From shape changes to skin rashes, you may not be aware of the more unusual symptoms. Here’s how to recognise the crucial signs. Photo / Getty Images
From shape changes to skin rashes, you may not be aware of the more unusual symptoms of breast cancer. Here’s how to recognise the crucial signs
As a health journalist, I’ve both read and written many stories about breast cancer. They often start in a similar way, with a woman feeling a lump in her breast. But when I was struck by the same disease, in August 2021, my symptoms were quite different.
The first sign that something was wrong had occurred several weeks before. In the car on the way to the gym, I noticed my right breast was tender where the seatbelt pressed on it. I’d often read that breast cancer isn’t painful, so I mentally ruled it out.
But a few days later, after a shower, I noticed the same breast appeared slightly higher than my left one. That didn’t worry me much either. Like most women, I’ve never been completely symmetrical and was even less so after menopause. I’d even been to see a GP a few years before about my growing wonkiness but everything was fine. This time I felt for a lump, but both my breasts had always been so lumpy that it was like looking for a needle in a haystack. I decided to put the matter to one side until after our family holiday in Norfolk.
But the feeling that all was not well nagged at me. After a shower one morning, I noticed my right breast was now definitely higher and felt a little firmer. On instinct, I raised my arms over my head to see what would happen. To my astonishment, the base of the right breast tucked inwards and became completely straight.
At that point, I emailed my GP surgery, still sure it was a cyst or some other benign condition. My GP called back within hours, asking me to come into the surgery immediately. After a brief examination, she made an appointment for me at a hospital breast clinic the next day. There, I had a mammogram and a series of biopsies. A week later, on September 2, I had my diagnosis. I had an extremely aggressive form of breast cancer.
There are about 55,900 new breast cancer cases diagnosed in the UK every year — that’s more than 150 every day. One in seven women will develop breast cancer in her lifetime. According to the charity Cancer Research UK, breast cancer is the most common cancer in the UK, accounting for 15 per cent of all new cancer cases. And my story shows the symptoms may not be what you might expect.
Professor Zoe Winters is a consultant oncoplastic breast surgeon and professor of breast surgery at University College London. “Lumps are the dominant symptom of breast cancer,” she says, “and we can get completely focused on them. But they are far from the only sign.”
It’s vital to be aware of unusual signs and symptoms, says Dr Stephen John Sammut, a clinician scientist at the Institute of Cancer Research in London.
“Around two-thirds of breast cancers are found by women noticing breast changes and getting these checked out by their GP,” he says. “Being breast aware means getting to know what your breasts look and feel like normally for you. The earlier breast cancer is detected, the higher the chances that the treatment will be successful.”
My own treatment took over a year and involved months of chemotherapy, targeted therapies to intercept my rogue cells, a double mastectomy with reconstruction and 18 sessions of radiotherapy. But, because my cancer was caught early enough, two years on from my diagnosis, my doctors believe I’m cancer free and likely to stay that way. I feel good, and I feel lucky.
Dr Sammut, of the Breast Cancer Now Toby Robins Research Centre, says to look out for the following potential symptoms:
The two biggest risk factors for breast cancer are sex and age. Women account for more than 99 per cent of breast cancer cases. Breast cancer is rare in men. “The most common symptom for men is a lump in the chest area,” says Dr Sammut.
“Around 80 per cent of breast cancers occur in women over the age of 50 and one in four cases are diagnosed in women aged 75 and over.” Only 5 per cent of breast cancers occur in women under 40. “For both men and women, having a family history of breast cancer is a risk factor, and there are some lifestyle elements that may affect your risk.”
Dense breasts are those with a high proportion of breast duct tissue compared with fat. They are usually an inherited trait. Professor Winter says having “dense breasts” can raise the risk of developing breast cancer significantly. This is because they have more cells that can become cancerous. Nearly half of women — 40 per cent — have dense breasts that double their breast cancer risk, while 10 per cent have extremely dense breasts that raise the risk between four and sixfold.
Professor Winter says dense breasts can be seen only on a mammogram. They cannot be felt and have nothing to do with breast size. Women are not told their density score after NHS mammograms, which she says is wrong. “Every woman should understand their density score.”
According to Cancer Research UK, having a mother, sister or daughter diagnosed with breast cancer approximately doubles the risk of breast cancer. This risk is higher when more close relatives have breast cancer, or if a relative developed breast cancer under 50.
The most common inherited mutated genes associated with breast cancer are called BRCA1 and BRCA2. One in 400 people carries a faulty BRCA gene. Out of every 100 women who have a BRCA1 gene mutation, 65 to 85 will develop breast cancer in their lifetime. In women with the BRCA2 gene, about 40 to 85 per cent will develop the disease. However, new research, funded by the Medical Research Council and led by the University of Exeter, suggests the risk may be much lower — about 20 per cent — if you carry a gene variant but don’t have family members who have had breast cancer.
