The Dr Louise Newson Podcast - 190 - Supporting women after breast cancer with Dr Tony Branson

Episode Date: February 7, 2023

Breast cancer specialist, Dr Tony Branson returns to the Dr Louise Newson podcast two years since his first appearance. Tony is a Consultant Clinical Oncologist at the Northern Centre for Cancer Care, based at the Freeman Hospital in Newcastle upon Tyne. In this episode the experts discuss the current situations women can find themselves in when having treatments for breast cancer and experiencing the onset of menopausal symptoms. Tony supports the women he sees through some challenging decisions around managing the risk of cancer recurrence while for some, treating menopausal symptoms with HRT to improve the quality of their lives.

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and well-being centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the Menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. So today with me, I have someone back by popular demand, actually. He's already been on the podcast before and some of you might have listened to him, but I have the pleasure of introducing or reintroducing to you, Dr Tony Branson,

who is a consultant clinical oncologist who works with women who've had breast cancer in the North East. So welcome Tony today. Thank you. So we first met several years ago now because I saw a lady in my clinic who had had breast cancer and I think she might have been on tamoxifen, one of the treatments after having breast cancer. And she told me that her cancer doctor was quite happy that she took HRT and she'd come down to see me for some advice. So I got that cancer doctor's name and got a hold of him and you're here in front of me now doing this podcast and it was really enlightening talking to you actually for lots of reasons but I love the way that your patient is in the centre of everything you do which for many of you

that have heard me talk before is certainly the way that I practice as medicine and indeed most clinicians do really but you're heavily experienced and really I just wanted to spend the next half an hour or so talking really about people who've had breast cancer cancer and how difficult it can be sometimes or often when they're menopausal and have very limited options often. Yes. I mean, the mutual patient we had, in fact, had a very, very low risk pre-invasive cancer and was actually referred to me merely to have some radiotherapy.

And we started discussing that, but it became very apparent during the discussion that she was very distressed and she was distressed because she'd been on HRT. prior to the diagnosis and had been told fairly firmly by the person who'd operated on her that she must stop the HRT and on stopping that had developed really quite a plethora

of difficult menopausal symptoms and was very upset by this and I couldn't really just sit there and just say well don't worry about that you're going to have some radiotherapy and everything will be fine so we started talking about it And basically the undercurrent or the basis of what I said was, look, I cannot tell you that to continue with your HRT carries no risk. But I certainly can tell you from all the evidence that we have that it carries a very small amount of risk.

And in view of the way in which your life is being so diminished by not taking your HRT that really, in my view, it would be more than reasonable for you to continue with it. and obviously she was quite relieved to hear that. And I felt this was not going out with the evidence. I didn't tell her that, you know, I could promise her that it wouldn't have any effect on her cancer coming back, although, in my opinion, whatever effect it had was likely to be diminishingly small. And probably I would have been hugely surprised if her cancer had returned and even more surprised if somebody could demonstrate to me it was due to her continuing HRT. So I think that was the beginning of that bit of the journey, although, I mean, prior to that,

I'd had discussions with patients with severe menopausal symptoms who had breast cancer, and we did talk about the risk and benefits. And I had, you know, on occasion actually prescribed probably not all that aptly, HR to help them. And then obviously, having through this met up with you, I became more interested in how we could make patients who'd had breast cancer a not inconsiderable number of whom were suffering very considerably and for whom we were not managing their problems that well, how we could be doing it better. Yeah, and it's very interesting actually, Tony.

Some of you might know, I actually wanted to do oncology, and it was only because I got married and had three children, I'd changed career track. But when I was working as a junior doctor in a big oncology unit in Southampton, and I saw lots of women who'd had breast cancer. And when I was training in Manchester, I saw lots of women who had breast cancer.

