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Thanks so much for having us. We are befriend Shal Boobs. Um We're going to be talking this morning about breast cancer, how you might think about it for yourselves as individuals. Uh and also how you might teach it to your patient's. Um and deal with patient's really, I'm going to ask my colleague to introduce herself and then I'll um introduce myself. So, hi, good morning. My name is Doctor Simon Shelly. I'm a retired GP. Um and but I now work and have done for many years as a tutor at one of the medical schools in London. So teach a lot of medical students. Um And then I've been involved with this program which is going into schools and some universities and talking about breast cancer, sort of risk and prevention, um self examination, et cetera. How as Michelle said, how we can talk to patients about doing that for many years as well? So, it's me. Thank you so much. So, I'm Doctor Michelle Ferris, um as with Simone, I'm general practitioner um in Northwest London. I have an honorary contract at the Institute for Cancer Genetics and I'm a clinical tutor at University College medical school. So, um, what is the cancer? I'm sure all of, you know, that the D N A is impacted both by genetics, which can be inherited. Um, and also by lifestyle which is something that individuals have control over and the genetics is damaged by aberrant lifestyle. Really? Okay. What that means really is that there's stuff that people can, um, do something about which is to modify how they live, um, and their stuff which they are going to contend with because they've inherited from both parents. Um not just one, one of the common things that people ask us is can you inherit genes just from your mom's with regard to breast cancer? The answer is absolutely not both parents and that's very important to keep in mind. So each of us has our individual risk of breast cancer. Um In the UK, the risk is now one in seven women. This had an update about a week ago. Um And before the age of 25 it's rare. It's about one in 1000 the communist ages between 50 and 60. Um And that's slightly odd. So we're going to find out why that is over the last 100 years. The risk of breast cancer has been increasing across all age groups, um particularly in the second half of the last century, last century. And we're going to find out why death rates over 50 are massively reducing. Um But in young people, that's not the case. Um And within our practice, we're doing research into that and working with the government again, we'll talk about that in greater detail. If you look across the world. Um Northwest London is the hotspot of breast cancer alongside Holland and the States. It's lowest in Sub Saharan Africa and Asia. But if you move from one country to another where there is potentially a low risk when you start um and move across to an area of high risk. So in the next picture, um these are easy, the European Jews being airlifted during the civil war to Israel when they left for reasons that will become apparent, their risk would have been incredibly low of breast cancer. But within two generations, if they take up risky lifestyle, then their risk of breast cancer will increase. And that's a concern if we're thinking about risk factors, largely, this is due to estrogen. Now, we all know that when your ovaries switch on, when you have your periods and your ovaries then switch off when you have your menopause. So between your menarche and your menopause is the time that estrogen is largely available. Um And we know that because of good nutrition, the age at which people are starting to have periods is reducing. So in the UK, currently, that's between 12 and 13, whereas 100 years ago, that would have been 16 or 17 and in China these days, it's still 16 or 17 and and similarly, the age at which you stop having periods has increased. Um when we talk about this two um students, I think it's really important to say that, you know, while pregnancy is hugely beneficial to reduce one's individual risk of breast cancer, that may not be an option for some people that may not be within their gift to get pregnant or even something that they want to do. But pregnancy has a massive reduction of your individual risk by about 25%. And the more babies and the more reduction in risk. And obviously each of us coming through medical school coming out the other end, we're going to be near a 30 by the time we start. So if you defer having a baby from the age of 22 the age of 35 then you've got a 30% increase in your breast cancer risk compared with that at 20. And for each year that you delay that increases. I'm not advocating no one uses any contraception. I'm just saying if you're looking at individual risk for somebody that is one of the factors that you need to incorporate. Um when we're talking about having Children, one of the hugest risk factors for not having multiple Children is actually affluence because 100 years ago, people would have had huge families in some societies that still continues because Children were dying of diphtheria or infectious disease or mothers were at risk of such things as well. And that now is not the situation. This is a wet nurse. So, in the middle ages, if you had a baby and your next door neighbor had a baby and in childbirth, that woman died leaving that child. And we've just seen the dreadful pictures from Syria and Turkey about such awful catastrophes. You would take that baby and you would breastfeed it. And for each year that a woman breastfeeds, they have a massive reduction in their own risk of about 4.3%. Now in the UK maternity leaves about six months. And we see women coming back into the workplace expressing milk for that baby. Um As you know, breast milk is incredibly important because it has um factors that protect against infection of all of the diseases that that woman has had that are infectious in her lifetime apart from chickenpox. And it also