Some of you will be reading this section because you have the job of preparing meals for someone with cancer who has a poor and finicky appetite. Try to remember that if-your friend or family member is losing weight, it is not your fault, nor is it theirs.

*191/40/1*

Next your practitioner should advise you on treatment for the symptoms. They can be treated either by tackling them directly or by treating their cause or both. For example, the pain of a broken leg can be treated with painkillers or by setting the fracture and immobilising the leg in a plaster cast, or both.

As a rule, treating the cause brings more long-lasting benefits than just treating the symptom itself. However, even if cancer is the cause of your symptoms, this does not mean that treating the cancer is necessarily the best approach. As always, you will have to weigh the cost against the benefit to decide what is best.

*158/40/1*

The long-term use of oral contraceptives may be associated with a watery, milky discharge from the nipple, which can be dealt with by stopping taking the contraceptive. As the pill is the most effective form of contraceptive, it may be worth putting up with a slight discharge if it does not cause you much distress. Always ask your doctor’s advice before stopping any form of contraceptive, and make sure you use another suitable type.

Paradoxically, a discharge may sometimes also result if the contraceptive pill is stopped.

A milky discharge may occur at puberty and, although it is likely to resolve itself without the need for treatment, it should be brought to the attention of your doctor:

Very rarely, a profuse watery, milky discharge may be caused by a pituitary tumour. If a tumour develops in the pituitary gland in the brain, it can cause increased secretion of the hormone prolactin which triggers the ‘let-down’ reflex which normally leads to the release of milk during pregnancy.

The following are some other, more important, causes of discharge from the nipple.

Duct papilloma

This is a benign tumour of any epithelium, which is the layer of cells covering the body’s surface and lining most of its hollow structures. In the breast, a papilloma may form in the ducts near the areola. Although some believe that duct papillomas may be linked to the development of breast cancer in women near the menopause, such an association has yet to be proved.

Symptoms

Papillomas occur mostly in women between the ages of 35 and 45, and may cause a bloodstained discharge from the nipple. A lump may be felt on examination.

Diagnosis and treatment

The nipple discharge may be examined under a microscope, but the results are often unreliable. These tumours may show up well on mammography when a radio-opaque substance is injected into the duct containing the papilloma. This investigation is known as a ductogram and is relatively painless.

Treatment is normally by microdochectomy, which involves expressing the discharge to identify the duct containing the papilloma and then inserting a probe into it. The duct, the inserted probe and the papilloma are then removed.

Duct ectasia and plasma cell mastitis

Duct ectasia is a benign disease in which the ducts just under the nipple become swollen with their own secretions.

Symptoms

The nipple of the affected breast may become inverted, and the ducts may secrete a green or yellowish fluid which can occasionally be bloody. The area around the ducts may become inflamed, giving rise to a type of ‘mastitis’.

Plasma cell mastitis can occur if the secretion of duct ectasia leaks out of the ducts and is recognized by the body’s defence mechanisms as ‘non-self. A ‘chemical’ inflammation results, which is fought by the plasma cells involved in the reaction against foreign bodies. This can also lead to the formation of abscesses around the areola, particularly if organisms are able to invade the ducts through an inverted nipple.

Diagnosis and treatment

Nipple discharge may be the only sign of duct ectasia, but a mammogram is sometimes done to exclude the presence of a cancer and to help confirm the diagnosis.

Both duct ectasia and plasma cell mastitis can be difficult to treat, although surgical excision or division of the affected central ducts just under the nipple usually has a good result.

In less serious cases, once reassured that there is no malignant disease present, many women are prepared to put up with the nipple discharge. Those who find it offensive may be treated by surgical removal of the major duct complex and, if necessary, correction of the inverted nipple. Loss of or reduction in nipple sensation may sometimes occur following surgery.

If an abscess forms as a result of mastitis, it may need to be surgically incised and drained. This operation must be done by an expert surgeon as simple incision may leave a scar which continues to drain, causing further nipple discharge. This condition is known as a mammillary fistula.

*14/39/5*