14 Mar 2023

The essential facts about Breast Cancer you need to know

How common is breast cancer in midlife? What are the latest treatment options? How do menopausal symptoms impact recovery?

Katie speaks with her father, Professor Michael Baum, a retired surgical oncologist who specialised in breast cancer treatment. He shares his insights and expertise based on working in this field for more than 50 years and explains how diagnosis and treatment of breast cancer has evolved over the years and just why he's optimistic about the future of breast cancer research.

Listen to the full conversation in The Latte Lounge podcast episode above.

Tell us about your own life in terms of how it was touched by breast cancer at a relatively young age and how that inspired you to enter this field of medicine?

I always wanted to be a surgeon.

And so after I qualified in the 1960’s at Birmingham University, I immediately embarked on a programme that would lead to me becoming a fellow of the Royal College of Surgeons (FRCS) in 1965.

My first consultant appointment was in Cardiff University Hospital, where I was a Senior Lecturer Consultant. I was very happy there, but at that time, my mother developed breast cancer. To say she developed breast cancer really understates it. She presented with bone metastasis.

So the first time I knew that she had breast cancer was when she complained of severe backache. She had obviously had cancer for a long time, and by the time it became clear that she had bone metastasis.

In those days, the treatments were pretty dreadful.

She was put on a cocktail of cytotoxic drugs, which, frankly, made her worse. She lost her lovely black hair, became bald, and didn't have enough analgesia for pain relief.

I became angry. I hated breast cancer and I was going after it.

Some years later, my young sister developed breast cancer and she remained well for 25 years, but sadly a few years ago, she developed secondary’s. So you can understand why I feel passionate about the subject.

breast cancer ribbon

How common is breast cancer now, and how has treatment evolved over the course of your career?

About one in 11 women develop breast cancer, about 55,000 a year in the UK, although the numbers might be inflated by "over-diagnosis" resulting from screening (vide infra).

The way to analyse how we are doing with treatments is to look at it in two ways:

One way is to look at the success of the treatment of breast cancer by where it sits in the "mortality league table". It is now relegated to seventh in the league, and so we look upon breast cancer these days as a curable condition in most cases. 

The other way of looking at it is for women to be more concerned about other diseases. Why obsess about breast cancer? Well, I know why, because it's got a long history.

It's a challenge for a woman's identity, particularly when the breasts are removed.

Although thankfully, due to the skills of some of the best cosmetic surgeons in the country, reconstruction after surgery does make an enormous difference to the emotional recovery for many women post mastectomy. 

These days, women should be more concerned about dementia, coronary artery disease, heart attack, strokes and osteoporosis, which are much more common causes of death than breast cancer. So, it's a double-edged thing, other diseases/illnesses are becoming much more common, whereas breast cancer remains at a fairly constant incidence rate and the mortality rate is falling. 

RELATED: My Story -  Breast cancer and the Menopause

How has treatment evolved? You were involved with breakthrough treatments in the very early days of tamoxifen. What sort of treatment options are now available and how that has impacted survival rates?

When I became a Fellow of the Royal College of Surgeons in 1965, one of the questions on the written paper was “how do you treat breast cancer”?

And that was an easy question, because everyone knew (or thought they knew) how to treat breast cancer - radical mastectomy.

But, 50% of these women were still dying within five years.

It was a battlefield. I was part of that battlefield against radical surgery.

And we now accept without question, in the vast majority of cases, you can adequately treat the local disease by removing a lump and treating the rest of the breast with radiotherapy.

Radiotherapy can be an external beam or internal beam (that's another story), but the cosmetic results are really very good. So, the good news is that most women are no longer ‘mutilated’.

However, there are some cases where there is  more than one focus scattered across the woman's breast, these multifocal cancers inevitably require a mastectomy.

But thankfully as I mentioned above, from a cosmetic point of view, the progress in reconstruction after surgery, by plastic surgeons, has been fantastic. 

But, however well you control the local disease, the threat to the woman's life, the distant metastases, or secondary’s are potentially still sitting there, asleep.