protects against gastroenteritis. So incredibly important for the baby, particularly if you're leaving it for someone else to feed and also protects against cot death. Now, we know that cut deaths are deaths within the first year of life which are not accounted for by any subversion or trauma or infection. These are simply unknown deaths. And we know that breast fed babies have less cot death. And also when you're feeding, um the breast feeding takes quite a long time and there's a lot of interaction between the family and the baby. So these babies tend to be intellectually advanced. There's huge impact from breastfeeding. Apart from the reduction in risk to the mother of breast cancer, at some point, you will offer patient's cycle hormones or you yourself will take them. Someone will say you've got heavy periods or you've got polycystic ovaries or you need contraception. And if you take the combined pills, so this is the pill that has estrogen and progesterone in it that you normally would take for 21 day days and then break for a week or three months and then break for a week. There's an increased risk after two years of breast cancer. Now, in a young woman where the risk of breast cancer is less than one in 1000 then that risk increase is very mild. If you take this pill for four years, um for that time, plus another 15 years, there is protection against ovarian cancer. And this is incredibly important when we come to look at genetics. Um Generally speaking, women who are using oral contraception being monitored. Certainly in this country, I dread to think what's going on in yours um where people are teaching breast examination, um and monitoring BP and stuff. So um these cancers tend to be less aggressive. I think that one should stress the patient's that um the pill may be absolutely what they need for all the reasons that their, their physicians or nurses would advise. But they should be aware of this breast cancer risk. I think um one of the problems that we have in our country is a lack of exercise and increased body weight. Now, I said to you before that the predominant age at which people develop breast cancer is between 50 and 60. And I also said the estrogen was key. And obviously, um if your menopausal, where is this estrogen coming from? And we know that one metabolizes fatty tissue to estrogen and therefore, that is stimulating the breast and also the uterus. So, endometrial cancers are more common and also um carcinoma of the breast. Uh I hope you can hear this. The audio isn't being shared. Okay. So we'll correct that shortly. The point of that really is to say um the exercise is incredibly beneficial. Um If one does three hours of exercise a week, um there's a massive 30% reduction in individual risk of breast cancer. So whatever one's risk would be, it's reduced by 30%. And what we encourage our school um uh population or university population to do is build that into their lives. Often, this is the first time your students perhaps are living independently. And um if you can encapsulate some kind of exercise, whether it's kickboxing or jogging or swimming or walking, whatever you want to do um during your week, then and, and continue that for your life, then that is a massive reduction and it's very easy for people to build into their lives. Um when we're talking about alcohol, we know that from research that we've done in our school cohort port populations that between 16 and 18, about 10% of them will already be binge drinking and alcohol. Even a small amount is really problematic for breast cancer. So for just one unit, which is a glass of wine or half a pint of beer, there's a 7% increase in an individual's risk of breast cancer for each unit regularly consumed each day. So something when we talk to the universities were told that actually everything that sociable revolves around alcohol. And I think culturally, that is something that we could do something about to reduce breast cancer risk. Obviously, when we're talking to young students while smoking isn't particularly a risk for breast cancer, we talk about all of the cancers that can be promoted by smoking both splits and also um cigarettes. Um and particularly obviously cervical cancer. Thank you. So you may not recognize this chap in England. He's extremely famous. He's a chef. Um He's now very bald. And about 15 years ago, he set up a teaching program for schools looking at how much saturated fat people were consuming. So this is animal fat as you know, um from either dairy products or from meat. And what he was advocating was less, we would support that because if you barbecue meat, but particularly those delicious burnt bits um that is incredibly carcinogenic. So we would advocate stewing rather than barbecuing, having meters a treat. And obviously for the next generation and for individuals, for their bone strength, one would like them to have calcium, but there are other kinds of milks that one could consume rather than dairy. Um And certainly skim milk has higher calcium rates than full fat milk. Uh So we still would like people for the next generation to have an adequate calcium. Um This is one of monies, amazing pictures um promoting um plants making their own food in the presence of sunlight. Um And obviously we do the same through our skin's making vitamin D and in Northwest London where we work, people are very covered up. Um And vitamin D levels are incredibly low, hence the increased risk of M S um but also breast cancer. So if you can get people to have breakfast outdoors, roll their sleeves up, have their faces exposed before the heat of the day and then maybe when they're walking to school, just roll their sleeves up. And similarly, after that time, put block on, move into the shade and the Australians would advocate wearing a hat. These are obviously skin cancer melanoma type risks, which we would also promote. Um I think any of you who plan to do your medicine on Mars will run into the