Paget disease of the nipple: the decisions you may face
4 treatment settings, 2 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.
Diagnosis
Punch or wedge biopsy of the nipple for any eczema-like change not settling within a few weeks, with bilateral mammography and breast MRI to map the disease behind it.
Histopathology means looking at cancer cells under a microscope, and immunohistochemistry stains them for specific proteins. Together they are still the foundation of every diagnosis.
- Cheap, fast, universal
- Companion diagnostic for most targeted drugs
Low-dose breast X-ray used for screening. Newer 3D versions find more cancers with fewer false alarms.
- Proven mortality benefit
- Cheap and scalable
MRI uses a strong magnet and radio waves, with no ionising radiation, to picture soft tissue in finer contrast than CT, so it is the standard scan for brain tumours, prostate, rectal cancer staging, liver lesions and breast screening in high-risk women. It is slow, expensive and blurred by movement.
- No ionising radiation
- Best soft-tissue and brain imaging
- Functional sequences (diffusion, perfusion)
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Subjective scoring
- Single-site sampling misses heterogeneity
- Reduced sensitivity in dense breasts
- Overdiagnosis of indolent lesions
- Slow and expensive
- Motion artefacts
- Gadolinium concerns in renal impairment
- Between Histopathology & immunohistochemistry, Mammography & tomosynthesis and MRI, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (diagnosis), which of the standard options do you recommend and why?Why: Guideline options include: Punch or wedge biopsy of the nipple for any eczema-like change not settling within a few weeks, with bilateral mammography and breast MRI to map the disease behind it.
Add these to your appointment list, or take the full question set for this cancer.
Localised disease
Central breast-conserving surgery removing the nipple-areola complex and underlying tumour with clear margins followed by whole-breast radiotherapy, or mastectomy for extensive or multicentric disease.
Fewer, larger daily doses instead of the classic five to seven weeks of small ones. Large trials in breast and prostate cancer showed the same control with the same or fewer late effects and far less time in hospital.
- One to three weeks instead of five to seven
- Same cancer control in randomised trials
- Frees machine capacity
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Long-term follow-up still accruing for the shortest schedules
- Not suitable where large volumes of normal tissue are treated
- Requires precise setup
- Is Hypofractionated radiotherapy the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (localised disease), which of the standard options do you recommend and why?Why: Guideline options include: Central breast-conserving surgery removing the nipple-areola complex and underlying tumour with clear margins followed by whole-breast radiotherapy, or mastectomy for extensive or multicentric disease.
Add these to your appointment list, or take the full question set for this cancer.
Axilla
Sentinel node biopsy when invasive carcinoma is present or when mastectomy is planned; not needed for Paget disease with in situ disease treated by breast conservation.
Removing just the first lymph node a tumour drains to, instead of all of them, to check for spread.
- Avoids lymphoedema from full dissection
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- False negatives in ~5-10%
- Is Sentinel lymph node biopsy the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (axilla), which of the standard options do you recommend and why?Why: Guideline options include: Sentinel node biopsy when invasive carcinoma is present or when mastectomy is planned; not needed for Paget disease with in situ disease treated by breast conservation.
Add these to your appointment list, or take the full question set for this cancer.
Systemic therapy
Determined by the underlying carcinoma: endocrine therapy, chemotherapy and HER2-directed treatment on the same criteria as other breast cancers.
The original targeted cancer drug (1977): a pill that blocks oestrogen's effect on breast cancer and halves recurrence, still essential for premenopausal women.
The first targeted antibody for a solid tumour (1998), which turned HER2-positive breast cancer from the worst subtype into one of the most treatable.
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Possible QT prolongation. Check ECG and electrolytes; review other QT-prolonging drugs.
- Between Tamoxifen and Trastuzumab, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (systemic therapy), which of the standard options do you recommend and why?Why: Guideline options include: Determined by the underlying carcinoma: endocrine therapy, chemotherapy and HER2-directed treatment on the same criteria as other breast cancers.
- Am I a candidate for Tamoxifen, Trastuzumab, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.