They have already disseminated and many of them are latent, and they can make themselves known at a later date.

But if we anticipate that, and treat patients with medication for the whole body, from the start, then we can improve the cure rate.

The first treatments were chemotherapy, which were pretty toxic, but then we introduced endocrine therapy, commonly tamoxifen, probably the most successful drug in the history of the treatment of breast cancers.

And that's currently used in most women today, particularly if the cancer has a receptor for hormones (oestrogen receptors positive or ER+).

The majority of breast cancers do have oestrogen receptors, and the disease can be controlled or cured by giving women the anti hormone treatments, which include tamoxifen, and other anti-oestrogens known as aromatase inhibitors (e.g. anastrozole), I won't go into too many details here, but they are generally well tolerated. 

There is also chemotherapy, for those women who don't have oestrogen receptors, (ER-) and the side effects of these cytotoxic drugs can be controlled.

And then there are the exciting new developments of endocrine therapy and immunotherapy just appearing on the horizon.

So the treatment of breast cancer is a major success story, so much so that the mortality rates have fallen dramatically.

breast cancer screening xray

What would you say to women about prevention and screening? I know you have very, very strong views, which will surprise a lot of people who haven't come across you yet on screening.

There are many things women can do to reduce the risk of developing Breast Cancer, such as exercise, weight loss and healthy diets.

Now, it just so happens that these behaviours that reduce the incidence of breast cancer are also good for reducing the risk of heart disease and hypertension too.

So, it’s about healthy lifestyles, women should exercise and women should control their weight. Women should have as many fruits and vegetables as they can.

They will feel better, they will look better, and they will reduce the risk of breast cancer and other diseases which are more likely to kill them.

So that's simple!

RELATED: Katie's Blog: Falling off the health and fitness wagon

And what about things like reducing smoking and alcohol?

There isn't a strong link with smoking and breast cancer, but smoking is a terrible habit as It's linked to many other cancers, particularly lung cancer.

Drinking in moderation is okay. But yes, too much alcohol, more than a unit a day, can increase the risk of breast cancer. 

RELATED: KATIE'S BLOG: Losing it! My midlife weight loss story

Let's talk about screening. A lot of women will get to their 50th birthday, and they'll get that letter in the post, especially here in the UK.

I probably know more about mammographic screening than anyone in the country. That sounds arrogant. The reason is, I've lived a long time; I'm 85 years old.

And I was one of the architects of the screening programme. I opened the first Screening Unit in England in 1987 and I served on the committee for screening for seven years, until I realised it did not live up to its promises.

What we know now can be summarised in a simple way. For every 2000 Women screened by mammography, over 10 years, we’ll avoid one breast cancer death. They will avoid one breast cancer death at the cost of death from something else.

So, 2000 women, one breast cancer death avoided traded by causes of death from other things. And that’s mainly because of the overdiagnosis of breast cancer. (“over-diagnosis" relates to picking up suspicious abnormalities on mammography that are not predetermined to progress to a life-threatening invasive cancer.)

I think screening for breast cancer was a good idea at that time. It was a courageous experiment. But when the data changes, you must change your mind. The data now no longer supports mammographic screening.

I'm not a critic, I'm a scientist. I go with the data. But the trouble is that screening has become politicised and no government would have the courage to say that it doesn't live up to the promise. 

RELATED: The history and mystery of breast cancer with Professor Michael Baum

When women go to that appointment, is that explained to them?


I remember the reason I resigned from the committee was, I was describing the data to women that failed to support the screening program.

And I was told if women knew that, they wouldn't accept the invitation. And I asked them to repeat that because I thought I hadn't heard right, that we deny women information that we have, because we know better than the women?

So I resigned as I couldn’t be part of a committee that hid some of the facts from women and I wrote a letter to the Lancet explaining my fury that they were denying important knowledge that we knew about to the women who were being invited to screening.

The problem was a condition called duct carcinoma in situ (DCIS), which is a condition that you only find when you're screened, and which looks like cancer but doesn't behave like cancer.