problem that radiation is an issue and NASA will be working incredibly hard to protect you both on the journey. They're on the journey. Back and whilst you're there perhaps underground, because we know from studies of air hostess six who flew on Concord that when they were flying high in the ozone layer, there wasn't enough protection from the radiation of the sun. They got more breast cancer than other air hostesses. And similarly, when you're looking at patient's and advising them to have chest x rays, do they really need yet another chest X ray? Because we're offering radiation to the breast at that point? Be thoughtful about what you're using. Um Obviously, in this talk, we are only talking about cancer. Um There are many other types of benign lumps within the breast, both fatty and uh innocent breast lumps. Um Here, we're only talking about breast cancer risk. So you, well, we've sent you a leaflet which you can look at, you can see that this is a sort of schema ties breast with a nipple in the middle. And these are the lifestyle risk factors that you can talk to your patient's about, which will massively reduce their risk. And this reduces risk both in people who have no genetic abnormality and also people who carrie genetic abnormality, it was an inheritance. So as I've said, we've talked about the modifiable risk and now we're moving onto genetic risk. You will see um in this picture, there is a family. Um I think every time we do this presentation, people say, but I can't get breast cancer through my dad's line, can I? And the answer is absolutely yes. So there are genes which code for breast and other cancers, um, particularly Bracha genes which will come onto if you have a family history of breast can answer in a first degree relative. So your mother or your sister that doubles individual risk and the more first degree relatives, the more the risk having said that 75% of people, women who have first degree relatives will not get breast cancer. And that may be either because it's not an inherited genetic risk or because they're leading lifestyle which is protective. We need to talk a bit about Ashkenazi Jews. Now, as you probably know, um, the Jewish population lived in Israel until Babylonian times when they were um uh expelled and went to live in Babylon. Now, um Iraq and then, um the population um somewhat came back after about 70 years and the rest of the population went on to Iran um into Russia, into um Poland Germany. Um, and obviously the Ukraine, um and those populations because of anti Semitism, we're living in risk of isolations, ghettos and around the 13 hundreds and 15 hundreds genes became uh mutated. Um We each have a Bracha gene, we each have a breast cancer gene and at three sites on that breast cancer gene, which are typical to the Ashkenazi Jewish population. Um, there was a mutation and depending on which mutation you have, these are called BRCA, one or BRACA to now the inheritance of these genes is dominant. And as you know, that means that in the same, whereas I color, if you're carrying brown eye color and your, one of your parents has brown eye color, you're going to have brown eye color. Unless they're, they've got a recessive gene which is not, which is being passed on in a different way. So if you pass on a Bracha gene to your, to your Children, then they will acquire risk. So we did a study in the practice looking at genetic risk. We know that this was called the G cap study alongside the University College hospital. Um And the Professor Manchanda, we know that there's an increased breast cancer risk from our studies in our practice of about 1.5 times in Ashkenazi Jews. So this is both premenopausal and post menopausal. Okay. So where, as we've said that 50 to 80% of breast cancers are in women who are menopausal in the Ashkenazi population, there's increased risk both pre menopausally and post menopausal and that's catastrophic for young families. Um If you are an Ashkenazi Jew, this figure has just been updated. So if you take 100 Ashkenazi Jews, probably 2.9% of them will carry one of these, what's called a founder mutation of in the breca domain. And if they have family history, about 10% will carry these genes. Now, because of the Holocaust. Um Sometimes I'll say to patient's to what's your family history? And they say no, I don't have any cancer. And if I say, do you know your family history? The answer is often no, I don't because the family was lost. Um So I think it's very important although people might not be presenting as Jews, um they will have Ashkenazi ancestry and we know that in around the Ukrainian in Russia, there's um particularly increased risk of breast cancer probably due to these mutations. Um Thank you. Now, Angelina Jolie, as you know, is an actress, she's also a, an ambassador for the U N. She's an Ashkenazi Jew. So her mother had ovarian cancer. We know that these braca genes code for breast cancer, they also code for ovarian cancer, pancreatic cancer in bracket two Melanomas Hodgkin's disease, bowel cancer. Um And I think um what she decided to do was get herself tested, um She found that she was also a bracket carrier. She may have taken the pill. We don't know. And if she had taken the combined pill with estrogen that would have suppressed her ovaries for the time that she was taking it. And the optimal time is four years. And then for 50 13 years after that time, she's got support to her ovaries to suppress ovarian cancer. And during that time, she would have her Children, she may well have breast fed, both of which reduced her breast cancer risk and risk to the vocal ovarian cancer. And then what she opted to do was to have risk reducing surgery. So she had bilateral mastectomies and prophylactic oophorectomy. Now, we have patient's in the practice who do this. Um because the lifetime risk of getting breast cancer, if you carry a Bracha gene, which is mutated is between 50 and 80% this is not something that your