What is Lobular Carcinoma in Situ or LCIS?

Lobular carcinoma in situ or LCIS is a non-invasive breast condition. LCIS is the name for abnormal cells that are contained to the lobules (milk glands) of the breast. It is considered a breast change, and not breast cancer.

What are the Symptoms of Lobular Carcinoma in Situ?

LCIS cannot usually be felt as a breast lump and does not usually present with symptoms sometimes seen in invasive breast cancers. Changes due to LCIS are only sometimes found on a mammogram.

Most cases of LCIS are found when a patient is undergoing a breast biopsy for another reason. Most patients are not aware of any symptoms at the time of diagnosis.

How is Lobular Carcinoma in Situ Diagnosed?

LCIS cannot usually be felt in the breast and usually isn’t visible on a mammogram. LCIS is diagnosed by a biopsy, where small pieces of breast tissue are removed and checked under a microscope in the lab.

How is Lobular Carcinoma in Situ Treated?

LCIS does not require treatment if there are no other abnormal changes to the breast. This is because LCIS typically does not spread beyond the lobule and become invasive breast cancer if it isn’t treated.

However, a woman with LCIS should be carefully monitored as having LCIS increases the chance of developing breast cancer in future. If you have been diagnosed with LCIS, your doctor may recommend more frequent physical exams and screening to monitor your breasts for signs of cancer.

In some cases, breast conserving surgery or preventative medication may be recommended to reduce the risk of invasive breast cancer developing in the future.

Is Lobular Carcinoma in Situ Life-Threatening?

Like DCIS, although these abnormal changes can turn into invasive cancer cells, it is not classified as breast cancer as we generally understand it. A woman cannot die from LCIS as the cells are contained to the lobules of the breast.

Lobular Breast Cancer

Lobular breast cancer is a subtype of breast cancer that originates in the lobules, the glands that produce milk in the breast tissue. This differs from the more common ductal carcinoma, which starts in the milk ducts. It is classified as invasive when cancer cells spread beyond the lobules into surrounding breast tissue.

The exact causes of lobular breast cancer remain unclear, but several risk factors have been identified. These include genetic mutations (such as alterations in the CDH1 gene), hormonal factors (such as increased estrogen levels), and a family history of breast cancer. One of the challenges with lobular breast cancer is that it often does not present with a distinct lump, making early detection through mammograms or breast self-examination difficult.

Early diagnosis is crucial for effective treatment and improved outcomes. Treatment options typically include a combination of surgery, radiation therapy, chemotherapy, endocrine (or hormone) therapy, and/or targeted therapies, depending on the stage and characteristics of the cancer. Ongoing advances in research continue to enhance understanding and treatment options for lobular breast cancer, offering hope for improved outcomes and quality of life for those affected.

What are the Symptoms of Invasive Lobular Carcinoma?

Some patients diagnosed with ILC may not present with any symptoms. When symptoms are present, they may include:

• A new lump in the breast, armpit area or around the collarbone.
• Thickening or hardening in the breast.
• A change in breast size or shape.
• Changes to the nipple, such as sores or crusting, an ulcer or inverted nipple.
• Clear or bloody nipple discharge.
• Changes to the skin including redness, puckering or dimpling (an ‘orange peel’ appearance).
• Breast tenderness or pain.

How is Lobular Breast Cancer Diagnosed?

Diagnosing ILC can be challenging due to the way the cells grow through the breast tissue. ILC typically grows in a line rather than a mass, making it difficult to see the full extent of the disease on a mammogram. Additional imaging with an ultrasound and breast MRI is sometimes required.

Imaging Tests

• Mammogram: A specialised X-ray of the breast to detect any abnormalities or unusual growths. However, ILC can be difficult to identify on mammograms.
• Ultrasound: This technique uses sound waves create images, providing a clearer view, especially if the mammogram raises suspicions.
• Breast MRI: A more detailed imaging test that can provide a comprehensive picture of the breast tissue.

Biopsy

If an imaging test shows an abnormality, a biopsy is performed. This involves taking a small sample of tissue from the suspicious area. A core needle biopsy is commonly used, where a thin, hollow needle is used to collect tissue for examination.

Pathology Examination

The collected tissue is sent to a laboratory, where a pathologist examines it under a microscope. The pathologist looks for specific characteristics, such as the presence of invasive lobular structures.

