective, but the breast feeding is really key. There seems to be a definite protective element to having regular breast feeding. Obviously, we re advocate for lots of reasons why breast feeding is breast is best, but it does seem to have a sort of a significant reduction on the individual risk of breast cancer. Is there anything you want to add to that? No. I think that's absolutely right. I think it's all of these elements. It's not just one thing, Um, and that's why it's really key to to push that education for your patients at every stage of their presentation. Really? What? Did you have? Another question? Yes. Mhm. I can't see the exercise. Can you see it, Michelle? Oh, here we go. When asked a question about exercise and mhm. Mhm. Okay, so exercise is very important. And I think that if people maintain exercise throughout their lives and that has huge impact not just on breast cancer, but other cancers, obviously heart disease as well. So yes, I think every opportunity. Please stress that for your patients. Do you encourage patients to check themselves or depending on age, examine them with the GP surgery? Well, we encourage them to check themselves. I mean, some they used to be when I was much younger. Doctor, we used to do a lot more examination surgery. People came in for pill checks. Um, lots of other sort of checks for cervical smears. We used to do some checks at the same time. Now, pill checks are much less frequent. You can get a prescription, often for up to a year. They can often go to the practice nurse, sometimes even go to the pharmacy. Um, and so sometimes the interaction with the GP is not as frequent as it was, and the time you have is not as long. So we would obviously take the opportunity, perhaps the first meeting of someone when they come back for their sort of initial check after posting Natal or or perhaps when they come back from pill, check to show them how to do it and then encourage them to check themselves at home. I mean, you don't want to check yourself every week. I mean, that's just I used to tell patients, perhaps once a month, you know, when the periods finished, because that's when the breasts are less sort of on the sort of influence hormones and may feel a bit less lumpy. And, um, just do it in the bathroom in the shower, and then any changes they may pick up, come and see us. So I think that if if if there's time to do it the GP surgery, then great opportunity, then that's excellent. But if you could a big message really try and encourage patients to educate patients to do it, because really, you're doing it once a year in the surgery. Yes, it's fine if the if there's a lump and it happens to be there that time. But you know they've got the rest of the year for it to present. Want people to check themselves regularly, pick up things as early as possible, not wait for that sort of yearly check or to really check or whatever it is. Uh, I mean, I can't live with this. Does the breast change during the period when the lady is getting close to the near menopause? Well, obviously, under the influence of hormones, the breast does change. Um, and we do know that age is the strongest risk factor for anyone having breast cancer. So one. And that's so that is the strongest risk factor. So the majority of breast cancers are beyond the age of 50 or 55. Post post menopausal. Sorry. So we know that the age is the most significantly There are a lot of change in the breast tissue, Um, during, um, the menopause and after the menopause, often a lot more fatty tissue is there as well. And that's often sometimes combining, combining someone with increased weight. We know that postmenopausal fact generally in the body not so much in the breast can produce estrogens, and that itself has an impact on the individual risk of breast cancer. So, as Michelle was saying, all through the life particularly, well, post menopause or exercise keep your weight down Is very significant things that people should be able to do or try and do to try and reduce the individual risk of breast cancer. Um, do you see any other questions that Michelle just having a look down? Because I'm sorry. You can put your shoes on if you want to ask us a question. Um, I'm just trying to, um, sometimes what we're asked is, um, if you have a an underwire bra, does that cause breast cancer? And the answer is absolutely not, um, so you can dispel that straight away for patients, right? Someone's written. I read that mastectomy does not guarantee for protection against the development breast cancer in the future, which is the pathogenesis disease in such a case, is true. I think it depends what their having mastectomy is for. So if you take someone who has had breast cancer and now they have a mastectomy, you can have some recurrence in the scar. You know, I don't think there may be a little bit of breast tissue left for the full is where you literally removed all the breast tissue is not done as often as it used to be done, and it's more common to have a lumpectomy and radiotherapy or partial mastectomy for mastectomy. And if you have one side removed remembering patients who've had breast cancer, they are increased risk of having cancer in the other breast. So if you have a mastectomy, um, as a prevention in patients who've got packaging and then you obviously you are significantly significantly reducing the risk of getting breast cancer. Whether you can say absolutely, there's no chance whatsoever in patients that have, um, sort of preventative surgery to prevent the risk of getting breast cancer in the future. That package and I'm not sure you can Absolutely. Michelle, what would you say that. I think that, as you say, it depends what you're having the mastectomy for and when you do risk reducing surgery. Certainly in the way that Angelina Jolie did it, some people would elect to leave their nipples. And obviously, if you're doing that, then there may well be breast tissue, which is left and could be at risk to you. Um, so I I do think that's terribly important. And obviously, when when you're doing a mastectomy, if it is a full mastectomy, you need to make sure that the margins are completely clear and that the skin is clear of tissue. And so the majority of cases that would be fine often if there is a cancer, it's combined with radiotherapy or chemo or whatever. But there is always risk. And I think when you're looking at patients who previously have had breast cancer because they've come back with, I don't know back ache or some other