patient's will just say this is what I've had done. They will have to come through their GP through the general practitioner or through a genetics clinic and have a serious discussion. And at the moment in London, what has been established is that the government this year have decided to offer free breakfast, chef testing to anyone in the community who has one Jewish grandparents. This is Ashkenazi or Sephardi, which other Jews who ended up in the Mediterranean after the second destruction of the temple with evacuation through the Romans. So they went to the Mediterranean. Um And so the those patient, those people at the moment are being offered mouth swabs. Uh and they're supposedly a service supporting their counseling and uptake during the NHS. We also have patient's where there's been massive bracket in the family. You can imagine the devastation when you see grandparents and siblings and parents dying of these cancer related genetic abnormalities. And um we can offer preimplantation diagnostics for the next generation. So some people would elect not to go forward transmitting bracket to the next generation because there's genetic change, it's not all bad. And there are drugs being developed called parp inhibitors. So if you carry bratitude, I had a patient this week who has got multiple primaries at the moment and likely bracket two, there are pump inhibitors which are available that mess up the genetic material even more to treat those cancers and can be hugely advantageous. So just because there's an abnormality, it doesn't mean it's all bad news. We work alongside genetics um in the UK, who have a recessive gene program, but also this year are coming on board um set rolling out this government initiative. So I think you have a family with Bracha. Um then I think talk to their GP offer referral to regional genetic service. Um and I hope those things are still robust where you are. Okay. I'm going to pass on to um Doctor Shelly. Now he's going to talk to you a bit about screening. Okay. So, thank you Michelle. So Michelle's talked about sort of risk of getting breast cancer individual's risk and how, what we can do as individuals to go about trying to reduce our risk. I'm going to talk a little bit about sort of more practical aspects of what of sort of looking up um trying to detect cancers, um patient's and also what patients' can do for themselves and what we can all do for ourselves. So, in the UK, we have a screening program for breast cancer from mammography. Actually, this slide is slightly incorrect. It's predominantly from age of 50. Now, it was 47 but I think it's mainly gone back to 50 every three years. Um Anyone who's registered with their general practitioner as female will be invited for a screening screening mammogram. Um So that's what you probably know the earlier we pick up breast cancer, the more likely is that we can cure it because nowadays, a lot of breast cancers can be cured. And so the screening program is aiming to pick up early breast cancers, which before they metastasize and obviously, when they are more, more treatable and hopefully curative. So just to remind us, excuse me, this is a cross section through the breast on the left and on the right is a picture of the mammogram. And as you know, the radiologists will look at these, often compare them to previous mammograms and decided that any abnormalities, I would have thought probably you've seen a mammogram being done. But if you haven't, we don't know much about it. Basically, you have to go into a small little room in the X ray department. Um And you or the person has to take their top off and the breast is sort of squeeze between two sort of X ray plates just for a few seconds and then the plates are released that way and then usually that way it is a little bit uncomfortable and obviously women have to get undressed and some women find the whole idea of getting undressed in front of somebody else, getting their breast sort of squashed a little tiny bit. They find it very difficult. And the take up of mammography particularly during the pandemic um has been been bad and there's a lot of backlog now and we're picking up a lot more cancers later because people, women didn't go for their mammograms. That's mammography. Now, mammography is not used in young people because um the breast tissue in young people is too dense and the interpretation of the mammogram is too difficult. So anyone really under the age of about 40 if you're worried about breast lump or something abnormal, the breast, then ultrasound or better than that, even MRI scan is much better, very accurate. And it's definitely the way forward for younger people. So it's MRI scan and ultrasound but not mammography for younger people. Okay. This is a slide which I'm sure you sort of had to learn many times over your sort of when you're at high school and now university and this is, you know, the menstrual cycle. And this is just to remind us that there is a huge fluctuation in the hormone levels over the course of the month at the bottom. You've got these sort of uterine low signing the middle, you've got the ovary, releasing the egg and then you've got your hormonal changes and you can see towards the left hand side of the diagram where the sort of the period is going on, the hormone levels are relatively low. And that is when we teach patient's to check themselves or we check ourselves, that is the one you want to check yourself towards the end of the period where the hormone levels are much lower during the month, the hormone levels are swinging, they're very high, particularly the latter part of the month, you got very high progesterone. And that's when the breast can feel a little bit lumpy, particularly laterally. And so I always tell patients to examine themselves after a period for that reason. So what do we tell patients to be aware of all the things that you probably know, I think most people would probably know that a breast