And it was thought that if we find all these cases of DCIS then the invasive cancers will go away.

It wasn't true. It was just adding a 20% additional burden on women without any benefit, (an example of over-diagnosis) and because it was a multifocal disease, there were more potentially unnecessary mastectomies, so it became clear that screening increased the numbers of mastectomy, and women deserved to know that.

Thankfully after about 10 years, it was finally introduced into the leaflet. 

breast cancer

If you don't go for screening, what should you do? 

I'm often asked this, if we don't have screening, what should we do?

Well, the question is, who says you should do anything? Women are living longer and healthier now than ever.

Why should we be doing anything other than to live a healthy lifestyle?

And should you become aware of any abnormality in the breast by chance, you make an appointment to see your GP.

RELATED: Single dose radiotherapy as effective for treating breast cancer, long term study finds

Is screening advisable in high-risk women where there's a high family incidence?

That's a good question. And it's a question we are debating at the moment. How do you manage someone with a BRCA1/BRCA2 mutation, which makes the family at high risk of breast cancer? 

Well, first of all, if you are worried that you've got a bad family history, then you should go and see a geneticist. There's a lot of breast cancer in my family, but we've tested negative, we don't have the mutation.

But if you do have the mutation, you obviously carry a very high risk of developing breast cancer at a relatively early age and so it’s important to have a joint informed conversation about your own personal risk with an experienced specialist. If you test positive the choice is between prophylactic mastectomies or screening with MRI annually.

The options have pros and cons, but the choice is the woman's choice, and the women should be given all the information that is there, and then be allowed to make an informed choice.


If you find a lump, is it going to keep on growing until it's too late, or do some stay there for years and not do any harm?

Much of my research has been based upon what we call mathematical models. I ask my medical students this: If you come across a tumour in your breasts, which is one centimetre in diameter and it's been there six years or six months, which would you prefer?

The correct answer would be 6 years. Remember they are the same size at the time of diagnosis, so the slow growing tumour is preferred. When we talk about early diagnosis, it is meaningless.

What you're saying is that early is small. Well, small, maybe bad, small may be good. The most important thing about cancer is its aggressiveness.

It's equivalent to a choice between a poodle and a rottweiler, both are dogs but beware the one with a bad temper and sharp teeth.

This is another reason why screening doesn't work. Screening is usually offered two years apart. Now, the cancers we pick up at screening are the good ones, because they can hang around for years.

The cancers we don't pick up at screening are usually the fast-growing ones. So that's the other fallacy about screening.

The bad cancers aren't going to wait to be found. And the good ones are never going to threaten your life in the first place. 20% of cases you find are carcinoma in situ, and pose no threat to you.

Cancer doesn't behave in a linear fashion. That’s a myth. Cancer is a chaotic model, you may have heard of the chaos theory.

I like to compare it to the weather which will help you understand the chaos theory. Little clouds don't become big clouds and rainstorms often come out of the blue.

So we're pretty good at weather forecasting. Because we’ve got the maths. The maths is non-linear chaos.

And I think one of the most important revolutions in our understanding of breast cancer was that. It's not a linear issue. It's a chaotic issue.

There's a lot of concern in the breast cancer community for those that have either got breast cancer or have had it and have suffered terribly with menopausal symptoms.

A lot of these women are advised that they can't go on hormone replacement therapy, because it's going to increase their risk of recurrence.

Some women who haven't had breast cancer are told that HRT causes breast cancer. Can you explain where this fear has come from?

It's this cliché that oestrogens cause breast cancer.

It's been said so often, people believe it. Well, it's not true.

If oestrogens cause breast cancer, then you’d get breast cancer at a young age when your levels are very high.

And you wouldn't get breast cancer in old age where the oestrogen levels are low.

The other thing is that it’s important to note that if you happen to get breast cancer when you're pregnant, when hormone levels are very high, those cancers do well.

Before tamoxifen came along, if we were facing a woman with advanced breast cancer, we would give them oestrogen. It would reduce the size of the tumour.

