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Mm Okay. So thank you for joining me this morning. Um And um I'm Doctor Elizabeth Cox. I'm retired breast position from um Adam Brookes Cambridge in the UK. So I'm going to share my screen now. If you want to ask any questions, that's fine as we go along, just either put your hand up or use the chat uh and we can chat as we go along. So I should scream. Uh Yeah. Mhm Okay. So um sorry. Uh so today I'm going to talk about uh taking a history about breast disease diagnosis and investigation and I'm going to do it as if you were having an elective in our department in the breast unit at Adam Brookes. Um So I'm sorry, you can't have come and have a real elective there, but this is give you a bit of a flavor of what we do there. So, um uh and while I'm doing that, I'm going to be talking about how a bit about how the NHS works um in the UK. So we start off with our imaginary patient who's a 50 year old woman and she discovers a new lump in her right breast So, um, here, uh, in the UK, patient's are encouraged to be what we call breast aware. So we used to talk about, um, doing breast self examination once a month after menstruation, but that wasn't found to be particularly beneficial. So, we just ask patient's too, um, be aware of their breasts when they're washing or dressing. Um, and, um, oh, gosh. Uh, and, um, uh, just be aware of what their breasts feel like normally for them. Um and then if they notice anything new to report that to the G P. So um mhm. So she rings the G P immediately and gets an urgent appointment to talk to her GP um and to see her G P. So she goes and sees her general practitioner. So this is the way that patient's in the UK, get to go to a hospital clinic by seeing their um doctor in the community who then if they feel it is um the beneficial to the patient, they will refer them to the local hospital. Um So the G P in um uh the UK work acts as a gatekeeper to the secondary care um specialist clinics having said that anyone with a new breast lump, whatever the age should be referred for investigation. So the GP refers her uh to what we call the two week wait, which is a specialist cancer service. Um and M breast, it's what we call a one stop clinic. So that everything you need doing all the tests and investigations are all done in one clinic visit. So we try to see patient's within two weeks of referral. Um, and then they see a doctor or a nurse in the clinic and then they have all the necessary investigations at that same clinic and they're told all the results um, from that clinic visit, except if a biopsy is taken because the biopsy has to be sent to the laboratory and processed. So it's a very good and efficient service. So, um our patient goes to the clinic and sees the doctor and we then take a history and examine her. So when we see the patient, we confirm their name and their date of birth, um we explain, we're going to take a history and examine them. We gain the patient's consent for doing that. And uh as breast examination is quite an intimate examination, um we always try and make the patient feel that there is by sitting at the same level as then um with and when we take the history, we prefer to do that with uh with them fully dressed rather than in a gown or, or undressed. Most of our patient's in the clinic will be female, but there will be some male patient's that usually with gynecomastia or a lipoma. Um and I'm giving a second lecture in two weeks time and we'll talk a bit more about benign breast conditions such as gynecomastia at that lecture, just to mention about 1% of breast cancers are in men. Um And they're usually elderly men and usually associated with one of the Bracha gene mutations. So, age is quite an important thing to find out because as you can see from this graph, um different conditions are uh more common at different ages. So you can see that benign conditions here along this graph tend to be in younger patient's uh and malignant conditions. This graph here uh tend to be um in older patient's and in fact, the biggest risk factor for breast cancer is age. So the older you are, the more likely you are to get breast cancer. Uh So the risk of breast cancer starts rising around the age of 50 to 60. Um and benign conditions start tailing off at that stage. Uh There are a couple of very rare conditions which can lead to a risk of breast cancer in younger ages, but they're incredibly rare, just mention them for completeness. So when we do a history, what do we ask? So often if you just say, tell me what brought you to the clinic today, they'll tell you everything in about a minute. Uh And that's mostly what you need to know, but we may want to dig down a little deeper into some of the symptoms. So if they have a lump, you may, we may want to know where it is, how long it's been there. What it's like, is it soft, firm, hard, smooth, probably does it change with the menstrual cycle? All these things are useful to know. So can try and think what the lump is? Pain? Is there pain with the lump? If so where does it radiate? Where does it go to? What makes it worse? What helps? How severe is it the nipple has that changed? Is there any discharge or bleeding or inversion of the nipple? Is there any redness or skin changes? Is it associated with the lump or the nipple? Does the