lump is what you look for. Um They don't know what breast lump feels like. They don't know how big it is. And sometimes patients don't realize that breast lumps can be very, very small and still be significant. Even I teach the patient's or students when we talk to them, the breast, anything that feels abnormal, it's the change any little tiny bit of something that they haven't for. But before that is significant, yes, we often feel them when they're like a P and I'm sure Michelle and I both unfortunately seen patient's when the breast lumps are huge, you know, they can be like a plum or even bigger than that and they haven't noticed it before. But if patient's get into the habit and if individuals get in the habit of checking themselves on a regular basis, they'll soon know what's normal for them. So, not only breast lumps, but changing the size, changing the shape of the breast and changing the nipple. So this is a painting by Modigliani which just shows that this lady has a breast, her right breast is more than her left. There's lots of artwork in many galleries over the world where there's ladies painted without any tops on. It's obviously what they used to paint. Um And you can see they just painted what they saw. So she has one breast definitely smaller than the other and that was quite normal for her and that's absolutely fine. So what we try and get over to the patient's is what is normal for them. That's fine. Any changes what you're looking for? So what do we tell pages to look for? Lumps, not just in the breast? Excuse me, remember they must check in the axilla as well because for the breast, tail of the breast goes right up into the axilla. And also remember that lymphadenopathy, which often, which often presentation of breast cancer will be someone noticing a lymph node in the, in the axilla. And then they'll go to the brain clinic and they'll do a mammogram, et cetera. So, lumps anywhere in the breast or the axilla dimpling of the skins, just dimpling or any change in the skin, whether it's dimpling, bumpiness, a rash, anything in the skin, maybe significant. So dimpling as you know, is when there could be an underlying cancer and it's sort of tugging at the sort of skin overlying and pulling it in. So you get like a little dimple and then the nipple changing the nipple now says, you know, some women have one nipple that's inverted and that's always been like that. Some women have both nipples that are inverted. If that's always been for them, that's absolutely fine. But we want them to report if something changes, if it looks like it's getting drawn in a little bit or if there's any crusting or discharge anything like that, a change, particularly one compared to the other, they really want to come and get that checked. So this is Rembrandt's mistress. Another painting of a lady without the top on if you look very carefully, her left breast. Um and the latter, I don't if you can see my arrow. But the latter outside the lateral part of her left breast is like a sort of a shadow and that is actually an underlying breast cancer. Again, he just painted what he saw. He wasn't a physician, didn't know much about medicine, but that is what she has got there. Our goal trees like ones. Mhm uh huh Simple in like orange peel speaking nipples nipple which has become turned in any change. Look, get it looked up straight away. Nine women in Scotland will have breast cancer. So don't get scared. Get checked. And we see lots of women who are scared who present late latest breast cancer. I had a lady deferred for two weeks who was completely terrified. And what we want to do is encourage people to come forward in a timely fashion. It's morning. Sorry, I didn't realize you couldn't hear the audio. I might have done something that you might be able to hear it next time. But I apologize. I thank you Michelle for just uh just move on. Cool. 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 dimples skin like Right. Sorry. Right. So that was a health education video by a team in Scotland which just was going to tell women that what sort of things to look for as far as breast cancer or breast abnormalities are concerned. And this is another campaign, this is called Know your lemons and they're just showing they're using lemons to represent the breast and where as you can get different sizes and different things. Looking in a lemon. So they may represent abnormalities in the breast and you can see the second one at the top. So it's an indentation then you've got redness or heat which is often abnormal fluid coming from the nipple, a lump and so on. This is just another representation which can be used to sort of sort of let women sort of see a different idea of what breast abnormalities might be like. This is an old slide going up to 2009 actually, which just shows breast cancer survival rates. And I'm really pleased that breast cancer survival rates have significantly increased since then. And this is actually out of date. So I'm actually going to move on from this. It is the same lady we saw earlier. The one has breast cancer membrane brats mistress. She, this is seven years down the line. She is still alive, which is quite interesting because she had looked like quite a big breast cancer, but she actually doesn't look too unwell. There was very little treatment back in this time to offer someone like this. Okay. So what I want to talk to, you know, a little bit about is is how you check yourself in particular, how we tell patient's to check themselves because know what to do for yourself is not quite the same as checking, patient's attending, patient's what to do. So what we tend to tell patient's is is that they have to get themselves undressed and look in the mirror. Some people find that quite difficult to do. They're not used to getting undressed, looking in the mirror and looking at their breasts. So you have to sort of encourage them to do. So, obviously, usually recommend in the