Hormone Receptor Testing

Testing for oestrogen and progesterone receptors helps determine if the cancer cells are sensitive to endocrine (or hormone) therapies.

Lymph Node Examination

If cancer is confirmed, the doctor may examine nearby lymph nodes to see if the cancer has spread. This is an important step in determining the extent or stage of the cancer.

Staging

Understanding the stage of cancer is crucial for planning the most appropriate treatment. Staging considers the size of the tumour, whether it has spread to the lymph nodes, and whether it has spread to other parts of the body.

Stages of Lobular Carcinoma

Invasive lobular carcinoma (ILC) goes through different stages. It is crucial for doctors to know the stage of the cancer to assess the severity of the disease and guide the treatment plan. The stages of cancer are:

• Stage 0 (Carcinoma in Situ): At this early stage, cancerous cells are confined to the lobules, and there is no invasion into surrounding tissues. This is often referred to as carcinoma in situ, meaning the cancer is localised and has not spread.
• Stage I: Cancer is still relatively localised, typically confined to the breast tissue. The tumour size is relatively small, and there is no evidence of lymph node involvement.
• Stage II: The tumour is larger or may involve nearby lymph nodes. Despite the larger tumour size, the cancer is still predominantly within the breast.
• Stage III: Cancer has spread more extensively to surrounding tissues and lymph nodes. The tumour may be large, and there may be evidence of invasion into nearby structures.
• Stage IV (Metastatic): At this advanced stage, cancer has spread beyond the breast and nearby lymph nodes to other organs or distant parts of the body. This is considered advanced and challenging to treat.

How is Invasive Lobular Carcinoma (ILC) Treated?

ILC are typically oestrogen receptor positive breast cancers, which makes them sensitive to the endocrine (or hormone blocking) treatments such as tamoxifen.

Depending on the stage of ILC, treatment may include a combination of surgery, radiation therapy, chemotherapy, endocrine (hormone) therapy, and targeted therapies. Treatment for ILC also may include breast surgery, radiation therapy and chemotherapy. In most cases, ILC is usually more responsive to endocrine therapy than chemotherapy and is generally preferred.

What are my Chances of Survival (Prognosis) if I am Diagnosed with Invasive Lobular Carcinoma?

Typically, invasive lobular carcinoma tumours are associated with a good prognosis, as they tend to be low grade and oestrogen receptor positive. However, this will depend on your age, health status, tumour type and stage of cancer.

Your age, stage of disease and tumour type has the greatest impact on your chance of surviving five years past your breast cancer diagnosis. For stage 1 breast cancer, the chance of surviving 5 years or beyond is nearly 100%. However, for stage 4 breast cancer, the chance of surviving 5 years or beyond drops to 22%.

Overall, the five-year survival rate for women diagnosed with breast cancer is 91.5%, and 86.4% for men.

Invasive ductal carcinoma (IDC) is a type of breast cancer that originates in a milk duct and invades the surrounding fibrous or fatty tissue of the breast. From there, it has the potential to spread to other organs in the body.

How Common is Invasive Ductal Carcinoma?

Invasive ductal carcinoma accounts for around 80 percent of all breast cancer diagnoses. It is also the most common type of breast cancer that affects men.

What are the Symptoms of Invasive Ductal Carcinoma?

Some patients diagnosed with IDC may not present with any symptoms. When symptoms are present, they may include:

• A new lump in the breast, or armpit area
• A change in breast size or shape
• Changes to the nipple, such as sores or crusting, an ulcer or inverted nipple
• Clear or bloody nipple discharge
• Changes to the skin including redness, puckering, or dimpling (an ‘orange peel’ appearance)
• Breast tenderness or pain

How is Invasive Ductal Carcinoma Diagnosed?

Invasive ductal carcinoma is diagnosed through a combination of a physical exam, imaging tests like mammogram and ultrasound, and a biopsy where a small tissue sample is examined for cancer cells. This help doctors confirm the presence of cancer and plan the best treatment.

How is Invasive Ductal Carcinoma Treated?

The treatment of IDC depends on the stage of the cancer and the characteristics of the tumour, including its size, location, spread, and type. Treatment options may include a combination of radiation therapy, chemotherapy, hormone therapy, and/or surgery.

What are my chances of Survival (prognosis) if I am Diagnosed with Invasive Ductal Carcinoma?