patient have other skin conditions such as eczema? Is there any ulceration of the breast or nipple? Is there any dimpling or, or this change that we sometimes see that's called per day orange. This is a French word that's correct into uh English uh medicine and it translates as orange peel. So the skin looks as though it has that surface that orange peel does later on. We'll see what that might look like in a dummy model. Are there any other symptoms? Temperature fever. Is the patient unwell. Uh indicating there may be an abscess or an infection. Are there any lymph nodes, any lumps in the axilla? Uh Is it, are they painful or not? All these questions can give you clues as to what might be going on in the breast when you see the patient um going on with the history. Is there any past history of breast cancer? Other breast problems or radiotherapy to the chest has a patient had a recent mammogram. So, in the UK, there's a screening program of mammograms. Patient's are invited to have routine mammograms every three years from the ages of 50 to 71. Um hmm uh is the patient on any medication, particularly HRT which can affect the breast considerably. What's the patient's menstrual cycle? Like if they have a very early onset of periods and very late menopause, that can put them a bit at risk of uh developing breast cancer because the breast is exposed to more hormones during the patient's um uh lifetime is the patient, the peri menopausal around the menopause because cyst formation is very common at that point. Has the patient had any Children or breast fed? Because people who haven't had Children are more at risk of breast cancer and pregnancy at an early age. Uh And breastfeeding can be protected against developing breast cancer. Oh, what does the patient do? Do they have a job that involves heavy lifting? Do they have young Children or grandchildren? Do they do a lot of computer work? All these can lead to uh muscle injuries which can cause pain in the breast from coming from the chest wall. So that's an important thing to ask when the patient comes with pain. Does the patient smoke or take alcohol or recreational drugs? So, smoking marijuana, uh and some other uh drugs are associated with developing gynecomastia. So that's quite important in male patient's and finally, other, is there any family history of breast cancer? Um uh someone else is going to talk about family history of breast cancer later in the week, I believe. So, I'm just going to briefly mention this. Uh So basically the larger the number of relatives, the younger the age of diagnosis of the relatives than the more likely there is to be a family history of breast cancer and particularly in the Ashkenazi Jewish population. Also, there's a link between breast cancer and ovarian cancer. So anyone who's had a very in cancer may well be at higher risk of developing breast cancer. Um So this um diagram just shows you some of the risk factors for developing breast cancer. So this looks at breast cancer incidents per 1000 women aged 50 to 59. Um and shows the number of women developing breast cancer over the next five years. So this is the base basic 23 breast cancers diagnosed per 1000 women aged 50 to 59 in the UK population. And the main point of this diagram is to show that if you drink two or more drinks uh or units of alcohol per day, that can increase your risk of developing breast cancer or if you're a smoker or if you're overweight with a beer, my greater than 30 these are lifestyle uh factors that can influence the development breast cancer. And uh interestingly if you take at least 2.5 hours of moderate exercise per week. It can really significantly reduce your risk of breast cancer. Uh So that's a very uh interesting way of looking at some of the risks of developing breast cancer. I'm going to skip over the family history just um included them um for uh completeness. Um But uh as I say, someone else later in the week is going to talk about that in a bit more detail. So we've taken a history from our patient. So we summarize back to the patient, the key points that we've learned from them. Uh And we asked the patient what they think is going on, what their worries are and what they are expecting from the consultation. We then go on to um examine the patient. Uh And we always have a chaperone to do that. Um particularly because it's what we would call an intimate examination. And I thought we watched together how to do a breast examination uh from this website here called geeky medics dot com. It's very good. It has a lot of uh uh videos showing you how to do all the examinations in the body. So I've just got to do a new share and find this here we are and we'll start here. So it's just loading up. I was going to refresh. I'm Simon's one of the junior doctors. Let's check your name and age, please. Uh Nice to meet you. Uh So today I need to perform the breast examination. Have you ever had one of these before? Okay. Which person conservative? And I got to look at my last breath. Sorry, folks. Okay. So what this examination will involve is me having a look and the feel of the breast tissue. You have to go ahead. Yeah. All right. What I'll do is I'll let you get undressed. So, taking your top things off, including your bra. So um I'm going to stop occasionally to say things. The first thing I think I would say