privacy of a bathroom or bedroom where no one's going to burst in. They don't feel uncomfortable and then they want to know what their breasts look like. Normally with their arms down and then lift their arms up because the breast tissue should move up equally, the nipple should move up in line and you shouldn't see any sort of dimpling. Sometimes you only see these things when the breast is lifted up, when the arms are lifted up. Also, when you lift the arms up, the breast comes up and you can see underneath the breasts a bit easier. Remember to check and look into the armpit as well. So the breast is like a target board if you like or like a dart board. So you want to make sure when they examine it, they check all the way around and into the axilla and around the nipple area. So I always used to teach patient, I told you I was retired, but to check the breast with the flat of the hand, not the fingertips, if you do the finger tips, and if patient's do that themselves, that just get horrible red marks on their breast tissue, the best things to use the flat. So maybe three fingers and press down sort of gently but firmly and just roll the breast tissue under their fingers. And that way they will feel sort of a contrast if they just literally press down and lift up. They won't feel very much. You see, the gods will move their hands slightly around in a circular fashion. Every doctor does it slightly differently, but that's the way they want to feel. And this is just reminding us to go up into the axilla. Remember to feel in the axilla as well. Now, we tell patients to do it lying down or I often just take 45 degrees. I often tell patient's to do it in the bath if they have baths, uh an angle of 45 degrees or propped up on some pillows or lying completely flat as well as sitting up or standing up because you will get the arm out of the way and then you expose the whole breast and the thing to do is use the opposite hand. So the right hand for the left breast, okay, much better than trying to examine your left breast with your left hand. So opposite hand for this breast lift this arm out the way. So you've got the whole breast air exposed and the axilla and then do that sort of standing up and lying down. Often it's easier to do it in the shower or with his bath because you hope you can get your hand a bit soapy with some soap on it. And that makes running your hand over the breast and the skin a little bit easier. And this is someone just checking around the nipple. Remember very gently, just feel around the nipple area and maybe just squeeze very gently to make sure there's no discharge or anything coming out. I've got a little video to show you if you just give me one second, I'm going to, if everything works. Uh No despair. Me a second. Can I go back to my other screen to bed me a second? So what we try and get over to patient's is that they need to um Pomalyst see their GP or the general partition if they notice any change. And I think that's the message to get across. There was one of the, the Scottish little video had a little caption which is very good because don't get scared to get checked. Women often very scared young women, mostly as Michelle said earlier, the risk of breast cancer is very, very low under the age of about 30 or 25. It's one in 1000 obviously, as you get older towards the age of 50 and above particularly perimenopause. And after that, the risk is higher that it is going to be something more serious. But we want women to come as a early as possible. So if there's any change, but they won't notice any change or they haven't checked themselves before. So it's really important that we a check ourselves as to keep ourselves healthy and be um that we encourage our patient's to check themselves whenever we can This is Kylie Minogue who some of, you know, is a world famous pop star. Uh and she had breast cancer. I don't know her personal journey, but she, I think she had a lot of treatment many years ago and she seems to be living um whenever we see on television, you know, sort of a wonderful life and which is shows that, you know, if you can pick these sort of cancers up early, there is a lot can be done and hopefully we're looking at cure. Now, we just wanted to mention this company's organization called Copperfield. Copperfield was set up by a young lady who had breast cancer in her twenties. Um And she now runs a similar program to ask. Well, we go into schools, she goes to festivals and talks to sort of women. Usually people all where everyone between the age from 18 upwards, usually about breast cancer, self breast examination and just making sure you can be breast aware. And this program we set up was in memory of these three ladies who were well known to Michele, actually knew the middle lady Nicky who was a teacher at a local school. And the other two were sort of colleagues of us a of Michelle. And in their memory and noticing that particularly in the area that we were working in North West London, and the incidence of breast cancer is incredibly high. And if we can do something to reduce that risk because the impact it has on young families and on all women of any age is enormous. So if we can do something to impact that, that was what we set this program up. So um Michelle, I think we should go to some questions were looking down my slide. Thank you. So I think when you look at research papers, you'll see that um breast examination, self examination is not particularly advocated for older women because mammography is more diagnostic. However, that's how people pick it up. Also partners pick it up. So we had one month where three partners picked up their um their spouses, breast cancer. Um And similarly because of the braca situation in younger women and the increased risk in the Ashkenazi population, we are advocating that we do teach breast examination so that those are the cord is sales really for students. Just want to use that one thing that just to go back to the bracket just to remind you that the majority of breast cancer is not genetic, 90% is probably not genetic. 