In Australia and New Zealand, survival rates for invasive ductal carcinoma have improved thanks to advancements in clinical trials research, which have led to more tailored and advanced treatments, prevention strategies, and screening techniques.

However, for some people, their breast cancer will progress to an advanced or metastatic stage which greatly reduces their chances of survival.

Factors such as age, stage of disease, and tumour type can impact the likelihood of surviving five years past a breast cancer diagnosis.

Overall, the five-year survival rate for women diagnosed with breast cancer is 91.5%, and 86.4% for men.

FAQ’s

How Serious is Invasive Ductal Carcinoma?

Invasive ductal carcinoma is a serious form of breast cancer, as it has the potential to spread beyond the milk ducts where it originates. The seriousness of IDC largely depends on the grade of the cancer and the stage at which it is diagnosed.  Early detection and appropriate treatment are crucial for a better prognosis.

Is Invasive Breast Cancer Aggressive?

Yes, invasive breast cancer, including invasive ductal carcinoma, is considered aggressive because it can invade surrounding tissues and spread to other parts of the body. The level of aggressiveness can vary depending on the grade of the cancer, with invasive ductal carcinoma   grade 3 being more aggressive compared to grade 1.

What is the Difference Between DCIS and Invasive Ductal Carcinoma?

The key difference between DCIS (ductal carcinoma in situ) and invasive ductal carcinoma lies in their potential to spread. DCIS is a non-invasive cancer, meaning the cancer cells are confined within the ducts and have not invaded surrounding tissues. On the other hand, invasive ductal carcinoma breaks through the duct walls and invades the surrounding breast tissue, which can lead to metastasis if not treated effectively.

What is the Difference Between Invasive Ductal Carcinoma and Metastatic Breast Cancer?

While invasive ductal carcinoma refers to cancer that has invaded surrounding breast tissue, metastatic breast cancer occurs when the cancer cells spread from the original tumour site to distant organs of the body, such as the bones, liver, lungs, or brain. This spread, known as metastasis, marks an advanced stage and will change the treatment plan and reduces survival rates.

What is the Invasive Ductal Carcinoma Recurrence Rate?

The recurrence rate of early invasive ductal carcinoma recurrence rate varies depending on several factors including stage of diagnosis, tumour grade, hormone receptor and HER2 receptor status as well as effectiveness of the initial treatment. Generally, higher grades and stages of invasive ductal carcinoma have higher risks of recurrence.

Recurrence can happen locally (near the site of the original tumour), regionally (nearby lymph nodes), or in distant organs. Effective initial treatment and ongoing surveillance are critical in managing the risk of recurrence and improving long-term outcomes.

What is HER2-Positive Breast Cancer?

HER2 positive breast cancer is a type of breast cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2). This protein promotes the growth of cancer cells.

HER2-positive breast cancer tends to grow faster compared with HER2 negative ones. However, they often respond well to treatments specifically designed for HER2-positive cancers. These cancers can either be hormone-receptor (HR) positive or negative.

How Common is HER2-Positive Breast Cancer?

Around 15-20% of all types of breast cancers are HER2-positive. It is more common in younger, pre-menopausal women.

What are the Symptoms of HER2-Positive Breast Cancer?

Some patients diagnosed with HER2-positive breast cancer may not present with any symptoms. When symptoms are present, they may include:

• A new lump in the breast, armpit area or around the collarbone
• Thickening or hardening in the breast
• A change in breast size or shape
• Changes to the nipple, such as sores or crusting, an ulcer or inverted nipple
• Clear or bloody nipple discharge
• Changes to the skin including redness, puckering, or dimpling (an ‘orange peel’ appearance)
• Breast tenderness or pain

If the cancer has progressed to the metastatic stage, additional symptoms may be present depending on where the cancer has spread. Learn more about metastatic breast cancer here.

How is HER2-Positive Breast Cancer Diagnosed?

HER2-positive breast cancer is diagnosed in the same way as most other breast cancers, which typically involves a mammogram and a biopsy. The biopsy is important for determining the HER2 status of the cancer, which helps to guide the treatment plan for the treating doctors. Sometimes the HER2 test is performed on the cancer tissue once it has been surgically removed.

If the breast cancer has spread to other organs, additional tests may be needed to determine the extent and location of the spread.

How is HER2-Positive Breast Cancer Treated?