And I knew that some of the treatments could affect the ovaries, but I didn't really associate it with the menopause because I was just not very educated about the menopause then. And when I started seeing women in my clinic, like this lady, we've described, and others who have had breast cancer, who are really struggling, often with symptoms of rain fog, memory problems, joint pains, fatigue, their quality of life is really, deteriorated. I then reflected on my time, especially in Manchester, and I was really quite sad that

I had missed out asking women and associating this cause and effect. And so I actually then got back in touch with Professor Tony Howell, who was still working in Manchester, who I did a project with. And I got on the train and went to see him and said, Tony, do you understand? Did you realize how your patients are suffering? He said, well, it's just a few flushes and sweats, isn't it, the menopause. And I said, no, it's far more. And I don't think he really realized. And he said, well, I'd sometimes write to the doctor, the GP, and say, well, if they're really struggling, you could consider HRT. And I said, but Tony, they're not getting it. People are just saying a blanket, no. And I'm really saddened actually with stories of women who've had breast cancer, who are then

menopausal, who were just told, well, just put up with it. And he hadn't really thought about it in the same way either because I think no disrespect to oncologists, they're focusing on treating the cancer and making sure that women survive as long as they can and not have recurrence or any ill effects of their cancer. But that's where it sort of ends really when it comes to the menopause, but it doesn't always end for the women, does it, when they're experiencing symptoms and don't know where to go to get help? I think it's interesting because I think it goes back a long way in that I do not recall being taught very much about the menopause as a medical student.

No. So when I qualified as a doctor, I was aware that women in their late 40s, early 50s would stop menstruating and not be fertile and that that was, as it were, the normal scheme of things. I mean, I must have known a bit about hot flushes and things, but I didn't really. have a great deal of consciousness about it. And then, I guess, I mean, interestingly, one of the things which sort of got to me more when I was teaching medical students when I first came to Newcastle was actually how little they knew about cancer as well.

I mean, the only people who, and in fact, I mean, we were told that we really shouldn't teach them about cancer. That was the job of the surgeons. Well, while I fully accept that actually, the majority of people who are cured of cancer actually are cured by surgeons. And while it's a bit of a sport to be occasionally a bit rude about them, they do an amazing job and they do make a big difference for people. But I think that there was at that stage, and there is less now,

but it's still there, an inability to work together through things that are, I say, perhaps a bit peripheral to actually managing, to getting rid of the cancer. And I think you're right in what you say, is that a lot of what we do is particularly dominated by ensuring that people who have cancer, if at all possible, are rid of it. And we sort of then believe that they will go on and live normal lives and not be worried by anything else, which, of course, is a complete illusion. You know, that's what's driving people.

And it's fair to say that since I've been in oncology, the outlook for women diagnosed with breast cancer has improved. both worldwide in this country, we've actually probably in terms of improvement done as well as just about anywhere else, although we started from a, perhaps a rather low baseline. So we're not doing too badly with breast cancer. But it's very easy to be seduced by those good results to then sort of rather forget about, you know, what some of the women are left with. I think there's been another bit. I mean, the last cancer, whatever it was, strategy document, they keep having slightly different names, was very big on survivorship and living with and beyond cancer. And although most of the principles within that are very good, helping people to achieve greater well-being and live healthy lives and generally get over their treatment and their disease,

It's all rather non-specific, and I think a lot of it doesn't take into account the various things that make people have difficulty getting back to a good life after cancer. I mean, there's a lot of talk about you don't get back to normal. It's a new normal. And in some respect, that's fully understandable in that having had a, what is a life-threatening disease, even if you're cured of it, is a life-changing event. and you are not the same person afterwards. But part of the difficulty is for a lot of these women, they're not the same person afterwards because they're left with a large number of really very difficult

and life-changing symptoms. And it's really, I mean, it's great that life expectancy is improved, of course, from breast cancer, but we know now that most women who've had breast cancer actually die from cardiovascular disease, so heart disease, rather than their breast cancer, which in some ways is wonderful. But in other ways, it means that we have to think of women as women who can develop other diseases, even though they've had breast cancer before.