85 plus percent is not genetic. So that's why although we talk about the bracket testing program, um that is, and if you have in certain communities like the Ashkenazi Jews and other parts across the world, I think Iceland and parts of Netherlands, they have an increased risk of that. It's a small percent. So this is a relevant program for everyone needs to do self breast examination and to encourage patients to do the same to pick up breast cancer and everyone as early as possible. Thank you. Additionally, we have um from the posh study, we have an increased risk in young black women. Um And I think that it's incredibly important to, again, to teach across the board. Um One of our medical students on the team who's now young doctor the first day that she left uh Sy INS and did her BSC with me actually, um, in general practice and then went onto the wards in casualty. They had a very busy day and they just said we'll do whatever you can. And all she knew how to do was examine breasts and she first patient that she examined, she picked up her first breast cancer. Um, and I think that's incredibly important. They were astounded. Um, Simon, I'm going to ask you, um, some of the questions that we get asked frequently. Um, do you have any questions, please feel free to put them in the chat box or you can just put on your mic? I mean, there's only a few of us here do. And if you have any questions, first of all that you'd like to ask us a mute yourself. Really? We'd love to hear from you. Okay. Don't worry. Oh, you can just, if you don't want to speak, you can just type a message in to chat box and we'll, we'll see. But we're going to just share some of the questions that we have been answered by students. Um during the long time we've been doing this presentation. Sure. Okay. So can men get breast cancer? So men can get breast cancer? I think, unfortunately, it's thought by men that they can't get breast cancer. Um So men can get breast cancer. Um It's very rare in men who don't have an inherited predisposition. So in men who don't carry a sort of a breast cancer gene or breast cancer risk gene, um it's very rare but men who do so. So for example, I've got data here which shows breast cancer in men is something that 0.1%. If they've got Bracha one, it goes up to 1%. And if they've got back to, to the mutation, that is, it goes between five and 10%. So men can also just to remind men anyone who is transitioning. So sometimes we have patients who come and says who are transitioning sort of become trans women. So they are taking estrogen hormones. So once they take extra exogenous hormones, particularly estrogens, they will increase their risk um significantly. And therefore they need to go onto the program and even men who are becoming trans women. Um so that women who are becoming trans men um who sometimes take testosterone, we don't know also the effect of testosterone is on breast tissue. So basically, really breast examination is for everyone. But particularly men who are, have Bracha who are recommit Asian positive or other breast cancer risk genes positive or are transitioning. Those are particularly important for them to, to sort of be breast aware. Yes. And we get asked if I have big breasts, will it increase my risk of breast cancer? Okay. That's a really important question. And I think if, if you go into general practice, that be something which patient's are concerned about. So the answer is no in a, in a nutshell. So breast, the breast caps arises in the lobular tissue in the sort of the ducks and the lobular tissue. Okay. Um And the milk ducks, it doesn't arise in the fatty and connective tissue. So in bed breasts, the the sort of the people who very large breasted or bigger breast than others usually is because they've got more fatty and connective tissue doesn't mean they're fat. You can have slim people with very big breast. It just means that area of the body, there's a lot of fat fatty tissue. So they the glandular tissue where the breast and the and the ducks tissue where the breast, all right, breast cancers arise will be roughly the same amount I will add. So they've got the same risk I will add that if you are large breasted, however, it might be more difficult to pick up a small breast lump to feel it. So in that respect, so your risk of getting it is the same, but it could be your risk of picking it up, examining yourself can be slightly more, more difficult and perhaps delay. So that's the only thing I would add to that. And also we do know women who women who happen to have large breasts because they are overweight. As Michelle said earlier, one, particularly after the menopause, menopause, they will in fact have a slightly increased risk of breast cancer. But breasts themselves in people just on its own, the actual size does not make them an increased risk. No, thank you. Um Would you like to comment on wired bras? Yeah, wire underwire bras for, for those that don't know about bras, bras come in all shapes and sizes as they say, and some of them have wires that go underneath the sort of the actual bra bit gives more. Some people find it more comfortable, more support, etcetera, different shape. So there was concerns years ago about underwire bras. No, there's no no evidence at all that underwire bras make any difference. No, thanks so much. Anybody have any questions? Yes, I'll ask you a couple of questions that we get asked. So let's talk about father to have prostate cancer because prostate cancer is very common in men. And what might that be very relation with prostate cancer and my individual risk of breast cancer? For example, can you hear a terrible noise in the background? So, uh as we talked about braca before, if you have braca genes coming through the paternal side, you may see in the father's history, prostate cancer or colon