HER2-positive breast cancer is primarily treated with HER2-targeted therapies. The most common of these in Australia and New Zealand is trastuzumab (Herceptin). The HERA clinical trial found Trastuzumab significantly reduced the likelihood of early HER2-positive breast cancer returning.

Women with early HER2-positive breast cancer may also receive this in combination with surgery, chemotherapy, other HER2-targeted treatments and radiation therapy.

For women with metastatic HER2-positive breast cancer, trastuzumab may be combined with other treatments including other HER2-targeted therapies. This will continue so long as the benefit o the patient outweighs the side effects.

If the breast cancer is also Hormone Receptor-positive (HR-positive), it will grow as a result of the female hormones oestrogen and/or progesterone. Hormone blocking (or endocrine) treatments may also be prescribed in this situation.

What are my chances of Survival (prognosis) if I am Diagnosed with HER2-Positive Breast Cancer?

The prognosis for HER2-positive breast cancer prognosis has improved significantly thanks to targeted treatments like trastuzumab (Herceptin).

Factors such as age, stage of disease, and tumour type greatly impact your chance of survival. Those diagnosed with stage one breast cancer have a 96% chance of surviving five years after diagnosis, while those diagnosed with stage four HER-2 positive breast cancer have over 50% chance of surviving five years after diagnosis of metastatic disease.

Overall, the five-year survival rate for women diagnosed with breast cancer is 91.5%, and 86.4% for men.

What Clinical Trials are Available for HER2 Breast Cancer Patients?

Clinical trials have been vital in advancing the treatment of HER2-positive breast cancer. 

To understand the experience of participating in a clinical trial, discover Laura’s story.

Supporting the latest breast cancer clinical trials today is the best way to change breast cancer outcomes – for you and your loved ones – tomorrow. Donate to improve treatment and save lives.

FAQ’s

Is HER2-Positive Breast Cancer Curable?

With the advancements in treatment, HER2-positive breast cancer is increasingly curable, especially when diagnosed early. The effective targeted therapies, like trastuzumab, have significantly improved the outcomes and life expectancy for HER-2 positive breast cancer.

What Does HER2-Positive Mean?

When a breast cancer is HER2-positive, it means that the cancer cells have an excess of the HER2 gene, leading to an overproduction of the HER2 protein. This overexpression helps the cancer cells grow and divide faster, but it also makes them more susceptible to targeted HER2 therapies.

Does HER2-Positive Breast Cancer Always Require Chemotherapy?

HER2-positive breast cancer treatment often includes chemotherapy, but it is not always required. The need for chemotherapy depends on factors such as size, grade and stage of the cancer. Targeted therapies can sometimes be used in combination with or instead of chemotherapy.

Is it Better to Have HER2-Positive or Negative Breast Cancer?

It is difficult to say whether it is better to have HER2-positive or HER2-negative breast cancer as both types have different treatment approaches and prognosis. However, HER2-positive breast cancer tends to respond well to targeted treatments, which have dramatically improved outcomes for this group.

Is HER2 Breast Cancer Aggresive?

HER2 breast cancer is typically more aggressive than other types of breast cancer due to its rapid growth rate. However, this type of cancer is also more responsive to specific targeted treatments, which can lead to better outcomes than some less aggressive, harder-to-treat cancers.

What is Early-Stage Breast Cancer?

Early breast cancer is an invasive breast cancer that is contained in the breast and may or may not have spread to the lymph nodes in the breast or armpit. If you have been diagnosed with Stage 1 or Stage 2 breast cancer, you have early-stage breast cancer.

Stage 1: A stage one breast cancer means the cancer cells has not spread from the original site to fatty tissues and/or lymph nodes. The tumour will be less than 2cm.

Stage 2: The cancer is larger than Stage 1 and/or has spread to nearby lymph nodes but has not spread beyond the breast tissue or lymph nodes. In stage 2 breast cancer, the tumour is less than 2cm and has spread to 1-3 lymph nodes in the armpit, or the tumour is between 2cm-5cm and has not spread to the lymph nodes.

What are the Symptoms of Early-Stage Breast Cancer?

Some patients diagnosed with early-breast cancer may not present with any symptoms. When symptoms are present, they may include:

• A new lump in the breast, or armpit area
• Thickening or hardening in the breast
• A change in breast size or shape
• Changes to the nipple, such as sores or crusting, an ulcer or inverted nipple
• Clear or bloody nipple discharge
• Changes to the skin including redness, puckering, or dimpling (an ‘orange peel’ appearance)
• Breast tenderness or pain

How is Early-Stage Breast Cancer Diagnosed?