And a lot of patients I talk to, and they've had breast cancer many years ago, they don't want to be defined by their breast cancer. And it's really important, I was reading an article recently, and it was entitled, falling off a cliff, what happens after breast cancer. And it was talking actually mainly about sexual health and about women who, have really awful vaginal dryness and reduce libido. And nobody really thinks about their sexual health as a woman who's had breast cancer, whereas if a man has prostate cancer and has treatment for prostate cancer, even before surgery, he has a lot of counselling about the possibility of not being able to have erections or having premature ejaculation, whereas it doesn't happen really with women.

And often it's not until they're directly asked if they have symptoms that they, admit that they have. It's not something that they were just offering a consultation. It's interesting because before I ended up doing only breast cancer, I was treating, in fact, when I was appointed, my main specialist's role was gynaecological cancer. That's a huge area of problems, particularly for women who have radical pelvic radiotherapy, which obviously for young women will stop ovarian function and I must admit that was one of the areas where I would regularly prescribe HRT because it seemed to me that this was merely trying to correct some of the effects of what we'd achieved as a side effect of our treatment and it's interesting when I went back to doing

this a bit to sort of fill in the manpower shortage this doesn't seem to be being done as routinely as before and I couldn't quite work out why that was and maybe that's another area a quite separate problem that needs to be looked into. But again, the other aspect, as you say, the whole business of sexual health. And I think there are all sorts of problems that relate to it. I mean, undoubtedly, having had cancer of any of the primary or sexual organs does take a bit of getting over in terms for some women, not all, but for some women, in being able to return to how they saw themselves as a sexual being in a relationship. And I think, to be honest, we are pretty poor at dealing with that.

And the interesting bit going back to the survivorship is that one of the elements behind it, which a lot of us have leapt on because of our workload, is that we've stopped doing with the breast cancer patients. Anyhow, what I used to describe as worrying the well in that we would see, patients at set intervals and we would do what I'd rather slightly glibly described as the laying on of hands and tell them that they were okay and they would feel euphoric and we'd feel good about telling them something good and then they would go away for another six months and then for the few weeks before that would start being worried and often get symptoms and we'd then reassure them

and so the cycle went on and in busily doing this and doing it also with this slight delusional view that we were going to either prevent them getting recurrence of their cancer or mitigate any recurrence that occurred by apparently spotting it earlier. And there's no evidence of benefits for doing this. But because we were doing this, we probably were not concentrating on the other elements of having had the disease, in particular the menopausal symptoms as a consequence of treatment, which either might be for premenopulital women who had ovarian failure as a consequence of chemotherapy, or ovarian suppression as a planned treatment, or treatment with tamoxifen, which, I mean,

tomoxifen is interesting because, you know, the variability of side effects where it is huge, ranging from really nothing as far as one can elicit from patients through to that it makes their lives intolerant. horrible. Then with the menopausal women, clearly more recently, where we started treating them with the rheumatase inhibitors, which lower their circulating estrogen to less than they would have anyhow when they're postmenopausal and giving them problems as a consequence of that, that we've not really in any way specifically dealt with that. And I think that has been a failing. And I think, I mean, it's interesting that the document about survivorship and what we would do after treatment, in general terms for cancer, said that we should instigate stratified follow-up. And it's very interesting that even the team at Gateshead, who I think are very proactive and looking forward and are looking to do more things with the menopausal symptoms, have sort of surreptitiously put in front of the term stratified the word risk.

