: Breast cancer is the most common form of cancer that I've seen in Bermuda and the most common cancer in women world-wide. I do think there's a reason to look carefully at the incidence of breast cancer in this country.

We do not at present have the information that allows us to compare the rate of breast cancer in Bermuda currently with the risk of this disease elsewhere in the world.

For the next calendar year predictions in the US are for 211,000 new breast cancers, so it is a substantial public health problem all over the world.

I think that we need to look at the demographics of the island a little more closely: Who's getting breast cancer, how old are they, what is their racial background, what are the risk factors? Are there any identifiable genetic predispositions that are unique to Bermuda?

: In general, women are advised to start having mammograms every one to two years from about age 40 up until age 50. Thereafter, they should have them annually. Mammograms can help detect breast cancer early, but in terms of general health a woman should also have an annual physical examination at which point the physician will examine her breasts.

There are other aspects of general health that are equally important, such as blood pressure, a pelvic examination and a pap smear.

Q: What does a mammogram procedure entail? Is it painful? How does it work? Is it basically like an x-ray? What does a mammogram image show?

A: A mammogram is an x-ray image of the breast. It may cause some minor discomfort but it is not a painful test.

Mammography prior to the age of 40 has less sensitivity because the breasts are quite dense and so it is more difficult to find abnormalities. We do see women with breast cancer under the age of 40 and sometimes even under the age of 30.

Women should be seeing a physician regularly at an early age, and discussing when they should begin having mammograms. If a woman has a family history of breast cancer, there may be a reason to consider screening mammography prior to age 40.

Firstly, a mammogram cannot tell you if you have breast cancer, only if there is an abnormality. Only about one in ten abnormal mammograms is going to be cancerous.

If there is an abnormality the mass in the breast may need further investigation including an ultrasound study and perhaps a biopsy. It could be a core needle biopsy or an open biopsy.

Breast cancer is a curable disease if it is found early. Ninety-five per cent of women who have early stage breast cancer can be cured. However, if it spreads elsewhere in the body it becomes a problem requiring long-term care and generally is no longer curable.

It has to do with prolonged oestrogen stimulation of the breast. Unopposed oestrogen stimulation seems to increase the risk of breast cancer.

Starting periods early, late menopause, late first pregnancies or having no children or the prolonged use of hormone replacement therapy for more than three years are significant risk factors. Obesity is another significant risk factor for breast cancer.

Only about five per cent of breast cancers are genetic in origin.

Diet and exercise are important and obesity seems to be a risk factor for some cancers and certainly breast cancer. Smoking is, of course, a major risk factor for many cancers although not for breast cancer in particular.

I think that mastectomies should be reserved for patients who are identified as being high risk from breast cancer and by high risk, I mean people with certain genetic mutations.

If that occurs we can identify that in a family because you'll find that mother and sister may have had breast cancer, aunts may have had ovarian cancer and an uncle had pancreatic cancer.

You'll notice a typical family history and those individuals need to be studied for their genetic abnormality, which predisposes them to malignancy. If you can find it you can then discuss certain risks statistically.

For instance, if a woman who has dual genetic abnormalities the likelihood of her having breast cancer at some time in her life may be as high as 80 per cent or higher and the likelihood of developing ovarian cancer might be 50 per cent.

So what should these people do to reduce their risks? You have to discuss the risks and the benefits and the choices with them. It's a very individual decision as to whether or not a mastectomy should be done. We're talking about five per cent of women who have this genetic abnormality.

When a woman develops breast cancer her daughters have a slightly higher risk and the tendency is for the daughters, if they do develop a breast cancer, to do so five to ten years earlier than the previous generation.

Women should have knowledge of how to examine their own breasts and be aware when there's something there that's different. They need to consult their physician in the event that they notice something that they feel is unusual. The family physician is probably the best person to speak to and to teach breast self-examination.

If detected early most patients can have a partial mastectomy and that should include some sampling of nodes underneath the arm. Conservative surgery is preferable when possible.

The first intervention is usually surgical to remove the cancer and decide the extent of the disease and then plan what other treatment is required.

The US and Canadian data have shown a small but significant drop in mortality for breast cancer, probably in part due to screening. The screening between the ages of 50 and 69 has reduced mortality by about 30 per cent.

It depends on the country. In western countries it's common for most women to have screening because it has become part of public health policy and is widely accepted and promoted. Statistically around the world for every 100 women with breast cancer you will have one man with breast cancer.

The treatment is essentially the same although the outcomes may not be as good, probably because of later diagnosis.

Perhaps that's because it might not occur to a man that a lump in the breast may be a cancer

I'm not in a position to answer because I've only been here a month but I can tell you that we have several individuals who have been working very hard to maintain the Oncology Service at BHB ? namely Laverne Proctor, our medical secretary, and oncology nurses Jennifer Gallo and Karen Scott.

The other thing we have which is astounding is PALS. It's a unique resource and I haven't seen anything like it anywhere else in the world ? they are terrific.

For the foreseeable future we will be dependent on our hospitals abroad for specialised treatment.

What I hope is that we can provide more cancer care here and we can minimise the need for patients to go abroad and the time spent away from home. We can accomplish this by establishing close working relationships with these referral centres.

From 1965 to 2000 the emphasis on cancer treatment and cancer research has been on a cure for cancer.

We found that it was difficult if not impossible to do in many circumstances except with patients who had early stage cancer.

The emphasis in the last five to ten years has been to see the disease differently ? to understand that it's a chronic disease and we have multiple interventions to treat patients so that the goal of treatment is no longer necessarily to cure the disease but to control it, to turn it from a terminal illness to a chronic problem.

We're already doing that. Will there be a "eureka" moment where we suddenly cure all cancers?

No, I don't think so. Do we expect to find coming down the pipeline interventions in which one disease or another will yield to treatment?

Yes, there are a number of circumstances where we've seen that in the last 20 years and that will continue.

Progress in caring for and curing malignant disease has been striking and there is much promise for the future.