As stage 1 breast cancer is small, it may be difficult to detect in a physical examination. Often stage one breast cancers are picked up in routine screening mammograms.

Stage 2 breast cancers are slightly larger, with the tumour measuring between 2cm to 5cm, and so it may be felt as a hard lump in the breast or under the arm during a physical examination, or self-examination. Stage two breast cancers are also often diagnosed through screening mammograms.

If early-stage breast cancer is suspected, your doctor may also request you have other scans such as an ultrasound or MRI. A biopsy of the tumour may also be needed to confirm the diagnosis and determine what type of breast cancer you have, which will help to influence your treatment regimen.

How Common is Early-Stage Breast Cancer?

According to the latest data from the Australian Institute of Health and Welfare, approximately 42% of breast cancers diagnosed each year in Australia are stage 1, and 35% are stage 2. New Zealand’s incidence rates are similar. Thanks to the successful BreastScreen Australia and BreastScreen Aotearoa programs, more breast cancers are being diagnosed in the earlier stages which is leading to higher survival rates.

Are there different kinds of Early-Stage Breast Cancer?

Yes. Early-stage breast cancer means that the breast cancer has not spread beyond the breast or nearby lymph nodes. Early-stage breast cancer can be one of four different major subtypes; Luminal A (Hormone Receptor positive, HER2 negative (HR+/HER2-) low grade), Luminal B (Hormone Receptor positive, HER2 negative or positive (HR+/HER2-/+) high grade), HER2 positive breast cancer or triple negative breast cancer.

Your treatment will often depend on what subtype of breast cancer you have.

How is Early-Stage Breast Cancer Treated?

The aim of treatment for early breast cancer is to remove the breast cancer and any cancer cells that may be in the breast or armpit. Treatment may also be needed for cancer cells that may have spread to other parts of the body but cannot be detected.

Treatment can involve radiotherapy, breast surgery, chemotherapy, hormonal therapies, and targeted therapies.

What are my chances of survival (prognosis) if I am diagnosed with Early-Stage Breast Cancer?

Breast cancer survival is sometimes measured in 5-year relative survival. This means how many people diagnosed with breast cancer are still alive five years after their initial diagnosis. Many of those who are alive at 5 years will still be alive and cancer-free for many years after that point.

Breast cancer survival differs and there are many factors that can influence this such as your response to treatment, the type of breast cancer you have, medical history, overall health, age, and tumour growth. You should discuss your personal situation with your doctor and/or treatment team.

What are the Symptoms of Ductal Carcinoma in Situ?

DCIS doesn’t typically present with any signs or symptoms and cannot usually be felt. It also doesn’t present with symptoms sometimes seen in invasive breast cancers. However, if you notice any irregularities in your breast, you should speak with your GP or doctor.

How is DCIS Diagnosed?

Most cases of DCIS are found following routine screening with mammograms and appear as small clusters of calcifications (areas of calcium that can be seen on the mammogram x-ray) that have irregular shapes and sizes. Calcifications can also occur without any evidence of DCIS or breast cancer, depending on the way that they look and are referred to as ‘benign’.

How is Ductal Carcinoma in Situ Treated?

Treatment of DCIS usually involves breast surgery and radiotherapy, and occasionally includes surgery to remove lymph nodes and hormonal therapies. The goal of DCIS treatment is to ensure the abnormal cells in the milk ducts of the breast do not spread and become invasive breast cancer, and to prevent it recurring.

Breast conserving surgery is often recommended for patients undergoing treatment for ductal carcinoma in situ. This is sometimes referred to as a lumpectomy, partial mastectomy, or wide local excision. Mastectomy, or the full removal of the breast, may be considered if the DCIS is widespread in the breast.

After breast surgery, radiation treatment may be recommended to lower the chance the DCIS will come back. If the patient has had a mastectomy for DCIS, radiation is not usually needed.

In addition to radiation, some patients with hormone receptor positive DCIS may take the drug tamoxifen or another hormonal therapy to lower the chance of the DCIS returning. Also, after a diagnosis of DCIS, there is a chance of another DCIS, or breast cancer occurring in one or the other breast, and this hormone blocking therapy helps reduce that risk.