is we wouldn't use the word feel because that's a little bit too intimate. Perhaps we might use the word examine you. So I'm going to examine you. That's my only criticism really of this video and I'm hoping this gown on to cover up, we could sabal big worked as a shot run throughout. Okay. So the next thing to say is that this area is depicting what what I was talking about this Purdue Orange, this um uh orange peel that we see sometimes um in breast cancer patient. So that's what I was meaning by the Purdue Orange. Okay. You know, if you could just put your hands on your hips for me and now just press down on the hips. Now you can put your hands behind your head and put your elbows back. Now just lean forward for him. Okay. Sounds good. OK. Leona, if you could lie down for me. Now, I'm going to examine the breath and if you could just put your right hands behind your head for me. Exactly. I just want to make sure that there's no discharge from the nipple. If you could just squeeze your right nipple between your film and index finger. Okay. Thank you. If you could just switch the hand behind your head. Thank you. Now, could you just tends your chest muscles? Leana, thank you. What I need to do now is to have a feel of the glands in your armpit. Okay. So if I can start the right, I'm just take all the weight of your arm. So just completely relax. It's okay. Mhm Sorry folks. Okay. Yeah, I'll do the same on your left side now. So again, just relax. Let me take all the way. Sorry, I'll just rewind that a bit. The chest muscle is Leota. Thank you. What I need to do now is have a feel of the glands in your armpit. Okay. So if I can start the right, I'll just take all the weight of your arm. So just completely relaxed. Hell yeah, I'll do the same on your left side now. So again, just relax. Let me take all the way. I'm just going to have a feel of the glands in your neck now. All right. That completes examination. Thank you very much, Leo. No, I'll just leave you to get dressed now. Thanks. Uh Today I performed a breast examination on a 23 year old one inspection of the right breast, there was evidence of nipple ulceration and there was erythema in the lower right quadrant on inspection of the left breast, those evidence of nipple retraction and also po'd orange in the left lower outer quadrant on palpation of the left breast. There was a firm craggy three by three centimeter mass. At approximately two o'clock, it was located four centimeters from the nipple and it appeared to be tethered to the underlying tissues. There were no other lump sum part patient and there was no lymph node involvement for completion. I'd consider further examinations to detect the presence of disseminated malignancy. I'd arrange ultrasound scan and also called biopsy or finding the aspiration of the marathon. So I'll just share my screen again. Did, did that work. Um share ing that I hope it did. Okay. So moving on from the examination, um we um so in summary, going back to our patient who's going through the clinic, she was a 50 year old female patient who noticed a tender painful lump in the right breast a week ago. She's not had a period since finding the lump. So doesn't know if it will change with her menstrual cycle. The pain is just in the lump and doesn't radiate anywhere else. She's not noticed any other changes. So she is what we call perimenopausal. So she's around the menopause. Her periods are becoming irregular uh and she's experiencing hot flushes and night sweats. She's not on any medication, not taken any HRT. And she has one elderly aunt had breast cancer in her eighties. Just to comment on that. It's very common for people to have an elderly relative who has had breast cancer at an older age. And that doesn't put her at any greater risk than anyone else developing breast cancer. When we examined her, there's a lump in the upper outer quadrant of the right breast. So when we examine patients', we describe where the lump is in terms of quadrants, upper, outer, upper, inner, lower, outer and lower inner. Uh the lump is smooth, discrete firm, mobile and tender. The nipples are normal. There are no skin changes and no lymph nodes. When we find out from her, what she's worried about, she's terrified. She has breast cancer and she's hoping she may be able to have some tests done today. And she wishes to get treatment started without delay. As she's heard that delay in treatment is one of the biggest causes of people dying from breast cancer. And she doesn't want to end up like her elderly aunt who left it too late. So this is very common for patient's to uh think the worst. Uh and assume that every lump is breast cancer. In fact, most of the patient's we see in the clinic, nine out of 10 won't have cancer. Um And uh so we can be reassuring to most patient's. So what do we do next? So this patient um um needs a mammogram. So any patient over the age of 40 whatever their symptoms, whether it's just pain and there's nothing to feel. Uh we do a mammogram. Um As as long as they haven't had a recent screening mammogram in the last six months, all previous mammograms that the patient has had will be reviewed at this clinic visit. So mammograms are an X ray of the breast. Uh and we get the images um they're now digital. So they come through um instantly once they've been done and the images are