And they've based a lot of what they do on how likely they think the woman's cancer is to come back, rather than need, which is how much of what's happened to them has made their life, has diminished their lives. And what could we do to help with that? Because deep down, although it's fair to say that women who have breast cancer that recurs and has spread to other parts of them, if that is ignored for a long time, the possibility of helpful treatment to control the cancer, we can't cure it, is significantly diminished. Actually, picking it up at a very early stage. As things stand, it may change, but as things stand, we have no evidence that doing that improves their survival outlook. In other words, treating something at a very early stage in these circumstances doesn't mean they're going to live any longer. So we've rather sort of been concentrating on the wrong thing and we've done a little bit of sort of throwing out the baby with the bathwater in that we treat the patients and we then tend to sort of say,

well, we don't need to do any more to you without always giving them the tools to manage their lives subsequently. Which is a great shame. I mean, it's really difficult for, I think any condition, isn't it, Tony, to generalise. So not everybody who has migraines will have a headache in a certain time with the aura or with visual disturbances or with sludge speech or whatever or everybody that has a heart attack will have the same pain and the same symptoms and the same prognosis. So with breast cancer, which is very common one in seven women, there are different ways that people experience, as you say, the medication, the treatment afterwards. And it's also, I often find that the menopause can be very different in them. Whether it's a menopause that's just naturally occurred or a menopause that's occurred from their

medication, it can be quite different. But also it can vary with time as well. And many women say to me, you know, I didn't mind feeling ill for the first one or two years after my breast cancer diagnosis because all I wanted to do was to live each day and know that it was longer since my diagnosis. But now it's five years after. I just can't live like this. I can't have another night where I am waking up with bone pain.

And I feel that I, you know, I'm going to the toilet all the time. And I've got such bad vaginal dryness. I can't sit down. I can't keep living like this. And I think that's when we have to individualise what we do and how we help people. And I think the whole area of hormonal treatment in breast cancer, either hormonal treatment as in things like aromatase inhibitor or tamoxifen for the cancer or giving HRT is very individualised. And it's impossible, isn't it, to say that you must have this or you

must never have this, for example, because everybody's different and what they want on one day might be very different the next day or the next year or the next decade, isn't it? I absolutely agree with that. And I think one of the difficult, is, as you say, when people are given a diagnosis of a cancer, it's pretty earth-shattering to most people. I mean, I slightly sort of say, well, I guess when you were told, you probably thought you wouldn't live beyond the end of the week. And then as time goes by, I know your horizon moves away and you start thinking about other things. Most of the treatment decisions about breast cancer are made round about the time of diagnosis. And it's interesting talking to women.

I mean, I've talked with them about the benefits of having chemotherapy and endocrine treatment, but particularly with chemotherapy, which is perceived to be pretty nasty at the time and is for some people. And a number of women who I've told, you know, the benefit for this is relatively small. It will only make a difference to a, you know, single-figured number of people. but a lot of them at that time, their view will be, but I'd be one of those people. I must do everything I possibly can to stay alive, prevent the cancer coming back,

because that's what's most important at that time. And as you've just said, as time goes by, those feelings sort of change. And I must admit, I mean, the only thing I've ever been able to put us from personal experience is if you have a high-speed car crash and it rolls over lots of times and you climb out of it unscathed, at the time you think that's fantastic. Nobody's been hurt or killed.

And then a bit later on you think, I've written the bloody car off. We do feel differently about things at different times. And I think for women with breast cancer, I mean, it varies as well. I mean, some of them go through significant periods of feeling everything's great. and then something that happens that sets them right back. Now, it may be that somebody, they know somebody who they've been with when they were being treated, relapsing. It's interesting. I mean, the effect of Lyndon McCartney dying from breast cancer was really quite profound for a lot of women who'd been treated for breast cancer.

I mean, there was a lot about it. I mean, she lived a very healthy life, apparently, had enormous resources to deal with her cancer. but she died from it. And for somebody who's in much more modest circumstances, well, if she can't survive, how can I? And that's quite hard. There isn't a straight answer to it. It's a feeling that they have.

I mean, all I can say to people about breast cancer and their fear of occurrence and whatever is, A, that the fear will vary from time to time, and B, that it's normal. It's not nice, but normal. It's the people. People who get in this terrible vicious circle of being worried about being worried. Yes.