cancer. Hodgkin's male breast cancer. But as Simon said, breast, male, breast cancer is very rare. But we have in the practice, for example, patient's whose fathers have got prostate cancer. And in the next generation, the breast cancers begin and the ovarian cancers. So it's very important that the population gets screened, get become aware of cancers allied to each other. Um And in different ethnicities because that does have a bearing on whether or not there might be a background gene. And as Simon said, genetic breast cancer is rare, but it's more likely if it's young. Um Last week, I had a patient who has three separate primaries all presenting at one time in the same breast, all with different markers. So we know they're all different. And I think instantly that rings bells that, that there may well be genetic association. Um And in the family, um there was prostate cancer and pancreatic cancer in her paternal line. So that's incredibly important. Um I think probably we're just about ending our time with you. Um If you have any, any questions, do please just a mute yourselves and ask them however benign they are that you think um I think one of the things that we do find with students is when we go to do small groups of breast examination because we have models that we demonstrate on. Um It's very rare to have a student who says, no, I don't want to examine that model and I think it requires gentle probing as to why they won't do that. Um And often it's to do with either family history or there's been some kind of abuse. Um So we do take um students off 1 to 1 um if they have further questions and we try to address those things. We also send out a parent leaflet before the presentation, not obviously to the university, but so that to warn parents about what we're going to be talking about and we sometimes get father's ringing up saying look, I've got Bracha, I haven't told my Children yet. How can I talk to them about it and we discuss that. Um We've got some questions coming. Now someone do benign breast tumor's always have to be removed even if their noncancerous. Are there other ways of differentiating benign breast disease from cancerous ones other than a biopsy? Um No, I don't always have to be removed. I mean, if there's any diagnostic doubt, I mean, I think a lot of women do not particularly want to walk around with any breast lump. And I think a lot of if you can biopsy obviously and you're absolutely certain that it's not a breast cancer, then yes, I mean, there are little fibroid enemas which are very common. A lot of women do have them removed. I mean, are there in different ways? Yes, probably there are. I mean, as, as an MRI scan, which I told you about earlier is something which, uh, and quite as sort of looked at the breast tissue and can differentiate between what might look abnormal or not. It'll be up to the surgeon and up to the patient whether or not based on that fight those findings, they decide they ought to have the breast lump removed. But a lot of women don't want to walk around with a lump in their breast. Michelle. Would you add anything to that? I think. Absolutely. I think most people would have them removed and want to have them looked at histologically. Um Hey, at the moment, we have a two week referral service. So anybody who has a lump, particularly, you know, if somebody's presenting with an axillary lump, they do not go and have an ultrasound through their GP, they will get referred directly through the breast team. Um and have um immediate biopsy. Um I have somebody who presented a few weeks ago with a big mass under the axilla that was rapidly enlarging, I think probably TB actually. Um but anybody who, who has an axillary mass, even if you can't feel anything in the breast, refer that through the breast team. Uh Did you put your hand up? You want to? Uh Yes, yes, ma'am. Uh I had a question regarding how much as in, in the, in the dignity you just showed, you said lifestyle can affect. But the chances of having breast cancer or not. And week 33 hours of weekly exercise reduces the chances as in what are the other lifestyle habits which can increase the chances? Like I've heard many times like smoking and alcohol can increase the chances. There was one time when I read an article in the newspaper, whether use of perfumes, our deodorants have some sort of influence the chances of getting breast cancer. Is it true that these smoking and alcohol does affect or have a huge influence in regarding this? So, um we've talked long, hard and hard about this. So if you remember there was a picture of a man having a drink in a pub and that's, they're deliberately because we think that alcohol is really a problem. You have a 7% increase in breast cancer risk for really quite a small intake, just one unit a day. Um And particularly when you've got people leaving their family homes and going off to independent living either through study or apprenticeships or whatever else is going on, then there is a risk that they become involved in um alcohol free environment or alcohol ridden environment rather. Um And that is really a problem. Smoking is not particularly of any risk to breast cancer note. Um But I think certainly it's a recap the lifestyle measures, breastfeeding, really important. You have a benefit of about 4.3% for each year that you breastfeed, um, having babies early, um, not drinking alcohol exercise for three hours a week, which can just be walking. Um, and, uh, if you need protection from the pill for your ovaries, um, then that would be very beneficial but to think carefully about who you're prescribing the pill to otherwise because there is a slightly increased risk, although it's small and there are other things that you can give contraceptively. Um and then um keep the weight down so that by the time people are menopausal, there isn't that increased risk of estrogen floating around in the body to stimulate both the breast and the uterus. How?