And then, in the biggest clinical trial, a randomised clinical trial of HRT versus no HRT in the long-term follow-up, those women who had oestrogen replacement therapy, because they had a hysterectomy, had a lower incidence of breast cancer.

So oestrogens can protect you against breast cancer, they don't cause breast cancer.

However this concern stemmed from the publication of the flawed Women's Health Initiative (WHI) trial back in 2002 and the alarming headlines still plague women and some medical professionals with fear to this day. 

RELATED POST: Professor Michael Baum’s response to the Lancet’s publication of a report on HRT

Why was there no press release sent out after the WHI follow up trial, saying, “oh, sorry, we got it wrong”.

Good news isn't published.

The results from the 2002 Women's Health Initiative trial were so flawed; it should never have been published.

The long-term follow up reversed the findings, and even showed that oestrogen alone (for those without a womb) actually reduced the risk of breast cancer.

RELATED POST: The benefits & risks of HRT with Dr Avrum Bluming

In the aftercare that you and your team would provide, what sort of treatment options would be offered to women who were struggling with menopausal symptoms?

We practise medicine to improve length of life, and quality of life. And when it comes to quality of life, you can measure it.

There are psychometric instruments for measuring quality of life.

So everything that we do in medicine is a balance between length of life and quality of life. Ideally, the treatments improve length of life, it would be nice if they also improved quality of life. 

I like to talk about oestrogen depletion disorder, rather than menopause.

I get upset when I see some women on social media say things like: “I sailed through the menopause, what's the matter with you?” I think to myself, well okay, you sailed through it, but many women don't. And it's not just hot flushes, it's depression. It's brain fog. And, then there are the long-term consequences.

So we would always consider hormone replacement therapy for women who were suffering after a joint informed discussion.

RELATED POST: Taking HRT after breast cancer with the BBC's Kirsty Lang

What advice would you give to women who perhaps are too embarrassed to discuss with their male doctors some of the more taboo side effects of menopause/cancer treatments ie vaginal dryness/atrophy?

One of my better earlier innovations was to train up clinical nurse specialists to work alongside me. because some of my female patients were embarrassed to discuss some of their more intimate symptoms with me or my other male colleagues. And vice versa.

Now, all breast clinics have clinical nurse specialists who can handle these very sensitive topics that some women feel uncomfortable discussing with men. 

Can you leave us with one take away message for anyone who is reading/listening to this interview? 

You cannot and must not consider managing breast cancer in isolation.

It's about the totality of women's health. That's important.

So my takeaway message is to look at reducing the risk of breast cancer as one component in the totality of women's health, finding ways to avoid dementia, coronary artery disease, stroke, and osteoporosis too.

Professor Baum has written a book called ‘The history and mystery of breast cancer’, which I urge people to read.

* Please note that screening for breast cancer is a very controversial topic because its benefits seem self evident, whereas harm from screening seem counterintuitive. 

Many experts believe that the balance of benefit v harm is very close and in the end women should be provided with enough of this evidence to make an informed choice. 

For this reason, Professor Baum has allowed us to post the chapter on screening from his book, 'The History and Mystery of breast cancer on our website.

You can also learn more about screening for cancer in this helpful video.

Watch the video version of the podcast

Discover more: Listen to more of The Latte Lounge podcast episodes - and don't forget to subscribe / follow to be notified of future episodes!

Recommend reading:

Oestrogen and Breast Cancer: Why some well-known facts aren’t facts
Health | Menopause

Oestrogen and Breast Cancer: Why some well-known facts aren’t facts

The oestrogen/breast cancer nexus is one such favoured hypothesis. The more a woman is exposed to oestrogen the greater the risk of breast cancer ergo the treatment of cancer requires depriving the woman of the oestrogen that is feeding the cancer. There is now a second rank theory that these concerns are amplified in the… Continue reading Oestrogen and Breast Cancer: Why some well-known facts aren’t facts

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The History and Mystery of Breast Cancer with Professor Michael Baum

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