read by two radiologists. Um and uh they will um see what's going on in the breasts from, from the images. So um some people may have very dense breasts, very dense breast issue, particularly in young people. Uh And that's why we tend not to do mammograms under the age of 40 because the breasts are very, very dense and it's very difficult to see what's going on. So it's a bit of a waste of time and density reduces as you get older. Um And so they become more useful as the patient gets older. And that's partly why the screening program starts at 50 when the breasts start to become more readable on a mammogram. So we now have a new technique called tomogram for women with who are young or have dense breasts. Um And that this technique helps us to uh better image the breast if it's very dense. So I've got some illustrations here. So this is what a mammogram X ray looks like. And this is just to show what I mean about the density of the breast. So this patient has a very fatty breast. So the breast tissue um as you go through the menopause turns into fatty tissue. So the mammogram becomes very nice and clear and readable. Um and um uh there are different um levels of density. So here at this end, we see a breast where you can't see very much because all the breast tissue is still breast tissue rather than fatty tissue and appears very dense on the mammogram. Here and here are grades in between moderately dense and slightly dense. And these are tomograms which as I say are used particularly in younger women. So if we here we see another mammogram of the breast and here we see how dense the breast tissue is and we've got this denser shadow here and that might be concerning. So, tomogram takes slices a bit like a CT scan, takes slices of the breast at different levels. And as we slice down through the breast with the x rays, you can see that uh this area turns out to be just another area of dense breast tissue. So this new technique will save this patient from having a biopsy of this area which can be very stressful very painful and the stress of waiting for that um tissue biopsy results for a week. Uh is very, very stressful for patient. So it's very good that we have this new technique where we can avoid a biopsy. So then the patient will go on in the same clinic to have an ultrasound. So any patient, any age who has a breast lump or a discrete area of nodularity should have an ultrasound. So the ultrasounds are performed either by a radiologist or an ultrasonography who's had specialist training. And the ultrasound is always done after the mammogram has been looked at and by the radiologist and depending on what is found on the ultrasound, a biopsy or a cyst drainage will be performed. So our patient's had a mammogram, has not had one done before and then she had an ultrasound done. So this is the mammogram machine just to show you what it's like. So the patient is standing up and the breast is squeezed between these two perspect sheets and it can be momentarily, very uncomfortable. Um but it is only momentarily as the breast is squashed flat um and then the pressure is released again. So this is a mammogram of our patient. And here we can see a lovely discrete lump, nice edges, bit very, very smooth. Um and um uh an area of dense of looking tissue compared to the surrounding tissue. Uh This is calcification probably in an old fibroadenoma. Uh and this is calcification uh in a blood vessel. So then the patient goes on to have an ultrasound. This as you probably know is a flat probe that sits on the flat of the breast uh and lots of jelly is used to help transmission. Uh and then a picture appears on the screen. And with our patient, the ultrasounds showed what you would expect from the mammogram, a very discrete lump um here, nice discreet edges and it's filled not with breast tissue, which is this stuff over here, but appears to be empty. So this is classical of a sister breast cyst. This is filled with serious fluid. And while the patient has the ultrasound done, a needle can be guided into this area and the cyst drained dry and then it will disappear and sister often painful. So when you drain the cyst, um the uh and the fluid is sucked out, then the pain will go away. So, uh as I said, the ultrasound confirmed a breast cyst and she had that aspirated to dryness. And then we explained to her what cysts are and she was discharged from clinic. There is no need to follow up patient. They may never have a cyst ever again. And she's not at higher risk of breast cancer because she's had a cyst. So there's no need to see her on a regular basis. But we do advise patient's to attend again of our, the G P and the two week wait system if she were to develop a new lump. Um and she was recommended to um join the breast screening programme when she was invited to go and have a mammogram just to tell you a little bit about cysts. So I'll probably talk about that a bit more in two weeks time. But cysts are often painful or tender. They are often suddenly non set, come on suddenly like our patient's and they may actually disappear spontaneously without any treatment. They are often recurrent. So you may get one or two more up to 10 in your lifetime. They start in your late thirties generally. Uh and will persist until you go through the menopause and out the other side, they will persist