Chemotherapy is not used for DCIS as the abnormal cells are contained in the breast.

DCIS can be treated successfully, and most women diagnosed and treated for DCIS will not develop a recurrence of DCIS, or invasive breast cancer.

Is DCIS Breast Cancer?

DCIS is not considered in the same category as breast cancer, as we more commonly understand it. However, a diagnosis of DCIS can increase your likelihood of developing invasive breast cancer later in life.

Is Ductal Carcinoma in Situ Life-Threatening?

Although these abnormal changes have the potential to turn into invasive cancer cells eventually, a diagnosis of DCIS is not life-threatening as a woman cannot die from DCIS. This is because the abnormal cells are contained within the milk ducts.

What Is Hand Foot Syndrome?

A side effect of some chemotherapy, and targeted therapy treatments, is Hand Foot syndrome, also known as hand and foot syndrome, Palmar-Plantar Erythrodysesthesia or PPE.

It’s a condition which affects the palms of the hands and soles of the feet, and can also affect the skin on the knees and elbows.

This side effect can make it harder to go about your daily activities, but there are treatments available and methods of reducing your risk of developing this condition.

Hand foot syndrome is a side effect from some chemotherapy drugs. Not all chemotherapy drugs will present with this side effect, but it is important to be aware, so symptoms can be addressed quickly if they appear.

Rebecca Angus is a senior podiatrist with an interest in this condition as she has a personal history of breast cancer, being diagnosed with the disease in 2018. She is also a member of the Breast Cancer Trials Consumer Advisory Panel (CAP).

“I’ve seen a lot of women come through the clinic with these side effects,” she said.

“Hand foot syndrome is a condition that can occur, particularly in women, that are taking taxines and other drugs, such as Xeloda.”

“It’s about the drugs toxicity levels and how high the toxicity level of the chemotherapy is.”

Hand foot syndrome is a skin reaction that occurs when a small amount of the chemotherapy medication leaks out of the small bloody vessels (capillaries), usually on the hands and feet, and damages the surrounding tissues. The severity of this depends on the dosage and duration of treatment.

Unfortunately, it can be a painful condition which can affect your quality of life. However, there are treatments available and ways to prevent this side effect from occurring.

What Are The Symptoms Of Hand Foot Syndrome?

Symptoms may appear shortly after starting treatment or can occur weeks after. Less commonly, it can occur after being on a drug for months.

Symptoms can include:

• A lifting of the nails in the hands and feet
• Peeling or cracked skin
• Blisters and/or calluses which can be painful
• Swelling of the hands and feet
• Infections of the nails
• Itching
• Rash
• A feeling of tightness or stiffness in the skin
• Numbness
• Redness
• Pain
• Tingling, burning, or itching
• Difficultly walking or using your hands

How is Hand and Foot Syndrome Treated?

In the first instance, you should make your doctor and/or treatment team aware of any side effects from your treatment. They may wish to change you treatment schedule or dosages to help reduce your discomfort. They may also prescribe corticosteroids to reduce any inflammation.

You may also be referred to an allied health professional like a podiatrist who will work with your treatment team to ensure you can continue with your treatment.

Ms Angus said a podiatrist can work with you to help ease any discomfort and pain, and help reduce the risk of infection or any further issues associated with hand foot syndrome.

“The way we treat it is with general nail care,” said Ms Angus.

“I’m usually trimming the patients nails and if they do have onycholysis (nail detaching from the nail bed), I’m trimming them back.”

“I’m also treating and swabbing for bacterial infections because once you start getting that onycholysis of the nail, you are then exposed to infections,” she said.

“So additional side effects can arise due to an infection, with some patients having to  have antibiotics and stop their treatment, and from my perspective, I would love to see that prevented.”

Other treatment options include using a 10% urea cream on the hands and feet, and regional cooling – using mitts on the feet and hands to prevent peripheral neuropathy and hand and foot syndrome.

Ms Angus said she also educates her patients on the best choice of footwear.

“I ensure my patients have good quality footwear, that actually fit properly, and I use things like neoprene uppers and stretchy materials to try and ensure there is no pressure on the skin.”

“The other thing that I’m doing with patients is making sure their socks are fitting properly,” she said.

“So it’s a process in which they come into the practice, we do that cursory neurological examination, and then we start looking at doing our routine general treatment and then giving them foot-care education afterwards.”