There are several other inherited genes associated with a greater risk. Professor Winter says, “Gene mutations associated with breast cancer also cause other cancers, primarily ovarian, pancreatic, thyroid, colon cancers, melanoma and high-grade prostate cancer.” However, Dr Sammut says, “Only 5 per cent of breast cancers are due to inheriting an altered gene. If you are worried about your family history, talk to your GP, who may refer you to a specialist family history clinic or regional genetics centre, depending on where you live.”
If you are considered at higher risk, you should be offered additional screening from a younger age. NICE guidelines say this could include annual mammograms or MRI scans. Women with a risky gene variant may choose to take medication to lower hormone levels to reduce their risk or have preventive mastectomies. High-risk women with a faulty BRCA gene who have risk-reducing mastectomies cut their risk of developing breast cancer by up to 90 per cent. However, this doesn’t mean it cuts the risk of dying of breast cancer by this much. Opting for enhanced screening to pick up early signs of cancer could mean the risk of dying is reduced only 8 per cent in women with the BRCA1 mutation and 3 per cent in women with BRCA2.
“Breast cancer results from a combination of the way we live our lives, our genes and our environment,” says Dr Sammut. “Unfortunately, we cannot predict who will get breast cancer. However, there are some lifestyle factors that may affect your risk.” He suggests:
He says: “There is growing evidence that smoking slightly increases the risk of breast cancer and the younger a woman is when she begins smoking, the higher her risk. The increased risk remains for at least 20 years after stopping smoking.” Compared with women who don’t drink at all, women who have three alcoholic drinks a week have a 15 per cent higher risk of breast cancer.
Studies show women who take regular exercise are up to 20 per cent less likely to develop breast cancer. This benefit is seen most clearly in postmenopausal women. Even brisk walking can cut breast cancer risk, but former breast cancer surgeon Liz O’Riordan, who is now a cancer patient advocate and educator, says: “Aim to get at least 30 minutes of aerobic exercise, three times a week, and two 30-minute sessions of strength or resistance training a week.” This can be done at the gym using weights machines or at home, or by doing pilates or any training that involves body-weight exercises such as planks and push-ups.
Professor Winters says the breast cancer risk from “old-style combination synthetic” HRT for menopausal women equates to “an extra nine to 34 cancers per 10,000 women”. But, she says, “with modern lower-dose HRT, the risks are probably lower now.” She says the safest way to take HRT is oestrogen alone via patches and gels, “as this doesn’t increase breast cancer risk”, but that’s only for women who have had a hysterectomy. If you have a uterus, you need to take progesterone, “which does increase risk”, to protect against womb cancer. For these women, Professor Winters suggests taking transdermal HRT via patches or gels, plus micronised progesterone in a tablet (Utrogestan) or a Mirena coil.
If you experience any of the cancer symptoms mentioned here, make an appointment to see your GP. You might want to make a quick note of when you first noticed your symptoms, the date of your last period, if you have them, and when you last had a mammogram, but the most important thing is to see a doctor as soon as possible. If your doctor decides to refer you to a breast clinic, they can do so with an urgent or non-urgent referral.
In the UK, urgent referrals are also called Two Week Wait referrals, because your appointment at the breast clinic will be within two weeks. Non-urgent referrals can take 4-6 weeks. Your doctor might decide to refer you with a Two Week Wait referral, to make sure you are seen quickly. This does not mean your doctor is convinced you have breast cancer. Nine out of 10 people referred do not have cancer. Dr Sammut says, “Over 90 per cent of people with breast cancer symptoms have a diagnosis confirmed or ruled out within 28 days.”
In New Zealand, women aged 45 to 69 are entitled to free screenings.
In the UK, “Women over the age of 50 are entitled to have breast screening every three years on the NHS Breast Screening Programme”, says Dr Sammut. “You will be invited up to the age of 71.” After this age, if you still want screening, you will have to call your local breast screening centre to request an appointment. Professor Winter says, “I advise women to never stop screening.”
Mammograms can miss up to 40 per cent of breast cancers in dense breasts. This is because fat looks black on mammogram images while both breast duct tissue and tumours show up as white. Cancer Research UK is conducting a trial to see if adding extra screening with ultrasound or MRI between mammograms can improve detection.
The good news is that survival rates have doubled in the past 50 years. Overall, 76 per cent of patients survive for at least 10 years. In women diagnosed between the ages of 55 and 64, almost nine out of 10 women (87.2 per cent) survive for at least 10 years.
Cancer Research UK says almost 100 per cent of women diagnosed at stage 1 will survive for at least five years. At stage 2 the figure is 90 per cent, and at stage 3 it’s over 70 per cent. Stage 4 cancer is when the cancer has spread to other parts of the body. This is considered to be incurable, but more than 25 per cent of patients will survive for at least five years, and more and more women are staying well for many years thanks to modern drugs.
The Princess of Wales is said to be focusing on her cancer recovery.