symptom that's a bit nebulous. I think it's really important that you remember that they've had breast cancer, um, and that you always check the other side and also the scar and the axilla just to make sure that there isn't anything. Um, and as I say, you know, rash is also important. So if you see a little just little blebs on the skin or whatever type it may be metastasis be Just be watchful. Be careful, someone said, You've you've told that taking the contraceptive pill for two years may increase the risk of breast cancer, but at the same time, taking them for four years may decrease the risk. I think Michelle will answer this question. Uh, is that right? Michelle? You just comment on that statement if you take the combined pill, So this is the pill that you take. It's called estrogen and progesterone in it that you take for 21 days and then break for a week. Or you might take it for three months and a break for a week. That has a slightly increased risk of breast cancer to that individual. If you take that same pill for four years after that four years during that four years, there's a reduction in ovarian cancer, and if you remember, I said that Braca genes code for breast and other cancers, ovarian cancer being one of them, and it's particularly horrible cancer for patients. Um, so if you take the pill for four years, your ovarian cancer risk reduces, then you might breastfeed. Then you might have your babys. Then you might elect to remove your ovaries to reduce your individual risk. If you're a bracket carrier, this isn't something that you just walk into your GP and say This is what I'm having. This is done with genetic counseling, um, discussion with oncologists, and it's a plan for individuals. Okay, um, so very complex. And also for the next generation, there may be a genetic selection of embryos. If patients have seen everyone in their family die around them, they may well also decide that they don't want to have the next generation have fracture. So it's a very complex story, right? It's a couple of questions about the size of breast, so I just So there's one that someone asked about If you have, I think breast augmentation, uh, obviously to make your breast bigger plastic surgery. So there's no evidence that plastic surgery, um, will increase your risk of breast cancer. Um, so that's the first thing. If you have breast reduction, you are removing some breast tissue. So theoretically we're not. Theoretically, you will reduce your risk of the less breast tissue there, but certainly no evidence that breast cancer is increasing. People who have augmentation just to add, though obviously, first of all, if two things, I'll add to that. Just a little caveats. If you have breast augmentation, you may find breast feeding more difficult in the future. Some women cannot breastfeed when they've had implants, and therefore, um, it may just be that you are getting the protection you might have got if you decided you have a child and you want to breastfeed. And second, the second thing I have is that sometimes having implants may make mammography a little bit more difficult to interpret because of the appearance of the implants on the mammogram. And so for that reason, but your individual risk that's picking it up your individual risk is is not reduce, the less because you can't breastfeed. Someone else has also written about whether or not if you've got big breasts, it makes it more likely to have breast cancer. And the answer to that is no again breast. The risk is there, whether you've got large breasts or small breast the breast tissue. Um, it's the It's the lobules where the milk comes from the ducks. That's where breast cancer is for people who have got large breasts often have a lot of fat and connective tissue. Once again, if that's associated with being a very large person, we do know that weight is an individual risk factor for breast cancer. So in that respect it might be just significant because they're generally large. And once again, if you have very large breasts and you're doing self breast examination, it can be a little bit more difficult to find a very small lump. So in that respect, you may not be as easy to pick it up yourself if you're doing self breast examination. But as an individual risk, then know having large breasts more breast that everyone needs to do self breast examination. There's any questions. Difficulty. Can you see anymore chat? Um, you got any more questions you can put your audios on and talk to us Absolutely lovely, and I was going to say what to say. Well, I just apologize that we couldn't see the presentation for whatever technical nonsense is going on, but we will endeavor to give it to you so that you can see yourselves and listen to it. Some of the questions we ask when we go into the schools remember they're not medical students. They're often we're just sort of girls, mostly mostly aged 16, 17. Sometimes they ask if you were an underwire bra. Does that make a difference? Um, that was an old myth that if you had a brother that had wires underneath, that would block lymphatics. Um, and there's no evidence to support that. Likewise, there's no evidence to support any problem using deodorants, waxing, hair removal, things like that. Some of the older, uh, antiperspirants used to contain, um, things like parabens, which is a chemical which possibly influence, um, some of the breast breast tissue. But nowadays, most of them don't do not. There's also something about if you use breast, uh, antiperspirants deodorants, which contain aluminium. Sometimes that can affect the mammogram appearance of people are going for mammograms. Um, sometimes perhaps ought to avoid aluminium containing, um, deodorants, but it doesn't affect the risk. So we're allowed to go and use deodorants and smell lovely. So that's absolutely fun. Um, any other questions that we've been asked by some of the some of the students. We often have to reassure the school students. In fact, breast cancer is very rare in young people because we talked to a very young age and our purpose of being there is not to sort of make them alarm. They may have breast cancer, but really to get them on to the path of looking at their lifestyle, changing things, you know, increasing their sort of exercise, reducing the alcohol, all the things Michelle talked about. And I'm going to get inventive sunlight keeping their weight down, etcetera, to reduce the individual risk and getting into the habit of checking themselves. That is our sort