Which, I mean, you can't stop them doing it. I mean, I always felt that the biggest waste of breath in the whole world is to say, don't worry. Makes you worry more when you hear the word worry, isn't it? Think about your breathing. So, yes, you're right. What matters to people change is one of the difficulties, I mean, chemotherapy can have unpleasant long-term effects, not in the majority, but in a significant number. you know, had a modest number of patients really in a terrible state after chemotherapy with

neuropathies, hair that's not grown back, you know, gum and teeth disease and things like that. And this is nothing to do with hormones. That's just there. Problem with endocrine treatment is firstly is that people sort of feel, well, you know, the side effects aren't that bad. And I think they have been minimized. And the other bit is, of course, it goes on for a long time. Up till recently, we did feel that the major benefit for tomoxifem came over a period of five years, and that was considered to be the time. Now, the reality is that we now have clinical evidence that going on for longer does reduce recurrence.

The question is whether the relative amount that it reduces it justifies continuing taking it. and for some women taking it to oxfen tablet every day may be giving them minimal symptoms and they may feel that's fine for others you know it's a living death and to say oh you must take it for 10 years it's a very brutal sentence put it like that yes and I think people often do feel very they feel that if they don't take it it's really going to have a huge difference

and risk is a really hard thing to work out especially when it's individual as well. But I remember you're saying on the previous podcast that we did together, for some women, they actually have a holiday. It's not really a holiday, is it? But they stop taking the aromatase inhibitorial or the tamoxifen or whatever, just to see if the side effects are, it is side effects as opposed to something else. And I see quite a lot of patients who just for six weeks might stop their medication,

just to get a bit of a breath, really and to do that relaxing and seeing if it makes any difference to them. And then that's a time where they can maybe talk to the oncologist about changing their hormone treatment or if they've been on it. Sometimes I've seen ladies who have been on it for four years and 10 months and they've been told it has to be five years and they really want to try and keep going. But that last bit is just so unbearable and you sort of think, well, that two months is probably not going to make a huge difference to you and it's quite safe to stop for a few weeks

and see for most women and that can be quite an empowering option i think sometimes for women isn't it to know they can do that it's certainly one that i would use regularly that if women are having a lot of symptoms that may well be related to their to moxifan i would definitely say stop it and stop it for at least six weeks and see how you feel. Interesting. I did my first day back at work after one of my returns from retirement last week. One of the patients who I saw, who was sent up by the breast care nurse, who had a not very high risk breast cancer, moderate risk, but not high, and was on Tamoxifen.

She'd had chemotherapy and had really not been well at all and had had odd. I mean, she said, oh, no, I didn't feel her brain was working. She had a lot of fatigue. She'd had a couple of falls, which were a bit hard to sort out, because it didn't sound like it was that she'd actually blacked out, but she had fallen. And the worry that the nurse had had was actually that she might be developing brain secondaries. And the symptoms were, didn't fit very well.

And it's interesting, in discussion with her, I mean, I said, look, you know, you've obviously got a lot of symptoms, which we've got to try and sort out one way or another. They don't really fit clearly into any clear pattern. I have to say, I wonder whether it's the tomoxyphil. And she said she'd wondered that. In fact, she'd been off it for about two weeks, which I said was probably not long enough.

So we've agreed that she will stop it for six weeks. I mean, she got odd sweating bits, which she associated with this, but I wasn't sure whether that wasn't. And I said, you know, I mean, she was 46, something like that. She'd had chemotherapy. And I said, well, and have your period to stop, which one would expect they would. And well, she'd been on the mini pill beforehand, so she didn't have periods then anyhow. So she was uncertain about that.

