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The noise uh uh through the nose, sorry. And the sphenoid sinus, all right, and then on to breast carcinoma. So, the risk factors for breast cancer are increased age smoking as it is with everything. Um family history. So that's BRCA one or two and then tp 53 high um estrogen exposure. So, exogenously, that would be if uh women have been taking the combined pill or HRT and then endogenous ones are um if they um if they had early menarche or late menopause or annularity because all of these sort of increase the amount of uh time where there's high estrogen levels and then certain environmental factors as well. So, irradiation due to multiple x rays or CT scans and then shift working. So apparently there's some evidence that lower melatonin is associated with an increased risk of breast cancer. So, symptoms that patients can complain about. So, a painless lump, usually um skin changes, nipple changes, uh So, inversion, any discharge, axillary lymphadenopathy. Um and uh if, if sort of the the the disease is quite advanced, then you can get bone pain um due to it's supposed to say bone me, sorry. Um And then you can get sort of respiratory uh symptoms as well. So, shortness of breath, shortness of breath, cough, pleuric, chest pain, if there's any um lung metastases. So there are different types of breast cancer. So, it's based on histological features. Um So you've got ductal breast cancer, um lobular breast cancer, and those are then further split into ductal carcinoma in situ or invasive ductal carcinoma and then lobular carcinoma in situ and invasive ca um invasive lobular carcinoma. So, the most common form is ductal carcinoma in situ. So that refers to sort of the proliferation of the cancer cells that haven't breached the basement membrane. So in situ means it hasn't breached the basement membrane and so it doesn't metastasize. So it's kind of considered pre malignant um in a similar way, lobular carcinoma in situ hasn't breached the, the the basement membrane yet. But you, but the more common cancers are found within the ducts as opposed to the lobules. Then you've got an inflammatory breast cancer which is a rare and very aggressive uh form of breast cancer. So this is where the cancer cells sort of block the lymph vessels in the skin of the breast. So patients will complain of skin changes. So it, so it can go erythematous, it can look pink purple, it looks like it's quite bruised and it affects more than a third of the breast. It presents quite rapidly. Um And you usually can't really feel a palpable lump. Um and then the skin can also take on an orange peel appearance as well. And it's often mistaken for a mastitis at first, but it's a very aggressive form of uh breast cancer. And then the mucinous breast cancer is very rare. Um It's also invasive. It starts in milk ducts and then can spread to other parts of the body. It's called mucinous because the cancer cells are surrounded by mucin, which is sort of like a jelly like substance. And then you've also got this unique presentation where patients typically um complain about eczema like changes around the nipple areola complex. Um It can be associated with underlying ductal carcinoma in situ or invasive ductal carcinoma. So, it's called Paget's disease of breast. So you have changes in the shape of the areola or nipple. You can get discharge um discoloration or redness, dryness or flaking inversion of the nipple or a knee itching as well. So you would want to refer for a two week wait and the criteria for a two week wait. Um is any woman over the age of 30 with an unexplained breast lump can be painful, but it, they usually are painless and you would still refer and then you would also refer on an urgent basis and you one who's over 50 with unilateral nipple discharge or retraction. So, unilateral nipple symptoms, you can consider um a two week wait. If there are skin changes that are suggestive of breast cancer. And then if there's um any unexplained axillary lymphadenopathy, if you feel any lumps in the axilla and the woman's over 30 then you would refer them as well. Um As a two week wait, if a woman is under 30 with an unexplained breast lump, um then you would consider a non urgent referral. So the age is really key. So the key one to keep in mind is 30 years old. So the investigations that you do like some you mentioned the triple assessment when they get seen at the One stop breast clinic. So that's a breast examination followed by imaging. So it's um either a mammogram or ultrasound. So you would do an um ultrasound in um younger women. Does anyone know why? Yeah, exactly. So in younger women, the breast tissue is quite dense and so it's re on mammogram, it's really hard to distinguish whether what they're looking at is breast tissue or whether there's an actual sort of mass there. And then you would want to um either do cytology or histology. So, cytology, you would, you, you would do fine needle aspiration of the lump and then histology. Um you would do a core biopsy. I think it's just a difference in the needle size and also what you're looking at. And so the management of um breast cancer um breast conservation is preferable, but it's not suitable for everyone. Of course, it depends on the staging of the cancer. Um So in terms of breast conservation, you can either do a wide local excision or oncoplastic breast conserving uh surgery. Um This is just a um a diagram as to what they do. Um But what, what happens in these um in these methods is they try and preserve as much breast tissue as possible. Um And um that, that also tends to have a