of main purpose of being there rather than alarming. Then they got to go home and check themselves immediately. They might have breast cancer. That's not what the purpose of the presentation is. Um, any other questions, any other questions we get. So we often we told that most breast lumps in young people, because some of them will have breast lumps, are usually benign, as you probably know. But check all breast lumps. That's another message we get over to the students is to find a breast lump, get it checked. That's it. End of whatever it is. You know, you don't want it to go away and not not get it. Um, we kind of get asked about prostate cancer if if fathers have prostate cancer. So you know, prostate cancer is very, very common, but and so we can't Not everyone who's father or or there's a family have got breast cancer. If there's a family history of also prostate cancer and other cancers as well that run in the family or the father had a cancer, a very young age, and those are sort of they may sort of ringing bells and make people more along. They could possibly be a genetic risk, a Braca Braca mutation. But anything else you can think about it. I'll just go through my list of questions. But sometimes I think anecdotally we see families coming forward where the girls have had this presentation and they will go home and tell their families, and the sister will phone me and say, I'd like to come and see you. I've got a breast lump or the mother will phone up and say, I think we've got back and our family on the back of this presentation. So when when we do this to schools and we send a parent leaflet beforehand explaining to the parents what we're going to be doing and about Braca. And so I've had fathers ring me up before now saying, I think we've got broken in our family. I have not discussed it with my daughter up until now, what are you going to say? And we'll then have that conversation at home, and we also will will see girls individually after a presentation if they think that they've got individual things to say so that we can guide them. So whether that's you know, they remember one cohort. There were three girls who had nipple discharge in a cohort of 100. Um, obviously they were signposted to the GPS. But I think it's really important that whenever you have a clinical contact with a patient that you remember that their breasts, um, need examining. Um, and they need to be discussed because obviously it can link in with whatever other presentations they have. It's very important the time we got left, just, um, so some of the other questions that they we do get asked a little bit now about people who are transitioning, as Michelle said, and the message we try and get over to them is anyone who's got breast tissue needs to be breast aware. And we I don't know, the impact that we know the impact of exogenous estrogen, so that can have obviously a negative impact on patients as far as more likely to get breast cancer. We don't know the impact of testosterone is, Michelle said. So the message we get over to to all the students is if you've got breast tissue and if you're taking extra hormones one way or another, then you need to particularly be breast aware. So in the UK, you'll get called for me for a mammogram from the age of 50 and that will be you'll get called dependent on the gender that you're registered with with your GP. So patients that have transitions and are now transmission or trans women but depending on what they're registered with with their GP will depend on whether they're called routinely, so sometimes they may have to request if they change their gender on their GPS. register to be to mail. They made not be called. So they have to request. Is that something that if you become GPS and this is a thing which may become more prominent in the future? They're just aware of what they're sort of sex assigned was at birth, and that may be and what they're doing with hormones that may affect and whether or not they need to have screening like every other people. Absolutely. I'm sorry we've already gone. It's already been over 10 minutes. Over the time. I'm fine, thank you very much for some of them. Want to know about the certificate? I'm not sure if you can. If you can help with that, they've asked a few questions. How can they download the certificate? All you have to do is click on the certificate. You should be able to download it easy, and then you have to add your name and that's it. And we really appreciate it. If you did the feedback. Also, it's really important for us to keep going. Um, I don't know why people are having issues with the certificate. If you click on it, you should be able to download it. Um, would you like us to send you our slides somehow? I'm not sure if we're able to share it with everyone. Um, but we certainly can. And if we managed to send it, we will. Okay. I'm sorry. I have such problems with it. Thank you very much. It was very interesting. Thank you, Doctor Ferris. Thank you, Doctor. Simone, It's me, Sharon Raymond. Welcome, everyone and goodbye. Please do share the slides with us. You can forward them to me, Doctor Paris. And then I can share them on. No problem. Thank you so much. I really appreciate it. Brilliant. Thank you so much. Thank you. Everyone, please make sure you do. Fill in the feedback form and the certificates will be put into the into the chat. You just have to click on the link. We absolutely need your feedback. It's really crucial for us to continue. So please, please fill in that feedback form and you'll need the name of the lecture. Doctor carries the date today, 20th of October, and just put breast breast cancer for the title of the lecture. Thank you so so much. Thank you, everyone. Thank you very much. I keep, uh, we've done the meeting for a bit longer, because just to give people time to get the feedback thing, I did actually put the slides up. Were you able to see them at all? Yeah, they were. They were about five minutes in. Yeah. You Sorry? Can you repost the link to the feedback? Hannah or Claudia, please, Just repost that link to the feedback. Did you realize, Michelle? I got the slides up, but how about after about 78 minutes? So when you were talking, I was going through. I couldn't get the video. I got the slides up. Not the first bit from We were talking about weight from then onwards. The slides You do. Sorry. Sorry to interrupt. Mind doing the kind of feedback between yourselves later? Because this is recorded. Thank you. Uh huh. Yeah.