And so basically what I did was to suggest she stayed off the tomoxyphen. And I've arranged actually for her to have a scan of her head because I don't think it sounded very much like it was spread to her brain. but it would be much easier for her if she knew that that wasn't the case, but easier for us as well. But it's interesting, these sort of odd and nebulous symptoms, and I certainly think in these circumstances it's well worth stopping either tomoxone or aromotase inhibitors. I mean, another thing is that there is some evidence to show that taking,

particularly with the rheumatase inhibitors, taking them for, say, three months and then having a couple of months off and then taking them for three months, taking the couple of months off, often would appear, as far as one can tell, and it's not the highest of high-level evidence, probably to be as effective, or at least not significantly less effective than taking them all the time. And for some people, that works quite well because particularly the bone pain and joint pain sort of builds up, and by not taking it all the time, it never gets to be so bad. I think there are all these little things that one can try. and I think it is important to have the discussion with people because I think as you've a little bit alluded to, this idea is, well, the doctor told me this is what I've got to take

and I've got to take it for a long time. I mean, it's interesting when they first started using adjutant to moxifene, it was you've got to take it for the rest of your life and then you only give them a prescription for 28 days, which worries them. Yes, so, I mean, things change. And I think what's been really useful working with you and for some of you that have heard my podcast I did recently with Dr Sarah Glynn talking about the work that we're doing together as a group to try and get this consensus document out, looking at the evidence, is we're very clear in the group that every woman should be treated individually and be allowed to have a choice. And that choice can change depending on how they feel. But I think some of the work that we're doing and certainly some of the work I'm doing that I'm quite.

vocal about has led to other oncologists, you know, I know some of your colleagues and others that you speak to, to start to think a bit more about the menopause, symptoms that could be related to the menopause and health risks and also the individual risks versus benefits for women taking HRT, which is going to change depending on all sorts of factors. So I feel like the conversation we started many years ago when I first met you, Tony, is sort of devoidable. developing even more, which I think is very exciting. And I'm really hoping that it's going to change the narrative, actually, for many women going forwards in future years as well.

I think one of the things which we've discussed a bit about the consensus bit, about the whole business of the effects of chemotherapy on the ovaries. And there's no doubt that it is quite clearly in the majority of cases. and it should be that for premenopausal women, the first line of approach in that respect is always tends to be based around fertility, partly because for young women, for whom having a family is very important,

there are now one can do, you know, egg harvesting and freezing, which may be an option. But because of concentrating on that, if one merely says the only consequence of ovarian, failure, there's a consequence of chemotherapy is not being able to reproduce, you're missing a whole bit that comes out of it because the ovaries do do other things. And I mean, the other side again, which, and I've been guilty of this, I'm sure, is to say

to somebody, well, if, you know, there's a very good chance you have this chemotherapy that it will stop your ovaries functioning, which will put you into a menopause. patient then says, you mean my periods will start? And I say yes. And they say, oh, that's good. And then that turns to be the end of the conversation. I mean, you know, let's leave on a hive, something that they perceive as a benefit.

Well, there may be other things which are very much not a benefit. No, and it is so important. And, you know, I think what we've teased out of this conversation is that women should be treated as a whole. they shouldn't be just defined by their breast cancer and they are allowed to have a voice in this conversation of their journey and that's really important there's no one size fits all for any sort of hormonal treatment or non-hormonal treatment or anything really i think the most important thing is women being able to have a voice and to be listened to and know that they can change their

mind they can decide their priorities might change as well with life so i think it's It's been really useful hearing your words of wisdom, which I always love listening to. But before we finish Tony, I'd just like to ask you for three take-home tips, which I always do at the end of the podcast. But three things that you think that would be really useful for women who maybe have had breast cancer many years ago, who are now thinking about their future health, really. What three things would you say or recommend that they could do? I think if you say many years ago, do you mean 10 years ago, 15 years ago? Yes, I do actually because we've done podcasts about more recent.

So I'm thinking about those women who have been 10 plus years since their breast cancer, who are maybe struggling with some menopausal symptoms and just wondering where to go now. And a lot of these women are maybe not under an oncologist anymore. So what would you recommend they do to try and get some help? I'm actually not fully aware, but will be, I hope. fairly soon working with some of the people around here is what the availability of menopause specialist treatment is. I mean, it tends to be gynecologists who are sort of referred to, and it's not necessarily for the majority of them, their major area of interest and expertise.