sort of better impact on the woman's quality of life after the surgery as well. But if it's quite widespread or if there's sort of um quite extensive spread to the lymph nodes, um then you may need to do mastectomies and there are sort of various different types of mastectomies. Um So you can get, um, so you can do a simple mastectomy, uh a skin sparing, mastectomy, nipple sparing or a modified radical mastectomy. So the, so there's just a picture here to demonstrate what the, what the difference is between all of them. Um I wouldn't get too bogged down about the details, but this is just to illustrate that there are various options. Um All right. And then you can, if, if the um if the case or the pa or the sort of stage of the cancer, um sort of requires it. You, you do usually do radiotherapy for all patients really. So, adjuvant just means you're doing it after the operation. So with wide local excision, you're doing whole breast radiotherapy, then with a mastectomy, you would only really do radiotherapy for sort of t three t four tumors or if there's four or more positive nodes. And then chemotherapy, you can give neoadjuvant. Um So that's when you give it before the surgery and that's to downstage the, the tumor prior to excising or prior to operating. And then adjuvant you would give, especially in cases with axillary node involvement because then your chemotherapy is a systemic, um it's a systemic cytotoxic um therapy which then can um really effectively target the nodes or any malignant cells in the nights. And then you can also have hormonal um hormonal treatments. So this is again adjuvant. So this you usually give after the surgery. So in um estrogen receptor, so er stands for estrogen receptor positive cancers. Um There are sort of 22 types that you can give based on whether the the patient is premenopausal or postmenopausal. So, tamoxifen is what you would give for um is what you would give to women who are premenopausal. Um So that's on the left hand side and then on the right, you would give aromatase inhibitors and these are to patients who are postmenopausal. So this is because there's, there's sort of not much um postmenopause, the bulk of the estrogen is coming from the conversion of androgens into estrogen. Um If the cancer itself is estrogen positive, you want to limit how much estrogen is in the body. So, if you give an aromatase inhibitor, aromatase is the enzyme that converts the androgen into the estrogen. So, if you inhibit that, then you inhibit how much estrogen or you decrease how much estrogen is in the body. And then you can also give a biological um adjuvant therapy for her two positive cancers. So, the classic one that you need to remember is um Herceptin. So, breast cancer is sort of overexpressed to her two receptors. Um and so Herceptin sort of um goes in and blocks that. And so it will decrease the division and the growth of the, of the malignant mass. All right. So we'll talk a bit about two week referral and how it will come up in an ay. Um So, oh yeah. So usually um when patients come in with a lump, they don't know that they're going to be referred to a two week wait and to a lot of patients being referred to two week waits may seem like a reality of they having of them having cancer. But in, in actuality, a lot of people who get sent to the one stop breast clinic don't actually end up having breast cancer. But in a communication station in Os, it's, it's quite likely that it would come up as a breaking bad news station. So in terms of how you would structure that you would use the spikes framework, which we will go over in the next slide, you want to ice them. So ask them about their ideas concerns expectations, reassure them that two week wait does not indicate cancer, but it is a possibility. So don't give them false hope. Um And that you're sending them to the ones stop breast clinic because um whatever they found on examination requires further investigation, but also sort of offer them differentials of breast lumps if, if that's what they've come in with um to put their mind at ease because breast cancer is probably the only thing that's on their mind and then highlight the importance of a two week wait. So um ear so early detection is linked to better outcome. So just to make sure um or ensure that people actually go to their appointment and then of course, make sure that you're actively listening to the patient and demonstrate the so the spikes framework. Um so the and spikes stands for setting. So it's, it's very important that you set up the meeting in a warm welcoming way. Um If the patient wants their family or close friends to be there to support, just make sure that these people are included as well and it's not neces, it's, it's quite nice to not have to rush into news like this. Um sort of take a moment to connect and build a rapport with your patients whether you understand it or not, it, it may be something that changes the patient's life um especially if they're quite an anxious patient. So take your time and show empathy, um P um is perception. So this refers to the patient's current level of knowledge about their medical issue and their thoughts. So this is sort of their, their sort of ice the ice bit. Um at this stage, if they don't quite understand what's going on, there's don't, don't sort of jump into um to challenge what the patient believes or any inaccurate, um inaccurate beliefs or opinions that they have just, just be there to listen. And then I is for invitation. So at this stage, you wanna ask the patient, if they want to know any details of their condition further or any treatment, they