if you remain on HRT. So if you're prone to cysts and go on to HRT, you will tend to have more cysts and um at the other uh age of hormonal change, when people first start their periods in adolescence, they can also be prone to cysts, excuse me. So, cysts are about the imbalance of hormones that occur in the early days of the menarche or around the menopause, you may get assist whilst breastfeeding. Uh and that when you aspirated, it will be full of breastmilk, we usually do aspiration under ultrasound control. But if there's a very large cyst and patient's have had cysts before, then sometimes you can just aspirated it uh without a ultrasound. Um And uh any new persistent, whether patient's had assist before or not, should be referred to the breast unit because uh patient's can develop breast cancer uh when they've had cysts in the past. So you can't assume it's just another cyst. If the patient's had to have a biopsy, then the biopsy is sent to the pathology department. And when we have the result of that pathology, the results are discussed at what we call the multidisciplinary team meeting. So this is a meeting where we review uh the examination findings, the mammograms and the ultrasounds uh and the pathology. And we all discuss all the results. The clinician who saw the patient, the radiologist who saw the mammograms and ultrasounds, the pathologists who see the uh specimen under the microscope and the breast surgeon who might need to perform surgery. We all discuss what we think is the best treatment for this particular patient. And then the patient is seen in the clinic to discuss the results of the biopsy and discuss what the MDT recommends as a treatment and management plan. Um sometimes uh after all the discussion between the patient and the breast surgeon, a breast MRI uh maybe requested to help plan or implement any treatment. So that's the vinyl breast um test really is the breast MRI. It's quite again, a relatively unpleasant uh investigation patient is faced down with their face uh in a holding um area, the breast hangs down through this area here, you can just see the breast there and the patient is moved into this donut like machine. And patient's say that this, unfortunately, it's very claustrophobic examination as you can imagine, but it can be very helpful in planning treatment. So the MRI tick again takes uh slices. And when you look at an MRI scan, uh this is dynamic and moving so you can move up and down but through the layers of the breast and it gives you a three D picture of the size of a breast lesion that a mammogram or even an ultrasound may not be able to tell you. And also it will tell you about um the lymph nodes and what's going on there as well. So that's the end of my talk. Um I don't know if there are any questions anyone would like to ask about what we've discussed this morning. Um Sorry, Doctor Elizabeth. Thank you for the lecture, please. Could you show the last slide again? Sorry. That's all right. Yes. Thank you. So this is the uh when they get to the screen. So this is uh huh a little technology problem here. Uh Sorry. There we are. That's better. So this is the breast that you saw hanging down so horribly in the MRI scan er and you take layers through the breast or rather it goes uh it's very dynamic. So this you can um uh scroll up and down the images and you can really see where this breast cancer starts and where it finishes. Um So that you can get, get some idea of where you might be wanting to operate when you're taking out a breast mass. Uh So it's very helpful in planning uh and deciding treatment. Um I think there are other lectures on breast cancer itself, which is why I haven't majored on that. Um But uh planning the treatment to know how much uh surgery you need to do is quite important because this helps prevent the patient having to have a mastectomy. Um uh you may be able to get away with just removing the lump itself. Also, some patient's may have chemotherapy first and then with the MRI scan, er, you can see that the mass shrinking away with chemotherapy. Are there any questions you'd like to ask about the MRI? No, that fantastic. Thank you so much. Thank you. That's okay. Any other questions anyone would like to ask? I think um how um patient's with breast blob problems are seen uh in each different country is very different. So I was just wanting to give you a bit of a flavor about how we do it in the UK. Um and what you might have seen had you come for uh an elective to our breast unit in, in Cape Bridge. So, uh in two weeks time, I'm going to give a lecture on benign breast disease. Um talking about all the benign things the noncancerous things that you can find, uh people have in the breast, be quite a lot of pictures. Um and uh images to show you why, what the sort of thing we can see, as I said about a nine out of 10 patient's that we see in the breast unit will not have cancer. So it's quite important to know about all of the nine things in the breast. Any other questions? Okay. Hannah. Are you there? Yes. Sorry. Sorry, I was just eating early um dealing with an admin emergency. Sorry. Yes, that's all right. Yes, I can see that. I've got my phone by me. Um so no, there doesn't appear to be any further questions. Are we happy to finish the the lecture now on? Um Yeah. Yeah, that's fine. I'll just stop the.