So I think getting some form of menopausal expertise brought into it, I think that we're going to have to look at being able to have conversations between oncologists and the menopausal specialist to give women a view of what their level of risk remains to be. For example, a woman who has an estrogen receptor negative breast cancer 10 years out, firstly, is diminishingly unlikely to get a recurrence of that breast cancer. and frankly, anything that is done to, you know, in the way of hormone replacement therapy or whatever, carries certainly no more risk to her than it would to any other woman who's never had breast cancer. So the breast cancer bit is out of the window.

And I think what you would say from the evidence that you have, that using the appropriate hormone replacement treatment, actually the risk of breast cancer, for a woman who hasn't had breast cancer, is diminishingly small, and it will be the same for them. For a woman who's had an Eastern receptor breast cancer, there is a risk that persists probably at least for 15,

maybe 20 years of recurrence. By that time, it's a very small risk, but I'm afraid it is a sort of regular event that we see. So now, the question that is unanswered, but there are pointers which would suggest that having hormone replacement therapy for these women doesn't actually change their risk to any significant degree. Now, it's always this difficult thing is that if something untoward happens to you, you always want to pin it on something, whereas it might be something that was going to happen anyhow. And I think the temptation, which is there, to sort of say, well, that's because you did that. And actually, we can't do that about anything. You know, in the old days, when I used to treat all cancers, you know, I could see somebody who was smoking 50 cigarettes a day who gets lung cancer.

I don't know that it was the smoking that gave him lung cancer. I know that it put his, made his risk very high. And the same goes for all of these things. And, I mean, one of the things I used to say to women, I've seen a lot of women who have presented with new breast cancers who have been at a time of presentation on HRT. Now, if you take the worst data that there are, the number of them whose cancer was actually caused by the HRT is a small proportion of those who got cancer. In other words, the majority of them would have got the breast cancer anyhow. But I'm afraid the nature of the need to pin it on something means that there will at least have been at some stage a subtle implication, well, it was the HRT. You know, even if it's almost sort of, well, you must stop the HRT because that's what gave you.

So I think it's important that people don't think like that or aren't encouraged to think like that. So I guess the other thing that really is that, as I say, we've moved from seeing people at routine intervals. I mean, my predecessor used to see everybody from diagnosis to death at very long intervals. I mean, he would see them every two years because he never did very much other than touch some bit of them and mutter an interval of time. He could see 70 or 80 follow-up patients in a clinic. when I took it over and went in and first told them who I was and then asked them how they were. The whole thing went horribly wrong. But what we're telling you to do is to say, right, you know, you must go out, live your life and be fine.

But to happen that are not right, you must be in touch, and then we will try and sort it out. Now, the problem is, the implication of that is if you get lumps or bumps or pain or whatever, we will investigate it to see if the cancer's come back. But I think we ought to take that further and say, if you are getting, difficult symptoms that almost certainly relate to your treatment or for which the treatment may have implications related to your previous diagnosis, then you should come back into the system. But we need to have in place within the system the right people to deal with that. What I hope we're going to be able to do, and I think the team in Gateshead are looking towards

it is to set up a specialized clinic looking at women with breast cancer with menopausal symptoms with input from both oncologists and breast care nurses and menopause experts so that we can get these women together, which will at least have some form of support for them, and it will also enable us to look towards getting some better research into what are the best means and safest means of managing their symptoms and keeping them well. Which is so important. And having more research in this area is really crucial. So I hope this is the start of lots of people thinking

and conversations that are going to continue for many years to come. So thank you ever so much for your time today, Tony. I really appreciate it. Nice to talk to you. Thank you. For more information about the perimenopause and menopause, please visit my website balance hyphen menopause.com or you can download the free balance app which is available to download from the app store or from Google Play.