might face what, what the two week wait entails. Um If they're not ready to hear about it, if they don't want to, you don't have to force them. Um and then wait, so essentially wait for permission from the patient before telling them um what you want to tell them. And then, OK, so that's knowledge. So you're gonna share the information with your patient again, try and chunk and check. So if you're telling them sort of one point, um ask them to repeat it back to you to see if they actually understood what you were telling them um than e for emotion. So it is breaking bad news. So um sort of what you've set up in your setting at the beginning will then hopefully allow your patient to express their emotions. Um And then for you to express your empathy and then s is the strategy in summary. So end the meeting on sort of an action plan of what's going forward. So what's gonna come next? Summarize your thoughts and the understanding of how the patients reacted and then set any expectations for the next time you're gonna see the patient or um for what's gonna come at the two week wait appointment and then on to the um screening program for breast cancer. So, in terms of who is invited, so it's women between the ages of 47 and 73. So it used to be 50 to 70 year olds, but they've changed that now. Um and they've sort of um expanded it three years, either side. So they're called every three years. And um they are um what essentially happens is they um undergo a two view mammogram um to visualize the breast tissue in both breasts. So, can anyone think about any drawbacks to the screening program? So, of course, early, early detection means early um early treatments and can lead to better outcomes. So that's the main benefit for any drawbacks. Ok. When did they change it? I'm not quite sure. I think it was quite recently. Um I think it was last year. Yeah. Exactly. Patient anxiety. Mhm. Yeah, I could find something benign. Yeah. Yeah. Exactly. Yeah. So the, the main ones are anxiety, especially if the patient has to be recalled. Um unnecessary biopsy, like someone's head and then um also it detects disease that probably would never have progressed into something invasive of any clinical significance. So, yeah, cost as well. So in terms of how you communicate this to the patient in an OS station. So you take a brief history, um you try and establish what the patient sort of knows about the screening program, ice them and then explain what it entails and explain what to expect on the day. So, um so it's, it's something that's offered to women, to women between 47 and 73. Um uh You'll be called every three years and they'll take images or they'll do um an X ray essentially of the breast to detect any changes and then to summarize and then address any concerns that they have. Um Also some key details is explained that all mammograms are usually carried out by females. It can be uncomfortable but not painful. Um The patients are usually invited to the screening program by a post. So to look out for that, um the appointment sort of lasts around 30 minutes. Um And um sort of explain what what is actually gonna happen. So um in order to image each breast is gonna be placed in, turn on the mammo on the mammography machine and then compressed with a clear plastic plate and then um and then explain that some patients may find this procedure uncomfortable as well. Um And then after screening, it's important to discuss next steps. So the patients will be contacted from the breast screening service regarding their results. And if required any follow up will be arranged. Um around one in 20 patients require further tests, but most of these will not have a breast cancer. And then of course, um make sure that you're demonstrating active listening and empathy during all of this. Um And I think, I think that's it for from my side. So if anyone has any questions, feel free to pop them in the chart and do stay for osteopro, it would be really good to sort of um to practice the communications uh side of um the screening program and explaining two week weights and stuff. Thank you. Thank you, Shivani. That was really useful. Um Can, yeah. So just with the oy practice, do stay for it because it is useful and if you are planning on staying for it, can you just pop a yes in the chat. Just so I know how many people are gonna stay. Um because on meal you have to like assign people to breakout rooms. Ok. So, so far there's four of you. So our facilitators are Marianne and Nana, who I can see are on the call right now. I don't know if you guys want to introduce yourselves. Hello. Uh My name is M one of the fifth years at Manchester. Hi, I'm Nina. I'm one of the fifties at Manchester too. Ok, great. Um And then I'll just send the feedback form. That's the link for the feedback form in the chart. You'll also get an email to you automatically. So, yeah, and then I'll just tell you which breakout rooms to join. If you just click the breakout sessions tab on the left, you can just pick the one you need to join. So maybe um Joseph and Sanna if you join Miriam's room and then fat if you join Nana's Room and then Deborah, if you join War's Room and if any of the rest of you want to join, just join anyone. Is it all right? If I head off Pavia. Oh yeah. Yeah. Yeah, that's fine. Thank you. Thank you. So if you just click on the breakout, so to the left of the screen, there's like a list of things that say main stage breakout sessions, event, and phone sponsors. If you click on the breakout room sessions, um it should give you the option of joining any of the three breakout rooms. Just join probably either Nanas or.